Cardiac

© USMLE Galaxy LLC

Part I:
Anatomy + Physiology

1
Components of the Cardiovascular System
1. Heart
2. Blood vessels
Arteries - carry oxygenated* blood away from the heart

Veins - carry deoxygenated* blood towards the heart

Capillaries - Exchange fluids between the blood and interstitial space

*exception - the pulmonary artery carries deoxygenated blood away from the heart
and the pulmonary vein carries oxygenated blood towards the heart!

The Heart
● Mediastinum
○ Area where the heart is located
○ Area above the diaphragm and between
the lungs
● Heart wall
○ Epicardium: Outer smooth layer
○ Myocardium: Thickest layer of cardiac
muscle
○ Endocardium: Innermost layer
● Pericardium
○ Double-walled membranous sac
● Pericardial space
○ Space between the parietal and visceral
layers
○ Contains pericardial fluid

2
Chambers of the Heart
● Atria
○ Receives blood from veins
○ Sends blood to ventricles
○ Separated by the interatrial
septum
● Ventricles
○ Receives blood from the atria
○ Sends blood to arteries
○ Separated by the interventricular
septum

Valves of the Heart

● Atrioventricular valves (AVs)
○ One-way flow of blood from the atria to the ventricles
○ Right:
■ Tricuspid valve
○ Left:
■ Bicuspid (mitral) valve
● Semilunar valves
○ One-way flow from the ventricles to either the pulmonary artery or to
the aorta
■ Pulmonic semilunar valve
■ Aortic semilunar valve

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 Body Heart Lungs

Lungs Heart Body

Blood flow through the heart

4
Coronary Vessels
● Supply the heart with oxygen and
nutrients
● Right coronary artery
● Left coronary artery

Cardiac cycle

5
So how does the heart know when to
contract and relax?

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Electrical conduction system

EKGs

7
What the EKG means
P wave:
Atrial depolarization

QRS complex:
Ventricular depolarization

T wave:
Ventricular repolarization

Measuring the EKG

8
6 second strip

HR: 9 x 10 = 90

P-wave: normal
PR Interval: 0.12-0.20
QRS: <0.12
Rate: 60-100
Regularity: Regular

Normal Sinus Rhythm

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 P-wave: “saw-tooth”
Causes: Interventions:
PR Interval: none
-Heart disease -Fix the cause
QRS: <0.12
-MI -Cardioversion
Atrial Rate: 250-400
-CHF -Pacing
Ventricular Rate: Varies
-Pericarditis -Antiarrhythmics: amiodarone
Regularity: Regular or
-Beta blockers: metoprolol
Irregular
-Calcium channel blockers:

Atrial Flutter diltiazem

P-wave: ‘wavy’ Causes: Interventions:

PR Interval: none -Heart Disease -Fix the cause
QRS: <0.12 -Pulmonary Disease -Cardioversion
Atrial Rate: >400 -Stress -Antiarrhythmics: amiodarone
Ventricular rate: Varies -Alcohol -Beta blockers: metoprolol
Regularity: irregular -Caffeine -Calcium channel blockers:
diltiazem

Atrial Fibrillation -Surgery: ablation

10
 G
T E NIN
A
E -T HRE HMIA!!
LIF RHYT
AR

P-wave: none Causes: Interventions:

PR Interval: none -MI -Fix the cause
QRS: >0.11 - ‘wide & -Ischemia
bizarre’ -Digoxin toxicity YES pulse:
Rate: 150-250 -Hypoxia Cardioversion
Regularity: Regular -Acidosis
-Hypokalemia No pulse:
-Hypotension -CPR
-Defibrillate
Ventricular Tachycardia (V-Tach) -Epinephrine

NG
AT ENI
E !!
F E -THR THMIA
LI HY
ARR

Causes:
P-wave: none -MI Interventions:
PR Interval: none -Ischemia -Fix the cause
QRS: none -Hypoxia -CPR
Rate: none -Acidosis -Defibrillate
Regularity: Irregular -Hypokalemia -Epinephrine
-Hypotension
-Most common cause of sudden
death
Ventricular Fibrillation (V-fib)
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Control of the heart
● Autonomic nervous system
○ Sympathetic nerves
■ Increase electrical conductivity and strength of myocardial
contraction
■ Norepinephrine and epinephrine
○ Parasympathetic nerves
■ Slow conduction of action potentials through the heart, reduce the
strength of contraction
■ Acetylcholine

