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Chapter 35
Cardiac Disorders
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Learning Objectives
• Label the major parts of the heart.
• Describe the flow of blood through the heart and
coronary vessels.
• Name the elements of the heart’s conduction system.
• State the order in which normal impulses are conducted
through the heart.
• Explain the nursing considerations for patients having
procedures to detect or evaluate cardiac disorders.
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Learning Objectives
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Identify nursing implications for common therapeutic
measures, including drug, diet, or oxygen therapy; pacemakers
and cardioverters; cardiac surgery; and cardiopulmonary
resuscitation.
Explain the pathophysiology, risk factors, signs and symptoms,
complications, and treatment for selected cardiac
disorders.
List the data to be obtained in assessing the patient with
a cardiac disorder.
Assist in developing nursing care plans for patients with
cardiac disorders.
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Anatomy and Physiology
of the Heart
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Anatomy
• Chambers
• Two upper atria (right and left)
• Two lower ventricles (right and left)
• Muscle layers
• Endocardium, myocardium, and epicardium
• Valves
• Atrioventricular valves
• Mitral and tricuspid
• Semilunar valves
• Aortic and pulmonic
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Heart Sounds
• The first heart sound (S1), referred to as lub,
occurs when the ventricles contract during
systole and when the mitral and tricuspid
valves close
• The second heart sound (S2), called dub,
occurs during ventricular relaxation or diastole
and is caused by the closing of the aortic and
pulmonic valves
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Figure 35-1
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Coronary Blood Flow
• Left coronary artery and the right coronary
artery
• Left coronary artery branches into the left anterior
descending and circumflex arteries
• Right coronary artery branches to supply the
sinoatrial (SA) and the atrioventricular (AV) nodes,
the RA and RV, and the inferior part of the LV
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Coronary Blood Flow
• Venous system parallels the arterial system:
the great cardiac vein follows the left anterior
descending artery and the small cardiac vein
follows right coronary artery
• Veins meet to form the coronary sinus (largest
coronary vein), which returns deoxygenated
blood from the myocardium to the right atrium
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Figure 35-2
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Figure 35-3
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Conduction
• SA node, called the pacemaker, initiates the impulse
• The impulse is carried throughout the atria to the AV node, located
on the floor of the RA
• Impulse is delayed in the AV node, then transmitted to the
ventricles through the bundle of His
• The bundle is made up of Purkinje cells and is located where the
atrial and ventricular septa meet
• Bundle of His divides into left and right bundle branches
• Left branch divides into anterior and posterior branches: fascicles
• Terminal ends of right and left branches: the Purkinje fibers
• When impulse reaches Purkinje fibers, ventricles contract
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Figure 35-4
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Conduction
• Cardiac innervation
• Heart innervated by sympathetic and
parasympathetic fibers of the autonomic nervous
system
• Sympathetic fibers distributed throughout the heart
• Sympathetic stimulation results in increased heart rate,
increased speed of conduction through the AV node, and
more forceful contractions
• Parasympathetic fibers (part of the vagus nerve) found
primarily in the SA and AV nodes and the atrial tissue
• Parasympathetic stimulation results in slowing of heart rate,
slowing of conduction through the AV node, and decreased
strength of contraction
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Cardiac Function
• Cardiac cycle
• Contraction and relaxation of the heart make up one
heartbeat
• Cardiac output
• Amount of blood (in liters) ejected per minute
• Factors that affect stroke volume: preload,
contractility, and afterload
• Myocardial oxygen consumption
• Myocardial tissue routinely needs 70% to 75% of
the oxygen delivered to it by the coronary arteries
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Age-Related Changes
• Heart
• Increased density of connective tissue and
decreased elasticity
• Number of pacemaker cells in the SA node
decreases, as does the number of nerve fibers in
the ventricles
• Blood vessels
