Cardiovascular Focus

1. Blood flow through the heart:

Vena cava, right atrium, tricuspid valve, right ventricle, pulmonary semilunar valve, pulmonary arteries,
lungs, pulmonary veins, left atrium, bicuspid valve, left ventricle, aorta, systemic circulation.
2. Identify the nursing care after
Pacemaker Insertion (ch25, p7 & p515)
Monitor ECG, Bed rest, Monitor VS, Apical pulse, Incision care check for bleeding Q2-4H; Changes in
rhythm, chest pain or VS changes must be reported to MD; Pts may have sling on operative side for 2448 hours to help prevent dislodgement of pacemaker lead from cardiac wall
Cardiac Catheterization (P406)
Firm pressure on insertion site for several minutes to prevent hemorrhage or hematoma formation. A
pressure dressing or sand bag may be applied after bleeding has stopped and is in place for several
hours. Vitals sign. Monitor for bleeding. Circulation checks distal to insertion site. Patient is on bed rest.
Extremity used for insertion is not moved or flexed for several hours after the procedure. Patients may
usually eat and are instructed to drink fluids to eliminate the dye from the body.
Coronary Angiography (P405)
The patient must be assessed for allergies, give informed consent, be NPO for four hours prior to the test
and be informed that the dye produces a hot, burning feeling when injected. After the procedure the
patient is assessed for several hours including vital signs, allergic reactions, hemorrhage at injection site,
Neurological and neurovascular checks.
3. Identify lab tests, signs and symptoms associated with an MI. (ch24 p4-6)
Myocardial Infarction is death of heart muscle caused by ischemia. Two types include; Non ST Segment
Elevation MI & ST Segment Elevation MI
Signs & Symptoms
Crushing, vice like pain that radiates to arm, sholders, neck, jaw. Shortness of breath. Restlessness,
Dizziness, Fainting, Nausea, Sweating.
Atypical S/S- usu women or older adults
Absence of classic pain, Dyspnea, Fatigue, Anxiety, Chest cramping, Epigastric pain, Abdominal pain,
Restlessness, Falling.
Older Adults S/S
SOB, Fatigue, Fast/Slow heart beats, Chest Discomfort, Silent MI, Collateral Circulation.
Women S/S
Prodromal symptoms the month before MI: Unusual fatigue, Sleep disturbances, Dyspnea.
Lab Tests
Serial ECG, Cardiac Troponin I or T, Myoglobin, CK-MB, C-reactive protein, Magnesium.

4. Understand what a PTCA(PCI), ECG, and Thallium scan are and preparations for the tests.
PTCA (PCI) Percutaneous Transluminal Coronary Angioplasty (NCLEX p673)
An invasive, nonsurgical technique in which one or more arteries is (are) dilated with a balloon catheter
to open the vessel lumen and improve arterial blood flow.
Preprocedure Interventions PTCA (NCLEX p673)
NPO after midnight, informed consent, assess allergies esp. to Iodine, hold metformin (Glucophage),
Prepare groin with antiseptic soap, shave per Drs. Orders or policy, VS, peripheral pulses, have pt report
chest pain during procedure.
ECG (pg 500)
Views Electrical activity of the heart, 12 or 18 lead gives 12 or 18 views of the hearts electrical activity.
Continuous monitoring usu use one lead that provides a good view Lead II or MCL1. There are no
special preparations for this test.
Thallium Scan (p403)
Thallium-201, a radioactive analog of potassium is injected IV, is absorbed by the muscles in 10 -15
minutes, the heart is scanned to see where the thallium has concentrated. Scan is repeated in 4 hours to
see changes. Healthy myocardial cells with good perfusion take up thallium. Areas without thallium are
cold spots and indicate ischemia or infarction. Test is used to detect impaired myocardial perfusion.
Exercise testing may be combined with thallium to detect changes in blood flow with activity and after
rest. Pt exercises for 2 minutes and is given thallium during. Scanned immediately and again in 2-4
hours cold spots on initial scan indicate ischemia, if they are gone in later images exercise induced
ischemia is present, if they remain the show scarred areas. Pt unable to exercise the can be given
Persantine (dipyridamole) or adenosine to simulate it.
Thallium Scan Preprocedure
I looked up Thallium prep. I think it is NPO after midnight, no caffeine products 24hr before test for
normal pts. NIDDM patients NPO and withhold meds. IDDM eat light breakfast toast and juice, 1/2
insulin dose and 4hr NPO before test
5. Understand what heart failure is, the differences between right and left sided heart failure, medication
usage and the goals of nursing management.
Heart Failure (ch26 p1)
Syndrome that occurs from progressive inability of the heart to pump enough blood to meet body's
oxygen & nutrient needs AKA CHF
Causes of heart failure
Coronary artery disease, cardiomyopathy, hypertension, heart valve disorders, myocardial infarction.
Pathophysiology
Each ventricle pumps equal amount of blood, if more than either ventricle can handle, the heart is not an
effective pump, left ventricle typically weakens first, failure of one leads to failure of the other.
Left Sided Heart Failure (523, ch26 p 1)
A certain amount of force must be generated by the left ventricle during a contraction to eject blood into
the aorta through the aortic valve. This force is called afterload. The pressure within the aorta and
arteries influences the force needed to open the aortic valve to pump blood into the aorta. This pressure