Receptors
● α-adrenergic receptors
○ α1
○ α2
● β-adrenergic receptors
○ β1
■ Stimulation increases the HR - chronotropy
■ Stimulation increases contractility - inotropy
○ β2
■ Stimulation causes bronchodilation

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 Hemodynamics

Hemodynamics
● Preload
○ Amount of blood returning to right side of the heart
● Afterload
○ Pressure against which the left ventricle must pump to eject blood
● Compliance
○ How easily the heart muscle expands when filled with blood
● Contractility
○ Strength of contraction of the heart muscle

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Ejection Fraction
● Amount of blood ejected per heartbeat
● Normal is 55% or higher
● Indicator of ventricular function

Stroke Volume
Volume of blood pumped out of the ventricles with each contraction

Determined by:

● Preload
● Afterload
● Contractility

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 Cardiac output
The amount of blood that the heart
pumps per minute

CO = SV x HR

WHY is CO so important!?
● Tissue perfusion!
● End organ function
● Delivery of oxygen and nutrients to each and every cell in the body!
● Poor cardiac output??
○ Decreased LOC (not enough blood flow to the BRAIN)
○ Chest pain, weak peripheral pulses (not enough blood flow to the HEART)
○ SOB, crackles, rales (not enough blood flow away from the LUNGS)
○ Cool, clammy, mottled extremities (not enough blood flow to the SKIN)
○ Decreased UOP (not enough blood flow to the KIDNEYS)

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16
 Part II:
Cardiac Pharmacology

Antihypertensives
● ACE inhibitors
○ Captopril
○ Enalapril
○ Lisinopril
● Angiotensin II Receptor Blockers
○ Losartan
● Calcium Channel Blockers
○ Amlodipine
○ Nifedipine
○ Verapamil
● Arterial and Venous Dilators
○ Hydralazine
○ Nitroglycerin
● Beta Blockers
○ -lol

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Enalapril
Therapeutic class: ACE inhibitor

Indication: Hypertension, CHF

Action: Blocks conversion of angiotensin I to angiotensin II, increases renin levels,

and decreases aldosterone leading to vasodilation

Nursing Considerations:

● Can cause a dry cough - should be discontinued if it does

● Monitor BP
● Contraindicated during pregnancy

Losartan
Therapeutic class: Angiotensin II receptor blocker (ARB)

Indication: hypertension, DM neuropathy, CHF

Action: inhibits vasoconstrictive properties of angiotensin II

Nursing Considerations:

● Monitor BP
● Monitor fluid levels
● Monitor renal and liver status
● Contraindicated during pregnancy

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Amlodipine
Therapeutic class: Calcium channel blocker
Indication: Hypertension, angina
Action: Blocks transport of calcium into muscle cells inhibiting excitation and
contraction, causes peripheral vasodilation
Nursing Considerations:
● Avoid grapefruit
○ Blocks the enzyme involved in metabolizing calcium channel blockers, causing their levels to
increase
● Monitor BP - orthostatic hypotension
● Can cause gingival hyperplasia

NCLEX Question
The nurse is providing discharge instructions to a client with accelerated hypertension who has been
newly started on Nifedipine. His home medications include calcium supplements for osteoporosis,
omeprazole for heartburn, furosemide, and lisinopril. Which statement(s) by the client demonstrates the
need for additional teaching regarding Nifedipine? Select all that apply.

a. “My gums may swell because of this medication.”

b. “I will avoid getting up too quickly from sitting or lying position.”
c. “I will stop taking calcium supplements since they may negate the effects of Nifedipine.”
d. “It is highly likely that I will get constipated from this drug”
e. “If I get cough and tongue swelling, I will hold Nifedipine”

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Answer: C, D, and E
A is incorrect. Gum/gingival hyperplasia is a common side effect with extended-standing use of Nifedipine.

B is incorrect. The client should avoid getting up too quickly from sitting or lying position. Because of peripheral
vasodilation, Nifedipine causes postural or orthostatic hypotension. So, the client should be aware of getting up slowly
from the lying/ sitting position so they do not become dizzy.

C is correct. The client should not stop taking their calcium supplements. There is no evidence to say oral calcium
supplements will reduce the effects of CCBs. Also, this client needs calcium supplements for his osteoporosis. Therefore,
this does not reflect correct understanding by the client and needs additional teaching.

D is correct. There is a less than 2% chance that the person can get constipated from Nifedipine, it is not true that the
client is highly likely to get constipated from Nifedipine. Therefore, this statement does not reflect correct understanding
by the client and needs additional teaching.

