NURSING INTERVENTION FOR

PATIENTS WITH CARDIOVASCULAR

DISORDERS

20/06/2024 By Workineh (Msc,AHN) 1

 ASSESSMENT OF CARDIOVASCULAR
FUNCTION
Objectives

• Describe the structure and function of the

cardiovascular system

• Demonstrate the proper techniques to perform a

comprehensive cardiovascular assessment.

• Discriminate between normal and abnormal

assessment findings

• Identify diagnostic tests and methods of

hemodynamic monitoring
20/06/2024 By Workineh (Msc,AHN) 2
 • Overview of Anatomy and Physiology

• Three layers: • Semilunar valves: aortic

Endocardium, and pulmonic
Myocardium,
• Coronary arteries
Epicardium
• Cardiac conduction
• Four chambers: Right
system
atrium and ventricle, left
(electrophysiology)
atrium and ventricle
• Cardiac hemodynamics
• Atrioventricular valves:
tricuspid and mitral

20/06/2024 By Workineh (Msc,AHN) 3

• Heart Wall, Chambers, and Valves
 Heart wall has numerous layers
➢ Pericardium: tough, fibrous, double-walled sac
that surrounds and protects heart
➢ Myocardium: muscular wall of heart; it does
pumping
➢ Endocardium: thin layer of endothelial tissue
that lines inner surface of heart chambers and
valves
 Each side of the heart has an atrium and ventricle

➢ Atrium: thin-walled reservoir for holding blood

➢ Ventricle: thick-walled, muscular pumping
chamber

20/06/2024
4 By Workineh (Msc,AHN)
Heart Chambers and Valves…
 Four chambers separated by valves, whose
main purpose is to prevent backflow of
blood
➢Valves are unidirectional: can only open
one way
➢Valves open and close passively in
response to pressure gradients in moving
blood
 Four valves in heart

➢Two atrioventricular (AV) valves

➢Two semilunar (SL) valves

20/06/2024
5 By Workineh (Msc,AHN)
• AV Valves
 Two AV valves separate atria and ventricles
➢ Tricuspid valve: right AV valve
➢ Bicuspid, or mitral valve: left AV valve
➢ AV valves open during heart’s filling phase, or
diastole, to allow ventricles to fill with blood
➢ During pumping phase, or systole, AV valves
close to prevent regurgitation of blood back up
into atria

20/06/2024
6 By Workineh (Msc,AHN)
• SL Valves
 SL valves are set between ventricles and
arteries
➢Each valve has three cusps that look like
half moons
➢Pulmonic valve: SL valve in right side of
heart
➢Aortic valve: SL valve in left side of heart
• Open during pumping, or systole, to
allow blood to be ejected from heart
20/06/2024
7 By Workineh (Msc,AHN)
• Anatomy of the Heart

20/06/2024 By Workineh (Msc,AHN) 8

• Greater Vessels, Heart Chambers and
Pressures

20/06/2024 By Workineh (Msc,AHN) 9

 • Cardiac Conduction System:
Electrophysiology
• Sinoatrial (SA) node (the primary
pacemaker of the heart), Located near the
superior vena cava in the right atrium.
• Atrioventricular (A V) node (the secondary
pacemaker of the heart)

• The bundle of His: conducts impulses to the

right and the left ventricles

• Purkinje fibers : conduct impulses throughout

the thick walls of the
20/06/2024 ventricles
By Workineh (Msc,AHN) 10
• The electrical impulses initiated by the SA
node are conducted along the myocardial
cells of the atria via internodal pathways
causes electrical stimulation and subsequent
contraction of the atria.

• Then the impulses are conducted to the

A V node

• After a slight delay (allowing the atria

time to contract and complete ventricular
filling)
20/06/2024 relays the impulse to the ventricles. 11
By Workineh (Msc,AHN)
• The impulse conducted through the bundle
of His

• Impulses travel through the bundle branches

to reach the Purkinje fibers that rapidly
conduct impulses throughout the thick walls
of the ventricles

• This action stimulates the ventricular

myocardial cells to contract

20/06/2024 By Workineh (Msc,AHN) 12

 • Cardiac Conduction System…

(60-100)

(40-60)

(30-40)

(30-40)

Fig20/06/2024
ure 25-3 By Workineh (Msc,AHN) 13
 • Cardiac Action Potential
• Depolarization: electrical activation of cell
caused by influx of sodium into cell while
potassium exits cell
• Repolarization: return of cell to resting state
caused by reentry of potassium into cell while
sodium exits
• Refractory periods
• Myocardial cells must completely repolarize
before they can depolarize again.
• Effective refractory period: phase in which
cells are incapable of depolarizing
• Relative refractory period: phase in which
cells require stronger-than-normal stimulus
to depolarize
20/06/2024 By Workineh (Msc,AHN) 14
Cardiac Action Potential Cycle

Figure 21-4
20/06/2024 By Workineh (Msc,AHN) 15
Cardiac Conduction System Cont’d….
With cell stimulation, ion channels open

Sudden influx of sodium and/or calcium
ions

Reversing the resting potential

Depolarization (electrical activation of
the cell): Phase 0

20/06/2024 By Workineh (Msc,AHN) 16

Cardiac Conduction System
Cont’d….
Simultaneously, potassium channels open: K+
move out: Phase 1 (Repolarization)

Sustained Inward Ca2+ flow with K+ out :
Phase 2 Plateau

Intracellular potassium to diffuse outward while
sodium ions are actively pumped out: Phase 3

Reestablishment of a positive charge to the
outside of the membrane

Called repolarization

Returns the membrane to its resting membrane
potential
20/06/2024 By Workineh (Msc,AHN) 17
 • Cardiac Cycle
• Refers to the events that occur in the heart
from the beginning of one heartbeat to the
next

• Number of cycles depends on heart rate

• Each cycle has three major sequential events:

• Diastole
• Atrial systole
• Ventricular systole
20/06/2024 By Workineh (Msc,AHN) 18
 • Cardiac Output
• Stroke volume(SV): amount of blood ejected with each
heartbeat
• average 60 to 130 mL
• determined by three factors:
• Preload: degree of stretch of cardiac muscle fibers
at end of diastole
• After load: resistance to ejection of blood from
ventricle
• There is an inverse relationship b/n afterload
and SV.
• Contractility: ability of cardiac muscle to shorten in
response to electrical
20/06/2024 impulse
By Workineh (Msc,AHN) 19
 Cardiac Output (cont.)
• Ejection fraction: percent of end-diastolic volume
ejected with each heartbeat (left ventricle)

• The normal ejection fraction is 55% to 65%.

• SV/End diastolic volume

• Cardiac output (CO): the amount of blood

pumped by ventricle in liters per minute

• CO in resting adult is 4 to 6 L/min but varies

depending on the metabolic needs.

• CO = SV × HR
20/06/2024 By Workineh (Msc,AHN) 20
• Influencing Factors

• Control of heart rate

• Autonomic nervous system, baroreceptors

• Control of stroke volume

• Preload
• Afterload: affected by systemic vascular
resistance, pulmonary vascular resistance

20/06/2024 By Workineh (Msc,AHN) 21

 • Contractility

• Contractility increased by catecholamines,

SNS, certain medications
• Increased contractility results in increased
stroke volume
• Decreased by hypoxemia, acidosis, certain
medications

20/06/2024 By Workineh (Msc,AHN) 22

Question

Which of the following best defines preload?

A. The amount of blood ejected with each
heartbeat
B. Amount of blood pumped by the ventricle in
liters per minute
C. Degree of stretch of the cardiac muscle fibers
at the end of diastole
D. Ability of the cardiac muscle to shorten in
response to an electrical impulse

20/06/2024 By Workineh (Msc,AHN) 23

 • ASSESSMENT OF CVS FUNCTION
• Health History

• Demographic information

• Family/genetic history

• Cultural/social factors

• Risk factors

• Modifiable (smoking, hypertension, high cholesterol,

diabetes, obesity ,physical inactivity)

• Nonmodifiable (age, gender, heredity , race)

20/06/2024 By Workineh (Msc,AHN) 24

 • Assessment of the CV System
Health History
• Common symptoms
• Chest pain/discomfort
• Pain/discomfort in other areas of the upper body
• SOB/dyspnea
• Peripheral edema, weight gain, abdominal
distention
• Palpitations
• Unusual fatigue, dizziness, syncope, change in
LOC
20/06/2024 By Workineh (Msc,AHN) 25
 • Past Health, Family, and Social
History
• Medications
• Nutrition
• Elimination
• Activity, exercise
• Sleep, rest
• Self-perception/self-concept
• Roles and relationships
• Coping and stress

20/06/2024 By Workineh (Msc,AHN) 26

 • Physical Assessment of CV System
• General appearance
• Skin and extremities
• Pulse pressure
• Blood pressure; orthostatic changes
• Arterial pulses
• Jugular venous pulsations
• Heart inspection, palpation, auscultation
• Assessment of other systems

20/06/2024 By Workineh (Msc,AHN) 27

 ❖ Heart sounds

➢The 1st heart sound (S1) occurs with closure of AV

valves and thus signals the beginning of systole

➢You can hear S1 over all the pericardium but usually it

is loudest at the apex.

➢The second heart sound (S2) occurs with closure of the

semilunar valves and signals the end of systole.

➢S2 is loudest at the base.

20/06/2024 By Workineh (Msc,AHN) 28

 Extra heart sound

Third heart sound (S3 gallop)

➢Normally diastole is a silent event.

➢How ever in some conditions, ventricular filling creates

vibration that can be heard over the chest.

➢These vibration are S3.

➢S3 occurs when the ventricles are resistant to filling

during the early rapid filling phase (protodiastole).

➢This occurs immediately after S2 when the Av valves

open and atrial blood first pours in to the ventricle.
20/06/2024 By Workineh (Msc,AHN) 29
 Cont’d

Fourth heart sound (s4)

➢S4 occurs at the end of diastole at pre-systole when

ventricle is resistant to filling.

➢The atria contract and pushes blood in to a non

compliant ventricle.

➢This creates vibrations that are heard as S4

➢S4 occurs just before S1.

20/06/2024 By Workineh (Msc,AHN) 30

 Cont’d
Murmur

➢Blood circulation through normal cardiac chambers

and valves usually makes no noise.

➢However, some conditions create turbulent blood flow

that result in a murmur.

➢A murmur is a blowing, swooshing sound, which can

be heard on the chest wall.