is called peripheral vascular resistance (PVR). Blood backs up from the left ventricle into the left atrium
and then into pulmonary veins and lungs. Increasing pulmonary pressure causes movement of fluid into
interstitium then alveoli, severe fluid build up leads to pulmonary edema. Hypertension is a major cause.
Right Sided Heart Failure (523, ch26 p1)
Left sided heart failure is major cause. Conditions that increase the work of the right ventricle increase
the amount of contractile force needed or they require pumping of excess blood volume (preload).With
increased pulmonary pressure the right ventricle must continually pump harder to overcome the extra
pressure, this strain eventually causes it to fail. When the right ventricle hypertrophies or fails because of
increased pulmonary pressure it is called Cor Pulmonale. Backward build up of blood in systemic
vessels and peripheral edema results.
Medications used to manage Heart Failure (ch26 p 4, 530)
O2,
Ace Inhibitors decrease afterload and hypertrophy, include: Capoten (captopril), Vasotec (enalapril),
Prinivil or Zestril (lisinopril), Lotensin (benazepril), Monopril (fosinopril), Univasc (moexipril),
Accupril (quinapril), Altace (ramipril), Mavik (trandolapril)
Beta Blockers improve cardiac output, reduces disease progression and sudden death,
Include: Zebeta (bisoprolol), Coreg (carvedilol), Troprol XL (metoprolol)
Diuretics decrease fluid overload, Include:
Loop, Potassium Wasting - Bumex (bumetanide), Lasix (furosemide), Demadex (torsemide)
Loop, Potassium Sparing Aldactone (spironolactone)
Thiazide (potassium wasting) Diuril (chlorothiazide), HydroDiuril (hydrochlorothiazide), Zaroxolyn
(metolazone)
Inotropic agents increase force and contraction of myocardium, Lanoxin (digoxin)
Vasodilators- decrease afterload, increases cardiac output, reduces cardiac workload
Include: Isorbid/Isordil (isosorbide), Apresoline (hydralazine), Nitroglycerin.
Goals of Nursing Management for Heart Failure
Improve hearts pumping ability and decrease hearts O2 demands, Identify and correct underlying cause,
Increase strength of heart contraction (digoxin), Maintain optimum water and sodium balance, Decrease
hearts workload.
6. Understand Pulmonary Edema, Pulmonary Embolism, Thrombophlebitis, and Angina and the S/S as
well as nursing implications for each.
Pulmonary Edema
Acute heart failure, severe fluid congestion in the alveoli, life-threatening, drowning in own secretions
S/S- Classic is pink, frothy sputum, Rapid respirations with accessory muscles, Severe dyspnea,
orthopnea, Crackles, wheezes, Anxiety, restlessness, Clammy cold skin
Therapeutic Interventions- Immediate treatment, reduce workload of left ventricle, treat underlying
cause, Fowlers position, O2 or mechanical ventilation, morphine diuretics Inotropic agents
vasodilators via IV
Pulmonary Embolism
Emboli that travels to the lungs usu. pulmonary artery,
S/S- sudden onset dyspnea for no apparent reason, gasping for air, anxious, tachycardia, tachypnea,
cough, crackels or friction rub, if infarction- hemoptysis, pleuritic chest pain, some are asymptomatic.