E is correct. The client should not hold Nifedipine if they get cough and tongue swelling. Cough and tongue swelling
(Angioedema) are common side effects seen with ACE inhibitors, not with CCBs. The client is also on Lisinopril (ACEI),
which may lead to this side effect, so the nurse will need to explain this to the client.

Arterial and Venous Dilators

Arterial Dilators
● Hydralazine
○ Causes decreased BP, arterial vasodilation, reduction in afterload, increased CO
○ SE: orthostatic hypotension, reflex tachycardia, headache, nausea; Long term use can cause RA or lupus–like
symptoms
● Minoxidil
○ More potent than hydralazine, can cause myocardial ischemia and pericardial effusion, and hirsutism
○ Topically used as Rogaine for hair growth

Venodilators
● Nitrates: nitroglycerin and isosorbide dinitrate
● Reduce preload, reduce venous return to heart (also dilates arteries at higher doses)
● SE: Headache, dizziness, flushing, orthostatic hypotension

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Beta Blockers
● Propranolol
● Atenolol
● Metoprolol
● Esmolol
● Sotalol

Propranolol
Therapeutic class: antiarrhythmic

Indication: hypertension, angina, arrhythmias, MI, cardiomyopathy, alcohol

withdrawal, anxiety

Action: blocks Beta 1 and 2 adrenergic receptors slowing the heart rate

Nursing Considerations:

● Do not discontinue abruptly, discontinue them slowly

● Can mask the signs of hypoglycemia; important to monitor blood sugars
● Caution with asthma and COPD - can potentially cause bronchospasm

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Antiarrhythmics
Anticholinergic and antiarrhythmic:
Class 1 = Sodium channel blockers:
● Procainamide ● Atropine
● Lidocaine
Misc:
Class 2 = Beta blockers:
● Propranolol ● Adenosine
● Esmolol

Class 3 = Potassium Channel blockers:

● Amiodarone
● Sotalol
● Ibutilide

Class 4 = Calcium Channel Blockers:

● Diltiazem
● Verapamil

Amiodarone
Therapeutic class: Antiarrhythmic
Indication: Arrhythmias
Action: Stops potassium from leaving cells and prolongs resting period of heart cycle
Nursing Considerations:
● Adverse effects of amiodarone: dizziness, tremors, ataxia, pulmonary fibrosis, bradycardia,
heart block, blue-gray skin discoloration
● Has iodine and can disturb thyroid
● Not given in pregnancy

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Adenosine
Therapeutic class: Antiarrhythmic
Indication: SVT
Action: Slows conduction through the AV node, interrupts re-entry pathways through
AV node, restoring normal sinus rhythm
Nursing Considerations:
● There will be a period of asystole after administration
● Warn the client - it will feel like someone kicked them in the chest!
● Warn the family - they will flatline on the monitor!
● Rapid push - or it will not work
● Use with extreme caution in asthmatics

Atropine
Therapeutic class: Antiarrhythmic; anticholinergic

Indication: excessive secretions, sinus bradycardia, heart block

Action: Inhibition of acetylcholine, increasing the HR, causing bronchodilation,

and decreasing secretions

Nursing Considerations:

● Monitor for urinary retention and constipation

● Avoid in clients with glaucoma

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Cardiac glycosides
● Digoxin

Digoxin
Therapeutic class: Cardiac glycoside

Indication: Heart failure, a-fib, a-flutter, CHF, cardiogenic shock

Action: Increases contractility (how strong the heart pumps), and decreases the rate (how fast the heart
beats). Acts on the cellular sodium-potassium ATPase, making the heart more efficient!

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Toxicity
Monitor for toxicity in any client taking digoxin!
Narrow therapeutic range!! → Therapeutic drug level: 0.5-2 ng/mL

● Early signs/symptoms:
○ Nausea & vomiting
○ Anorexia
○ Vision changes - yellow/green halos
● Late signs/symptoms
○ Bradycardia → arrhythmias

Monitor for these signs and symptoms and report them to the health care
provider early!

Risk factors for toxicity

● Clients with hypokalemia (K<3.5)
○ **If your client is on a loop diuretic and digoxin, they are more likely to become toxic!**
○ Licorice extract acts like aldosterone (Na/water retention & K loss) → hypokalemia → Dig
toxicity. Licorice extract is in black licorice.
● Clients with hypomagnesemia (Mg<1.8)
● Clients with hypercalcemia (Ca>10.5)
● The elderly!
○ These clients have decreased renal and liver function, making it harder for them to clear any
drugs, so digoxin levels can build up and become toxic more quickly!