20/06/2024 By Workineh (Msc,AHN) 31

 Cont’d

Conditions resulting in murmur include:

➢Velocity- of blood increases as in exercise,

thyrotoxicosis

➢Viscosity of blood decrease as in anemia

➢Structural defects in the valve

20/06/2024 By Workineh (Msc,AHN) 32

 Objective data

The neck vessels:

1. The carotid arteries

➢palpate each carotid arteries medial to the

sternomastiod muscle in the lower third of the neck.

➢Excessive vagal stimulation here could slow down the

heart rate and palpate gently.

20/06/2024 By Workineh (Msc,AHN) 33

 Cont’d

➢Palpate only one carotid at a time to avoid

compromising arterial blood to the brain.

➢ Feel the contour and amplitude of the pulse.

➢Normally the contour is smooth and the normal

stroke is 2+ or moderate.

➢Your finding should be the same bilaterally.

➢Diminished pulse fells small and weak occurs with

decreased stroke volume.
20/06/2024 By Workineh (Msc,AHN) 34
 Cont’d

Auscultate the carotid artery:

➢For persons older than middle age or who show

symptoms or signs of cardiovascular disease,
auscultate each carotid artery for the presence of bruits

➢This is blowing, swishing sound indicating blood flow

turbulence; normally there is none

➢Ask the person to hold his or her breath while you

listen so that tracheal sounds do not mask or mimic a
carotid artery bruit

20/06/2024 By Workineh (Msc,AHN) 35

 Cont’d

2. The jugular vein

➢From the jugular vein you can asses the central venous
pressure(CVP) and thus the heart efficiency as pump.
➢Although the external jugular vein is easier to see, the
internal (esp. the right) is attached more directly to
the superior venacava and thus is more reliable for
assessment.
➢You can not see the internal jugular vein it self but you
can see its pulsation.

20/06/2024 By Workineh (Msc,AHN) 36

 Cont’d

➢ Position the person any where from a 30-45 degree

angle, where ever you can best see the pulsations.

➢Turn the person’s head slightly away from the examined

side.

➢Note the external jugular vein overlying the

sternomastoid muscle

20/06/2024 By Workineh (Msc,AHN) 37

 Cont’d

➢In some persons, the veins are not visible at

all; where as in others, they are full in the
supine position.

➢As the person is raised to a sitting position,

these external jugulars flatten and disappear,
usually at 45 degree.

➢Full distention of external jugular veins above

45 degree signify increased CVP.
20/06/2024 By Workineh (Msc,AHN) 38
 Cont’d

➢Now look for pulsation’s of the internal jugular

vein in the area of the supra sternal notch or
around the origin of the sternomastoid muscle
around the clavicle.

➢You must be able to distinguish internal jugular

vein pulsation from that of the carotid artery.

➢It is easy to confuse because they lie close

together
20/06/2024 By Workineh (Msc,AHN) 39
 The pericardium

Inspect the anterior chest

➢You may or may not see the apical impulse (pulsation

of left ventricle,) when visible it occupies the fourth or
fifth intercostals space at the mid clavicular line.

➢Easier to see in children or those with thinner chest

walls.

Abnormal

➢A heave or lift of the ventricle during systole with

ventricular hypertrophy.
20/06/2024 By Workineh (Msc,AHN) 40
 Cont’d

Palpation

Palpate the apical impulse ( apex beat):

➢Localize the apical impulse precisely using one finger

pad.

➢Asking the person to “exhale and then hold it” aids to

find the pulsation

➢You may need to roll the person midway to the left to

find it

20/06/2024 By Workineh (Msc,AHN) 41

 Cont’d
Note

➢Location - the apical impulse should occupy only one

inter space the fourth or fifth, and be at or medial to
the mid clavicular line

➢Size- normally 1cm X 2cm

➢Amplitude- normally a short gentle taps

➢Duration –short, normally occupies only first half of

systoles.

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 Cont’d

➢The apical impulse is palpable in about half of adults

and not palpable in obese person or persons with
thick chest wall.

➢With high cardiac out put (anxiety fever and anemia)

the apical impulse increase in amplitude and duration.

20/06/2024 By Workineh (Msc,AHN) 43

 Cont’d

Palpate across the pericardium:

➢Using the palmer aspect of your fingers, gently palpate

the apex, the left sternal border and the base
searching for any other pulsation.

➢Normally there are none. If any are present note the

timing.

20/06/2024 By Workineh (Msc,AHN) 44

Cont’d

20/06/2024 By Workineh (Msc,AHN) 45

 Cont’d

Abnormal:

➢A thrill is a palpable vibration. It feels like throat of a

purring cat.

➢It signifies turbulent blood flow and accompanies loud

murmurs

Percussion:

➢Has been used to out line the heart’s borders, replaced

by the chest x- ray study

➢W/c is more accurate in detecting heart enlargement

20/06/2024 By Workineh (Msc,AHN) 46
 Cont’d

➢To search for cardiac enlargement in out patient or at

home, place your stationary finger in the person’s fifth
intercostals space on the left side of the chest near the
anterior axillary line.

➢Slide your stationary hand to ward your self

percussing as you go, and note the change of sound
from resonance over the lung to dull over the heart)

20/06/2024 By Workineh (Msc,AHN) 47

 Cont’d

➢Normally, the left border of cardiac dullness is at the

mid clavicular line in the 5th interspaces and slopes in
to ward the sternum as you progress upward that by
the second interspaces the border of dullness concede
with the left sternal border.

➢The right border of dullness normally matches the

sternal border.

20/06/2024 By Workineh (Msc,AHN) 48

 Cont’d

Auscultation:

➢Identify the auscultatory areas where you will listen.

➢These include the four traditional valve “ areas”.

➢The valve areas are not over the actual anatomic

location of the valves but are the sites on the chest
wall where sounds produced by the valves are best
heard with the direction of blood flow.

20/06/2024 By Workineh (Msc,AHN) 49

 Cont’d

➢Second right inter space – aortic valve area

➢Second left inter space – Pulmonic valve area

➢Left lower sternal border – tricuspid valve area

➢Fifth interspace at around left mid clavicular line-

mitral valve area.

➢Use diaphragm for relatively higher pitched sounds

and the bell for relatively lower pitched sounds.

➢Concentrate, and listen selectively to one sound at

a time.
20/06/2024 By Workineh (Msc,AHN) 50
Placement of Stethoscope to Hear Sounds of
Heart

20/06/2024 By Workineh (Msc,AHN) 51

Cont...

20/06/2024 By Workineh (Msc,AHN) 52

 Cont’d

➢ Begin with the diaphragm end piece and use the following
routine

1. Note the rate and rhythm

2. Identify s1 & s2

3. Assess s1 and s2 separately

4. Listen for extra heart sounds and

5. Listen for murmurs.

❖Note the rate and rhythm the rate ranges normally from 60
to 100 beats/ minutes. The rhythm should be regular

20/06/2024 By Workineh (Msc,AHN) 53

 Cont’d
Abnormal:

➢Premature- beat an early isolated beat or a pattern

occurs early sound every third or fourth beat.

➢Irregular- no pattern to the sounds; beats come

rapidly and at random intervals

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 Cont’d

Identify s1 and s2:

➢S1 is the first pair of lub-dup.

To distinguish s1 from s2

➢S1 is louder than s2 at the apex; s2 is louder than s1

at the base

➢S1 coincides with the carotid artery pulse

➢Feel the carotid gently as you auscultator at the apex;

the sound you hear as you feel each pulse is s1

20/06/2024 By Workineh (Msc,AHN) 55

 Cont’d

➢S1 coincides with the R- wave (the upstroke of

the QRS complex) if the person is on ECG
monitor.

➢Listen to s1 and s2 separately – note whether

each heart sound is normal or diminished.

➢Focus on systole then on diastole and listen for

any heart sounds.

20/06/2024 By Workineh (Msc,AHN) 56

 Cont’d

➢Listen with the diaphragm and then switch to bell

covering all the auscultory area.

➢When you detect an extra heart sound listen carefully is

characteristics and 3rd or 4thheart sound either may be
normal or abnormal.

20/06/2024 By Workineh (Msc,AHN) 57

Cont’d

20/06/2024 By Workineh (Msc,AHN) 58

 Cont’d

Listen for murmurs:

➢A murmur is a blowing swooshing sound that occurs

with turbulent blood flow in the heart or great vessels.

➢If you hear a murmur describe it by indicating these

characteristics

20/06/2024 By Workineh (Msc,AHN) 59

 cont‘d

1. Timing – its occurrence in systole or diastole

2. Loudness – describe the intensity in terms of

six grades
❖ Grade 1- barely audible, heard only in a quite
room and then with difficulty
❖ Grade II- clearly audible but faint
❖ Grade III- moderately loud
❖ Grade IV- loud associated with a trill palpable
on the chest wall
20/06/2024 By Workineh (Msc,AHN) 60
 Cont’d

❖ Grade V- very loud, heard with one corner of the

stethoscope lifted off the chest wall

❖Grade VI- loudest, still heard with entire stethoscope

lifted just off the chest wall

3. Location- describe the area of maximum intensity of

the murmur (where it is best heard) by noting the valve
area or intercostals space

20/06/2024 By Workineh (Msc,AHN) 61

 Cont’d

Change the position:

➢After auscultating in the supine position , roll the

person to ward his or her left side

➢Listen with the bell at the apex for the presence of any
diastolic filling sounds.

➢S3 and s4 and the murmur of the mitral stenosis some

times may be heard only when on the left side

20/06/2024 By Workineh (Msc,AHN) 62

 Cont’d

➢Ask the person to sit up and lean forward slightly

➢Listen with the diaphragm at the base, right and left

side

➢Check for the high pitched diastolic murmur of aortic or

pulmonic regurgitation

➢Murmur of aorta regurgitation sometimes may be

heard only when the person is leaning forward in the
sitting position.

