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IM
Practical Nursing
Medical-Surgical
Nursing I
Teacher Edition
www.okcimc.com
800-654-4502
10-123456789
CIMC
HO1038
MODULE 4
cardiac Nursing
N
urses will care for patients who have
a variety of cardiac conditions. These
conditions may be structural, mechanical, or electrical in nature. This module is a review of the normal structure and function of the
heart and diseases and other conditions that may
compromise these three important components
of heart function. This knowledge will be used to
recognize signs and symptoms of abnormal cardiac
function and understand how abnormal cardiac
function affects the patient and the way the LPN
delivers patient care. The nurse must be able to
discuss and demonstrate safe, effective care for the
cardiac patient. Additionally, the nurse must have
the knowledge to assist with and modify appropriate nursing care, support, and teaching needed for
patients with cardiac conditions and their families.
i
Review the Learning Objectives with
the students. Look
ahead to the Learning
Activities in this unit and
plan to introduce them.
L E a r Nn iI Nn g O b j E c t iI v E s
1. Explain the function of the heart.
integumentary system.
2. Distinguish among cardiac
disorders.
integumentary
disorders.
3. Relate
diagnostic
tests
surgical
proceduresdisorders.
to the nursing care of
Describe
treatments
of and
various
integumentary
patients with cardiac disorders.
Te ac hi ng S U g g e st i on s
4. Evaluate pharmacological effects of medications used to treat
4. Evaluate
pharmacological
integumentary
disorders. effects of medications used to treat cardiac
disorders.
5. Explain diagnostic or surgical procedures used with integumentary
5. Contribute
disorders. to the plan of care for patients experiencing alterations in
• A
long with many
helpful websites, there
are now many “apps”
available to help
students and nurses
obtain needed information from their smart
phones, tablet devices,
etc. Search iTunes or
other application databases for the most upto-date “apps” available
for each content area.
See the following links
for possible apps related
to the cardiac system.
cardiac function.
6. Contribute to the plan of care for patients experiencing alterations in
6. Assist
with patient
education related to self-care for cardiac disorders.
integumentary
function.
7. Assist with patient education related to self-care for integumentary
function.
• B
e sure to advise the
students that these
“apps” may cost to
download.
■ h
ttp://appfinder.
lisisoft.com/app/easyecg.html
■ h
ttp://appfinder.
lisisoft.com/app/medsurg-cardiovascularrespiratory.html
2
CIMC • MEDICAL SURGICAL NURSING I
■ www.fastfactsforcriticalcare.com/
■ http://itunes.apple.com/us/app/acc-pocket-guidelines/id307934258?mt=8
■ h
ttp://itunes.apple.com/us/app/heart-pro/id393231526?mt=8
module O v e r v i e w
This module provides concise information regarding cardiac disorders including their symptoms and associated
medications, diagnostic tests, surgical procedures, and nursing care. Students should be encouraged to reacquaint
themselves with the cardiac system information from their Anatomy and Physiology coursework.
2
CIMC • MEDICAL SURGICAL NURSING I
L E a r N i N g
O b j E c t i v E
O bj ecti v e Explain the function of the heart.
OvErviEw Of carDiac
fUNctiON
The main reasons that a patient may have a cardiac
condition are the malfunction of the electrical impulse to and within the heart, restricted blood flow
to the heart (circulatory) and mechanical (muscular)
abnormalities.
Electrical
Myocardial contraction cannot occur without an
electrical impulse. The sinus atrial (SA) node is
referred to as the primary pacemaker of the heart and
it lies in the right atrium. The SA node fires an electrical impulse that follows a specific pathway until it
ultimately reaches the ventricles, causing systole, or
contraction.
As the electrical impulse leaves the SA node, it quickly travels down the internodal pathways, causing
contraction of the atria. This contraction causes the
blood contained within the atria to be emptied into
the awaiting ventricles.
As the electrical impulse reaches the bundle of HIS,
it is still traveling quickly. In order for the atria to
effectively contract and empty, this impulse must be
slowed. This is done at the bundle of HIS. The electrical impulse is captured and slowed before relaying
it to the other structures.
The next structures on this pathway are the bundle
branches. The right and left bundle branches divide
as they leave the bundle of HIS and branch down the
inner septum of the right and left ventricle. The last
structures are the Purkinje fibers. These are fingerlike
projections that wrap around the ventricular walls,
allowing the electrical impulse to stimulate these
structures and cause contraction. Diseases and disorders can result from the ability of the heart to carry
this electrical impulse. Should there be a change in
the rate of the impulse, the heart may not work as
effectively as needed.
Structural (Circulatory)
The heart is made of four hollow chambers, a right
and left atrium and a right and left ventricle. The
two atria lie at the top of the heart and receive blood
from specific structures. The right atrium receives
blood from the vena cava as it returns from the body.
This blood is un-oxygenated and carries with it waste
products that are to be expelled by the lungs. The left
atrium receives blood from the lungs. This blood is
oxygenated and is capable of providing nutrients to
awaiting organs and tissues.
The pathway of blood flow follows:
•
Therightventriclereceivesbloodfromtheright
atria
•
Fillspassivelyduringdiastole
•
Rightatriacontracts,squeezingbloodfromits
chamber
•
Astheatriacontracts,itexertspressureonaoneway valve called the tricuspid valve
▶
This valve serves as a one-way door to prevent blood from backwashing into the atria
as the ventricle contracts.
•
Bloodfillstheventricles,causingthemuscular
wall to stretch and increase the force by which
the blood is ejected during systole
•
Bloodleavingtherightventricleentersthepulmonary circulatory system, and is carried to the
lungs
•
Carbondioxideismovedintothelungsand
exhaled and oxygen picked up by inhalation
•
Bloodthenreenterstheheartvialeftatrium
receives the oxygenated blood from the lungs
•
Bloodgoesthroughthemitralvalvetotheleft
ventricle and ejects blood into the aorta, which
carries the blood to all other arterial structures
As valves open and close, distinctive sounds can be
heardwiththehelpofastethoscope.Conditions
that interfere with the normal opening or closing of
these valves are detected during assessment. Abnormal sounds, such as gallops or murmurs, indicate that
further assessment and testing are warranted.
MODULE 4 • CARDIAC NURSING • stUDENt EDitiON
3
Te ac hi n g S Ug g e s t i on s
Instruct students to review the modules covering the cardiovascular system from their anatomy and physiology
course for more detailed information.
M O D U L E 4 • C a r d i a c N u r s i n g • T E ACH E R E D I T I O N
3
D i d You Know?
The left ventricle is the largest
chamber of the heart.
Mechanical (Muscular)
The outer layer of the heart is called the pericardium.
It is composed of two layers, the fibrous and the
serous. These two layers have a few drops of fluid between them to prevent friction as the structures rub
against each other as the myocardium contracts.
Cardiacmusclesandstructuresreceivebloodsupply
from the coronary arteries.
Primary coronary arteries include:
4
4
•
Rightcoronaryartery
•
Leftanteriordescendingcoronaryartery
•
Leftcircumflexartery
Each of these arteries has multiple branches reaching
intotheentiremuscularstructureoftheheart.Because of their location, coronary arteries have a major
differencefromotherarteries.Becausetheheartis
contracting during systole, these vessels are being
squeezed and cannot possibly fill with blood. The
coronary arteries actually fill during diastole, when
the heart is at rest. If there is an occlusion in one or
more of these arteries, such as when a patient has
plaque formation in one or more of these arteries, the
blood flow could be obstructed causing tissue death.
In contrast, the pulmonary artery carries un-oxygenated blood from the right ventricle to the lungs. The
pulmonary vein carries oxygenated blood from the
blood to the left ventricle. This is the only time that
a normally functioning artery caries un-oxygenated
blood and a normally functioning vain carries oxygenated blood.
look it up!
Go to www.nhlbi.nih.gov/health/
health-topics/topics/hhw/
CIMC • MEDICAL SURGICAL NURSING I
CIMC • MEDICAL SURGICAL NURSING I
LEarNiNg activity
Lea rni ng Acti v i ty Ans wers
1
NaME
1. If a hole existed between
the right and left atria,
un-oxygenated blood
from the body would
mix with oxygenated
blood from the lungs
and be pumped out
through the left ventricle
to the body. This is
called an atrial septal
defect (ASD) or Patent
Foramen Ovale (PFO).
If the hole is small, it may
have minimal effect on
heart function. When
a large defect exists
between the atria, a large
amount of oxygen-rich
(red) blood leaks from
the heart’s left side back
to the right side. Then
this blood is pumped
back to the lungs,
despite already having
been refreshed with
oxygen. Unfortunately
this creates more work
for the right side of the
heart. This extra amount
of blood flow in the lung
arteries can also cause
gradual damage.
Introduction
In this activity, the flow of blood through the heart and lungs will be reviewed. Later in this module, disorders of the heart that also affect the lungs will be discussed.
Activity
•
Workindividuallyoringroupsoftwoasassignedbythefacilitator.
•
Useanatomyandphysiologysoftwareorananatomyandphysiologytextwhileworkingonthisactivity.
•
Drawadiagramoftheheart,includingthegreatvessels(superiorandinferiorvenacava,pulmonaryartery
and veins, and the aorta).
•
Usebluearrowstoindicatethepathofun-oxygenatedbloodthroughtheheart,lungs,andgreatvessels.
•
Useredarrowstoindicatethepathofoxygenatedbloodthroughtheheart,lungs,andgreatvessels.
Special tools/equipment
Art supplies, anatomy and physiology software or text
Application
Display your diagram of blood flow through the heart.
Look at the displays and answer and discuss the following questions:
1. Whatwouldhappentobloodflowthroughtheheartifaholewaslocatedbetweentherightandleft
atria?
2.Whatwouldhappentobloodflowthroughtheheartifaholewaslocatedbetweentherightandleft
ventricles?
3.Whatwouldhappentobloodflowthroughtheheartifthemitralvalvedidnotopenandcloseproperly?
MODULE 4 • CARDIAC NURSING • stUDENt EDitiON
5
2. If a hole existed between the right and left ventricles, un-oxygenated blood in the right ventricle could mix
with oxygenated blood in the left ventricle and be pumped into the body, thereby decreasing the amount of
available oxygen to the body tissues. This is called a ventricular septal defect (VSD). In normal development,
the wall between the chambers closes before the fetus is born, so that by birth, oxygen-rich blood is kept
from mixing with the oxygen-poor blood. When the hole does not close, it may cause higher pressure in the
heart or reduced oxygen to the body. www.heart.org/HEARTORG/Conditions/CongenitalHeartDefects/
AboutCongenitalHeartDefects/Ventricular-Septal-Defect-VSD_UCM_307041_Article.jsp
3. If the mitral valve did not open and close properly, blood from the left ventricle would push back into the left
atrium as the ventricle beats. Less blood would be pumped out to the body. Blood would flow back into the left
atrium (mitral regurgitation). When the mitral valve doesn’t function properly, blood can’t move through your
heart or to the rest of your body as efficiently. Mitral valve regurgitation can make you tired and short of breath.
The increased volume in the left ventricle ultimately backs up into the CV system causing pulmonary
congestion. www.mayoclinic.com/health/mitral-valve-regurgitation/DS00421
M O D U L E 4 • C a r d i a c N u r s i n g • T E ACH E R E D I T I O N
5
L E a r N i N g
O b j E c t i v E s
learning
w
ww
link
Object i v e Distinguish among cardiac disorders.