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Important Nursing Consideration
When should you HOLD your digoxin dose??

In general, if the pulse is less than 60, you should hold digoxin. This will be
slightly different in different age groups. Always check your order!

Antidote: digoxin immune fab

NCLEX Question
A nurse is caring for a client receiving digoxin. The client’s most recent serum
digoxin level was 2.5 ng/mL. Which of the following essential nursing actions
should the nurse take? Select all that apply.

A. Withhold the client’s scheduled dose

B. Administer the dose as prescribed
C. Assess the client's urinary output
D. Assess the client's most recent sodium level
E. Assess the client’s heart rate and rhythm

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Answer: A and E
The client’s digitalis level of 2.5 ng/mL is indicative of toxicity. Digoxin has a narrow therapeutic index, which
means it can cause significant side effects, such as cardiac arrhythmias (e.g., bradycardia, heart block, ventricular
arrhythmias), even at plasma concentrations only twice the therapeutic plasma concentration range. Normal
corrective serum digoxin levels range from 0.5 - 2 ng/mL. A level higher than two ng/mL is considered toxic. The
nurse is correct to withhold the scheduled dose (Choice A) and assess the client’s heart rate and rhythm (Choice
E) as the client is likely to be experiencing bradycardia.

Choice B, C, D, and F are incorrect. It would be wrong to administer the next dose, as this would exacerbate the
toxicity. An assessment of the urinary output and sodium is not relative to digitalis toxicity and is not the priority
here. Calling the physician to notify regarding the toxic level is appropriate, but there is no reason to obtain a 2D
echocardiogram. A 2D echocardiogram will not add any additional information at this point. Instead, an
electrocardiogram must be obtained to look for any rhythm disturbances due to digoxin toxicity.

Critical Care Medications

● Inotropes: increase the contractility of your heart
○ Dopamine
○ Dobutamine
○ Milrinone
● Vasopressors (vasoconstrictors): cause constriction of the blood vessels,
helping to increase the blood pressure
○ Norepinephrine
○ Epinephrine
○ Vasopressin
○ Phenylephrine

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Intravenous
access

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Central Venous Catheter (CVC)
● IJ
● PICC
● Hickmann
● Broviac
● TT

Part III:
Cardiac Disorders

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Diseases of the Veins
● Chronic venous insufficiency/PVD
● Deep venous thrombosis
● Superior vena cava syndrome

Peripheral vascular disease

● Inadequate venous return over a long period
● Causes pathologic ischemia
○ Blood flow back to the heart is affected
○ Brown discoloration
○ Uneven wound edges around ankle
○ Swelling
○ Pedal pulse IS present
● Treatment
○ Elevate legs
○ Focus on proper wound care

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Deep Vein Thrombosis (DVT)
● Thrombus - A clot that remains attached to the vascular wall
● Causes
○ Venous stasis
■ Immobility
■ Age
■ LHF
○ Vein wall damage
○ Hypercoagulable states
■ Pregnancy, oral contraceptives, malignancy
● Prevention
○ Assess at-risk individuals
○ Promote venous return
■ SCD’s, ted hose, encourage mobility
● Treatment
○ Anticoagulants

Superior Vena Cava Syndrome

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Diseases of the Arteries
● Atherosclerosis
● Hypertension
● Orthostatic (postural) hypotension
● Aneurysm
● Embolism
● Peripheral arterial disease
● Coronary artery disease
● Chronic stable angina
● Acute coronary syndromes
○ Unstable angina
○ Myocardial infarction

Atherosclerosis
● Inflammatory disease
● Begins with endothelial injury
● Evolves into a fibrotic plaque
● Plaques build up and decrease blood flow to the areas they are located
● Plaques can rupture and cause:
○ Thrombosis
○ Vasoconstriction
○ Ischemia
● Most common cause of coronary artery disease and cerebrovascular
disease

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Hypertension

Assessment
● Often asymptomatic until severe
● Vision changes
● Headaches
● Dizziness
● Nosebleeds
● SOB
● Angina

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Complications
● Stroke
● MI
● Renal Failure
● Heart Failure
● Vision loss

34
 Treatment & Education
● Medications
○ ACE inhibitors
○ Beta Blockers
○ CCB
○ Diuretics
● Diet
○ DASH
○ Low salt
○ Avoid caffeine and alcohol
○ Weight loss
○ Smoking cessation
● Lifestyle
○ Less sitting more walking

NCLEX Question
A hypertensive client has prescribed antihypertensive medication. The client tells a clinic
nurse that they prefer to take an herbal substance to help lower their blood pressure.
Which is the most appropriate response for the nurse?