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 • Laboratory Tests
• Cardiac biomarkers (creatine kinase (CK),

CK isoenzymes (CK-MB), and proteins

(myoglobin, troponin T , and troponin I)

• Blood chemistry, hematology, coagulation

• Lipid profile

• Brain (B-type) natriuretic peptide

• C-reactive protein

• Homocysteine
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❖ Electrocardiography

• 12-lead ECG
• Continuous monitoring
• Hardwire using one or two leads
• Telemetry (wireless)
• Lead systems
• Ambulatory monitoring

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 • Cardiac Stress Testing

• Exercise stress test

• Pt walks on treadmill with intensity
progressing according to protocols
• ECG, V/S, symptoms monitored
• Terminated when target HR is achieved

• Pharmacologic stress testing

• Vasodilating agents given to mimic exercise

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 • Diagnostic Tests

• Radionuclide imaging:
• Myocardial perfusion imaging
• Positron emission tomography (PET)
• Test of ventricular function, wall motion
• Computed tomography (CT)
• Magnetic resonance angiography

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 • Echocardiography

• Noninvasive ultrasound test that is used to:

• Measure the ejection fraction
• Examine the size, shape, and motion of
cardiac structures

• Transthoracic

• Transesophageal

20/06/2024 By Workineh (Msc,AHN) 68

 • Cardiac Catheterization
• Invasive procedure used to diagnose structural and
functional diseases of the heart and great vessels
• Right Heart Catheterization
• Pulmonary artery pressure and oxygen
saturations may be obtained; biopsy of
myocardial tissue may be obtained
• Left Heart Catheterization
• Involves use of contrast agent

20/06/2024 By Workineh (Msc,AHN) 69

 • Nursing Interventions-Cardiac Cath

• Observe catheter site for bleeding, hematoma

• Assess peripheral pulses
• Evaluate temp, color, and cap refill of affected
extremity
• Screen for dysrhythmias
• Maintain bed rest 2 to 6 hours
• Instruct patient to report chest pain, bleeding
• Monitor for contrast-induced nephropathy
• Ensure patient safety

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 • Hemodynamic Monitoring

• Central venous pressure

• Pulmonary artery pressure

• Intra-arterial B/P monitoring

• Minimally invasive cardiac output monitoring

devices

20/06/2024 By Workineh (Msc,AHN) 71

 • Pulmonary Artery Catheter and Pressure
Monitoring System

Figure 25-12
20/06/2024 By Workineh (Msc,AHN) 72
 ❖ Management of Patients with Arrhythmias and
Conduction Problems
• Dysrhythmias: disorders of the formation or
conduction (or both) of the electrical impulses in the
heart
• These disorders can cause disturbances of:
• Rate
• Rhythm
• Both rate and rhythm
• Potentially can alter blood flow & cause hemodynamic
changes
• Diagnosed
20/06/2024
by analysisByof ECG waveform
Workineh (Msc,AHN) 73
 ❖ ELECTROCARDIOGRAM (ECG)
• Electrocardiogram (ECG):a record of a test that
graphically measures the electrical activity of the heart,
including each phase of the cardiac cycle

ECGs can identify

❖ Arrhythmias

❖ Hypertrophy,

❖Conduction blocks

❖Myocardial ischemia and infarctions

20/06/2024 By Workineh (Msc,AHN) 74

ECG cont.…

20/06/2024 By Workineh (Msc,AHN) 75

ECG electrode placements

20/06/2024 By Workineh (Msc,AHN) 76

 Waves, Complexes, and Intervals
Isoelectric line

• The baseline of an ECG tracing

• Denotes resting membrane potentials

• Deflections from this point are lettered in

alphabetical order (P, Q, R, S, T, U)

• Following each deflection, the tracing normally

returns to the isoelectric point

20/06/2024 By Workineh (Msc,AHN) 77

ECG is composed of:

Waveforms
Segments or intervals
➢P wave
➢ PR interval
➢QRS complex
➢ ST segment
➢T wave
➢ QT interval
➢U wave ➢ PP interval

➢ RR interval

20/06/2024 By Workineh (Msc,AHN) 78

ECG

20/06/2024 By Workineh (Msc,AHN) 79

 ECG paper cont.…
Standard ECG recording paper is divided into small and
large squares
Smaller squares = 1mm = 0.04-second intervals
5 small squares = 1 Large square = 0.20 sec
The lines between every 5 smaller boxes are
heavier, so that each 5-mm unit:
➢Horizontally = 0.2 seconds (5 x 0.04 = 0.2)
➢Vertically = 0.5mV
The ECG can therefore be regarded as a moving graph
with 0.04- and 0.2-second divisions

20/06/2024 By Workineh (Msc,AHN) 80

ECG cont.…

20/06/2024 By Workineh (Msc,AHN) 81

Summary of events of a cardiac cycle
Of the 8 physiologic events only 3 are
visible

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 Analysis of the ECG
ECG Paper

Most ECG monitors are equipped with optional

printers that can generate a gridded printout if
desired

As the stylus of the recording device is deflected by

electrical currents, the recording paper is moving at a
speed of 25 mm/s

➔ ECG tracing whose components can be measured

20/06/2024 By Workineh (Msc,AHN) 83

 Analysis of ECG Cont’d…
P wave
The first deflection
Represents depolarization of atrial muscle
cells
Does not represent contraction of atrial muscle,
nor firing of the SA node but, these events are
deduced based on the shape and consistency
of the P waves
Although atrial repolarization follows
depolarization, the ECG provides no evidence
of this event
Normally <= 2.5 mm in height and <= 0.11
sec (2.75mm)
20/06/2024 By Workineh (Msc,AHN) 84
 Analysis of ECG Cont’d…
PR interval

Measured from the beginning of the P wave to the

beginning of the R portion of the QRS complex

Starts with atrial muscle depolarization and ends

with the start of ventricular depolarization

❖The electrical impulse passes through the AV

node into the ventricle during this interval

Represents the time needed for SA node

stimulation, atrial depolarization, and conduction
through the AV node before ventricular
depolarization
20/06/2024 By Workineh (Msc,AHN) 85
 Analysis of ECG Cont’d…
Normally ranges from 0.12 to 0.20 seconds
(3 to 5 small boxes) in duration.
Prolonged PR interval ➔ AV block

20/06/2024 By Workineh (Msc,AHN) 86

 Analysis of ECG Cont’d…
❖ QRS complex
Represents depolarization of ventricular
muscle cells
➢Q portion is the initial (-ve) downward
deflection
➢R portion is the initial (+ve) upward
deflection
➢S portion is the return to the baseline/
isoelectric point

20/06/2024 By Workineh (Msc,AHN) 87

 Analysis of ECG Cont’d…

QRS does not represent ventricular contraction

One assumes that contraction will commence

at the peak of the R portion of the complex

Unlike contraction of the atria, ventricular

contraction can be confirmed clinically by
palpating a pulse or by monitoring a pulse
oxymetery waveform.

20/06/2024 By Workineh (Msc,AHN) 88

Analysis of ECG Cont’d…
QRS
Range 0.06s – 0.10sec
1.5mm-2.5mm

20/06/2024 By Workineh (Msc,AHN) 89

 Analysis of ECG Cont’d…
T wave

Following depolarization, ventricular muscle

repolarizes, and is with the same direction as
the QRS complex

20/06/2024 By Workineh (Msc,AHN) 90

 Analysis of ECG Cont’d…
PP interval
Measured from the beginning of one P wave
to the beginning of the next p wave.
Used to determine the atrial rhythm and
atrial rate
RR interval
Measured from one QRS complex to the
next QRS complex
Used to determine ventricular rate and
rhythm

20/06/2024 By Workineh (Msc,AHN) 91

 Suggested steps, Cont’d….

Step 1: Is the Rhythm Regular or Irregular?

❖If the intervals between QRS complexes (R-R

intervals) are consistent

➢Regular ventricular rhythm

❖Consistent PP intervals

➢Regular atrial rhythm

20/06/2024 By Workineh (Msc,AHN) 92

 NSR

Atrial Fibrillation
20/06/2024 By Workineh (Msc,AHN) 93
 Suggested steps, Cont’d….
Step 2: Are All QRS Complexes Similar, and
Are They Narrow or Wide?
 Duration of the QRS complex should not exceed
0.10 seconds (2½ small squares)
 Range 0.06s – 0.10sec
 1.5mm-2.5mm
 A widened complex indicates:
➢Ventricular enlargement (hypertrophy)
➢Ventricular depolarization is being initiated by
pacemaker tissue below the AV node, e.g.,
ventricular-paced rhythm.

20/06/2024 By Workineh (Msc,AHN) 94

 ECG

Narrow QRS complexes

The rhythm is being initiated by a pacemaker
at the AV node or higher ➔ supraventricular
rhythm

Second - -Degree AV Block (Mobitz Type I)

20/06/2024 By Workineh (Msc,AHN) 95
ECG

Third degree AV block (complete)

20/06/2024 By Workineh (Msc,AHN) 96

 Suggested steps, Cont’d….
Step 3: Are All P Waves Similar and Are PR
Intervals Normal?
If P waves are all similar, and normal in
shape, one can assume that the SA node is the
primary pacemaker
➔ Sinus rhythm
If P waves vary in shape or are absent
➔Other tissue(s) are functioning as pacers

20/06/2024 By Workineh (Msc,AHN) 97

The PR interval is normally 0.12–0.20
seconds (3–5 small squares).

Longer PR intervals

❖Impulse is being delayed from entering the

ventricles and the condition is designated
AV block

20/06/2024 By Workineh (Msc,AHN) 98

 Step 4: Determining Ventricular Heart
Rate from the ECG
Two Methods
i. If Regular rhythm
Count the number of small boxes within an RR
interval and divide 1500 by that number or
Count larger boxes within an RR interval and
divide 300 by that number
Example
If there are 15 small boxes between two R waves,
the heart rate is 1500 ÷ 15 =100 bpm
If there are 5 large boxes, the heart rate is 300
÷ 5= 60 bpm

20/06/2024 By Workineh (Msc,AHN) 99

 NB: A 1-minute strip contains 300 large
boxes and 1500 small boxes.

20/06/2024 By Workineh (Msc,AHN) 100

 Cont…
ii. If Irregular rhythm
Less accurate method for estimating heart
rate
Count the number of RR intervals in 6
seconds (30 larger boxes) and multiply that
number by 10.
Example:
❖Number of RR intervals in 6 seconds is 7,
so HR= 7x10= 70bpm

20/06/2024 By Workineh (Msc,AHN) 101

NB: The same methods may be used for determining atrial
rate, using the PP interval instead of the RR interval
20/06/2024 By Workineh (Msc,AHN) 102
 Suggested steps, Cont’d….
Step 5: Do Waves and Complexes Proceed
in Normal Sequence?