Therapeutic Interventions- Thrombolytics, anticoagulants, cardiac cath, embolectomy, O2, intubation or

mechanical ventilation, vena cava filter.
Thrombophlebitis
Clot formation and inflammation within the vein, superficial veins, DVT deep vein, danger of emboli
Etiology- Venous stasis- reduced blood flow, Damage to vein lining- IV catheters, Increased blood
coagulation- smoking, oral contraceptives, estrogen therapy, hematological disorders,
S/S- None
Superficial veins- redness, warmth, swelling, tenderness
Deep veins- leg usu. swelling, edema, pain, warmth, tenderness, Homans sign in 40%
Therapeutic InterventionsSuperficial veins-warm moist heat, analgesics, NSAIDs, compression stockings.
Deep veins- low molecular weight heparin or heparin, coumadin, bedrest elevate the extremity,
warm moist heat, compression stockings, thrombolytics, thrombectomy, vena cava filter.
Angina
Symptom of ischemia, chest pain, can be caused by CAD, Vasospasm, Valvular Heart Disease, HTN,
Heart failure
Stable Angina- arteries cannot increase blood flow to heart during increased activity, usually stops with
rest or vasodilator.
Variant Angina (Prinzmetals Angina)- longer duration, can occur at rest, often same time each day,
coronary artery spasm cause, serious condition.
S/S- pain that radiates, heaviness, tightness, viselike, crushing pain in center of chest, usu in the morning,
Pale, Diaphoretic, Dyspneic
Female Angina S/S- Chest pain, jaw pain, heartburn, atypical symptoms include- describe less severe
pain, fatigue, nausea, breathlessness
Therapeutic Interventions weight reduction, low fat low cholesterol diet, stress reduction,
Medications- nitro, calcium channel blockers diltiazem, amlodipine, Beta blockers propranolol,
metoprolol, atenolol, ACE inhibitors captopril, lisinopril, ramipril, enalapril, Statins- atorvastatin,
fluvastatin, lovastatin, pravastatin, simvastatin, rosuvastin, Antiplatelets ASA, Plavix (clopridogrel)
Nursing Care- acute pain interventions, O2, VS, sublingual nitro, remain with the pt. emotional support.
7. Identify the Compensatory Mechanism to maintain blood flow. 26.2
Compensatory mechanisms are designed to maintain cardiac output, but also contribute to cycle of heart
failure, maintains cardiac output when low by sympathetic nervous system to raise heart rate- increases
cardiac O2 needs, Renin- Angiotensin- Aldosterone system, Antidiuretic hormone save water- increasing
fluid volume, Chambers enlarge (dilation), Muscle mass increases (hypertrophy) increases cardiac O2
needs.
8. Identify the nursing interventions for atrial fibrillation, PACs, and ventricular fibrillation.
A-Fib (Atrial Fibrillation) (ch25 p4)
Rules- Irregularly Irregular Rhythm, Atrial rate not measurable, ventricular rate < 100 controlled
response, > 100 Rapid ventricular response, No identifiable P waves, No measurable P-R interval, QRS
interval < 0.10 seconds, S/S palpations, faint radial pulse
Therapeutic Interventions- Synchronized cardioversion, Meds- Digoxin, Beta blockers, Calcium channel
blockers, Amiodarone, Dronedarone, Pradaxa (dabigatran)(labs less often), coumadin, Ablation,
Bilateral pacing, Implantable atrial defibrillators, surgical maze procedure.
PACs Premature Atrial Contractions
Rules- PAC interrupts rhythm, heart rate is per underlying rhythm, early beat P waves abnormal shape,
P-R Interval usu normal, QRS interval < 0.10 seconds, S/S None
Therapeutic Interventions- None, treat cause, beta blockers