• The number of pacemaker cells in the SA node
decreases, as does the number of nerve fibers in
the ventricles
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Nursing Assessment of
Cardiac Function
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Chief Complaint and History of
Present Illness
• Symptoms related to cardiac disorders include
fatigue, edema, palpitations, dyspnea, and pain
• Note when symptoms occur, what aggravates
them, and what relieves them
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Medical History
• Hypertension, kidney disease, pulmonary
disease, stroke, rheumatic fever, streptococcal
sore throat, and scarlet fever
• Document previous cardiac disorders and
hospitalizations. List recent and current
medications and note allergies in appropriate
records
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Family History
• Assess whether immediate relatives have had
hypertension, coronary artery disease (CAD),
other cardiac disorders, or diabetes mellitus
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Review of Systems
• Systematically assess whether the patient has
experienced the following: weight gain, fatigue,
dyspnea (shortness of breath), cough,
orthopnea (difficulty breathing in a supine
position), paroxysmal nocturnal dyspnea
(sudden dyspnea during sleep), palpitations,
chest pain, syncope (fainting), concentrated
urine, or leg edema
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Functional Assessment
• Determine how this illness has affected the
patient’s ability to carry out usual activities
• Activity and rest patterns and usual diet
• Ask about sources of stress and coping
strategies
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Physical Examination
• Vital signs
• Blood pressure, pulses, and respirations
• Skin
• Heart sounds
• Heart murmurs
• Extremities
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Figure 35-5
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Diagnostic Tests and Procedures
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Electrocardiogram (ECG)
Ambulatory ECG (Holter monitor)
Implantable loop monitor/recorder (ILR)
Echocardiogram (heart sonogram)
Transesophageal echocardiogram (TEE)
Magnetic resonance imaging (MRI)
Multiple-gated acquisition scan
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Diagnostic Tests and Procedures
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Stress test (exercise tolerance test)
Perfusion imaging
Thallium imaging
Ultrafast computed tomography
Cardiac catheterization
Electrophysiology study (EPS)
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Figure 35-6
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Laboratory Tests
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Arterial blood gases
Pulse oximetry
Cardiac enzymes
Creatine phosphokinase
Cardiac protein markers
Complete blood count
Lipid profile
B-type natriuretic peptide (BNP)
C-reactive protein (CRP)
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Figure 35-7
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Drug Therapy
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Cardiac glycosides
Antianginals
Antidysrhythmics
Angiotensin-converting enzyme (ACE)
inhibitors (ACEIs)
• Diuretics
• Anticoagulants
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Drug Therapy
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Heparin
Low-molecular-weight heparin (LMWH)
Warfarin
Antiplatelet agents
Fibrinolytic agents (also called thrombolytics)
Lipid-lowering agents
Analgesics
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Diet Therapy
• Low-fat, high-fiber diet
• Well-balanced diet
• Emphasis on fruits, vegetables, grains, and proteins
low in fat (fish, legumes, poultry, lean meats)
• Cholesterol intake should be limited to
200 mg/day; foods with trans fatty acids, limited
to 8
• Exercise program may help achieve optimal
weight
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Diet Therapy
• Sodium
• A diet containing sodium 2 g/day most often
prescribed
• Potassium
• Patients taking potassium-wasting diuretics need
adequate potassium in the diet
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Other Therapeutic Measures
• Oxygen therapy
• Pacemakers
• Temporary
• Permanent
• Cardioversion
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Cardiac Surgery
• Common surgical procedures
• Pacemaker insertion
• Repair or replace valves or septa or remove tumors
• Coronary artery bypass surgery
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Cardiac Surgery
• Preoperative nursing care
• Interventions
• Fear and Anxiety
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Cardiac Surgery
• Postoperative nursing care
• Interventions
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Ineffective Breathing Pattern
Pain
Ineffective Thermoregulation
Decreased Cardiac Output