 Each P wave should be followed by a QRS

complex, which is followed by a T wave.
This assures a normal sequence for each
cardiac cycle.

20/06/2024 By Workineh (Msc,AHN) 103

 Dysthymia cont…
• They are named according to the site of origin of the
impulse and the mechanism of formation or conduction
involved.

• For example, an impulse that originates in the sinoatrial

(SA) node and that has a slow rate is called sinus
bradycardia
Sites of origin
- Sinus node
- Atria
- Av node of junction
- Ventricles
20/06/2024 By Workineh (Msc,AHN) 104
 Normal sinus rhythm
• Occurs when the electrical impulse starts at a regular
rate and rhythm in the SA node and travels through
normal conduction pathway.
ECG criteria
• Ventricular and atrial rate: 60 to 100 adult
✓Ventricular and atrial rhythm: Regular
✓QRS shape and duration: Usually normal, but may
be regularly abnormal
✓P wave: Normal and consistent shape; always in front
of the QRS
✓PR interval: Consistent interval between 0.12 and
0.20 seconds
✓P: QRS ratio: 1:1

20/06/2024 By Workineh (Msc,AHN) 105

Types of Dysrhythmias
Dysrhythmias include
✓sinus node
i. Sinus tachycardia
ii. Sinus bradycardia
iii. Sinus arrhythmia
✓Atrial
➢Premature Atrial Complex
➢Atrial Flutter
➢Atrial Fibrillation

20/06/2024 By Workineh (Msc,AHN) 106

 Type of dysrhythmias cont…
✓Junctional
❑Premature Junctional Complex

❑Junctional Rhythm

❑Atrioventricular Nodal Reentry Tachycardia

✓Ventricular dysrhythmias

❖Premature Ventricular Complex (PVC)

❖Ventricular Tachycardia

❖Ventricular Fibrillation

❖Idioventricular Rhythm

❖Ventricular Asystole
20/06/2024 By Workineh (Msc,AHN) 107
Normal sinus rhythm

20/06/2024 By Workineh (Msc,AHN) 108

 cont`d
1.Sinus node dysrhythmias

A. Sinus bradycardia
- Occurs when sinus node creates an impulse at a
slower-than-normal rate.
❑Causes:-
▪ Lower metabolic needs (eg, sleep, athletic training,
hypothermia, hypothyroidism),
• Vagal stimulation (eg, from vomiting, suctioning,
severe pain, extreme emotions),
• Medications (eg, calcium channel blockers,
amiodarone, beta-blockers),
• Increased intracranial pressure, and myocardial
infarction (MI),
20/06/2024 By Workineh (Msc,AHN) 109
 Sinus bradycardia cont.…
• The following are characteristics of sinus
bradycardia
• Ventricular and atrial rate: Less than 60 in the adult
• Ventricular and atrial rhythm: Regular
• QRS shape and duration: Usually normal, but may be
regularly abnormal
• P wave: Normal and consistent shape; always in front
of the QRS
• PR interval: Consistent interval between 0.12 and 0.20
seconds
• P: QRS ratio: 1:1
20/06/2024 By Workineh (Msc,AHN) 110
 Sinus bradycardia cont.…
Medical Management

• Depends on the cause and symptoms

• If the bradycardia produces s/s , 0.5 mg of atropine

given IV bolus and repeated every 3 to 5 minutes,
maximum dosage of 3 mg

• If the bradycardia is unresponsive to atropine,

medications, such as dopamine, isoproterenol, or
epinephrine, are given

20/06/2024 By Workineh (Msc,AHN) 111

Sinus tachycardia

Sinus bradycardia By Workineh (Msc,AHN)

20/06/2024 112
 cont`d
B. Sinus Tachycardia
- Occurs when the sinus node creates an impulse at a
faster-than-normal rate.
➢Causes
o Acute blood loss, anemia, shock, hypervolemia,
hypovolemia,

o CHF, pain,

o Hyper metabolic states, fever, exercise,

anxiety, or

o Sympathomimetic medications
20/06/2024 By Workineh (Msc,AHN) 113
The ECG criteria for sinus tachycardia
• Ventricular and atrial rate: Greater than 100 in
the adult but usually less 120
• Ventricular and atrial rhythm: Regular
• QRS shape and duration: Usually normal, but may
be regularly abnormal
• P wave: Normal and consistent shape; always in front
of the QRS, but may be buried in the preceding T
wave
• PR interval: Consistent interval between 0.12 and
0.20 seconds
• P:20/06/2024
QRS ratio: 1:1 By Workineh (Msc,AHN) 114
 Medical management
• Abolishing its cause

• Vagal maneuvers (carotid sinus massage, gagging,

forceful and sustained coughing, and applying a cold
stimulus to the face

• Administration of adenosine

• synchronized cardioversion (i.e., electrical current

given in synchrony with the patient’s own QRS complex)

20/06/2024 By Workineh (Msc,AHN) 115

Medical management cont..

• IV beta-blockers (Class II antiarrhythmic)

• Calcium channel blockers (Class IV antiarrhythmic)

20/06/2024 By Workineh (Msc,AHN) 116

 C. Sinus arrhythmia

• Sinus arrhythmia occurs when the sinus

node creates an impulse at an irregular
rhythm; the rate usually increases with
inspiration and decreases with expiration

• Non respiratory causes include heart disease

and valvular disease, but these are rarely seen

20/06/2024 By Workineh (Msc,AHN) 117

 The ECG criteria for sinus arrhythmia
• Ventricular and atrial rate: 60 to 100 in the adult

• Ventricular and atrial rhythm: Irregular

• QRS shape and duration: Usually normal, but may be
regularly Abnormal
• P wave: Normal and consistent shape; always in front
of the QRS
• PR interval: Consistent interval between 0.12 and
0.20 seconds

• P: QRS ratio: 1:1

• Sinus arrhythmia does not cause any significant
hemodynamic effect and usually is not treated
20/06/2024 By Workineh (Msc,AHN) 118
2. Ventricular arrhythmia
• Ventricular arrhythmias originate from foci within the
ventricles

Includes

• Premature ventricular complexes (PVC)

• Ventricular Tachycardia

• Ventricular fibrillation

• Idioventricular rhythms

• Ventricular asystole

20/06/2024 By Workineh (Msc,AHN) 119

 A. Premature ventricular complexes (PVC)
• A PVC is an impulse that starts in a ventricle and is
conducted through the ventricles before the next normal
sinus impulse

• PVCs can occur in healthy people, especially with intake

of caffeine, nicotine, or alcohol

• May be caused by cardiac ischemia or infarction,

increased workload on the heart, digitalis toxicity,
hypoxia, acidosis, or hypokalemia

• The patient may feel nothing or may say that the heart
“skipped a beat”
20/06/2024 By Workineh (Msc,AHN) 120
 ECG criteria for PVC
• Ventricular and atrial rate: Depends on the
underlying rhythm (e.g., sinus rhythm)

• Ventricular and atrial rhythm: irregular

• QRS shape and duration: 0.12 seconds or longer;

shape is bizarre and abnormal

• P wave: may be absent (hidden in the QRS or T wave)

or in front of the QRS

• PR interval: If the P wave is in front of the QRS, the

PR interval is less than 0.12 seconds

• P: QRS ratio: 0:1,1:1

20/06/2024 By Workineh (Msc,AHN) 121
Medical managements
• PVCs that are frequent and persistent may be treated
with amiodarone or beta-blockers, but long-term
pharmacotherapy for PVCs is not usually indicated

20/06/2024 By Workineh (Msc,AHN) 122

 B. Ventricular Tachycardia
• VT is defined as three or more PVCs in a row, occurring
at a rate exceeding 100 bpm

• The causes are similar to those of PVC

20/06/2024 By Workineh (Msc,AHN) 123

 ECG criteria for VT
• Ventricular and atrial rate: Ventricular rate is 100 to
200 bpm; atrial rate depends on the underlying rhythm

• Ventricular and atrial rhythm: Usually regular; atrial

rhythm may also be regular

• QRS shape and duration: 0.12 seconds or longer;

shape is bizarre and abnormal

• P wave: Very difficult to detect

• PR interval: Very irregular, if P waves are seen

• P: QRS ratio: difficult to determine

20/06/2024 By Workineh (Msc,AHN) 124

Medical managements
Non pharmacologic

• CPR should be provided to patients with sustained VT

with cardiac arrest

• O2 via face mask or nasal catheter

• Continuous ECG monitor

• Suction device and endotracheal intubation set should

be ready

• Correct electrolyte disorders Reassure patients with

non-sustained ventricular tachycardia
20/06/2024 By Workineh (Msc,AHN) 125
 Medical managements cont...
• Defibrillation is the treatment of choice for pulseless VT
Pharmacologic
First line
Intravenous amiodarone
Stable VT regimen:
• Step 1: 150mg over first 10 minutes (dilute in 100mL
D5W)
• Step 2: 360mg over next 6 hours (dilute 500mL
D5W): 1 mg/minute
• Step 3: 540mg (dilute in 500 to 1000ml D5W) over
next 18 hours: 0.5mg/minute

20/06/2024 By Workineh (Msc,AHN) 126

 Pharmacologic cont...
• Pulseless VT (cardiac arrest) regimen: If
unresponsive to defibrillation attempts and CPR
• Amiodarone, I.V push, 300mg (undiluted), if VT or VF
recurs, administer supplemental dose of 150mg and
continue CPR
Alternative
Intravenous lidocaine
• Both stable VT and Pulseless VT (cardiac arrest)
regimen:
• Lidocaine, I.V, 1-1.5mg/kg; repeat with 0.5-
0.75mg/kg every 5-10 minutes if no response
(maximum cumulative dose: 3mg/kg)
• Follow with continuous infusion of 1-4mg/minute
20/06/2024 By Workineh (Msc,AHN) 127
 C. Ventricular Fibrillation
• The most common arrhythmia in patients with cardiac
arrest, which is a rapid, disorganized ventricular
rhythm that causes ineffective quivering of the
ventricles

• No atrial activity is seen on the ECG

• The most common cause coronary artery disease & MI

• Other causes include VT, cardiomyopathy, valvular

heart disease, several proarrhythmic medications,
acid–base and electrolyte abnormalities, and electrical
shock
20/06/2024 By Workineh (Msc,AHN) 128
 ECG criteria for VF
• Ventricular rate: Greater than 300 bpm