Coronary Heart Disease
Risk Factors — Search
site for Coronary Heart
Disease Risk Factors
Cardiacdisorderscanbemechanical,circulatory,or
electrical in nature. They may also involve one or more
of the internal structures of the heart. Any progressive
chronic process condition that obstructs blood flow in
the coronary arteries is referred to as coronary artery
disease(CAD).Themostcommonoftheseconditions
is atherosclerosis, in which plaque builds up on the inside of the coronary artery walls. This plaque is made up
of cholesterol, lipids, and cellular debris. As the plaque
builds, the lumen of the vessel involved becomes narrower. This causes a decrease in blood flow through the
vessel and ultimately leads to tissue damage caused by:
Object i v e Assist with patient education
•
Obesity—Increasestheworkloadoftheheart
and contributes to other risk factors.
•
Sedentarylifestyle—Lackofregularexercise
contributes to cardiovascular disease; exercise
helps decrease other risk factors such as obesity,
hypertension, and hyperlipidemia.
•
Stress—Thebody’sresponsetostressincreases
heart rate and affects cells in the myocardium;
vasoconstriction due to stress response can further narrow arteries and raise blood pressure.
•
Oralcontraceptives—Increaseriskofclotsand
other factors that contribute to heart disease.
•
Psychosocialfactors—PeoplewithTypeApersonality traits that include aggressiveness, competitiveness, perfectionism, compulsiveness, and
an urgent sense of time have been found to be
more likely to develop cardiac disease, especially
when combined with other risk factors.
related to self-care for cardiac
disorders.
www.americanheart.org/
•
Lackofenoughnutrientsavailabletothetissue
causing oxygen-deprivation
Non-modifiablefactorsinclude:
•
Wasteproductsbuildup,leadingtotissuedamage
•
•
Abloodclot,oranotherformofembolismor
debris lodges which ceases circulation to tissues
distal to the lesion, resulting in tissue ischemia,
and ultimately tissue necrosis
Familyhistory—Tendencytowarddevelopingcardiac disease within families is well-documented.
•
Age—Approximately50%ofallMyocardial
Infarctions (MI)occurinpersonsover65yearsold.
•
Sex—Menhavegreaterincidenceofheartdisease
than women; post-menopausal women are affected due to a decrease in estrogen production.
•
Race—Ethnicityhasahugeimpactontheincidenceofcoronaryarterydisease(CAD).African
AmericanshaveanearlyageofonsetofCAD
and have a higher incidence in women than in
Caucasianwomen.
c i r c U L at O ry D i s O r D E r s
CADiscausedbybothmodifiableandnon-modifiable risk factors.
Modifiableriskfactorsincludethosewhichtheindividual can change or omit.
•
Smoking—Individualswhosmokehavechances
for cardiovascular disease two to three times
greater than those who do not smoke.
•
Hyperlipidemia—Highlipid(fat)levelsinthe
blood, including cholesterol and triglycerides,
contribute to plaque formation on artery walls.
•
Hypertension—Bloodpressurehigherthan140/90
increases the risk for developing heart disease.
•
Diabetesmellitus—Elevatedbloodglucosemay
damage the lining of arteries and contribute to
atherosclerosis; diabetes also interferes with fat
metabolism, causing high serum lipid levels.
6
D i d You Know?
African Americans also have a higher
incidence of hypertension than
Caucasians. Native Americans younger
than 35 have nearly twice the mortality
rate due to heart disease than other
Americans. This may be due to a high
incidence of obesity and diabetes.
Hispanics have a lower death rate from
heart disease than non-Hispanics.
CIMC • MEDICAL SURGICAL NURSING I
Cla ssroom Ac t i v i t y
Have students break into groups and create a concept map based on the risk factors for CAD and how to manage the risk factors to decrease the chances of developing CAD. http://eduwithtechn.wordpress.com/2007/04/14/some-free-concept-mapping-programs/
6
CIMC • MEDICAL SURGICAL NURSING I
aNgiNa
Angina is brought on when the individual experiences a situation in which the workload of the heart is
increased. Any of the following will increase cardiac
workload and could bring on angina:
•
Exposuretocold
•
Exercise
•
Unusuallyheavymeals
•
Emotionalstress
•
Strenuousactivity
learning
w
ww
link
Unstableanginaisaprolongedepisodeofseverepain
or discomfort that occurs at rest, has never occurred
before, or is worse than previous episodes.
Patient teaching for those diagnosed with angina is
imperative. Diet, exercise, and healthy living choices
areveryimportant.Refertothemodule“Concepts
ofHealthandWellness”forspecificexamples.The
diagnosis of angina is grave and many times the
condition progresses to the point of a myocardial
infarction. However with early diagnosis, aggressive
treatment, and healthy life choices, mortality can be
decreased.
Angina
www.nlm.nih.gov/medlineplus/angina.html
Videos
Disorder
Angina
Structure Affected
•Coronaryarteries
•Myocardium
Physical Findings
•Pain
▶Beneathsternum
radiating to neck
and jaw
▶Radiatingdown
left arm
▶ Epigastric area
radiating to neck,
jaw, and arms
▶ Neck and jaw
▶ Left shoulder and
inner aspect of
both arms
▶Betweenshoulder
blades in the back
•Ischemiatocardiac
muscle
•Myocardialdamage
www.5min.com/Tag/
angina?CategoryID=177
Nursing Care
•Instructpatienttostopactivityat
thefirstsignofanginalpain
•Monitorvitalsigns,noting
changes or abnormalities
•Assessfordiaphoresis
•Assessanxietylevel
•Notelocation,intensity,radiation,
and duration of pain
•Assessforfeelingofimpendingdeath
•Assessanyprecipitatingfactors
that resulted in angina pain
•Assessforchangesinfrequencyor
worsening of symptoms
•Determinewhetherpainhasoccurred before and what has relieved it
•GiveNitroglycerin(NTG)sublingual, as ordered, and tell patient to
lie down
•Ifpainnotrelievedafterone
tablet, or as directed by physician,
instruct patient to go to emergency room or if in acute care, notify
the nursing staff
•Administeroxygenasordered
•Promoterestandavoidactivities
that increase workload on the heart
MODULE 4 • CARDIAC NURSING • stUDENt EDitiON
M O D U L E 4 • C a r d i a c N u r s i n g • T E ACH E R E D I T I O N
7
7
acUtE cOrONary syNDrOME
learning
w
ww
link
Pathophysiology
Whenapatientisadmittedwithadiagnosisofacute
coronary syndrome, they often exhibit signs and
symptomssimilartoamyocardialinfarction(MI)—
often referred to as a heart attack.
Disorder
AcuteCoronary
Syndrome
Acute Coronary Syndrome
•Myocardial
infarction
www.mayoclinic.com/
health/acute-coronarysyndrome/DS01061
•Myocardial
ischemia
8
8
Structure Affected
•Coronaryarteries
become completely
occluded
•Inflammatoryprocess
occurs
▶Bodytemperature
elevates
▶Whitecellcount
rises
•Cardiacenzymesare
released from the dead
tissue cells
•Nooxygenatedblood
can get to that area
of the myocardium
causing tissue death or
necrosis of the tissue
•Necrotictissueof
the myocardium is
eventually replaced by
scar tissue
Physical Findings
•Anxiety
•Dyspnea
•Weakness/faintness
•Nausea
•Pallor
•Erraticbehavior
•Hypotension,shock
•Changeincardiac
rhythm
•Vomiting
•Fever
•Diaphoresis
•Shortnessofbreath
•Retrosternalpainas
crushing or vice-like,
or like a heavy object
sitting on the chest
radiating to the neck,
arm, jaw, and teeth
•Feelingofimpending
doom
•Symptomsaremore
severe and last longer
than an angina attack
Nursing Care
•Ongoingassessment
•Monitorforsignsand
symptoms associated with
complications
•Administeroxygen@2-4
l/minasdirected
•Monitorforanxiety
•Monitorforbleeding
gums, petechia, bruising,
or black tarry stools due
to thrombolytic medications
•Reportunstablevital
signs, increased pain,
diaphoresis and any signs
of worsening condition or
bleeding gums, petechia,
bruising, black tarry stools
•Provideemotionalsupport
CIMC • MEDICAL SURGICAL NURSING I
CIMC • MEDICAL SURGICAL NURSING I
c O M p L i c at i O N s f r O M M i
•
Ventricular fibrillation is a life-threatening
arrhythmia that occurs when the ventricles of
the heart quiver rather than pump blood. If left
untreated this is a fatal condition unless defibrillation shocks the heart into a rhythm.
•
Cardiogenicshockoccurswhentheheartmuscle
is damaged so severely that the heart is not able to
pump effectively and causes a decrease in blood
supply to vital organs. This may lead to multisystemfailure.Bloodpressureisveryloworcannot be measured. Life-saving measures are taken
when this occurs. If left untreated the patient will
die.
•
•
•
Ventricular aneurysm occurs when damage to
the ventricle causes the ventricle wall to thin
and balloon out. This further complicates the
pumping mechanism of the myocardium and
can ultimately result in rupture of the myocardial
muscle.
Pericarditisoccurswhenthesacaroundtheheart
becomes inflamed after the MI damages the ventricle. This inflammation causes the pericardial
muscle to rub against its surrounding protective
sac. If not treated, fluid will begin to accumulate
within the sac, ultimately resulting in a tamponade, which prevents the muscle from expanding
after contraction. This is discussed more with
inflammatory conditions.
Embolismoccurswhenabloodclottravels
through the circulatory system. The clot may
originate in the atria or in the peripheral circulation. The clot may eventually lodge in the lungs,
brain, or heart.
c O N g E N i ta L H E a r t D E f E c t s
learning
w
ww
link
Many cardiovascular disorders in children are present
at birth. Abnormalities occur during the formation
of the heart and great vessels in utero. The abnormalities may be the result of genetic or environmental factors. Exposure of the fetus to rubella, alcohol,
and certain drugs may increase the risk of congenital
heart defects. If the mother has diabetes mellitus
or is of advanced age, the baby has an increased risk
fortheseproblems.Familiesthathaveincidenceof
congenital heart defects, chromosomal abnormalities, and other types of congenital anomalies have
an increased risk for a baby with congenital heart
defects.(SeeMaternalNewbornNursingforspecific
information about nursing care for children with this
disorder.)
Ventricular Fibrillation
MEcHaNicaL (MUscULar)
DisOrDErs
www.heart.org/
HEARTORG/Conditions/Arrhythmia/
AboutArrhythmia/
Ventricular-Fibrillation_
UCM_324063_Article.jsp
Valvular heart disease
Video
http://video.app.msn.
com/watch/video/ventricular-fibrillation/bdfmliee
Pathophysiology
The valves of the heart act like one-way doors to keep
the blood flowing in the appropriate direction. The
valves open when blood pushes through and close
whenthechamberisfilled.Therearetwoconditions
that can develop within the valves, interfering with
their function: valvular stenosis and valvular insufficiency.Theseconditionsinterferewiththeblood
flow through the heart structures.