A. Tell the client that herbal substances are unsafe and should never be used
B. Encourage the client to discuss the use of herbal substances with their primary
healthcare provider
C. Teach the client how to take their blood pressure and ask them to monitor it every
fifteen minutes
D. Tell the client that if they take the herbal substance, it will require the nurses to check
their blood pressure closely
E. Tell the client that the herbal substance is a better alternative to the prescribed
antihypertensive medication

35
Answer: B
The most appropriate response is B. Although the use of herbal substances may have some beneficial effects,
not all herbs are safe to use. Clients who are on conventional medication therapy are discouraged from using
herbal materials with similar pharmacological effects because the combination may lead to an excessive reaction
of unknown interaction effects. The nurse would advise the client to discuss the use of the herbal substance with
their primary healthcare provider.

Options A, C, D, and E are inappropriate nursing actions.

Option E is incorrect because it contradicts established medical knowledge and best practices. The use of herbal
substances as a substitute for prescribed antihypertensive medication is not supported by scientific evidence. In
fact, it can be dangerous to rely solely on herbal substances for managing hypertension, as their efficacy and
safety are not well-regulated or studied. Health professionals generally discourage the use of unverified herbal
remedies as a primary treatment for hypertension. It is important to promote evidence-based practices and
encourage clients to discuss any complementary or alternative therapies with their primary healthcare provider
to ensure proper management of their condition.

Orthostatic hypotension
● BP drop that occurs when the client changes from lying, to sitting, to standing
● Client may faint
● Falls can cause serious injury

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Aneurysms
● Localized dilation of a vessel wall Abdominal Aortic Aneurysm (AAA)
○ Most common - aorta
● Most common
● Causes
● Abdominal, back pain
○ Atherosclerosis
○ HTN ● Gnawing/sharp pain
○ Smoking Thoracic Aortic Aneurysm
○ Family history ● Shortness of breath
● Hoarseness/struggling with swallow
● Back pain
Rupture -
● Life threatening
● Severe pain
● Do not palpate pulsating mass

Embolism
● Embolus - clot that dislodges and is mobile and can occlude the vasculature
● Can be made of many substances
○ Air
○ Bacteria
○ Fat
○ Blood clot
○ Amniotic fluid
● At-risk clients:
○ Pregnancy
■ Hypercoagulable - can form a thrombus that dislodges and causes embolism
■ Amniotic fluid can be forced into the bloodstream during labor causing an
embolism
○ A-fib
■ Clot can form in the blood pooling in the atria and be dislodged
○ Long bone fracture
■ Fat can be released from the bone marrow after trauma

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 Air embolism
● Air embolism:
○ Air bubble enters a vein or artery
○ Very rare
○ Complication of surgical procedure
■ High risk: placement of CVC or arterial catheter
● If your client suddenly desaturates during one of these procedures - suspect an
air embolism!
● Positioning:
○ Durant’s maneuver
■ Left lateral trendelenburg
○ This should prevent an air embolism from lodging in the lungs - will stay in the right heart

Fat embolism
Symptoms:
▪ Hypoxia
▪ Dyspnea
▪ Tachypnea
▪ Confusion
▪ Altered level of consciousness
▪ Petechial rash (does not always
occur)

Associated with orthopedic fractures

such as long bone and pelvic fractures

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Peripheral Arterial Disease
● Atherosclerosis of arteries that perfuse the limbs
○ Especially the lower extremities
● Causes decreased perfusion to the lower extremities
● Assessment findings:
○ Pallor
○ Pulselessness
○ Hairlessness
○ Intermittent claudication
■ Pain that occurs in legs when walking
■ Pain gets better with rest
● Treatment
○ Dangle legs
○ Antiplatelet therapy

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Coronary Artery Disease
● Occlusion of the coronary arteries
● Most often results from atherosclerotic plaques
● Risk factors:
○ Advanced age
○ Hypertension
○ Dyslipidemia
○ Smoking
○ Obesity
○ Sedentary lifestyle
● Can cause myocardial ischemia
○ Chronic stable angina - reversible

Chronic Stable Angina

● Chronic disease caused by
narrowing of coronary arteries and
plaque build up
● There are periods of decreased
blood flow to the heart muscle
● Decreased blood flow leads to
decreased oxygen and ischemia
● Ischemia causes chest pain
● Pain is predictable and goes away
with rest or nitroglycerin