• Ventricular rhythm: Extremely irregular, without a

specific pattern

• QRS shape and duration: Irregular, undulating waves

with changing amplitudes

• There are no recognizable QRS complexes

20/06/2024 By Workineh (Msc,AHN) 129

ECG criteria

20/06/2024 By Workineh (Msc,AHN) 130

 Medical management
• Ventricular fibrillation is always characterized by the
absence of an audible heartbeat, a palpable pulse, and
respirations

• Because there is no coordinated cardiac activity,

cardiac arrest and death are imminent if the
arrhythmia is not corrected

• Early defibrillation is critical to survival,

• CPR until defibrillation is available

• Amiodarone and epinephrine may facilitate the return

of a spontaneous pulse after defibrillation
20/06/2024 By Workineh (Msc,AHN) 131
 D. Idioventricular Rhythm
• Idioventricular rhythm (ventricular escape rhythm)
occurs when the impulse starts in the conduction
system below the AV node

• When the sinus node fails to create an impulse (e.g.,

from increased vagal tone) or when the impulse is
created but cannot be conducted through the AV node
(e.g., due to complete AV block), the Purkinje fibers
automatically discharge an impulse

20/06/2024 By Workineh (Msc,AHN) 132

 ECG criteria
• When idioventricular rhythm is not caused by AV block,
it has the following characteristics

• Ventricular rate: Between 20 and 40 bpm; if the rate

exceeds 40 bpm, the rhythm is known as accelerated
idioventricular rhythm

• Ventricular rhythm: Regular

• QRS shape and duration: Bizarre, abnormal shape;

duration is 0.12 seconds or more

20/06/2024 By Workineh (Msc,AHN) 133

ECG criteria

20/06/2024 By Workineh (Msc,AHN) 134

 Medical management
• Identifying the underlying cause

• Administering IV epinephrine, atropine, and

• Vasopressor medications

20/06/2024 By Workineh (Msc,AHN) 135

 E. Ventricular Asystole
• Commonly called flatline, ventricular asystole is
characterized by absent QRS complexes confirmed in
two different leads, although P waves may be apparent
for a short duration

• There is no heartbeat, no palpable pulse, and no

respiration

• Without immediate treatment, ventricular asystole is

fatal

20/06/2024 By Workineh (Msc,AHN) 136

Ventricular Asystole

20/06/2024 By Workineh (Msc,AHN) 137

 Medical management
• High-quality CPR with minimal interruptions

• Identifying underlying and contributing factors

• After initiation of CPR, intubation and establishment of

IV access are the next recommended actions, with no
or minimal interruptions in chest compressions

20/06/2024 By Workineh (Msc,AHN) 138

 Nursing Process: The Care of the Patient
with a Dysrhythmia
Assessment
• Assess indicator of cardiac output and oxygenation,
especially changes in level of consciousness.
• Physical assessment includes:
• Rate and rhythm of apical and peripheral pulses
• Assess heart sounds
• Blood pressure and pulse pressure
• Signs of fluid retention
• Health history: include presence of coexisting
conditions and indications of previous occurrence
• Medications
20/06/2024 By Workineh (Msc,AHN) 139
Nursing Process: The Care of the Patient
with a Dysrhythmia

Diagnosis
• Decreased cardiac output
• Anxiety
• Deficient knowledge

20/06/2024 By Workineh (Msc,AHN) 140

 Collaborative Problems/Potential
Complications
• Cardiac arrest

• Heart failure

• Thromboembolic event, especially with atrial

fibrillation

20/06/2024 By Workineh (Msc,AHN) 141

Nursing Process: The Care of the Patient with a
Dysrhythmia:
Planning
• Goals may include eradicating or decreasing
the occurrence of the dysrhythmia to maintain
cardiac output, minimizing anxiety, and
acquiring knowledge about the dysrhythmia
and its treatment.

20/06/2024 By Workineh (Msc,AHN) 142

Decreased Cardiac Output

• Monitoring
• ECG monitoring

• Assessment of signs and symptoms

• Administration of medications and assessment

of medication effects

• Adjunct therapy: cardioversion, defibrillation,

pacemakers

20/06/2024 By Workineh (Msc,AHN) 143

Other Interventions
• Anxiety
• Use a calm, reassuring manner.
• Measures to maximize patient control to
make episodes less threatening
• Communication and teaching
• Teaching self-care
• Include family in teaching

20/06/2024 By Workineh (Msc,AHN) 144

 MANAGEMENT OF PATIENTS WITH
CORONARY VASCULAR DISORDERS

20/06/2024 By Workineh (Msc,AHN) 145

 ❖ Presentation outlines

• Coronary Atherosclerosis

• Angina pectoris

• Acute coronary syndrome (ACS) and

myocardial infarction (MI)

20/06/2024 By Workineh (Msc,AHN) 146

 ❖ LEARNING OBJECTIVES

• Describe the pathophysiology , clinical

manifestations, and treatment of coronary
atherosclerosis, angina pectoris, and
myocardial infarction

• Use the nursing process as a framework for

care of the patient with angina pectoris and
with acute coronary syndrome

20/06/2024 By Workineh (Msc,AHN) 147

 ❖ Coronary Atherosclerosis
• Atherosclerosis is the abnormal accumulation of
lipid deposits and fibrous tissue within arterial
walls and lumen

• In coronary atherosclerosis, blockages and

narrowing of the coronary vessels reduce blood
flow to the myocardium

• Coronary artery disease (CAD) is the most

prevalent cardiovascular disease in adults
20/06/2024 By Workineh (Msc,AHN) 148
Pathophysiology of Atherosclerosis
• A, B. Atherosclerosis begins as
monocytes and lipids enter the intima
of an injured vessel
• Smooth muscle cells proliferate within
the vessel wall (C),contributing to the
development of fatty accumulations and
atheroma (D).As the plaque enlarges,
the vessel narrows and blood flow
decreases
(E). The plaque may rupture and a
thrombus might form, obstructing
blood flow
20/06/2024 By Workineh (Msc,AHN) 149
20/06/2024 By Workineh (Msc,AHN) 150
 Risk Factors for Coronary Artery Disease

• Four modifiable risk factors cited as major

(cholesterol abnormalities, tobacco use, HTN, and
diabetes)
• Elevated LDL: primary target for cholesterol-
lowering medication
Non modifiable factors
• Family history of CAD (first-degree relative with
cardiovascular disease at 55 years of age or
younger for men and at 65 years of age or
younger for women)
• Increasing age (more than 45 years for men;
more than 55 years for women)
• Gender (men develop CAD at an earlier
age than women)
20/06/2024 By Workineh (Msc,AHN) 151
 • Clinical Manifestations
• Symptoms are caused by myocardial ischemia
• Symptoms and complications are related to
the location and degree of vessel obstruction
• Angina pectoris (most common manifestation)
• Other symptoms: epigastric distress, pain
that radiates to jaw or left arm, SOB, atypical
symptoms in women
• Myocardial infarction
• Heart failure
• Sudden cardiac death

20/06/2024 By Workineh (Msc,AHN) 152

 ❖ Prevention of CAD
• Control cholesterol
• Dietary measures
• Physical activity
• Medications
• Cessation of tobacco use
• Manage HTN
• Control diabetes

20/06/2024 By Workineh (Msc,AHN) 153

 ❖ Angina Pectoris
•A syndrome characterized by episodes of
paroxysmal pain or pressure in the anterior chest,

• The cause is insufficient coronary blood flow,

resulting in a decreased oxygen supply when there
is increased myocardial demand for oxygen in
response to physical exertion or emotional stress

• In other words, the need for oxygen exceeds the

supply

20/06/2024 By Workineh (Msc,AHN) 154

❖ Types of angina

20/06/2024 By Workineh (Msc,AHN) 155

 Assessment and Findings for Angina
Clinical manifestations
• May be described as tightness, choking, or a heavy
sensation
• Frequently retrosternal and may radiate to neck,
jaw, shoulders, back or arms (usually left)
• Anxiety frequently accompanies the pain
• Other symptoms may occur: dyspnea or
shortness of breath, dizziness, nausea, and
vomiting
• The pain of typical angina subsides with rest or NTG
• Unstable angina is characterized by increased
frequency and severity and is not relieved by rest
and NTG.
• Requires medical intervention!

20/06/2024 By Workineh (Msc,AHN) 156

20/06/2024 By Workineh (Msc,AHN) 157
 ❖ Diagnosis of angina
• Clinical manifestations of ischemia
• ECG changes indicative of ischemia, such as T-
wave inversion, ST segment elevation, or the
development of an abnormal Q wave
• Cardiac biomarker :(creatine kinase [CK]),
CK isoenzymes (CK-MB), and proteins
(myoglobin, troponin T, and troponin I)
• Exercise or pharmacologic stress test in which
the heart is monitored continuously by an ECG,
Echocardiogram, or both
• The patient may also be referred for a nuclear
scan or invasive procedure (e.g., Cardiac
catheterization, coronary angiography).
20/06/2024 By Workineh (Msc,AHN) 158
 ❖ Medications for Angina

• Nitrates / Nitroglycerin
• Beta-adrenergic blocking agents/ Metoprolol
• Calcium channel blocking agents/ Amlodipine
• Anti platelet/ Aspirin
• Anticoagulant medications/Heparin

20/06/2024 By Workineh (Msc,AHN) 159

 ❖ Question
• The nurse is caring for a patient who has severe
chest pain after working outside on a hot day and
is brought to the emergency center. The nurse
administers nitroglycerin to help alleviate chest
pain. Which side effect should concern the nurse
the most? And why?