Cardiogenic Shock
www.ncbi.nlm.nih.
gov/pubmedhealth/
PMH0001237/
Pericarditis
www.ncbi.nlm.nih.
gov/pubmedhealth/
PMH0001234/
Embolism
www.nlm.nih.gov/
medlineplus/ency/article/001102.htm
MODULE 4 • CARDIAC NURSING • stUDENt EDitiON
M O D U L E 4 • C a r d i a c N u r s i n g • T E ACH E R E D I T I O N
9
9
Valvular Heart Disease
learning
link
www
Disorder
•Valvularstenosis
•Valvular
insufficiency
Valvular Heart Disease
www.medicinenet.com/
heart_valve_disease/article.htm
Structure Affected
•Occurswhenthevalve
becomes thick
•Narrowingofthe
opening between the
heart valves
•Valveisunableto
close completely
•Interfereswiththe
blood flow through
the heart structures
http://legacy.owensboro.
kctcs.edu/jsmith/Valvular%20Heart%20Disease.ppt
Search for Valvular
Heart Disease
Physical Findings
•Heartmurmur
•Wheezesandcracklesin
the lungs or edema (pitting or non-pitting)
•Anxiety
•Dyspnea
•Weakness/faintness
•Nausea
•Pallor
•Erraticbehavior
•Hypotension,shock
•Historyofrheumatic
fever
•Fatigueorweakness
when performing activities of daily living
(ADLs)
•Chestpain
•Dizziness,fainting
•Complaintsofheart
palpitations
•Weightgain
•Exertionaldyspnea,
nocturnal dyspnea
www.world-heart-federation.org
Important note!
Patients with valvular disease should be
instructed to remind health care providers
of their condition so the providers can give
prophylactic antibiotics prior to invasive
procedures.
Nursing Care
•Monitor
▶Vitalsigns
▶Cardiacmonitoringif
in acute care
▶ Signs and symptoms
associated with complications
•Givemedicationtolower
blood pressure and prevent clot formation
•Encouragetechniquesto
reduce anxiety or tension
•Instructpatienttodrink
fluids often unless in heart
failure
•Assessforpainifocclusion to extremities is
suspected
•Assistwithambulation
and encourage movement
of extremities
•Administeroxygen
•Maintainhomeostasis
•Controldysrhythmias
•Monitorforheartfailure
i N f L a M M at O ry H E a r t
DisOrDErs
Anyofthethreelayersoftheheart—pericardium,
myocardium,andendocardium—canbecome
inflamed.Rheumaticfeverisaninflammatorydisease
that is usually caused by throat and upper respiratory
infections.
•
CausedbygroupA,betahemolyticstreptococci.
•
Ifthetreatmentisnotadequate,theinfectioncan
progress to rheumatic fever.
•
Effectsonheartvalvesmaynotbeseenfor10to
40yearsaftertheillness.
10
CIMC • MEDICAL SURGICAL NURSING I
Cla ssroom Ac t i v i t y
When dealing with heart diseases that cause specific heart sounds, have your students listen to these sounds and
explain how the disease makes the sound. It will help them with their assessment skills and also provide another
way to bring information together as they learn.
• V
alvular Stenosis www.careflash.com/video/mitral-valve-stenosis?1c=3en
• V
alvular Insufficiency (Regurgitation) www.careflash.com/video/valvular-regurgitation?lc=en
10
CIMC • MEDICAL SURGICAL NURSING I
Inflammatory Heart Disorder
Disorder
•Rheumaticfever/
disease
Pericarditis
Structure Affected
•Heartmuscle
•Decreasestheheart’s
ability to pump effectively
•Antibodiescross-react with joints, skin,
subcutaneous tissue,
central nervous system, and layers of the
heart causing inflammation
•Valvethickensand
becomesfibrous,
which interferes with
its ability to open and
close correctly
•Interfereswiththe
blood flow through
the heart structures
Physical Findings
•Heartmurmur
•Wheezesandcrackles
in the lungs or edema
(pitting or nonpitting)
•Anxiety
•Dyspnea
•Weakness/faintness
•Nausea
•Pallor
•Erraticbehavior
•Hypotension,shock
•Historyofrheumatic
fever
•Fatigueorweakness
when performing activities of daily living
(ADLs)
•Quality,duration,and
onset of chest pain
•Dizziness,fainting
•Complaintsofheart
palpitations
•Weightgain
•Exertionaldyspnea,
nocturnal dyspnea
•Polyarthritis
•Inflammationofthe •Shortnessofbreath
sac around the heart
•Slowedheartrate
•Causesfibrosisand
•Severehypotension
constriction of the
and weak pulse qualpericardium
ity
•Restrictionoccursasa •Heavinessinthechest
result of fluid accumu- •Chestpain
lation in pericardial
•Movingandbreathing
space and can become
worsens the pain
fatal
•Sittingupandleaving
forward relieve pains
•Diminishedheart
sounds.
•Cardiac Tamponade
MODULE 4 • CARDIAC NURSING • stUDENt EDitiON
M O D U L E 4 • C a r d i a c N u r s i n g • T E ACH E R E D I T I O N
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Nursing Care
•Monitor:
▶Vitalsigns
▶Cardiacrhythmifin
acute care
•Givemedicationtolower
blood pressure and prevent clot formation
•Encouragestressreduction techniques
•Instructpatienttodrink
fluids often unless in heart
failure
•Encourageactivitiesthat
reduce activity
•Giveprophylacticantibiotics before any invasive
procedure for at-risk
patients
▶Rheumaticheart
disease
▶CHF
▶ Degenerative heart
disease
▶IVdrugusers
•Assistwithambulation
and encourage movement
of extremities
•Giveoxygenasordered
•Maintainhomeostasis
•Controldysrhythmias
•Monitorforheartfailure
•Assessforsignsofinfection and post-procedure
bleeding gums, petechia,
bruising, black tarry stools
Rheumatic fever/disease
www.chw.org/display/
PPF/DocID/23071/
router.asp
Pericarditis
www.ncbi.nlm.nih.
gov/pubmedhealth/
PMH0001234/
Video
www.youtube.com/watch
?v=iXpP7Bju1jw&NR=1
&feature=fvwp
Cardiac Tamponade —
Video
www.youtube.com/
watch?v=QwgfuDegC5Y
11
11
learning
link
www
Inflammatory Heart Disorders Continued
Disorder
Endocarditis
Structure Affected
•Infectionorinflammation of the inner
lining of the heart or
heart valves
Myocarditis
•Inflammationofthe
myocardium
Endocarditis
www.ncbi.nlm.nih.
gov/pubmedhealth/
PMH0002088/
Physical Findings
•Infectiveorganisms
embed into the heart
lining and valve tissue
•Vegetationfromthe
bacteria growth may
occur
•Vegetationmayscar
the valves or break
away, causing an
emboli or abscesses in
other organs
•Infectiveorganisms
embed in the heart
muscle
Nursing Care
•SeeRheumaticandPericarditis
www.endocarditis.org/
index.html
Video
www.youtube.com/
watch?v=V_G5qqv7Oqc
Important note!
Cardiomyopathy is a term used to describe a group of heart muscle diseases that affects the
structure or function of the myocardium. The majority of patients over age 55 die within two years
of the onset of symptoms. Death is usually caused by CHF or ventricular dysrhythmia.
Myocarditis
www.ncbi.nlm.nih.
gov/pubmedhealth/
PMH0001204/
www.mayoclinic.com/
health/myocarditis/
DS00521
www.texasheartinstitute.
org/hic/topics/cond/
myocard.cfm
Note s
ELEctricaL DisOrDErs
Cardiac Dysrhythmias
Whentheconductionsystemoftheheartdoesnot
function normally, a dysrhythmia results. Some dysrhythmias can even be heard during auscultation of
theheart.Othersarenoticedonaheartmonitoror
12-leadEKG.OnthemonitororEKGstrip,when
the electrical stimulus for the heartbeat arises from
theSAnode,aPwavewilloccurbeforeeveryQRS
wave.WhentheSAnodefires,theimpulsetravels
down the atria, and will be depicted as a P-wave on
anECGtracing.Thisiscalledatrialdepolarization.
Whentheventriclescontract,arecordingknownas
theQRScomplexwillrepresentventriculardepolarization. The last component recording showing
cardiac function is indicated by the recording of the
“T-wave”,whichrepresentstheventricularrepolarization.Whendeterminingcardiacrhythm,these
When teaching about
cardiac dysrhythmias it is
best to first explain what
12
each wave in a normal
sinus rhythms means and
relate it to what is happening in the heart during that wave.
• P-wave (atrial depolarization) = atria contract
• QRS- (ventricular depolarization) = ventricles contract
• T-wave (ventricular repolarization)
• No wave shows up for atrial repolarization because it is hidden
inside of the QRS complex
• In lead 2, as electricity flows from the top of the heart towards
the bottom of the heart there will be an elevation on the ECG
tracing (normal). If there is a depression on the ECG tracing it
would indicate that electricity is flowing in the opposite direction (abnormal). Any wave that is absent, abnormally shaped or
widened would indicate an abnormal waveform.
12
structures serve as a focal point. A patient who is in
normalsinusrhythmwillhaveallECGstructuresin
normalconfigurations,rates,andfrequency.Dysrhythmia recognition can be detailed and complex
atbest.Forthesafetyofpatients,LPNsshouldbe
able to recognize some of the more common, and
potentially lethal, dysrhythmias.
Many health care workers will use the term dysrhythmiaandarrhythmiainterchangeably.Bothsimply
mean an abnormal cardiac rhythm.