Risk for Infection
Anxiety
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Cardiac Disorders
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Coronary Artery Disease (CAD)
• Arteriosclerosis
• Abnormal thickening, hardening, loss of elasticity of arterial walls
• Atherosclerosis
• Form of arteriosclerosis; inflammatory disease that begins with
endothelial injury and progresses to the complicated lesion seen in
advanced stages of the disease process
• Progression of lesions
• Fatty streak
• Fibrous plaque
• Complicated lesions
• Collateral circulation
• Branches grow from existing arteries; provide increased blood flow
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Coronary Artery Disease (CAD)
• Risk factors
• Nonmodifiable
• Age, gender, heredity, and race
• Modifiable
• Increased serum lipids, high blood pressure, cigarette
smoking (nicotine), diabetes mellitus with elevated blood
glucose, obesity, sedentary lifestyle
• Other factors
• Stress, sex hormones, birth control pills, excessive alcohol
intake, high homocysteine levels
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Angina Pectoris
• The most common symptom of CAD
• Demand for oxygen by myocardial cells exceeds
supply
• Stable angina
• Occurs with exercise or activity and usually subsides with rest
• Unstable angina
• Pain more severe, occurs at rest or with minimal exertion, is
often not relieved by NTG or requires more frequent NTG
administration, and is not predictable
• Variant angina
• Caused by coronary artery spasm; may not be associated with
CAD
• Unpredictable and often occurs at rest
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Angina Pectoris
• Medical treatment
• Initial therapy for patients with angina
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A
B
C
D
E
Aspirin and antianginal therapy
Beta-blocker and blood pressure
Cigarette smoking and cholesterol
Diet and diabetes
Education and exercise
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Acute Myocardial Infarction
• Risk factors for AMI
• Obesity, smoking, a high-fat diet, hypertension,
family history, male gender, diabetes mellitus,
sedentary lifestyle, and excessive stress
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Acute Myocardial Infarction
• Pathophysiology
• Begins with occlusion of a coronary artery
• Over 4-6 hours, ischemia, injury, infarction develop
• Ischemia results from a lack of blood and oxygen to
a portion of the heart muscle
• If ischemia is not reversed, injury occurs
• Deprived of blood and oxygen, the affected tissue
becomes soft and loses its normal color
• Continued ischemia: infarction of myocardial tissue
• Ischemia lasting 20 minutes or more is sufficient to
produce irreversible tissue damage
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Acute Myocardial Infarction
• Complications
• Heart failure, cardiogenic shock, thromboembolism,
and ventricular aneurysm/rupture
• Signs and symptoms
• Pain
• Heavy or constrictive pain located below or behind sternum
• May radiate to the arms, back, neck, or jaw
• Patient becomes diaphoretic and lightheaded and
may experience nausea, vomiting, and dyspnea
• The skin is frequently cold and clammy
• Patient experiences great anxiety; feeling of
impending doom
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Acute Myocardial Infarction
• Medical diagnosis
• History and the physical signs and symptoms
• Laboratory evidence and ECG changes
• Cardiac markers
• Troponin, myoglobin, and cardiac enzymes
• Electrocardiogram
• Ischemia: ST segment depressed; T wave is inverted
• If there has been total occlusion of a coronary artery, the
ECG will show ST elevation (STEMI)
• Following infarction, another change often seen on the ECG
waveforms is a significant Q wave
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Figure 35-8
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Acute Myocardial Infarction
• Medical treatment
• Drug therapy
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Sublingual or intravenous nitroglycerin
Morphine or Demerol
Oxygen
Fibrinolytic therapy
Aspirin and beta-adrenergic blockers
• Percutaneous coronary intervention (PCI)
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Intracoronary stents
Coronary atherectomy
Laser angioplasty
Radiation therapy
• Coronary artery bypass graft surgery
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Figure 35-9
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Figure 35-10
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Figure 35-11
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Acute Myocardial Infarction
• Assessment
• Ask patient to describe the pain, including type,
location, duration, and severity
• Interventions
• Pain
• Decreased cardiac output
• Anxiety
• Cardiac rehabilitation
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Heart Failure