A. Dry mucous membranes

B. Heart rate of 88 bpm

C. Blood pressure of 86/58 mm Hg

D. Complaints of headache
20/06/2024 By Workineh (Msc,AHN) 160
❖ Assessment of the Patient with Angina
Pectoris
• Symptoms and activities, especially those that
precede and precipitate attacks

• Risk factors, lifestyle, and health promotion

activities

• Patient and family knowledge

• Adherence to the plan of care

20/06/2024 By Workineh (Msc,AHN) 161

❖ Collaborative Problems of the Patient
with Angina Pectoris

• ACS, MI, or both

• Arrhythmias and cardiac arrest

• Heart failure

• Cardiogenic shock

20/06/2024 By Workineh (Msc,AHN) 162

 ❖ Planning and Goals for the Patient
with Angina Pectoris
Goals
• Immediate and appropriate treatment
• Prevention of angina
• Reduction of anxiety
• Awareness of the disease process
• Understanding of prescribed care
• Adherence to the self-care program
• Absence of complications

20/06/2024 By Workineh (Msc,AHN) 163

 Nursing Interventions for the Patient
with Angina Pectoris

• Treat angina
• Reduce anxiety
• Prevent pain
• Educate patients about self-care
• Continuing care

20/06/2024 By Workineh (Msc,AHN) 164

 Nursing Intervention: Treat Angina
Priority
• Patient is to stop all activities and sit or rest in bed
(semi-Fowler positioning)
• Assess the patient while performing other
necessary interventions.
• Assessment includes VS, observation for
respiratory distress, and assessment of pain.
• In the hospital setting, the ECG is assessed or
obtained
• Administer medications as ordered or by
protocol, usually NTG.
• Reassess pain and administer NTG up to three
doses
• Administer oxygen 2 L/min by nasal cannula
20/06/2024 By Workineh (Msc,AHN) 165
 Nursing Intervention: Reduce Anxiety

• Use a calm manner

• Stress-reduction techniques

• Patient teaching

• Addressing patient’s spiritual needs may assist

in allaying anxieties

• Address both patient and family needs

20/06/2024 By Workineh (Msc,AHN) 166

 Nursing Intervention: Preventing Pain

• Identify the level of activity that causes

patient’s prodromal S&S

• Plan activities accordingly

• Alternate activities with rest periods

• Educate patient and family

20/06/2024 By Workineh (Msc,AHN) 167

 Nursing Intervention: Patient Teaching
• Balance activity with rest
• Follow prescribed exercise regimen
• Avoid exercising in extreme temperatures
• Use resources for emotional support (counselor)
• Avoid over-the-counter medications that may
increase HR or BP before consulting with health
care provider
• Stop using tobacco products (nicotine increases
HR and BP)
• Diet low in fat and high in fiber-DASH

20/06/2024 By Workineh (Msc,AHN) 168

 Nursing Intervention: Patient Teaching

• Medication teaching (carry nitroglycerin at all

times!)

• Follow up with health care provider

• Report increase in S&S to provider

• Maintain normal BP and blood glucose levels

20/06/2024 By Workineh (Msc,AHN) 169

20/06/2024 By Workineh (Msc,AHN) 170
20/06/2024 By Workineh (Msc,AHN) 171
 ❖ Acute Coronary Syndrome (ACS) and
Myocardial Infarction (MI)
• Emergent situation
• Characterized by an acute onset of
myocardial ischemia that results in myocardial
death (i.e., MI) if definitive interventions do not
occur promptly
• Although the terms coronary occlusion, heart
attack, and MI are used synonymously, the
preferred term is MI
• The spectrum of ACS includes unstable angina,
NSTEMI, and ST-segment elevation myocardial
infarction (STEMI).
20/06/2024 By Workineh (Msc,AHN) 172
 ❖ Pathophysiology
• In unstable angina, there is reduced blood
flow in a coronary artery , often due to
rupture of an atherosclerotic plaque
• A clot begins to form on top of the
coronary lesion, but the artery is not
completely occluded
• This is an acute situation that can result in
chest pain and other symptoms that may
be referred to as preinfarction angina
because the patient will likely have an MI
if prompt interventions do not occur

20/06/2024 By Workineh (Msc,AHN) 173

 Pathophysiology cont....
• In MI, plaque rupture and subsequent thrombus
formation result in complete occlusion of the
artery , leading to ischemia and necrosis of the
myocardium
• Vasospasm of a coronary artery ,decreased
oxygen supply (e.g., from acute blood loss, anemia,
or low blood pressure),and increased demand for
oxygen (e.g., from a rapid heart rate,
thyrotoxicosis, or ingestion of cocaine) are other
causes of MI.
• In each case, a profound imbalance exists
between myocardial oxygen supply and demand
• The area of infarction develops over minutes to
hours. As the cells are deprived of oxygen,
ischemia develops, cellular injury occurs, and
the lack of oxygen results in infarction, or the
death
20/06/2024 of cells. By Workineh (Msc,AHN) 174
 ❖ Effects of Ischemia, Injury, and Infarction
on ECG

• Ischemia causes inversion of the T wave

because of altered repolarization

• Cardiac muscle injury causes elevation of

the ST segment.

• Later, Q waves develop because of the

absence of depolarization current from the
necrotic tissue and opposing currents from
other parts of the heart
20/06/2024 By Workineh (Msc,AHN) 175
 Assessment of the Patient with ACS
❖ Chest pain
• Occurs suddenly and continues despite rest
and medication
Other S&S: SOB; nausea; anxiety; cool, pale
skin; increased HR, RR
❖ ECG changes
• Elevation in the ST segment in two contiguous
leads is a key diagnostic indicator for MI
Lab studies: cardiac enzymes, troponin
( troponins I&T cardiac-specific and reliable
indicator), creatine kinase (CK-MB), myoglobin

20/06/2024 By Workineh (Msc,AHN) 176

 Unstable angina:
• Clinical manifestations of coronary ischemia,
but ECG and cardiac biomarkers show no
evidence of acute MI
STEMI:
• The patient has ECG evidence of acute MI
• There is a significant damage to the
myocardium
NSTEMI:
• The patient has elevated cardiac biomarkers
(e.g., troponin) but no definite ECG evidence
of acute MI.
• There may be less damage to the
myocardium.
20/06/2024 By Workineh (Msc,AHN) 177
 ❖ Medical management
Initial Management
• Supplemental oxygen,
• Aspirin,
• Nitroglycerine,
• Morphine is the drug of choice to reduce
pain and anxiety
• It also reduces preload and afterload,
decreasing the work of the heart
• The response to morphine is monitored
carefully to assess for hypotension or
decreased respiratory rate

20/06/2024 By Workineh (Msc,AHN) 178

 Management cont...
• Emergent Percutaneous Coronary
Intervention (PCI)
• Thrombolytics
• Inpatient Management
Following PCI or thrombolytic therapy ,
• Continuous cardiac monitoring in ICU
• Continuing pharmacologic management
includes aspirin, a beta blocker, ACE inhibitor

20/06/2024 By Workineh (Msc,AHN) 179

 ❖ Collaborative Problems of the Patient
with ACS
• Acute pulmonary edema
• Heart failure
• Cardiogenic shock
• Arrhythmias and cardiac arrest
• Pericardial effusion and cardiac tamponade

20/06/2024 By Workineh (Msc,AHN) 180

 ❖ Planning and Goals for the Patient with
ACS
Goals:
• Relief of pain or ischemic signs (e.g., ST
segment changes) and symptoms
• Prevention of myocardial damage
• Maintenance of effective respiratory function,
adequate tissue perfusion
• Reduction of anxiety
• Adherence to the self-care program
• Early recognition of complications

20/06/2024 By Workineh (Msc,AHN) 181

❖ Nursing Interventions for the Patient with
ACS
• Relieve pain and S&S of ischemia
• Improve respiratory function
• Promote adequate tissue perfusion
• Reduce anxiety
• Monitor and manage potential complications
• Educate patient and family
• Provide continuing care

20/06/2024 By Workineh (Msc,AHN) 182

Management of Patients with Infectious,

Inflammatory and Structural Cardiac

Disorders

6/20/2024 By Workineh (Msc,AHN) 183

Infectious and Inflammatory Cardiac Disorders

Presentation outline

• Rheumatic Fever

• Infective endocarditis

6/20/2024 By Workineh (Msc,AHN) 184

 • Objectives

At the end of this presentation you will be able to:

• Identify the definition of each infectious diseases of

the heart

• Describe the pathophysiology, clinical manifestations

and diagnosis of infectious diseases of the heart

• Recognize the medical, surgical and nursing

management of infectious diseases of the heart

6/20/2024 By Workineh (Msc,AHN) 185

 INFECTIOUS DISEASE OF THE HEART
• Any of the heart’s three layers may be affected by an
infectious process
The infections are named for the layer of the heart most
involved: infective endocarditis (endocardium),
myocarditis (myocardium), and pericarditis
(pericardium)
• Rheumatic endocarditis is a unique infective
endocarditis syndrome
• The ideal management is prevention

6/20/2024 By Workineh (Msc,AHN) 186

I. Rheumatic endocarditis/Acute rheumatic
fever
• Acute rheumatic fever (ARF), which occurs most often in
school age children

• It may develop after an episode of group A beta

hemolytic streptococcal pharyngitis

• Patients with rheumatic fever may develop rheumatic

heart disease (RHD) as evidenced by a new heart
murmur, cardiomegaly, pericarditis, and heart failure

6/20/2024 By Workineh (Msc,AHN) 187

 Rheumatic endocarditis cont.…
• Prompt treatment of “strep” throat with antibiotics can

prevent the development of rheumatic fever

• The streptococcus is spread by direct contact with oral

or respiratory secretions

• Although the bacteria are the causative agents,

malnutrition, overcrowding, poor hygiene, and lower

socioeconomic status may predispose individuals to

rheumatic fever

6/20/2024 By Workineh (Msc,AHN) 188

 Rheumatic endocarditis cont.…
• ARF is an illness often results in lasting damage to
heart valves

• Also known as RHD and it is an important cause of

premature mortality

• ARF is an auto-immune response to bacterial infection

with group A streptococcus (GAS)

• People with ARF are often in great pain and require

hospitalization

6/20/2024 By Workineh (Msc,AHN) 189

 Rheumatic endocarditis cont.…
• It is characterized mainly by carditis, arthritis and
chorea appearing, alone or in combination, with
residual chronic heart disease

• Antibodies produced against the streptococci antigen

cross and cause immunologic damage to the:

• Heart valves

• Heart muscle

• Pericardium

6/20/2024 By Workineh (Msc,AHN) 190

 Diagnosis:
Based on Modified Jones criteria
Major Criteria Minor Criteria
Carditis Clinical
Migratory poly arthritis ▪Fever
▪Arthralgia
Sydenham’s Chorea
Subcutaneous nodules Laboratory :Elevated ESR
C reactive protein
leukocytosis
Erythema marginatum ECG: Prolonged PR interval
Plus: Supportive evidence of recent Group A streptococcal infection
( e.g. positive throat culture or rapid antigen detection test
N.B: Diagnosis of acute rheumatic fever requires:
2 major Jones criteria or 1 major plus 2 minor Jones criteria.
6/20/2024 By Workineh (Msc,AHN) 191
 I. Carditis