CIMC • MEDICAL SURGICAL NURSING I
CIMC • MEDICAL SURGICAL NURSING I
Common Arrhythmias
Arrhythmia
Sinus bradycardia
Sinus tachycardia
Atrialfibrillation
Atrioventricular
blocks
First-degreeAV
block
Structure Affected
SA node does not function
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Physical Findings
Nursing Care
Abnormal pacemaker
•Monitorvitalsigns
•Sicksinussyndrome •Monitorsurgicalsiteafter
•Wanderingpacemaker
pacemaker insertion
Heartratebelow60
beats per minute
•Heartbeatingrapidly Heartrateabove100
•Abnormalimpulsesor beats per minute
cardiac damage
•Monitorvitalsigns
•Observefordizzinessand
syncope
•Instructpatienttorest
should this occur
•Tellpatienttotakemedications as directed
•Teachpatienthowtotake
their pulse
•Monitorvitalsigns,lightAtria are quivering,
•Atrialratecanbeas
headedness and fainting
rather than pumping
highas350-600per
blood
minute
•Monitorforpotential
•Ventriclesrespondto
complications such as
some of the electrical
clot formation or reduced
stimulus and have a
blood flow
rateof100-180beats •Administermedications
as ordered
per minute
•Supportpatientduring
cardioversion
•SAnodefiresanim•Irregularheartrateon •Monitorpulserate
pulse, matters are going
theEKG
•Reportifpulsegoesbelow
well until that electrical •Patientmaycomplain
60
impulse reaches the
of the heart beat skip- •Reportsignsofsyncope
bundle branches
ping a beat
or fainting
•Impulsecanbe
•Monitortheclientfora
blocked completely
worsening of the arrhyth•Scartissue,aging
mia
changes, and certain
chemical imbalances
can cause a slowing
of the impulse as it
travels through the
branches
•Abnormalitiescanoccur in one or both of
the bundle branches
Impulse traveling from
Benignanddoesnot
*See Atrioventricular blocks
the SA node to the
require pharmacological
Purkinjefiberstakeslon- intervention
gerthan20seconds
MODULE 4 • CARDIAC NURSING • stUDENt EDitiON
M O D U L E 4 • C a r d i a c N u r s i n g • T E ACH E R E D I T I O N
Common Arrhythmias
— Online tutorial
www.rnceus.com/
course_frame.asp?exam_
id=16&directory=ekg
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13
Common Arrhythmias Continued
Arrhythmia
Second-degreeAV
block
•TypeOne
(Wenckebach)
•TypeTwo
Third-degree block
(complete heart
block)
Structure Affected
Physical Findings
NormalPRinterval,
•Allotherstructures,
which progressively
rate,rhythm,andPR
lengthens until a total
interval are within
QRScomplexisdropped
normal limits benign,
but some may require
medical intervention
•Bothwarrantclient monitoring for a
worsening or progression of the rhythm to
a more lethal one
•Norelationshipof
•Profoundlysymptomatrial and ventricular
atic, and immediate
function, the atria do
intervention is wartheir own thing while
ranted
the ventricles pace
•Symptomssimilarto
themselves
heart attack except
•PRintervalsare
there is usually no pain
varied, and ventricular •Lightheadednessand
heartratebelow40
rate is dramatically
slowed
beats per minute
Nursing Care
*See Atrioventricular blocks
•Monitorexternalpacemaker
•Monitorvitalsignsand
EKG
•Providedressingcareat
lead insert site
•Tellthepatientthattemporary pacing is usually
initiated until underlying
and long-term treatment
options, such as permanent pacing
Premature
Abnormal contractions •Appearwideandun- •Monitorfrequencyand
report if greater than six
ventricular
that originate in the venusual, and most have
per minute
an opposite deflection
contractions(PVCs) tricle, not the SA node,
•Monitorforsignsofthe
of the normal sinus
and come earlier than
client being symptomatic
beatsontheEKG
the next anticipated beat
recordings
from a decrease of blood
would occur
•Occurinpairsorruns
flow associated with the
arrhythmia
•Warrantconcernand
Causesinclude:
•Administermedications
ongoing monitoring
•Irritabilityofventricle
to treat underlying causes
wall
•Canleadtoventricu•Instructpatienttoavoid
•Exercise
lar tachycardia
activities that can cause
•Stress
PVC
•Electrolyteimbalance
▶Reducestress
•Digitalistoxicity
▶ Avoid overexertion
•Hypoxia
during exercising
•MI
▶ Maintain electrolyte
•Drugtoxicity
balance
•Monitorelectrolytes
•Givemedsasorderedand
monitor for drug toxicity
14
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CIMC • MEDICAL SURGICAL NURSING I
CIMC • MEDICAL SURGICAL NURSING I
Common Arrhythmias Continued
Arrhythmia
Ventricular
tachycardia
Structure Affected
Ventriclesareunable
torefillwithbloodfor
perfusion
Causes
•Hypoxemia
•Drugtoxicity(digitalis)
•Quinidine
•Electrolyteimbalance
•Bradycardia
Ventricular
fibrillation
Ventriclesarequivering,
rather than pumping,
blood
Physical Findings
Nursing Care
•Life-threateningar•Administerasordered
rhythmia
amiodarone or Pronestyl
•100beatsperminute, •Givemagnesiumsulfate
usuallybetween140
iforderedtocorrectdefiand240bpm
cient blood levels
•Profoundhypoxiaof •Monitorforsignsofthe
vital organs
client being symptomatic
from a decrease of blood
flow associated with the
arrhythmia
•Administermedications
to treat underlying causes
•Instructpatienttoavoid
activities that can cause
PVC
▶Reducestress
▶ Avoid overexertion
during exercising and
maintain electrolyte
balance
•Monitorelectrolytes
•Givemedsasorderedand
monitor for drug toxicity
•Supportpatientduring
cardioversion if warranted
•Life-threatening
•PerformCPR
•Heartisnolonger
•Administerorassistwith
pumping blood to
defibrillationandmedicavital organs or the rest
tions(IV)—epinephrine,
of the body, there is
lidocaine
no blood pressure
•Assistduringpatient
•Deathifleftuntreated
resuscitation
•Givesupplementaloxygen
andIVfluids
Artificialpacemakersaredesignedtoassistinreducing symptoms associated with chronic or life-threateningabnormalities.Onetypewillpreventtheheart
from slowing below a preset number of beats per
minute.Thereareseveraltypesofartificialpacemakers. The physician may set the rate of the pacemaker
when it is implanted or implant a pacemaker that
respondstothepatient’sactivity.
MODULE 4 • CARDIAC NURSING • stUDENt EDitiON
M O D U L E 4 • C a r d i a c N u r s i n g • T E ACH E R E D I T I O N
15
15
le a r ni n g ac t i v i t y a nsw e r s
LEarNiNg activity
2
NaME
Answers will vary.
Introduction
Heartmonitorsprovideassessmentinformationthatcansavealife.TelemetrystripsorEKGsinpatients’
chartsofferinsighttothepatient’scondition.TheLPNmustbeabletorecognizeseriouscardiacdysrhythmiasandunderstandthemalfunctionoftheheart’sconductionsystem.
learning
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Activity
Workindividuallyoringroupsoffiveasassignedbythefacilitator.Useamedical-surgicalnursingtext,EKG
text, or other references for this activity.
Chooseoneofthefollowingdysrhythmiasaboutwhichtobecomethe“expert”:
“Lung Cancer” mnemonic, an example
for students to apply to
the heart
www.mediglyphics.com/
public/Demo/pathology___lung_cancers
•
Atrialfibrillation
•
Prematureventricularcontractions(unifocalandmultifocal)
•
Ventriculartachycardia
•
Ventricularfibrillation
•
Complete(third-degree)heartblock
Make a poster about your chosen dysrhythmia. Include the following:
•
TheappearanceofthedysrhythmiaonanEKGstrip
•
Whatisoccurringintheconductionsystemoftheheartduringthisdysrhythmia
•
Howboththestripandtheconductionsystemdeviatefromnormalheartfunction
•
Theusualtreatmentforthisdysrhythmia
•
Nursingresponsibilitiesrelatedtothiscondition
Special tools/equipment
Art supplies
Application
Display the illustration for other learners. Answer any questions about the dysrhythmia asked by other learners. Your illustration will be evaluated using the following rubric.
16
CIMC • MEDICAL SURGICAL NURSING I
Te ac hi ng Su g g e s t i on s
•D
iscuss each poster as a group and make any additions/subtractions to the posters that the class agrees upon.
When all posters have been discussed and adjusted, take a digital picture of them and distribute (email) copies
of each poster to each member of the class for study purposes.
•H
ave each group develop a visual mnemonic over the different wave-forms; include the same criteria as the
poster presentations. This could be done for any disease process.
16
CIMC • MEDICAL SURGICAL NURSING I
Grading Rubric
A Level 3 illustration will:
—IncludeanaccurateandthoroughillustrationofthedysrhythmiaonanEKGstrip
—Includeacompleteillustrationoftheconductionsystemoftheheart,showingtheinterruptioncausedby
the dysrhythmia
—IncludeanexplanationofhowtheEKGstripdiffersfromaregularsinusrhythm
—Includeanexplanationofhowtheconductionsystemoftheheartisinterruptedduetothisdysrhythmia
—Includeathoroughexplanationoftheusualtreatmentforthisdysrhythmia
—Bedoneinanorganizedmanner
—Beturnedinontheduedate
A Level 2 illustration will:
—IncludeafairlyaccurateillustrationofthedysrhythmiaonanEKGstrip
—Includeanillustrationofthedysrhythmiaoccurringintheconductionsystemoftheheart
—IncludeanexplanationoftheEKGstrip
—Includeanexplanationofhowthisdysrhythmiaoccursintheheart
—Includeanexplanationofthemajortreatmentforthisdysrhythmia
—Beturnedinwithinonedayofduedate
—Bedoneinafairlyorganizedmanner
A Level 1 illustration will:
—LackanaccurateillustrationofthedysrhythmiaonanEKGstrip
—Lackacompleteillustrationofthedysrhythmiaoccuringintheconductionsystemoftheheart
—LackanexplanationoftheEKGstrip
—Lackanexplanationofwhatoccursintheheartduringthisdysrhythmia
—Lackaccurateinformationaboutthetreatmentforthisdysrhythmia
—Beturnedinmorethanonedaylate
—Lackorganization
NO POINTS will be awarded the illustration/learner that:
—DoesnotincludeanillustrationofthedysrhythmiaonanEKGstrip
—Doesnotincludeanillustrationofthedysrhythmiaeffectontheconductionsystemoftheheart
—Doesnotincludeinformationabouttreatmentforthedysrhythmia
—DoesnotparticipateintheLearningActivity
MODULE 4 • CARDIAC NURSING • stUDENt EDitiON
M O D U L E 4 • C a r d i a c N u r s i n g • T E ACH E R E D I T I O N
17
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H E a rt fa i L U r E
•
Heartvalvedisease
If either the right or the left side of the heart fails to
pump blood effectively, the lungs will be affected.
•
Inflammatoryheartdisease
•
Infection
Congestiveheartfailure(CHF)occurswhenthe
heart can no longer effectively pump blood through
the body.
•
Stress
•
Hyperthyroidism
•
Anemia
•
Fluidreplacementtherapy
Possible causes include:
Heart Failure
•
MI
www.ncbi.nlm.nih.
gov/pubmedhealth/
PMH0001211/
•
Prolongedhypertension
•
Diabetesmellitus
Disorder
HeartFailure
www.heartfailure.org/
eng_site/hf.asp
Videos
www.youtube.com/
watch?v=3YddwXP
WVSc&NR=1
www.youtube.com/watch
?v=JXA6LjmKsaU&featu
re=related
18
18
Structure Affected
•Damagedcardiac
muscle
Physical Findings
Reductionincardiac
output
•Fatigue
•Angina
•Anxiety
•Oliguria
•Decreasedgastrointestinal motility
•Pale,coolskin
•Weightgain
•Restlessness
Nursing Care
•Ongoingassessmentis
imperative
▶Vitalsigns
▶Cardiacmonitoringif
in acute care
•Monitorsignsandsymptoms for complications
•Administratermedication
to lower blood pressure
and increase heart function
•Instructpatienttodrink
fluids according to physician order
•Assessforshortnessof
breath and abnormal
pulse rate
•Assistwithambulation
and encourage movement
of extremities
•Administeroxygenas
directed
•Maintainhomeostasis
•Encouragepatientto
conserve energy because
of the extra strain on the
heart due to activity
CIMC • MEDICAL SURGICAL NURSING I
CIMC • MEDICAL SURGICAL NURSING I
Disorder
Left ventricular
failure(LVF)
Rightventricular
failure(RVF)
Structure Affected
•Leftventriclecannot
pump enough blood
to meet the needs of
the body
Physical Findings
Nursing Care
•Bloodthatisnot
*SeeHeartFailure
pumped out of the
left ventricle fails to
reach the peripheral
circulation
•Congestionoccurs
in the lungs because
blood is not able to
leave the lungs and go
to the left ventricle
•Fluidleaksfromthe
blood into the air
spaces of the lungs,
causing shortness of
breath
•Dyspnea
•Paroxysmalnocturnal
dyspnea (PND)
•Orthopnea
•Pulmonarycrackles
•Hemoptysis
•Cough
•Rightventriclecannot •Backupoffluidfrom *SeeHeartFailure
pump blood efficientleft ventricular failure
ly to the lungs
or lung disease
•Enlargementdueto
•Bloodcannotbe
hypertension in the
pumped forward into
pulmonary circulation
the lungs
•Bloodbacksupinthe
systemic circulation
•Fluidleavestheblood,
causing peripheral
edema
•Distendedjugular
veins(DJV)
•Anorexia,nausea,and
abdominal distension
•Liverenlargement
•Ascites
•Edemaoffeet,ankles,
and sacrum, which may
progress up the legs
MODULE 4 • CARDIAC NURSING • stUDENt EDitiON
M O D U L E 4 • C a r d i a c N u r s i n g • T E ACH E R E D I T I O N
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Right ventricular failure
www.ncbi.nlm.nih.