• Etiology and risk factors
• Two types
• Disorders that increase the workload of the heart
• Disorders that interfere with heart’s pumping ability
• Patients at risk for HF: those with CAD, AMI,
cardiomyopathy, hypertension, COPD, pulmonary
hypertension, anemia, disease of the heart valves,
and fluid volume overload
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Heart Failure
• Pathophysiology
• The LV, RV, or both fail as pumps
• Usually left side of heart fails first; right side fails as
a result of the left-sided failure
• Compensation
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Sympathetic compensation
Renal compensation
Natriuretic peptides
Ventricular hypertrophy
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Heart Failure: Signs and Symptoms
• Left-sided heart failure
• Anxious, pale, and tachycardic
• Consecutive blood pressure readings may show a
downward trend
• Auscultation of the lung fields reveals crackles,
wheezes, dyspnea, and cough
• S3 and S4 heart sounds heard
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Heart Failure: Signs and Symptoms
• Right-sided heart failure
• Increased central venous pressure, jugular venous
distention, abdominal engorgement, and dependent
edema
• Anorexia, nausea, and vomiting from the abdominal
engorgement
• Fatigue, weight gain, decreased urinary output
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Heart Failure
• Medical diagnosis
• History, physical examination, radiographs, and
laboratory test results
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Heart Failure
• Medical treatment
• Drug therapy
• ACE inhibitors, diuretics, beta-adrenergic blockers,
inotropic agents, cardiac glycosides, and nitrates. In
addition, certain patients will benefit from B-type natriuretic
peptide
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Intra-aortic balloon pump (IABP)
Ventricular assist devices (VADs)
Biventricular pacing
Surgery
• Coronary artery bypass grafting, valve repair or
replacement, partial left ventriculectomy, and cardiac
transplantation
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Heart Failure
• Assessment
• Heart sounds, rate, and rhythm
• Jugular vein distention
• Baseline respiratory assessment of rate, rhythm,
and breath sounds is vital
• Measure weight and blood pressure accurately
• Inspect skin and palpate for turgor and edema
• Intake and output records and daily weights
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Heart Failure
• Interventions
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Decreased Cardiac Output
Impaired Gas Exchange
Fluid Volume Excess
Activity Intolerance
Anxiety
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Infective Endocarditis
• Etiology and risk factors
• Primarily affect the valves
• Incidence has decreased with the use of antibiotics,
but there has been a resurgence of the problem in
intravenous drug abusers
• Patients with valvular disease also at risk
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Infective Endocarditis
• Pathophysiology
• Pathogens, usually bacteria, enter the bloodstream
by any of the previously mentioned means
• The pathogen accumulates on the heart valves
and/or the endocardium and forms vegetations
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Infective Endocarditis
• Complications
• Heart failure and embolization
• Signs and symptoms
• Fever, chills, malaise, fatigue, and weight loss
• Chest or abdominal pain; may indicate embolization
• Petechiae inside the mouth and on the ankles, feet,
and antecubital areas
• Osler’s nodes on the patient’s fingertips or toes
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Infective Endocarditis
• Medical diagnosis
• History, physical examination, results of lab studies
• Echocardiography
• Serial blood cultures; elevated WBC
• Medical treatment
• Antimicrobials, rest, limitation of activities
• Prophylactic anticoagulants
• Surgery to replace an infected prosthetic valve
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Infective Endocarditis
• Assessment
• Review patient’s history for risk factors, recent
invasive procedures, pathologic cardiac conditions,
and onset of symptoms
• Assess for temperature elevation, heart murmur,
evidence of HF (cough, peripheral edema), and
embolization
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Infective Endocarditis
• Interventions
• Administer prescribed antibiotics
• Assess cardiac output and monitor for complications
• Teach patient about the medications prescribed and
any restrictions imposed
• Encourage adequate rest
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Pericarditis
• Etiology and risk factors
• Inflammation of the pericardium
• May be primary disease or associated with another
inflammatory process
• The disease may be acute or chronic
• Acute pericarditis caused by viruses, bacteria,