❑occurs in as many as 40- 60% of patients and

may manifest as:

▪ New murmur

▪ Cardiomegaly

▪ Congestive heart failure

6/20/2024 By Workineh (Msc,AHN) 192

 II. Migratory polyarthritis

• Occurs in 75% of cases and involves many joints at a

time

• The larger joints are mainly affected

III. Subcutaneous nodules:

• Occur in 10% of patients and are edematous

fragmented collagen fibers

• They are firm painless nodules on the extensor

surfaces of wrists, elbows, and knees

6/20/2024 By Workineh (Msc,AHN) 193

 Cont,

III. Erythema marginatum :

• Occurs in about 5% of cases

• The bright pink, nonpruritic, map like macular lesions

occur mainly on the trunk and proximal extremities

IV. Sydenham’s chorea

• Is a characteristic movement disorder that occurs in

5-10% of cases

• Sydenham’s chorea consists of rapid purposeless

movements of the face and upper extremities
6/20/2024 By Workineh (Msc,AHN) 194
Cont,

6/20/2024 By Workineh (Msc,AHN) 195

 Treatments
• Secondary prophylaxis with BPG is recommended for all
people with a history of RHD

• Four-weekly BPG is currently the treatment of choice

• Prophylaxis should continue for at least 10 years from

the last episode of acute thematic fever

• Further information about rheumatic fever and

rheumatic endocarditis can be found in pediatric nursing
courses

6/20/2024 By Workineh (Msc,AHN) 196

 II. Infective endocarditis
• It is a microbial infection of the endothelial surface of
the heart

• It usually develops in people with prosthetic heart

valves or structural cardiac defects (valve disorders)

• It is more common in older people (> 65years), who are

more likely to have degenerative or calcific valve
lesions, reduced immunologic response to infection, and
the metabolic alterations associated with aging

6/20/2024 By Workineh (Msc,AHN) 197

 Infective endocarditis cont.…

• Staphylococcal endocarditis infections of the valves in

the right side of the heart are common among IV illicit
drug users

• Hospital-acquired infective endocarditis occurs most

often in patients with debilitating disease or indwelling
catheters and in patients who are receiving
hemodialysis or prolonged IV fluid or antibiotic therapy

6/20/2024 By Workineh (Msc,AHN) 198

 Infective endocarditis cont.…
Epidemiology

• General prevalence of 3 to 9 cases per 100 000

persons, which increases to approximately 2000 cases
per 100 000 intravenous drug abusers.

• The disease is rare, but it has a high mortality rate;

approximately 14% to 22% of patients die during their
hospital stay, and up to 40% of patients die within 1
year of diagnosis

6/20/2024 By Workineh (Msc,AHN) 199

 Infective endocarditis cont.…
Pathophysiology

• The normal endocardium is relatively resistant to

infection, and the constant flow of blood makes it
particularly difficult for a microorganism to adhere to
and initiate a focal infection

• A deformity or injury of the endocardium leads to

accumulation on the endocardium of fibrin and platelets
(clot formation)

6/20/2024 By Workineh (Msc,AHN) 200

 Infective endocarditis cont.…
• Infectious organisms, usually staphylococci,
streptococci, enterococci, pneumococci, or chlamydia,
invade the clot and endocardial lesion

• Other causative micro-organisms include fungi (e.g.

Candida, Aspergillus) and Rickettsia

6/20/2024 By Workineh (Msc,AHN) 201

 Infective endocarditis cont.…

• The infection most frequently results in platelets,

fibrin, blood cells, and microorganisms that cluster as
vegetations on the endocardium

• The vegetations may embolize to other tissues

throughout the body

6/20/2024 By Workineh (Msc,AHN) 202

Active large bacterial endocarditis vegetations of the
aortic valve

6/20/2024 By Workineh (Msc,AHN) 203

 Infective endocarditis cont.…

• The infection may erode through the

endocardium into the underlying structures
(e.g. valve leaflets), causing tears or other
deformities of valve leaflets, dehiscence of
prosthetic valves, deformity of the chordae
tendineae, or mural abscesses

• Usually the onset of infective endocarditis is

insidious
6/20/2024 By Workineh (Msc,AHN) 204
Active bacterial endocarditis of the aortic valve.
Vegetations have caused destruction of one cusp and
perforation of another cusp.

6/20/2024 By Workineh (Msc,AHN) 205

 Infective endocarditis cont.…
Clinical Manifestations
• The primary presenting symptoms are fever and a
heart murmur

• The fever may be intermittent or absent, especially in

patients who are receiving corticosteroids, in those who
are elderly, or those who have heart failure or renal
failure

• A heart murmur may be absent initially but develops in

almost all patients.

6/20/2024 By Workineh (Msc,AHN) 206

 Infective endocarditis cont.…

• Murmurs that worsen over time indicate progressive

damage from vegetations or perforation of the valve
or the chordae tendineae.

• Clusters of petechiae may be found on the body

• Irregular, red or purple, painless flat macules

(Janeway lesions) may be present on palms, fingers,
hands, soles, and toes

6/20/2024 By Workineh (Msc,AHN) 207

 Janeway lesions

6/20/2024 By Workineh (Msc,AHN) 208

Petechiae of infective endocarditis
6/20/2024 By Workineh (Msc,AHN) 209
Infective endocarditis cont.…

• Hemorrhages with

pale centers (Roth

spots) caused by

emboli may be

observed in the

fundi of the eyes

6/20/2024 By Workineh (Msc,AHN) 210

 Infective endocarditis cont.…

• Splinter hemorrhages
(i.e. reddish-brown
lines and streaks)
may be seen under
the fingernails and
toenails

6/20/2024 By Workineh (Msc,AHN) 211

 Infective endocarditis cont.…
• Osler nodes :small, painful nodules may be present in

the pads of fingers or toes

• Cardiomegaly, heart failure, tachycardia, or

splenomegaly may occur

• Central nervous system manifestations include

headache; cerebral ischemia; and strokes, which may

be caused by emboli to the cerebral arteries

6/20/2024 By Workineh (Msc,AHN) 212

6/20/2024 By Workineh (Msc,AHN) 213
 Infective endocarditis cont.…
Potential complications

• Heart failure

• Valvular stenosis or regurgitation

• myocardial damage

6/20/2024 By Workineh (Msc,AHN) 214

 Infective endocarditis cont.…
Assessment and Diagnostic Findings
• signs and symptoms

A definitive diagnosis is made when a micro-organism is

found in two separate blood cultures, in a vegetation, or
in an abscess

• Echocardiography

6/20/2024 By Workineh (Msc,AHN) 215

❖ The Duke Criteria for the Clinical Diagnosis of
Infective Endocarditis

Major Criteria

❑Positive blood culture:

❑Positive echocardiogram:

• Definitive vegetation

• Abscess

6/20/2024 By Workineh (Msc,AHN) 216

 Minor Criteria
• Predisposition: predisposing heart condition or IV
drug abuse
• Fever >38.0 oC.
• Embolic phenomena: major arterial emboli, septic
pulmonary infarcts,
• Immunologic phenomena: glomerulonephritis,
Osler's nodes, Roth's spots, rheumatoid factor
• Microbiologic evidence: positive blood culture but
not meeting major criterion
• Echocardiogram: consistent with infective
endocarditis but not meeting major criterion

6/20/2024 By Workineh (Msc,AHN) 217

 Definitive Diagnosis(IE)

▪ Two major criteria or

▪ One major and three minor criteria or

▪ Five minor criteria allows a clinical diagnosis of definite

endocarditis

6/20/2024 By Workineh (Msc,AHN) 218

 Infective endocarditis cont.…
Medical Management

• Antibiotic therapy is usually administered parenterally

in a continuous IV infusion for 2 to 6 weeks ( to ensure
eradication of the dormant bacteria within the dense
vegetations)

• Penicillin is usually the medication of choice

• In fungal endocarditis, an antifungal agent, such as

amphotericin B is the usual treatment

6/20/2024 By Workineh (Msc,AHN) 219

 Infective endocarditis cont.…
Surgical management
It may be required:

• If the infection does not respond to medications

• If the patient develops heart failure or an intracardiac

abscess, or the patient has recurrent systemic
embolization

6/20/2024 By Workineh (Msc,AHN) 220

 Infective endocarditis cont.…

Surgical interventions include:

• Valve debridement or excision

• Debridement of vegetations

• Debridement and closure of an abscess and

• Closure of a fistula

6/20/2024 By Workineh (Msc,AHN) 221

 Infective endocarditis cont.…
Nursing Management

• The nurse monitors the patient’s temperature

• Assess heart sounds

• The nurse monitors for signs and symptoms of:

• Systemic embolization

• Pulmonary infarction

6/20/2024 By Workineh (Msc,AHN) 222

 Infective endocarditis cont.…
• Organ damage such as stroke, meningitis, heart
failure, myocardial infarction, glomerulonephritis,
and splenomegaly

• All invasive lines and wounds must be assessed daily for

redness, tenderness, warmth, swelling, drainage,

• The patient and family are instructed about activity

restrictions, medications, and signs and symptoms of
infection

6/20/2024 By Workineh (Msc,AHN) 223

 Prevention
• A key strategy is primary prevention in high-risk
patients (e.g. those with previous infective
endocarditis, prosthetic heart valves)

• Antibiotic prophylaxis is recommended for high-risk

patients immediately before and sometimes after:

• Dental procedures

• Tonsillectomy or Adenoidectomy

• Surgical procedures that involve respiratory

mucosa
6/20/2024 By Workineh (Msc,AHN) 224
 Infective endocarditis cont.…
• Bronchoscopy with biopsy or incision of respiratory
tract mucosa

• Cystoscopy or urinary tract manipulation for patients

with enterococcal urinary tract infections or
colonization

• Surgery involving infected skin or musculoskeletal

tissue

6/20/2024 By Workineh (Msc,AHN) 225

Structural Heart Disorders

Valvular heart diseases

 Presentation outlines
• Mitral disorders
• Aortic disorders

6/20/2024 By Workineh (Msc,AHN) 227

 ❖ Objectives
• On completion of this portion, you will be able to:
• Define valvular disorders of the heart

• Describe the pathophysiology and clinical

manifestations of patients with mitral and aortic
disorders

• Describe the medical and nursing management of

patients with mitral and aortic disorders

6/20/2024 By Workineh (Msc,AHN) 228

 VALVULAR HEART DISEASES
• When any heart valve does not close or open
properly , blood flow is affected