gov/pubmedhealth/
PMH0001186/
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19
Disorder
Pulmonary edema
learning
link
www
Pulmonary Edema
www.youtube.com/
watch?v=aD2ICdcKgLM
http://nursingcrib.com/
critical-care-and-emergency-nursing/cardiogenic-pulmonary-edema/
Care plan information
www1.us.elsevierhealth.
com/MERLIN/Gulanick/Constructor/index.
cfm?plan=23
Structure Affected
Physical Findings
•Extensivefluidsaccu- •Leftventricleissemulate in the lungs
verely compromised,
•Redbloodcellshave
causing a backup of
left the blood and
fluid into the lungs
moved into the alveoli •Pink,frothysputum
due to fluid congesis a cardinal sign of
tion
pulmonary edema(air
mixes with fluid in
theairsacs—alveoli—ofthelungs,
causingfrothy/bubbly
sputum)
▶Restlessness
▶ Agitation
▶ Disorientation
▶ Diaphoresis
▶ Severe dyspnea
▶ Tachypnea
▶ Tachycardia
▶ Pallor or cyanosis
▶ Productive cough
of large amount
of pink, frothy
sputum
▶ Audible wheezing,
crackles
▶Coldextremities
Nursing Care
•Placetheclientintheorthopneic position or high
Fowler’sposition
▶ Analgesic (morphine)
▶ Nitroglycerin
▶ Diuretic
▶Vasodilator
▶ Inotropic
•Monitor
▶Respiratorystatus
▶ Pain level
▶ Anxiety level
▶ Headache due to nitroglycerines
▶Fluidoutput
▶ Electrolytes
Important FaCt!
When comparing the two types of heart failure, LPNs should recognize that left ventricular
failure causes lung congestion, while right ventricular failure causes peripheral edema. If medical
intervention is not initiated, either condition will eventually affect the function of the other. For
example, lung congestion or dysfunction causes right ventricular failure. In both situations, blood is
not pumped into and out of the lungs efficiently, causing congestion and gas exchange impairment.
20
20
CIMC • MEDICAL SURGICAL NURSING I
CIMC • MEDICAL SURGICAL NURSING I
LEarNiNg activity
Lea rni ng Acti v i ty Ans wers
3
NaME
1. A blockage occurs in
the coronary artery,
obstructing blood
flow to a portion of
the myocardium. The
myocardium becomes
necrotic, then fibrotic,
with scar tissue.
Introduction
People are often confused by the terms heart attack and heart failure. In reality, they are two very different
situations.However,aheartattack(MI)caneventuallyleadtoheartfailure(CHF).
Activity
Prepareabrochurethatcanbeusedforpatientteaching.Besureinformationonthebrochurewillanswerthe
questions below. Include patient actions that can prevent complications of both conditions.
2. The heart is unable to
pump blood effectively
because the muscle of the
ventricle (myocardium) can
no longer contract strongly.
The blood is not pumped
throughout the body as it
should be; instead, it pools
in extremities and causes
edema.
Readaboutbothconditionsandanswerthefollowingquestions:
1. Whatcausesamyocardialinfarctiontooccur?
2. Whatcausescongestiveheartfailuretooccur?
3. Whichoftheseconditionshasasuddenonset?
4. Whichoftheseisachroniccondition?
5. HowmightanMIleadtoCHF?
Application
3. MI
Present your brochure to the facilitator or classmates.
4. CHF
MODULE 4 • CARDIAC NURSING • stUDENt EDitiON
21
Te ac hi n g S Ug g e s t i on s
As more and more people access health related information on the internet it is important that we teach our students how to present such information. Take this same
assignment and have the students present the information on a classroom blog. This can
be done using a learning management system or by creating your own classroom blog on
the internet (for free). The following sites will help students to build writing and computer skills as well as learn the information they are presenting. This activity can be done
throughout the curriculum as we teach and reinforce patient teaching concepts.
•w
ww.blogger.com/
•w
ordpress.com/
• www.myblogsite.com/
M O D U L E 4 • C a r d i a c N u r s i n g • T E ACH E R E D I T I O N
5. An MI damages the
ventricular muscle. The
damaged area is unable
to contract effectively.
initially because the
tissue is fragile, but
then it becomes scarred
and very fibrotic. This
lessens the contractility
of the muscle, thus
decreasing the amount
of blood ejected during
systole. This decrease
leads to failure, as the
heart is unable to empty
completely, and causes a
backup of blood in the
other body structures. The
larger the MI, the greater
the risk of developing
failure. Remember that
initially. right-sided
heart failure will result in
systemic symptoms such
as peripheral edema, while
left-sided failure will result
in pulmonary symptoms.
21
L E a r N i N g
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O b j E c t i v E
Object i v e Relatediagnostictestsandsurgical
procedures to the nursing care of
patients with cardiac disorders.
Diagnostic tests for cardiac disorders include heart
testing and blood testing. The heart function can be
tested in a variety of ways.
Diagnostic Tests
Test
Pericardiocentesis
Pericardiocentesis
www.webmd.com/heartdisease/guide/pericardiocentesis
Coronary
Angiography
Video
http://youtube.com/
watch?v=nS_VUNZTk-Y
Coronary Angiography
www.nhlbi.nih.gov/
health/dci/Diseases/ca/
ca_whatis.html
Nursing Care
http://wps.prenhall.
com/wps/media/objects/737/755395/angiography.pdf
Video
www.youtube.com/
watch?v=Eoq9yrT-Ejk
22
22
Purpose
Procedure
•Reducefluidfrom
•Needleaspirationof
within the linings of
fluid between the linthe heart
ings of the heart
•Injectionofdyeinto •Imageofthevesthe heart and blood
sels is visualized on
vessels
a monitor, and any
•Visualizethesizeand
abnormalities, such as
shape of the heart
narrowing or blockchambers and to see
ages, are seen
narrowing or obstruction of the coronary
arteries
Nursing Care
•Providecareofdrainagetube
•Monitorvitalsigns
•Monitordrainagefromtube
•PatientisNPOfor6-8hours
prior to the procedure
•Assessforallergytoiodine,
shellfishorcontrastdye
•Recordbaselinevitalsigns
and mark pedal pulses
Pre-procedure
•Informpatient
▶ Table will tilt, but will be
secured to table and will
not fall
▶IVwillbegoing
▶ Must lie still
▶EKGelectrodeswillbe
in place
▶ May feel hot flush for a
minute if dye is injected
▶ May be asked to cough
▶Willbemonitoredclosely during the procedure
Post-procedure
•Takevitalsignsaccordingto
facility policy (usually same
aspost0opsurgery)
▶Every15min.X4
▶Every30min.X4
▶EveryhourX4oruntil
stable
•Assesspedalpulseswith
vital signs
•Assesscatheterinsertionsite
for bleeding gums, petechia,
bruising, black tarry stools
•Ensuresandbagand/or
pressure dressing is applied
for 1-3 hours
•Patienttoavoidhipflexion
on affected side and is to
remain on bedrest
CIMC • MEDICAL SURGICAL NURSING I
CIMC • MEDICAL SURGICAL NURSING I
Diagnostic Tests Continued
Test
Exercise or stress
test
Echocardiogram
PET scan
Purpose
•Usedtodetermine
myocardial ischemia
•Detectdifferencesin
left ventricular wall
before and during
exercise
•Evaluatethepatient’s
cardiac status in relation to exercise
learning
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Procedure
•Patientisconnected
toEKGmonitorsand
givenaspecific,controlled type of exercise
to do, such as walking
on a treadmill, that
gradually increases in
speed and incline
Nursing Care
•Explaintheprocedure
•Givedirectionsastoeating
lightly before the procedure
orifNPO
•Nosmokingorcaffeine6-8
hours before the test
•Givepatienttheinstruction about wearing walking shoes and comfortable
clothing
•Monitorcloselyafterwards
for signs of heart distress
NOTE: This may be done
chemically instead of by
actually exercising
•Pericardialeffusion,
•Colorsareusedtoin- •Informpatient:
▶ There is no pain involved
ventricular function,
dicate blood flow, and
valvular insufficiency
in procedure
chamber size, muscle
isreadilyidentified
▶ Have to lay down during
wall thickness and
•High-frequencyultrathe procedure
motion, cardiac outsound with bounce off ▶Shouldn’ttakeverylong
put, tumors, valvular
function, and congenof the heart
(usually under one hour)
ital heart disorders
•Graphshowswhere
▶Usuallydoneonoutpatient basis
the sound waves
•Showsthesize,shape,
and position of carreflect heart tissue
diac structures
•Distinguishesbe•Usesradioactivesub- •Explainthatradioactive
tween viable and
stances to examine the
isotopes are used
nonviable myocardial
functionofaspecific •Askpatientaboutallertissue
organ
giestoiodine,shellfish,or
•Identifythemostapcontrast substance
propriate candidates
•Informpatient:
for angioplasty and
▶Willhavetolaystill
bypass surgery. A PET
while machine is doing
scan can also detect
the scan
CADwithoutinsert▶Bloodsugarmustbe
ing a catheter and dye
between60-140mg/dl
▶MayhavetobeNPO
before test
▶ Avoid caffeine and
tobacco24hoursbefore
the test
MODULE 4 • CARDIAC NURSING • stUDENt EDitiON
M O D U L E 4 • C a r d i a c N u r s i n g • T E ACH E R E D I T I O N
Echocardiogram
www.youtube.com/
watch?v=2XR6etAY_w&feature=related
PET Scan
www.youtube.com/
watch?v=9JISCohidOg
www.youtube.com/watch?
v=pOejGHnvSV0&featur
e=related
23
23
Diagnostic Tests Continued
Test
Holter monitor
Thallium scan
Purpose
Procedure
•Usedforpatientswho •SmallportableEKG
complain of irregular
recorder
heartbeats that do not •Attachedtoapatient
show up on a resting
using one to four elec12-leadEKG
trodes and the monitor is carried on a belt
or shoulder strap
•Monitorkeepsa
24-hourrecordofthe
person’sheartbeat
•Physiciancompares
the diary to the
dysrhythmias on the
EKGstriptodetermine events that may
contribute to heart
irregularities
•Showsareasofthe
•Injectionofthallium
heart that are ischemic
(radioactive isotope)
or infarcted
•Visualizationwill
show only normal
cells
•Abnormalcellsor
“coldspots”willappear as dark areas if
there is inadequate
oxygenation of the
tissues
Nursing Care
•Patientkeepsadiaryof
activities and symptoms
duringthe24-hourperiod
during which he or she
wears the monitor
•Maynotremoveelectrodes
for duration of the test
•Recordallactivitieseven
brushing teeth, climbing
stairs, sexual intercourse,
bowel movements, sleeping,
etc
•Tellpatienttowearloose
shirt during the test
•Explainthatradioactive
isotopes are used
•Askpatientaboutallergiestoiodine,shellfish,or
contrast substance
•Informpatient:
▶ Lay still while machine is
doing the scan
▶ Electrodes will be applied
▶MayhavetobeNPOfor
a few hours before test
▶ The test may take a few
minutes, but parts of it
may be done a few hours
apart
▶ Avoid caffeine and
tobacco24hoursbefore
the test
Important FaCt!