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Treatment
● Nitroglycerin
○ Venous and arterial dilation → decreased afterload → increased CO
○ Given sublingual
○ Administer 1 pill q5 minutes for 3 doses
○ Do not swallow
○ Keep in a dark bottle in dry, cool place
○ Expected side effect = headache

Education
● DECREASE THE WORKLOAD OF THE HEART!
○ Rest
○ Do not overeat
○ No caffeine
○ Avoid temperature extremes
○ No smoking
○ Promote weight loss
○ Reduce stress

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Unstable Angina
● Pain DOES NOT go away with rest or nitroglycerin
● Reversible myocardial ischemia
● If not treated very quickly, will progress to a myocardial infarction

Myocardial infarction
● Prolonged decreased blood flow to the heart results in irreversible damage
to the muscle of the heart
● Goal is to act quickly and limit the damage
● Subendocardial infarction
○ No ST-segment elevation
○ Non-STEMI
● Transmural infarction
○ ST-segment elevations on EKG
○ STEMI
○ Require immediate intervention

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Assessment
● Chest pain
○ Crushing
○ Radiating to left arm or jaw
○ Between shoulder blades
● Epigastric discomfort/indigestion
● Fatigue
● SOB
● Vomiting
● Elevated troponin

Treatment
● Cath lab within 90 minutes for PCI
○ Especially important if it’s a STEMI!
● ON-TIME
○ O: Oxygen
○ N: Nitroglycerin
○ T: Thrombolytics (if appropriate)
○ I: Antiplatelets (e.g., aspirin or other medications)
○ M: Monitoring and Medical care
○ E: EKG to assess heart activity

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Education
● Quit smoking
● Diet
○ Low fat
○ Low salt
○ Low cholesterol
● Exercise
○ Avoid isometric exercises
○ Walking is a good choice

NCLEX Question
A 45-year-old man is rushed to the ER with reports of substernal chest pain and
diaphoresis. Cardiac troponin levels were taken and found to be elevated. The ER
nurse understands that nursing interventions would focus on which priority?

A. Increase oxygenation to the heart and reduce the heart’s workload

B. Prevent complications and confirm a diagnosis of myocardial
infarction
C. Alleviate the client's anxiety
D. Pain relief
E. Provide emotional support and distraction techniques

44
Correct answer: A
A is correct. The client is showing signs and symptoms of myocardial infarction. The priority for nursing care
should be focused on increasing oxygen delivery to the heart and reducing its workload to prevent further
damage.

B is incorrect. Confirming the diagnosis should be done; however, since the client is already exhibiting signs of
reduced myocardial oxygenation (chest pain), the nurse should prioritize oxygen delivery to the client.

C is incorrect. It is the nurse’s responsibility to alleviate the client’s anxiety; however, the nurse should prioritize
oxygenation to the client.

D is incorrect. Pain relief should be important in the care of the client with myocardial infarction; however, it
should not take priority over myocardial oxygenation.

E is incorrect: While emotional support and distraction techniques may be beneficial in alleviating the client's
anxiety, they do not address the primary priority in a case of suspected myocardial infarction (MI). The priority
should be focused on immediate interventions that can help stabilize the client’s condition and minimize cardiac
damage.

Disorders of the heart wall

● Pericarditis
● Pericardial effusion
● Cardiomyopathies
○ Dilated
○ Restrictive
○ Hypertrophic
● Valve disorders
● Endocarditis

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Pericarditis
● Inflammation of the pericardium
● Causes
○ Infection
○ Tumor
○ Drugs
● Assessment findings
○ Sharp chest pain
○ Tachypnea
○ Fever, chills
○ Weakness
● Treatment
○ NSAIDs

Pericardial Effusion
● Collection of fluid in the pericardial sac
● Impairs cardiac function if severe
○ Obstructive cardiogenic shock
● Assessment findings
○ Chest pain
○ Muffled heart sounds
● Treatment
○ Pericardiocentesis

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 Cardiac tamponade
● Blood, fluid, or exudate have leaked into pericardial sac
● Causes: MVC, R ventricular biopsy, pericarditis, CABG

Assessment

● Chest pain
● Shortness of breath
● Decreased CO
● Muffled/distant heart sounds
● JVD
● Narrowed pulse pressure (<40)

Treatment - pericardiocentesis and surgery!