V-Fib Ventricular Fibrillation

Rules- Chaotic, extremely irregular rhythm, heart rate not measurable, NO P-waves, P-R Interval, QRS
Interval.
S/S- Unconscious, no heart sounds, peripheral pulses, BP, respiratory arrest, cyanosis, pupil dilation,
Therapeutic Interventions- ACLS protocols, immediate defibrillation, CPR, Epinephrine, Vasopressin,
Amiodarone, Magnesium, Endotracheal intubation.
9. Define hypertensive emergency and urgency and their nursing implications. (ch22. p3)
Hypertensive Emergency
Systolic > 180, Diastolic > 120, Risk for/ Progression for target organ dysfunction, immediate gradual
reduction of BP to protect target organs, Treat with Nitroprusside (Nipride) IV
Hypertensive Urgency
Severe BP elevation without target organ dysfunction progression, Severe HA, nosebleeds, SOB, severe
anxiety, TX oral meds.
10. Understand aortic stenosis, mitral stenosis, and mirtal valve regurgitation, their etiologies ad how to
care for each.
Aortic Stenosis (ch23 p3)
Pathophysiology- Aortic valve narrowed, left ventricle contracts more forcefully, left ventricle
hypertrophies, decreased cardiac output, eventual heart failure
Etiology- Congenital defects, rheumatic heart disease, calcification with aging,
S/S- None early, angina, murmur, syncope, orthopnea, dyspnea, on exertion, fatigue, pulmonary edema
Therapeutic Interventions- Surgery- aortic valve replacement, valvotomy, treat heart failure symptoms,
prophylactic antibiotics per criteria
Mitral Stenosis (ch23 p2)
Pathophysiology- Mitral valve thickening, chordae tendineae shorten, narrows valve opening, blood
flow is obstructed from left atrium, left atrium enlarges
S/S- Same as mitral valve regurgitation, None early, murmur, exert ional dyspnea, cough, hemoptysis,
fatigue, palpitations, A-Fib, chest pain
Therapeutic Interventions- Prophylactic antibiotics per criteria, anticoagulants d/t A-Fib, Percutaneous
balloon valvuloplasty, Mitral valve repair with: balloon valvotomy- opens stenosed heart valve,
commissurotomy repair stenosed valve, annuloplasty- repair or reconstruction of valve flaps. Mitral
valve replacement
Mitral Valve Regurgitation
Pathophysiology- Incomplete mitral valve closure, backflow of blood to left atrium, left atrium dilates,
extra volume to left ventricle, left ventricle dilates from extra volume, eventually may fail.
S/S- Same as mitral stenosis, None early, murmur, exert ional dyspnea, cough, hemoptysis, fatigue,
palpitations, A-Fib, chest pain
Therapeutic Interventions- None unless symptoms, prophylactic antibiotics per criteria, ACE inhibitors,
Anticoagulants, mitral valve repair/replacement
Nursing Interventions For All Valvular Disorders
Monitor for normal cardiac function
VS, I&O, Daily WT. Sodium restriction, Smoking cessation, Meds as ordered, Assist ADLs,
provide rest periods, Energy conservation, Assess for edema, Diuretics as orders monitor K+
11. Define peripheral vascular disease and pericarditis and care for both.
Peripheral Vascular Disease Includes

Peripheral Arterial Disease (PAD) (ch24 p8&9)