Holter Monitors
Current models allow the patient to wear the unit for extended periods of time by staying in a
stand-by mode and recordings are made only when the patient presses and activates the record
function. The other type of device will actually record for a pre-set time interval prior to, during,
and after the event.
24
24
CIMC • MEDICAL SURGICAL NURSING I
CIMC • MEDICAL SURGICAL NURSING I
Diagnostic Tests Continued
Test
CTScan
Purpose
•Diagnosestumors,
nodules, hematomas,
lesions, cysts, abscesses, pleural effusion
and enlarged lymph
nodes, abnormal
cardiac tissue
Procedure
•CTscaniscrosssectional visualization
of tissues which allows
foridentificationof
slight variations in
tissue thickness
•Maybewithorwithout contrast (assess for
allergies)
•Moreenhancedthan
x-rays
•Spiralorhelicalversion produces thinner
slices and data more
enhanced
•Providesbettercon•Computerizedimtrast between normal
ages which assist in
identificationofsubtle
and pathologic tissues
changes in tissue
•Reducesboneartifacts
structure
learning
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Nursing Care
Pre-procedure
•Explainprocedureto
patient
•Obtainconsent
•Assessforallergies
•InstructpatienttobeNPO
according to facility policies
Post-procedure
•Havepatientincreasefluids
to assist in dye exertion
•Answerquestionsabout
howpatientwillfindout
about the results
CT scan — Explanation
video
www.youtube.com/
watch?v=5GWKCtjRu-M
Pulmonary angiography
www.nlm.nih.gov/
medlineplus/ency/article/003813.htm
•Nursingresponsibilityprior
to exam is to check for allergies in patient
•Assistpatienttoremoveall
metal before the procedure
due to the magnet used for
capturing the images
Pulmonary angiog- •Visualizationofpul•EKGelectrodes
Pre-procedure
raphy
monary vasculature by
applied for cardiac
•Explaintheprocedure
radioactive contrast
monitoring
•Obtainconsent
medium injected
•Catheterisplaced
•Informpatientthatawarm
through pulmonary
in femoral vein and
flush may occur
artery and is used to
passed into the infe•Checkforpatientallergies
identify circulatory
rior vena cava
•TellpatienttobeNPOafter
alterations
•Catheterismoved
midnight the night before
into the right atrium •Givepre-proceduralmeds
and the right ventricle
as ordered
•X-raysaretakenat
Post-procedure
timed sequences
•Observecatheterinsertion
site for inflammation, hemorrhage or hematoma
•Assessvitalsigns
•Applycoldcompresstothe
puncture site
•Informpatientthatcoughing
may occur after procedure
•Tellpatienttobeonbed
restfor12-24hoursaccording to physician orders
MRI
MODULE 4 • CARDIAC NURSING • stUDENt EDitiON
M O D U L E 4 • C a r d i a c N u r s i n g • T E ACH E R E D I T I O N
25
25
Diagnostic Tests Continued
learning
link
www
Test
Purpose
Procedure
LungScan/Ventila- •Scanusesaradioactive •IVinjectionof
tion-perfusion
isotope injected to
radioisotope given to
identify areas of venpatient
tilation and perfusion •Gammaraydetecto lungs
tor is passed over the
patient and records
uptake of radioisotope
•Patientisplacedin
various positions to visualize different areas
of the body
Lung Scan/
Ventilation-perfusion
www.nhlbi.nih.gov/
health/dci/Diseases/lvq/
lvq_whatis.html
Pulmonary
function test
26
26
•Usesaspirometerto
measure lung volume
capacities in forced
breathing techniques
•Differentiationof
restrictive vs. obstructive disorders
Nursing Care
Pre- procedure
•Obtainconsent
•Explaintheprocedure
•Assurepatientthatexposure to large amounts of
radioactivity will not occur
•Administer10dropsof
Lugol’ssolutionseveral
hours before test as blocking agent against iodine 131
•Tellpatientfastingisnot
needed
•Havepatientremovejewelry around chest area
Post-procedure
•ApplypressuretoIVsite
•Tellpatientthatnoradiation precautions are needed
Patient breaths in and
Explain the test:
out through mouthpiece •Tellpatientthatcooperainto a spirometer
tion is needed to get best
results
•Tellpatientnottouse
bronchodilators, smoke
or use inhalers for 6 hours
before test
•Obtainheightandweight
Post-procedure
•Monitorforrespiratory
problems
CIMC • MEDICAL SURGICAL NURSING I
CIMC • MEDICAL SURGICAL NURSING I
Laboratory Tests
learning
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Laboratory Test
Completebloodcount
Indications of abnormal results
•Bodyiscompensatingforchronichypoxemia
•Lowhemoglobincountindicatesadecreasedabilityofredbloodcells
to carry oxygen and also indicates anemia
•Patientwithchestpainmayhaveaverylowhemoglobincountinstead
of heart disease
Whitebloodcell
•Infectionorinflammation
Bloodcultures
•Detectthecausativeorganismofinfectiveendocarditis
Coagulationstudies
•ElevatedPTorPTTifpatientisreceivinganticoagulationtherapy
•Toohighmayindicateuncontrolledanticoagulationstateandphysicianmustbenotified
Erythrocyte sedimentation rate •Elevationindicatesrheumaticfever,MIand/orinfectiveendocarditis
(ESR)
Serum electrolytes
•Abnormalpotassiumcanbelife-threatening
Serum lipids
•Elevatedcholesterolandtriglyceridesindicatevasculardisease(CAD)
•ElevatedHDL(goodcholesterol)indicatesadecreaseintheriskfor
cardiac disease
Arterial blood gases
•ElevatedpHindicatesthepatientisinalkalosis
•LowbloodpHmayindicateacidosis
•Lowbloodoxygen(PAO2)–poorbloodandtissueoxygenation
Cardiacenzymestudies
•ElevatedCPK-MBisoenzymehelpsdeterminetheseverityandthe
onset of an MI
•Determinestheappropriatenessofthrombolytictherapy
LDH
•ElevatedwithanelevatedCreatinephosphokinase-MBisindicativeof
an MI
CardiactroponinI
•Indicatesischemicmyocardialinjury
Bloodnatureticpeptide(BNP) •ElevatedBNPindicatesthatchemicalshavebeenreleasedasaresultof
the heart muscle being stretched
•Indicatesheartfailureinitsearlystages
MODULE 4 • CARDIAC NURSING • stUDENt EDitiON
M O D U L E 4 • C a r d i a c N u r s i n g • T E ACH E R E D I T I O N
Laboratory Tests information
www.labtestsonline.org
27
27
Surgical Interventions
learning
link
www
Intervention
Coronary
artery bypass graft
(CABG)
Purpose
•Returnbloodflowto
the cardiac muscle
Procedure
•Usesthesaphenous
veins in the legs or the
internal mammary
artery to graft around
occlusions in the coronary arteries
•Oneendissurgically
attached to the aorta
and the other end is
sutured to the coronary artery, distal to
the blockage
•WhenAninternal
mammary artery is
used, the distal end
of the artery is freed
from the chest wall
and sutured to the
coronary artery, distal
to the blockage
Valvereplacement
surgery
•Allowforbetter
control of blood flow
within the heart
•Valveleafletsthat
have been fused are
surgically separated,
so they can open and
close correctly
•Replacingastenosed
or insufficient heart
valve with a mechanical valve, a valve from
a pig heart (porcine),
or a valve from a
cadaver
CABG
www.nhlbi.nih.gov/
health/dci/Diseases/cabg/
cabg_whatis.html
Valve Replacement
surgery
www.texasheartinstitute.
org/hic/topics/proced/
vsurg.cfm
Openmitralcommissurotomy
28
28
Nursing Care
NOTE: Patient usually is in
intensive care following this
surgeryforseveraldays.When
the patient comes to the stepdown or post-intensive care
unit, the LPN will provide the
care listed below.
•Maintainpatientonbedrest
•Doroutinepost-intensive
care protocol
•Monitorforanxiety
•Maintaintelemetry
•Monitorforexcessivestrain
on the heart by watching
vitalsignsandpatient’s
responses to activity
•Graduallyincreaseactivities
as directed by physician
•Assesspainlevelandadminister pain medications
as directed
•Normalroutineforpostopcare:
▶ Encourage use of incentive spirometer
▶ Monitor oxygen saturations
▶ Monitor for temperature elevations
▶ Monitor wound for infection or complications
▶ Allow for verbalization
of concerns and fears
▶Reinforceteachingplan
▶ Prevent falls
*Coronaryarterybypassgraft(CABG)
CIMC • MEDICAL SURGICAL NURSING I
CIMC • MEDICAL SURGICAL NURSING I
Surgical Interventions Continued
Intervention
Purpose
Procedure
Percutaneous
•Allowsreturnblood •InsertionofcathTransluminalCorflow to coronary artereter into the femoral
onary Angioplasty
ies blocked by plaque
artery and threaded
(PTCA)withstent
formation
through to the coroplacement
nary arteries
•Balloonisinflated
to push plaque back
against the wall
•Wiremeshstentmay
be placed to hold the
vessel open
Ablation
•Reducerecurrent
symptomatic arrhythmias that are a direct
result of an abnormal
pathway
learning
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Nursing Care
Withinweeksofplacement,
the inner walls of the vessel actually grow into the stent, making the positioning permanent
Post-test
•Takevitalssignsaccording
to facility policy (usually
same as post op surgery)
▶Every15min.X4
▶Every30min.X4
▶EveryhourX4oruntil
stable
•Assesspedalpulseswith
vital signs
•Assesscatheterinsertion
site
•Assesspatientforbleeding
gums, bruising, and black
or tary stools
•Ensuresandbagand/or
pressure dressing is applied
for 1-3 hours
•Instructpatienttoavoidhip
flexion on affected side and
to remain on bedrest
•Performsamapping Pre-Procedural
procedure in which
•Explaintheprocedure
the cardiac arrhyth•Obtainconsent
mias are duplicated
•TellpatienttobeNPO6-8
•Pathwayisthenoblithours before the procedure
erated through cutting •Havepatienttakemornor burning, alleviating medications with sips
ing the possibility of
of water if approved by
the electrical impulse
physican
becoming errant
•Givepre-proceduralmedications as ordered
PTCA w/ stent placement
www.youtube.com/
watch?v=veP5R-pzJVk
Ablation
www.nhlbi.nih.gov/health/
dci/Diseases/ablation/ablation_whatis.html
Post-procedure
•Observecatheterinsertion
site for inflammation, hemorrhage or hematoma
•Assessvitalsigns
•Tellpatienttobeonbed
restfor12-24hoursaccording to physician orders
•Tellpatientnottoliftorpush
anything for several days
MODULE 4 • CARDIAC NURSING • stUDENt EDitiON
M O D U L E 4 • C a r d i a c N u r s i n g • T E ACH E R E D I T I O N
29
29
L E a r N i N g
O b j E c t i v E
Object i v e Evaluate pharmacological effects of
medications used to treat cardiac
disorders.
Variousmedicationsareusedtotreatcardiacdisorders. These medications include dopamine and other
inotropic agents that increase myocardial contractility without increasing oxygen consumption. They
raise systemic arterial pressure and cardiac output.