Cardiomyopathies
● Disease of the myocardial tissue
○ Dilated
○ Restrictive
○ Hypertrophic

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Disorders of the heart valves
Types of heart valves Stenosis

● Tricuspid Narrowing, blocks blood flow

● Mitral
Regurgitation
● Aortic
● Pulmonic Valves don’t close properly causing backflow

Endocarditis
● Infection and inflammation of the endocardium
○ Valves
● Can lead to:
○ Valve abnormalities
■ Stenosis
■ Regurgitation
○ Poor cardiac output
○ Bacteremia
○ Bacterial emboli
● Treatment:
○ Antibiotics

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 Complications of Heart
Disease

Dysrhythmias
● Dysrhythmia = Arrhythmia
○ Disturbance of heart rhythm
● Range in severity from occasional missed beats or rapid beats to disturbances
that impair myocardial contractility and are life-threatening
● Caused by:
○ SA node generates abnormal rate
○ Impulse is not conducted properly.
Arrhythmias:
● Sinus Bradycardia ● Supraventricular Tachycardia (SVT)
● Sinus Tachycardia ● V-tach
● Heart Blocks ● V-fib
● A-fib
● A-flutter

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Heart failure
The inability of the heart muscle to pump enough blood to meet the body's
needs for blood and oxygen

● Often results as a complication of other diseases

● #1 cause of HF is hypertension
● Other causes:
○ Cardiomyopathy
○ Endocarditis
○ MI
● Two types: Left and Right

Left-sided Heart Failure

Left side of the heart cannot move blood forward to the body.

Blood is backing up in the LUNGS.

Assessment:

● Pulmonary congestion
● Wet lung sounds
● Dyspnea
● Cough
● Blood tinged sputum
● S3
● Orthopnea

50
Right Heart Failure
Right side of the heart cannot move blood forward to the lungs.

Blood is backing up in the BODY.

Assessment:

● Jugular venous distention

● Dependent edema
● Hepatomegaly
● Splenomegaly
● Ascites
● Weight gain
● Fatigue
● Anorexia

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Treatment
● DECREASE THE WORKLOAD OF THE HEART!
● Primary strategy is to decrease afterload:
○ ACE Inhibitors
■ Arterial dilation→ decreased afterload → increased stroke volume
○ ARBs
■ Decrease BP → decreased afterload → increased CO
● Increase contractility
○ Digoxin
● Diuresis
○ Client needs help reducing excess fluid

52
Education
● Take diuretic medications in the AM
● Monitor electrolyte levels while on diuretics
● Low sodium diet
○ This helps decrease fluid
● Elevate the HOB
○ Will help with diuresis
● Daily weight
○ Same time
○ Same scale
○ Same clothes
● Report rapid weight gain (3 lb in a week or 1-2 lb overnight)

NGN Practice

53
The nurse cares for a 56-year-old in the emergency department experiencing
epigastric pain, shortness of breath, and dizziness.

Nurses’ Notes
1900 – A 56-year-old female presents to the emergency department (ED) with reports of epigastric
pain, shortness of breath, and dizziness. The client reports that the symptoms started eight hours
ago and have progressively worsened. The client arrives pale and diaphoretic. The client has a
medical history of type II diabetes mellitus and stated that her blood glucose has been ‘very high.’
The blood glucose was taken, and it was 110 mg/dL.

Which five (5) client findings require follow-up by the nurse?

a. Reports of epigastric pain

b. Blood glucose of 110 mg/dL
c. History of diabetes mellitus type II
d. Reports of shortness of breath
e. Progressive worsening of symptoms
f. Reports of dizziness
g. Pale skin and diaphoresis

54
 Which five (5) client findings require follow-up by the nurse?

a. Reports of epigastric pain

b. Blood glucose of 110 mg/dL
c. History of diabetes mellitus type II
d. Reports of shortness of breath
e. Progressive worsening of symptoms
f. Reports of dizziness
g. Pale skin and diaphoresis

The nurse cares for a 56-year-old in the emergency department

experiencing epigastric pain, shortness of breath, and dizziness.

What statement by the nurse would help interpret the findings?

a. Why did you wait to come to the emergency department?

b. What was your last hemoglobin A1C result?
c. Does the epigastric pain radiate anywhere?
d. When was the last time you were seen by your physician?

55
The nurse cares for a 56-year-old in the emergency department
experiencing epigastric pain, shortness of breath, and dizziness.

What statement by the nurse would help interpret the findings?

a. Why did you wait to come to the emergency department?

b. What was your last hemoglobin A1C result?
c. Does the epigastric pain radiate anywhere?
d. When was the last time you were seen by your physician?