Chronic, progressive arterial narrowing, reduced blood supply, ischemia develops
S/S- Intermittent claudication(), cool skin, reddish purple skin when dependent, pale when
elevated, diminished or absent peripheral pulses
Care- low fat, low cholesterol, low calorie diet,
Meds- lipid lowering agents, Pentoxifylline (Trental), thrombolytics,
Invasive TX- Percutaneous Transluminal Angioplasty (PTA), atherectomy, stents, aortic-femoral
bypass.
Raynauds Disease
Vasoconstriction with cold or stress causing ischemia, mainly affects hands,
Phases- Blanching, pain, reddening
Therapeutic Interventions- keep warm, avoid vasoconstriction, take vasodilators
Buergers Disease
Recurring inflammation of sm/md vascularity of hands and feet, vasospasms, ischemia,
gangrene, unknown cause, heavy smoking contributes
S/S- Intermittent claudication, the 6 Ps, lower extremities red or cyanotic in dependent position.
Therapeutic Interventions- Smoking cessation, calcium channel blockers, skin assessment
Pericarditis (ch23 p8)
Acute or chronic inflammation of the pericardium, ventricular filling is reduced, decreased
cardiac output and BP
Therapeutic Interventions- pericardiocentesis, treat cause, antibiotics, hemodialysis, pericardial
window (portion of outer pericardial layer is removed to allow continuous drainage),
pericardiectomy (removes entire pericardium), bedrest, NSAIDs
Nursing management VS, monitor cardiac function, signs of tamponade, NSAIDs,
corticosteroids, position of comfort, report heart failure or emboli signs.
Teach- good hygiene, oral/dental care, report symptoms of fever, chills, sweats
12. Identify risk factors for atherosclerosis.(ch24.p1)
Modifiable Risk Factors
DM, HTN, smoking, obesity, sedentary lifestyle, increased serum homocysteine or iron,
infection, depression, hyperlipidemia, elevated apolipoprotein B, excessive alcohol intake
Non-Modifiable Risk Factors
Age, gender, ethnicity, genetic predisposition for hyperlipidemia
13. Actions, Nursing implications, and side effects for:
Coumadin (warfarin) (p505)
Actions: Anticoagulant- increases clotting time, reduces risks of clots in a-fib.
Nursing Implications: Monitor INR/PT regularly (INR/PT between 2-3 above 3 is critical), monitor for
bleeding or bruising, Tylenol not ASA, Antidote is Vitamin K
Side Effects: Hemorrhage (increased with NSAIDs)
Digoxin (Lanoxin) (p530)
Actions: Inotropic Agent- increases force and contraction of myocardium, which increases cardiac
output, slow heart rate to reduce workload of heart and control atrial fibrillation if present.
Nursing Implications: Take apical pulse 1 min below 60 notify MD. Older pts more susceptible to
toxicity, monitor dig levels (0.5-2ng/ml, toxic above 2ng) Electrolytes (hypokalemia, hypomagnesemia,
& hypercalcemia make more prone to toxicity)
Teaching- Take as prescribed, same time each day, take pulse before each dose notify MD below 60,
report signs of toxicity.

Side effects- Fatigue, nausea, vomiting, HA, anorexia, bradycardia, cardiac arrhythmias.
Toxicity- abd pain, anorexia, N, V, visual changes (blurred, yellow-green halos, photophobia, diplopia),
bradycardia, dysrhythmias.
Nitroglycerin
Actions: Vasodilator -Decreases afterload, which increases cardiac output and reduces cardiac workload,
used for pts who cannot take ACE inhibitors.
Nursing Implications: Take blood pressure and pulse before giving, notify MD if outside normal limits,
Teaching rise slowly, HA common initially, TX with asa.
Side effects- HA, dizziness, hypotension, tachycardia
Bumex (bumetanide) & Lasix (furosemide) (p530)
Actions: K+ wasting loop diuretic that decreases fluid overload
Nursing Implications: Check BP & Pulse before giving, Monitor electrolyte levels esp. K+ and pts on
digitalis, Fluid status- daily wt., I&O, thirst, oliguria, through out therapy, Give per pt lifestyle usu. in
am to avoid nocturia
Side effects- Hypokalemia, hypochloremia, hypomagnesemia, hyponatremia, dehydration, hypotension.
SIDE NOTES:
Arteriosclerosis is artery/arteriole walls thicken, harden & lose elasticity
Atherosclerosis is form of arteriosclerosis, with plaque formation in arterial walls
Six Ps
Pain
Pulselessness
Paralysis
Pallor
Paresthesia
Poikilothermia