Pharmacological Effects
Category and
Uses
Actions
Examples
Cardiac
•Atrialfibrilla- •Slowsthe
Glycoside
tion
heart rate and
•Digoxin
•Otheratrial
strengthens
(Lanoxin)
arrhythmias
the heartbeat,
•Rapidheart
increasrate
ing cardiac
output
•Strengthens
the forces of
the heartbeat
and slows
the heart
rate, which
helps increase
circulation
Calcium
channel
blockers
•Verapamil
•Amlodipine
•Isradipine
•Nicardipine
30
•Unstable
•Relaxes
angina
smooth
•Hypertension
muscles in
•Supraventricthe coronary
ular tachycararteries so
dia
they dilate
and carry
more blood
to the heart
Side Effects
•Headache
•Drowsiness
•Confusion
•Fatigue
•Depression
•Headache
•Drowsiness
•Dizziness
•Anxiety
•Depression
•Weakness
•Fatigue
•Insomnia
•Cracklesin
lungs
•Pittingedema
•Thirst
Nursing Considerations
•Checkforadigitalislevelbefore giving digitalis (Lanoxin,
Digoxin).Alevelabove2.0is
considered toxic
•Takeapicalpulseandhold
iflowerthan60beatsper
minute
•Monitorelectrolytes:potassium, sodium, chloride,
magnesium, calcium
•MonitorI&O
•Cautionpatienttoavoid
over-the-counter medications
including cough, cold and
allergy preparations
•Tellpatienttonotifyphyscian if having loss of appetite,
lower stomach pain, diarrhea
or yellow-green visions
•Reportshortnessofbreath,
weight gain, edema or persistent cough. These may indicate worsening of condition
•Teachpatienttotakepulse
and to take medication at the
same time daily
•Assessfluidvolumestatus
•Monitorintakeandoutput
•Weighdaily
•Monitorvitalsignsespecially
blood pressure and pulse
•Monitorplateletlevel;if
lowerthan150,000/mm3
stop medication and notify
physician
CIMC • MEDICAL SURGICAL NURSING I
Cla ssroom Ac t i v i t y
Have students make flash cards to include the information listed. Have them note the common parts of medication
names for some of the drug categories (Calcium Channel Blockers ending in “pine”, ACE inhibitors ending in “pril”, etc.)
30
CIMC • MEDICAL SURGICAL NURSING I
Pharmacological Effects Continued
Category and
Uses
Actions
Examples
Anticoagulants •Preventionof •Prevent
•Heparin
thrombosis
emboli from
•Coumadin
formation
forming in
•Useduring
the atria,
and after
which would
open heart
circulate to
surgery
the brain and
causeCVA
•Decreasethe
incidence of
clotting
Side Effects
Nursing Considerations
•Hematuria
•Fever
•Chills
•Hemorrhage
•Rash
•Urticaria
•Hematoma
•Checkthepartialthromboplastin time (PTT) before
administering therapeutic
doses of heparin
•Checklabreferencevalues
for indications of excessive
anticoagulation
•Assessforbleedinggums,
petechia, bruising, black tarry
stools
•Monitorforhypersensitivity
or skin rash
•Headache
•Checkforaprothrombin
Antiplatelet
•Reducesrisk •Decrease
•Dizziness
time (Pro-Time, PT) before
•Plavix
of stroke,
vasocon•Hypertension
givingwarfarin(Coumadin).
MI, or acute
striction
•Edema
A value that is greater than 2½
coronary
and platelet
clumping
•Nausea
times the control is considsyndrome
(aggregation) •Vomiting
eredexcessive.Checkwiththe
physician before administeron vessel
•Diarrhea
ingCoumadin
walls
•Bleeding
•GIbleeding •Checkthepartialthromboplastin time (PTT) before
•Backpain
administering therapeutic
•Upper
respiratory
doses of heparin
infection
•Checklabreferencevalues
for indications of excessive
anticoagulation
•Assessforbleedinggums,
petechia, bruising, black tarry
stools
•Monitorforhypersensitivity
and skin rash
•Monitorliverfunction,bilirubin, creatinine
•MonitorCBC,HCT,Hgb
Coronary
•Chronic
•Dilate
•Headache
•Monitorfororthostaticblood
vasodilator
stable angina
coronary
•Syncope
pressure
•Nitroglycerin •Congestive
blood vessels •Posturalhy- •Assesspainforduration,dur(Nitro bid)
heart failure
and increase
potension
ing activity, frequency
•Isosorbide
related to MI
blood flow to •Nausea
•Monitorandreportsideef(Isordil)
the myocar- •Vomiting
fects
dium
•Pallor,sweating, rash
MODULE 4 • CARDIAC NURSING • stUDENt EDitiON
M O D U L E 4 • C a r d i a c N u r s i n g • T E ACH E R E D I T I O N
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31
Pharmacological Effects Continued
Category and
Uses
Actions
Examples
Diuretics
•Decrease
•Actsonthe
•Hydrochloedema
distal tubule
rothiazide
•Lowerblood
in the kidney
(HCTZ)
pressure
•Increases
excretion of
electrolytes
and water
Electrolyte
replacement
•Slow-K
32
•Neededfor
adequate
transmission of nerve
impulses
and cardiac
contraction
Nursing Considerations
•Hypokalemia
•Drowsiness
•Fatigue
•Weakness
•Headache
•Blurredvision
•Nausea
•Polyuria
•Orthostatic
hypertension
•Monitorelectrolytes
•Tellpatienttoriseslowlyto
avoid orthostatic hypertension
•Monitorforsideeffects
•Monitorforlowmagnesium
(signs are anxiety, muscle twitching, nausea, tetany, vomiting)
•Monitorforlowpotassium(elevated blood pressure, anorexia,
lethargy, confusion, headache)
•Teachpatienttoeatfoods
high in potassium, avoid alcoholandOTCmedications
•Monitorpotassiumlevel
•MonitorEKGforabnormalities
•MonitorI&O
•Watchfordecreasedurine
output
•Teachpatient:
▶ Eat food high in potassium
▶AvoidOTCmedications,
antacids, analgesics and salt
substitutes as these may cause
an increase in potassium
▶ Take medication with a full
glass of water
•Confusion
•Bradycardia
•Cardiac
depression
•Nausea
•Vomiting
•Oliguria
•Cold
extremities
•Low
potassium
•Volume
depletion
•Dehydration
ACEinhibitors •Reduce
•Selectively
•Fever,chills
•Captopril
peripheral
suppresses
•Hypotension
•Enalapril
vascular resisrenin-an•Lossoftaste
•Ramipril
tance
giotension•Impotence
•Dilate
aldosterone
•Dysuria
peripheral
system
•Dyspnea
arteries
•InhibitsACE •Cough
•Helpim•Decreases
prove cardiac
blood presoutput
sure
32
•Prevent
hypokalemia
which can
cause dysrhythmias
Side Effects
•Monitor:
•Bloodpressure
▶I&O
▶Renalfunction
▶ Potassium levels
▶ Edema
▶Weightdaily
•Tellpatient:
▶ Not to discontinue
abruptly
▶Don’ttakeOTCsuchas
cold meds
▶ To take drug according to
schedule
▶Riseslowlytoprevent
orthostatic hypotension
▶ Take blood pressure daily
CIMC • MEDICAL SURGICAL NURSING I
CIMC • MEDICAL SURGICAL NURSING I
Pharmacological Effects Continued
Category and
Uses
Actions
Examples
Beta-adrenergic •Supraventric- •Blocksstimublocking agents
ular tachycarlation of beta
•Atenolol
dias
adrenergic
•Esmolol
•Hypertension
receptors in
•Nadolol
•Otherabnorthe myocarmal cardiac
dium
rhythms— •Slowsconsinus tachyduction of
theAVnode
cardia
•Decreases
heart rate
Side Effects
Nursing Considerations
•Confusion
•Light-
headedness
•Bradycardia
•Headache
•Nausea
•Vomiting
•Urinary
retention
•Dyspnea
•Cough
•SeeACEinhibitors
Diuretics that do not spare potassium, such as Lasix,
remove excessive potassium.
M E D i c at i O N c O M b i N at i O N s
Oftenmedicationsaregiventogetherina
combination of antiplatelet aggregation and
vasodilatation. Aspirin, Ticlid, and Plavix are the
most common antiplatelet agents utilized. This
decreases the likelihood of blood clots or other
cellular debris occluding the narrowed lumens of the
coronaryvessels.Vasodilatorsarealsoutilized.
Three main classes include nitrates, beta-adrenergic
blocking agents, and calcium channel blockers. The
table below gives names of medications used.
Medication Combinations
Nitrates
Nitroglycerin
Nitro-Stat
Nitro-Dur
Beta-Adrenergic Blockers
Inderal
Lopressor
Corgard
Tenormin
Timolol
Calcium Channel Blockers
Procardia
Calan
Cardizem
Cardene
As with other conditions and diseases, patients with
cardiac disorders need education on their condition,
what they should and should not do, and how to
take prescribed medications. The LPN needs to assist
with patient education so patients will be able to care
for themselves outside a nursing facility.
MODULE 4 • CARDIAC NURSING • stUDENt EDitiON
33
Te ac hi n g s u g g e s t i on s
Facilitators may need to further discuss Valsalva’s maneuver and its affect on the cardiac system.
M O D U L E 4 • C a r d i a c N u r s i n g • T E ACH E R E D I T I O N
33
Le a r ni n g Ac t i v i t y Answ e r s
LEarNiNg activity
4
NaME
Answers will vary.
Introduction
The LPN frequently cares for patients who have cardiac disorders either as a primary or a secondary diagnosis. This activity illustrates major medications, diagnostic tests, and treatment.
learning
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link
Activity
Createaconceptmapandpresentinformationtotheclassorthefacilitator.Chooseoneofthefollowingtopics to use as the key idea in your concept map:
Concept Maps information
http://cmap.ihmc.us/
publications/researchpapers/theorycmaps/
theoryunderlyingconceptmaps.htm
•
Myocardialinfarction
•
Coronaryarterydisease(CAD)/anginapectoris
•
Congestiveheartfailure
•
Valvulardisease
•
Inflammatoryheartdisease
•
Cardiacdysrhythmias
•
Congenitalheartdefects
•
Pulmonaryedema
Includemajormedications,diagnostictests,treatment,andnursingcareassub-ideas.Usecolor,drawings,
and icons to show relationships between key ideas and sub-ideas.
http://eduwithtechn.wordpress.
com/2007/04/14/somefree-concept-mappingprograms/
Special tools/equipment
Art supplies
Application
Explaintheconceptmap.Comparethemapwithothersintheclassandmakeconnectionsbetweenkeyand
subtopics. The concept map will be evaluated using the following rubric.
34
CIMC • MEDICAL SURGICAL NURSING I
Note s
Concept maps are a good way to learn about specific groups of concepts and how they are inter-related. There
are several free resources on the internet to assist in making digital concept maps. One program that is easy to
use and commonly available on most school computers is PowerPoint. Using the “insert>shapes” a person can
easily draw a concept map.
34
CIMC • MEDICAL SURGICAL NURSING I
Grading Rubric
A Level 3 concept map will:
—Includeclearlyidentifiablekeytopicandsubtopics
—Includeaccurateandcompleteinformationaboutallfoursubtopics
—Includecolor,icons,drawings,orothermethodsofconnectinginformation
—Beexplainedinaclearandunderstandablewaytoothergroupmembers
—Bewell-organizedandcompletedontheduedate
A Level 2 concept map will:
—Includeakeytopicandallappropriatesubtopics
—Includecompleteandaccurateinformationaboutthreeofthefoursubtopics
—Includetheuseoficonsorcolorforconnectinginformation
—Beexplainedfairlyclearlytoothergroupmembers
—Befairlyorganizedandcompletedwithinonedayoftheduedate
A Level 1 concept map will:
—Includeakeytopicandlacksomesubtopics
—Includecompleteandaccurateinformationabouttwoofthesubtopics
—Lackiconsorcolorwhenconnectinginformation
—Beexplainedunclearlytoothergroupmembers
—Lackorganizationandbecompletedmorethanonedaylate
NO POINTS will be awarded to the concept map/learner that:
—Doesnotincludeakeytopicandatleasttwosubtopics
—Doesnotconnectinformationaboutthetopics
—Isnotexplainedtoothersinthegroup
—DoesnotparticipateintheLearningActivity
MODULE 4 • CARDIAC NURSING • stUDENt EDitiON
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L E a r N i N g
learning
w
ww
link
Object i v e Contributetotheplanofcarefor
patients experiencing alterations in
cardiac function.