• When valves do not close completely , blood flows

backward through the valve, a condition called
regurgitation (also referred to as insufficiency)

• When valves do not open completely , a condition

called stenosis, blood flow through the valve is
reduced

• Regurgitation and stenosis may affect any heart valve

• The mitral valve may also prolapse

6/20/2024 By Workineh (Msc,AHN) 229
 Mitral disorders
I. Mitral prolapse
• Is the stretching of the valve leaflet into the atrium
during systole

• Is a deformity that usually produces no symptoms

• Rarely , it progresses and can result in sudden death

• In most cases, there is no clear cause, but it has

been associated with inherited connective tissue
disorders,

• The annulus often dilates; chordae tendineae and

papillary muscles may elongate or rupture
6/20/2024 By Workineh (Msc,AHN) 230
 Pathophysiology
A portion of one or both mitral valve leaflets balloons
back into the atrium during systole. Rarely ,
ballooning stretches the leaflet to the point that the
valve does not remain closed during systole

• Blood then regurgitates from the left ventricle

back into the left atrium

• Although uncommon, mitral valve prolapse can

result in mitral regurgitation, which can cause heart
enlargement, atrial fibrillation, pulmonary
hypertension, or heart failure
6/20/2024 By Workineh (Msc,AHN) 231
 Mitral prolapse cont...
Clinical Manifestations

• Most people with mitral valve prolapse never have

symptoms

• A small number of patients will have fatigue,

shortness of breath, lightheadedness, dizziness,
syncope, palpitations, chest pain, or anxiety

6/20/2024 By Workineh (Msc,AHN) 232

 Mitral prolapse cont...
Assessment and Diagnostic Findings

• Extra heart sound (mitral click)

• A systolic click is an early sign that a valve leaflet is

ballooning into the left atrium

• Murmur of mitral regurgitation may be heard if

the valve opens during systole and blood flows
back into the left atrium

• Echocardiography

6/20/2024 By Workineh (Msc,AHN) 233

 Mitral prolapse cont...
Medical management

• Directed at controlling symptoms

• If a patient who reports palpitations (arrhythmia),

the patient may be advised to eliminate caffeine and
alcohol from the diet and to stop the use of
tobacco products

• Treat arrhythmia and heart failure, if present

• Mitral valve repair or replacement

6/20/2024 By Workineh (Msc,AHN) 234

 II. Mitral Regurgitation
• Mitral regurgitation is a condition in which blood
flows from the left ventricle back into the left
atrium during systole
• May be chronic or acute
• The most common cause in developed countries;
degenerative changes of the mitral valve (mitral
valve prolapse) and ischemia of the left ventricle
• The most common cause in developing countries is
rheumatic heart disease and its sequelae
• Infective endocarditis may cause acute mitral
regurgitation
6/20/2024 By Workineh (Msc,AHN) 235
• Collagen vascular diseases (e.g., systemic lupus
erythematosus), cardiomyopathy , and ischemic
heart disease may result in changes in the left
ventricle, causing papillary muscles, chordae
tendineae, or leaflets to stretch, shorten, or
rupture

• These conditions are often referred to as

functional, or secondary mitral regurgitation

6/20/2024 By Workineh (Msc,AHN) 236

 Pathophysiology

• Mitral regurgitation result from problems with one

or more leaflets, chordae tendineae, the annulus, or
the papillary muscles

•A leaflet may shorten or tear , and chordae

tendineae may elongate, shorten, or tear . The
annulus may be stretched by heart enlargement,
or it may be deformed by calcification.

• A papillary muscle may rupture, stretch, or be

pulled out of position by changes in the
ventricular wall
6/20/2024 By Workineh (Msc,AHN) 237
• Each beat of the left ventricle pushes blood
backward into the left atrium, adding to blood
flowing in from the lungs.

• This excess blood causes the left atrium to stretch

and thicken, or hypertrophy , then dilate

• Over time, blood coming in from the ventricle prevents

blood flow from the lungs into the atrium

• The lungs become congested, eventually adding

extra strain to the right ventricle

6/20/2024 By Workineh (Msc,AHN) 238

During diastole, the increased blood volume from
the atrium fills the ventricle

The volume overload causes ventricular hypertrophy

Eventually , the ventricle dilates, and systolic heart

failure develops

6/20/2024 By Workineh (Msc,AHN) 239

• Chordae tendineae (fine strong filaments arising
from the strong papillary muscles) and extending to
valve cusps are attached to the free edges of AV
valves.

• Prevent eversion of AV valve (opening of the valves

in the opposite direction)

• Papillary muscles (protrude from the inner

surface of the ventricular walls) contract when
ventricles contract & pulling downward on the
chordae tendineae.

6/20/2024 By Workineh (Msc,AHN) 240

6/20/2024 By Workineh (Msc,AHN) 241
 Clinical Manifestations
• Chronic mitral regurgitation is often asymptomatic,
but acute mitral regurgitation manifests as severe
and sudden congestive heart failure

• Dyspnea, fatigue, and weakness

• Palpitations, shortness of breath on exertion, and

cough

Assessment and Diagnostic Findings

• The systolic murmur of mitral regurgitation

• The murmur may radiate to the left axilla

• Echocardiography
6/20/2024 By Workineh (Msc,AHN) 242
 Medical Management
• Patients who develop pulmonary congestion are
managed with medications used for heart failure

• Patients with heart failure benefit from afterload

reduction by treatment with ACE inhibitors, direct
arterial dilators (e.g., hydralazine), and betablockers

• Mitral valvuloplasty (i.e., surgical repair) or valve

replacement (replacement of the dysfunctional
valve )

6/20/2024 By Workineh (Msc,AHN) 243

 III. Mitral Stenosis
• Mitral stenosis results in reduced blood flow from
the left atrium into the left ventricle

• It is usually caused by rheumatic endocarditis,

which progressively thickens mitral valve leaflets
and chordae tendineae, causing the leaflets to
fuse together

• Eventually , the mitral valve orifice narrows and

progressively obstructs blood flow into the ventricle

6/20/2024 By Workineh (Msc,AHN) 244

 Clinical Manifestations
• Dyspnea on exertion (DOE) caused by pulmonary
venous hypertension

• Fatigue and decreased exercise tolerance

• Dry cough or wheezing

• In severe cases hemoptysis, palpitations, Orthopnea,

paroxysmal nocturnal dyspnea (PND), or repeated
respiratory infections

• Left atrium dilate, hypertrophy , and become

electrically unstable, which may result in atrial
arrhythmias
6/20/2024 By Workineh (Msc,AHN) 245
 Assessment and Diagnostic Findings
• Low-pitched ,diastolic murmur, best heard at the
apex

• Weak and irregular pulse ( atrial fibrillation) and

may have signs or symptoms of heart failure

• Echocardiography

• ECG, exercise testing, and cardiac catheterization

with angiography

6/20/2024 By Workineh (Msc,AHN) 246

 Prevention
• Prophylaxis for recurrent rheumatic fever with
rheumatic carditis may require 10 or more years
of antibiotic coverage (e.g., penicillin G
intramuscularly every 4 weeks, penicillin V orally
twice daily , sulfadiazine orally daily , or
erythromycin orally twice daily)

6/20/2024 By Workineh (Msc,AHN) 247

 Medical management
• Treat congestive heart failure

• Anticoagulant medications

• Cardioversion

• Beta-blockers, digoxin, or calcium channel

blockers;

• Patients are advised to avoid strenuous activities,

competitive sports, and pregnancy

• Valvuloplasty , usually a commissurotomy (i.e.,

splitting or separating leaflets)
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 AORTIC DISORDERS
I. AORTIC REGURGITATION

• Aortic regurgitation is backward flow of blood into

the left ventricle from the aorta during diastole

Causes

• congenital valve abnormality,

• dilation of the aorta,

• Rheumatic endocarditis, syphilis,

• blunt chest trauma, deterioration of a surgically

replaced aortic valve
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 Clinical manifestations
• Develops without symptoms in most patients

• Pounding or forceful heartbeat, especially in the

head or neck

• Patients who develop left ventricular hypertrophy

may have visible or palpable arterial pulsations
at the carotid or temporal arteries

• DOE and fatigue, signs and symptoms of

progressive left ventricular failure (shortness of
breath, orthopnea, or PND)
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 Assessment and Diagnostic Findings
• A high-pitched, blowing diastolic murmur is heard
at the third or fourth intercostal space at the left
sternal border

• The pulse pressure may be widened

• The water hammer (Corrigan’ s) pulse, in which the

pulse strikes a palpating finger with a quick,
sharp stroke and then collapses

• Dx confirmed by echocardiography , MRI, or cardiac

catheterization

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 Medical Management
• Treat arrhythmias and heart failure if occur

• Control high blood pressure

• Patients who are symptomatic should be instructed

to restrict sodium intake to prevent volume
overload

• The treatment of choice is aortic valve

replacement or valvuloplasty

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 II. Aortic Stenosis
• Aortic valve stenosis is narrowing of the orifice
between the left ventricle and aorta
• Stenosis is usually caused by degenerative
calcification
• Calcification may be caused by proliferative and
inflammatory changes that occur in response to
years of normal mechanical stress,
• Congenital leaflet malformations or an abnormal
number of leaflets (i.e., one or two rather than
three)
• Rheumatic endocarditis
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 Clinical Manifestations
• Many patients are asymptomatic

• Often, the first symptom to appear is DOE,

• Orthopnea, PND, and pulmonary edema

• Reduced blood flow to the brain may cause

dizziness, and in more severe aortic stenosis, syncope

• Angina pectoris,

• Blood pressure is usually normal but may be low

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 ❖ Assessment and Diagnostic Findings
• A loud, harsh systolic murmur is heard over the
aortic area (i.e., right second intercostal space)

• Palpable vibration due to turbulent flow of blood

• Echocardiography ,

• MRI, or computed tomography (CT) scanning

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 Medical management
• Medications are prescribed to treat arrhythmias or
left ventricular failure

• Definitive treatment for aortic stenosis is

replacement of the aortic valve,

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 Prevention
• Prevention is primarily focused on controlling risk
factors namely diabetes, hypertension,
hypercholesterolemia, and elevated triglycerides,
and avoiding tobacco products

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 Thank you!

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