fungi, chemotherapy, or AMI (Dressler’s
syndrome)
• Chronic pericarditis caused by tuberculosis,
radiation, or metastases
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Pericarditis
• Pathophysiology
• In acute pericarditis, inflammatory process
increases amount of pericardial fluid and
inflammation of the pericardial membranes
• In chronic pericarditis, scarring of the pericardium
fuses the visceral and parietal pericardia together
• Loss of elasticity results from the scarring
• Constrictive process prevents adequate ventricular
filling
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Pericarditis
• Complications
• Pericardial effusion or accumulation of fluid in the
pericardial space
• May lead to cardiac tamponade
• Signs and symptoms
• Chest pain
• Most severe on inspiration
• Sharp and stabbing but may be described as dull or
burning
• Relieved by sitting up and leaning forward
• Dyspnea, chills, and fever
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Pericarditis
• Medical diagnosis
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Serial ECGs
Echocardiogram
CPK-MB
Blood cultures
• Medical treatment
• Analgesics, antipyretics, anti-inflammatory agents,
and antibiotics
• Surgical creation of a pericardial window for chronic
pericarditis with effusion
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Pericarditis
• Assessment
• Assessment of heart sounds especially important
• Interventions
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Rest and reduction of activity
Administer and teach patient about medications
Emotional support
Vital signs; auscultate for pericardial friction rub
Note pain characteristics and response to
analgesics and anti-inflammatory agents
• Monitor the ECG for dysrhythmias
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Cardiomyopathy
• Disease of the heart muscle
• Cause often unknown; may be secondary to another
disease process
• Usually leads to heart failure
• Three types: dilated, hypertrophic, and restrictive
• Risk factors with dilated CMP are excessive use of
alcohol, pregnancy, and infections
• Hypertrophic CMP: common in younger individuals
• Amyloidosis, sarcoidosis, and other
immunosuppressive disorders may predispose
individuals to restrictive cardiomyopathy
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Figure 35-12
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Cardiomyopathy
• Pathophysiology
• Dilated cardiomyopathy: dilation of the ventricle and
severely impaired systolic function
• Hypertrophic cardiomyopathy: LV hypertrophies and
there is thickening of the ventricular septum
• Restrictive cardiomyopathy: the myocardium
becomes rigid and noncompliant
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Cardiomyopathy
• Signs and symptoms
• Dilated cardiomyopathy: dyspnea, fatigue, left-sided
heart failure, and moderate-to-severe cardiomegaly
• Hypertrophic cardiomyopathy: dyspnea, orthopnea,
angina, fatigue, syncope, palpitations, ankle edema,
and S4 sounds
• Restrictive cardiomyopathy: dyspnea, fatigue, rightsided HF, S3 and S4 sounds, and mitral valve
regurgitation
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Cardiomyopathy
• Medical diagnosis
• Echocardiography
• Chest radiography
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Cardiomyopathy
• Medical treatment
• Dilated cardiomyopathy: positive inotropic drugs,
diuretics, ACE inhibitors and vasodilators; heart
transplant
• Hypertrophic cardiomyopathy: antidysrhythmics,
antibiotics, anticoagulants, calcium channel
blockers, beta-blockers; surgical interventions;
implantable cardioverter-defibrillator
• Restrictive cardiomyopathy: similar to that of HF
therapy. Heart transplantation may be considered
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Cardiomyopathy
• Assessment
• Primarily for heart failure
• Be alert for dyspnea, cough, edema, dysrhythmias,
and decreased cardiac output
• Interventions
• Similar to that of patients with HF
• A hopeful atmosphere and careful explanation of
care requirements
• Encourage the family to support the patient
• Guide the patient to make lifestyle changes
• Encourage patient to make decisions and choices
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Figure 35-13
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Sudden Cardiac Death
• When heart activity and respirations cease abruptly
• Most common reason is coronary heart disease
• Often preceded by ventricular tachycardia or
ventricular fibrillation and occasionally by severe
bradydysrhythmias
• Sudden cardiac death may be the first indication of
CAD
• Other causes: left ventricular dysfunction,
cardiomyopathy, hypokalemia, antidysrhythmics, liquid
protein diets, and high alcohol consumption
• Those who survive sudden cardiac death need
extensive testing to determine its nature and cause