LPNs will be assigned the task of direct patinet care
and will be responsible for contributing to the plan
ofcare.Forexample,thefollowingisapartiallistof
nursing diagnoses that may be associated with patients experiencing angina or myocardial infarction:
Care Plan Constructor
— for purchase
www1.us.elsevierhealth.
com/MERLIN/Gulanick/Constructor/
Free Care Plans
www.carescribble.com/
downloads.php
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O b j E c t i v E
•
Painrelatedtodecreasedmyocardialcirculation
•
Alteredtissueperfusionrelatedtonarrowed
coronary artery
•
Anxietyrelatedtocardiacdysfunction
•
Activityintolerancerelatedtocardiacdysfunction
•
Knowledgedeficitaboutangina
CIMC • MEDICAL SURGICAL NURSING I
CIMC • MEDICAL SURGICAL NURSING I
LEarNiNg activity
Lea rni ng Acti v i ty Ans wers
5
NaME
Answers will vary.
Introduction
The LPN will care for patients with cardiac disease. This activity focuses on the appropriate care for such
patients.
Activity
Workindividuallyoringroupsofthreeasassignedbythefacilitator.Reviewthemoduleanddiscussthe
nursing care for the following patients.
Chooseoneofthefollowingtopicstoresearchandpresent:
•
PreventionofcomplicationsafterMI
•
NursingcareofpatientswithCADandanginapectoris
•
AcutecareofthepatientwithMI
•
Cardiacrehabilitation
•
Careofthepatientwithvalvulardisease
•
Careofthepatientwithinflammatoryheartdisease
Application
Present the researched information to the class. It will be evaluated using the following rubric.
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Grading Rubric
A Level 3 presentation will:
—Includecompleteinformationaboutthetopic
—Includevisualaidsandhandoutstohelplearnersremembertheinformationpresented
—Includethoroughinformationabouthowthetopicaffectsnormalheartfunction
—Includealistoffourormorereferencesusedinyourresearch
—Bewell-organizedandcompletedinthetimeallowed
A Level 2 presentation will:
—Includepertinentinformationaboutthetopic
—Includevisualaidsorhandoutstohelplearnersremembertheinformationpresented
—Includeminimalinformationabouthowthetopicaffectsnormalheartfunction
—Includealistofthreeormorereferencesusedinresearch
—Befairlyorganizedandcompletedwithinoneminuteofthetimeallowed
A Level 1 presentation will:
—Includeminimalinformationaboutthetopic
—Lackvisualaidsorhandouts
—Lackinformationabouthowthetopicaffectsnormalheartfunction
—Includetworeferencesusedinresearch
—Lackorganizationandbecompletedinmorethanoneminuteovertime
NO POINTS will be awarded the presentation/learner that:
—Lacksbasicinformationaboutthetopic
—Lackstwoormorereferencesusedinresearch
—DoesnotparticipateintheLearningActivity
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CIMC • MEDICAL SURGICAL NURSING I
CIMC • MEDICAL SURGICAL NURSING I
LEarNiNg activity
Lea rni ng Acti v i ty Ans wers
6
NaME
Answers will vary.
Introduction
The LPN will care for patients with congestive heart failure, although it may be a secondary rather than a
primary diagnosis. The effects and side effects of the medications administered and symptoms of worsening
CHFarereviewedinthisactivity.
Activity
Workindividuallyoringroupsofthreeorasassignedbythefacilitator.Readthefollowingscenarioforthis
activity.
SCENARIO
Thepatientisadmittedtothehospitalwithseverecongestiveheartfailure.Whenthechartisreviewed,you
notice the following orders:
•
Bedrestwithbathroomprivilegesastolerated;
•
2gmsodiumdiet;
•
Oxygenat40%permask;
•
Fluidrestrictionof2liters/24hours.
Thepatientisallowedtohave800mLoffluidonyourshift.Youalsonotethatsheisonthefollowingmedications:Lasix,Lanoxin,nitroglycerinsublingual,potassiumsupplement,Nitrobid,andCapoten.Shehasan
IVheplockwithnoprimaryfluids.
Whenthepatientisassessedsheisshortofbreathandslightlycyanotic.Shehasremovedheroxygenmask,
sayingitissmotheringher.Shehas+4edemaofherlowerlegs,ankles,andfeet.Shecomplainsofthirstanda
drymouthandisaskingforaCokeorSprite.Whenvitalsignsaretaken,thefollowingreadingsareobtained:
B/P174/98,T.97.8,P.104,andR.30.Cracklesinalllungfieldsbilaterallyareheard.Sheasksyoutohelp
her to the bathroom so she can urinate.
Chooseoneofthefollowingnursingdiagnoses.Determinenursinginterventionsappropriateforthepatient
in the scenario.
•
Impairedgasexchange
•
Activityintolerance
•
Anxiety
•
KnowledgedeficitregardingCHF
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Fluidvolumeexcess
•
Self-caredeficit,hygiene,andgrooming
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Te ac hi n g Su g g e s t i on s
Use this same scenario in a simulation experience. Have the student’s research the information presented on this
page and carry it out during a simulated experience with a mannequin. Be sure to provide specific objectives for
the students to complete during the simulation experience. Break the students into groups of three (primary
nurse, secondary nurse, observer/recorder). Keep the scenario to around 20 minutes in length and be sure to
include a “debriefing” period to discuss the case and the actions the students did or did not take. This can also be
presented in the classroom environment with a mannequin as the instructor guides the class through the management of this type of patient. You can rotate the students through completing the interventions you are covering.
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Application
Present the nursing interventions to the class. Answer questions that may arise. Know the rationale for each
interventionrecommended.Compilethenursingdiagnosesandinterventionsindescendingorderofpriority.Contributetoacareplanforthepatientwithcongestiveheartfailure.Usetheinformationincareplans
you develop for clinical patients, after individualizing it for a specific patient.
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CIMC • MEDICAL SURGICAL NURSING I
CIMC • MEDICAL SURGICAL NURSING I
KEy sUMMary
• The heart is a hollow four-chambered organ composed of muscular and connective tissue.
The three layers of the heart are the pericardium, myocardium, and endocardium. The
heartbeat is originated by an electrical impulse from the sino-atrial node, which is located in
the right atrium.
• Heart valves act as one-way doors that allow blood to be maintained in a one-way track
through the circulatory system.
• Damage to heart muscle often results in heart failure. If the damage is on the right side of
the heart, symptoms will be peripheral, usually manifested as edema. If the damage is leftsided, symptoms will be pulmonary.
• Risk factors for cardiac disease include modifiable — smoking, diet high in fats and
cholesterol, sedentary lifestyle, obesity and stress — and non-modifiable: — age, race,
gender, and family history.
• Examples of diagnostic tests used to confirm cardiac disease include lab, treadmill, EKG,
angiography, and varying scans such as PET and thallium.
• Cardiac disorders can be mechanical, circulatory, or electrical in nature. They may also
involve one or more of the internal structures of the heart.
• Pharmacological treatment of diseases affecting the heart includes nitrates, cardiac
glycosides, beta blockers, ACE inhibitors, vasodilators, anticoagulants, and calcium channel
blockers.
• Patient teaching for those with heart disease includes diet modification, lifestyle changes,
exercise, medication, and stress reduction.
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HOSA Spotlight
• Have learners follow HOSA guidelines for an individual or group project using this or a similar topic.
• H
ave the class or a committee of facilitators’ rate the projects using a HOSA rating sheet. The winning project
could be entered in the state HOSA competition.
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gLOssary
Aneurysm: A widening or dilation of a portion of vein or artery. Upon visual inspection
there will be an area resembling a bulge.
Atherosclerosis: Hardening and/or thickening of venous walls. Most often caused by a
build-up of plaque and fatty deposits.
Atria: Plural form of atrium, a small hollow chamber of the heart. These structures are
found in the upper part of the heart, are differentiated by right and left, and receive blood
from the body and lungs, respectively.
Cardiac tamponade: A condition in which a pericardial effusion restricts heart
movement.
Cardioversion: An electrical shock to the heart that helps restore normal sinus rhythm.
Two metal paddles are placed on the patient’s chest, and a lower-level electric shock
(usually 100 joules or less) passes through them to the heart.
Dysrhythmia: Term that is used interchangeably with arrhythmia. Both terms refer to an
abnormal beat or rhythm of the heart. The rhythm can be slow, fast, or irregular in nature.
Fibrillation: Very rapid irregular contractions of a muscle. Most often used to describe a
cardiac rhythm in which the structure (atrium or ventricle) is quivering.
Myocardial Infarction: The death of a segment of the heart muscle.
Pericardiocentesis: A procedure that involves accessing the pericardial cavity with a
needle and aspirating the fluid accumulated within the pericardial space.
Systole: The period of time in which the heart muscle is contracted, thus expelling blood
from its chambers.
Vasoconstriction: Condition in which the walls of a vessel are narrowed.
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CIMC • MEDICAL SURGICAL NURSING I
CIMC • MEDICAL SURGICAL NURSING I
rEsOUrcE bibLiOgrapHy
Publications
Christensen B., and Kockrow, E (2006). Foundations and Adult Health Nursing; (5th ed.).
St. Louis: Mosby.
DeWitt, Susan (2009). Medical Surgical Nursing Concepts and Practice. Portland; Saunders.
Estes, Mary Ellen Zator (2006). Health Assessment and Physical Examination (3rd ed.).
New York; Delmar.
Kozier, B., G. Erb, et al. (2004). Fundamentals of Nursing. Upper Saddle River, NJ:
Pearson Prentice Hall.
Miller-Keane (2003). Encyclopedia & Dictionary of Medicine, Nursing, & Allied Health (7th ed.).
Philadelphia: Saunders.
Mosby (2006). Mosby’s Dictionary of Medicine, Nursing & Health Professions (7th ed.).
St. Louis: Mosby Elsevier.
Nursing Focus. Stillwater, OK: Oklahoma Department of Career and Technology Education,
Curriculum and Instructional Materials Center, 2002.
Pender, N. J., C. L. Murdaugh, et al. (2006). Health Promotion in Nursing Practice.
Upper Saddle River, NJ: Pearson Prentice Hall.
Roe, S (2003) Delmar’s Clinical Nursing Skills and Concepts, Thompson,
Delmar Learning. United States.
White L. (2005). Foundations of Nursing (2nd ed.). United States; Thompson Delmar.
Wilkinson, J. M. and K. V. Leuven (2007). Fundamentals of Nursing: Theory, Concepts and Applications.
Philadelphia, PA: F. A. Davis Company.
Online
Healthy People
www.healthypeople.gov/
National Health Information Center, U.S. Department of Health and Human Services
www.health.gov/nhic
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NOtEs
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CIMC • MEDICAL SURGICAL NURSING I
CIMC • MEDICAL SURGICAL NURSING I