The nurse cares for a 56-year-old in the emergency department

experiencing epigastric pain, shortness of breath, and dizziness. The
client reports that the pain radiates to her arm.

Which problem is the client most likely experiencing?

a. Pancreatitis
b. Acute Coronary Syndrome
c. Peptic Ulcer Disease
d. Esophagitis

56
The nurse cares for a 56-year-old in the emergency department
experiencing epigastric pain, shortness of breath, and dizziness. The
client reports that the pain radiates to her arm.

Which problem is the client most likely experiencing?

a. Pancreatitis
b. Acute Coronary Syndrome
c. Peptic Ulcer Disease
d. Esophagitis

The nurse cares for a 56-year-old in the emergency department

experiencing epigastric pain, shortness of breath, and dizziness.
Nurses Notes’ Vital Signs Diagnostic Tests
o o
1900 – A 56-year-old female Oral temperature 99.0 F (37 C); Pulse 119 12-Lead Electrocardiogram –
presents to the emergency bpm; Respirations 22; BP 92/58 mm Hg; O2 Rate: 112 beats-per-minute
department (ED) with reports of saturation 91% on room air. Rhythm: Sinus Tachycardia with
epigastric pain, shortness of ST elevations
breath, and dizziness. The client
reports that the symptoms
started eight hours ago and has
progressively worsened. The
client arrives pale and
diaphoretic. The client has a
medical history of type II
diabetes mellitus and stated that
her blood glucose has been ‘very
high.’ The blood glucose was
taken, and it was 110 mg/dL.

57
The nurse obtains vital signs and a 12-lead electrocardiogram.
For each possible intervention, click to specify if it is indicated or not indicated.

Intervention Indicated Not Indicated

Establish continuous cardiac monitoring

Obtain a prescription for albuterol via

nebulizer

Establish intravenous (IV) access

Prepare the client for a chest computed

tomography (CT) scan

Apply supplemental oxygen

The nurse obtains vital signs and a 12-lead electrocardiogram.

For each possible intervention, click to specify if it is indicated or not indicated.

Intervention Indicated Not Indicated

Establish continuous cardiac monitoring x

Obtain a prescription for albuterol via x
nebulizer

Establish intravenous (IV) access x

Prepare the client for a chest computed x
tomography (CT) scan

Apply supplemental oxygen x

58
The physician provides orders for the nurse. The nurse obtains
assistance from a licensed practical/vocational nurse (LPN/VN).
Click to specify which physician order should or should not be delegated to the licensed practical/vocational
nurse (LPN/VN).

Physician Order Delegate Do Not Delegate

Administer 325 mg Aspirin PO

Titrate nitroglycerin via intravenous

infusion

Clip the groin area

Obtain the client’s medication history

The physician provides orders for the nurse. The nurse obtains
assistance from a licensed practical/vocational nurse (LPN/VN).
Click to specify which physician order should or should not be delegated to the licensed practical/vocational
nurse (LPN/VN).

Physician Order Delegate Do Not Delegate

Administer 325 mg Aspirin PO x

Titrate nitroglycerin via intravenous x

infusion

Clip the groin area x

Obtain the client’s medication history x

59
The nurse cares for a 56-year-old female in the intensive care unit after being diagnosed
with acute coronary syndrome.

The nurse assesses the client two hours after undergoing percutaneous coronary
intervention (PCI) with access in the femoral artery.

Nurses’ Note Vital Signs Laboratory

2200 – Client was restless and feeling Oral temperature 97.0o F (36o C); Capillary Blood Glucose

‘not good’. The femoral catheter site Pulse 120 bpm; Respirations 19; 197 mg/dL

remained clean and dry. Extensive BP 100/67 mm Hg; O2 saturation

bruising noted over the flank area with 95% on room air. Reference Range

some induration. Reported no pain. Vital < 200 mg/dL for random

signs obtained and the primary level

healthcare provider was notified.

Drag one (1) condition and two (2) assessment findings to complete the
sentence.

The client may is showing early signs of __________________ based on the

_______________ and ________________.

Conditions Assessment Findings

diabetic ketoacidosis heart rate
shock blood glucose
myocardial infarction blood pressure
atrial fibrillation restlessness

60
Drag one (1) condition and two (2) assessment findings to complete the
sentence.

The client may is showing early signs of __________________ based on the

_______________ and ________________.

Conditions Assessment Findings

diabetic ketoacidosis heart rate
shock blood glucose
myocardial infarction blood pressure
atrial fibrillation restlessness

61