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Sudden Cardiac Death
• Implantable cardioverter/defibrillator
• For patients with life-threatening recurrent
ventricular fibrillation who are unresponsive to
medications or pacemakers
• The device senses heart rate, diagnoses rhythm
changes, and treats ventricular dysrhythmias
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Nursing Care
• Promote psychosocial adaptation
• Body image change and a fear of shocks
• Patients and families need teaching and
support
• Family instructed in CPR
• ID bracelet and a card with instructions about
the ICD setting carried at all times
• Advise to avoid strong magnetic fields
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Valvular Disease
• Mitral stenosis: narrowing of the opening in the mitral
valve that impedes blood flow from the LA into the LV
• Mitral regurgitation: allows blood to flow back into the
LA during diastole
• Mitral valve prolapse: one or both leaflets enlarges and
protrudes into the LA during systole
• Aortic stenosis: valve cusps become fibrotic and calcify
• Aortic regurgitation: fibrosis and thickening of the aortic
cusps progress until the valve no longer maintains
unidirectional blood flow
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Cardiac Transplantation
• The first heart transplantation was performed in
1967 in South Africa by Dr. Christiaan Barnard
• Today in the United States, approximately 2500
are done annually for end-stage heart disease
• Donor must meet the criteria for brain death,
have no malignancies outside the central
nervous system, be free of infection, and not
have experienced severe chest trauma
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Cardiac Transplantation
• Donor and recipient organs carefully matched
• Recipient must be free of infection at the time
of transplantation
• Patient prepped as any open-heart procedure
• Cardiopulmonary bypass initiated; recipient’s heart
is removed except for the posterior portions of the
atria
• Donor heart trimmed and anastomosed to the
remaining native heart
• Patient removed from bypass, heart restarted, and
chest is closed
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Cardiac Transplantation
• Aftercare similar to that of coronary artery
bypass surgery
• Hemodynamic monitoring, ventilation, cardiac
assessment, care of chest tubes, and accurate
intake and output measurements are vital
• Modified protective isolation used
• Patients and families taught sign/symptoms of
infection, to avoid crowds and others with
infections
• Lifelong immunosuppression
• Rejection monitored by endomyocardial
biopsies
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Electrocardiogram Monitoring
• 12-lead electrocardiogram
• Looks at heart from 12 directions or perspectives
• Permits more precise evaluation of the heart’s
electrical activity
• Continuous ECG monitoring
• Most units that perform continuous monitoring use
the five-lead system with four limb electrodes and a
chest electrode
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Figure 35-15
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Electrocardiogram Monitoring
• Interpretation of electrocardiograms
• Heart’s electrical activity represented by deflections,
positive and negative, from the baseline
• P wave, QRS complex, and T wave
• Criteria for interpreting electrocardiograms
•
•
•
•
•
•
•
Rate calculation
Rhythm
P waves
PR interval
QRS complex
T waves
QT interval
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Electrocardiogram Monitoring
• Interpretation of electrocardiograms
• Normal sinus rhythm
• The most common cardiac rhythm is sinus in origin
because the impulse originates in the SA node; is
conducted normally
• Common dysrhythmias (rhythm disturbance from
problem in the conduction system)
• Atrial dysrhythmias
• Junctional or escape rhythms
• Ventricular dysrhythmias
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Figure 35-17
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Figure 35-18
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Figure 35-19
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Figure 35-20
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Figure 35-21
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Figure 35-22
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Figure 35-23
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Figure 35-24
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Figure 35-25
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Figure 35-26
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Figure 35-27
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Figure 35-28
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Figure 35-29
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Figure 35-30
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Hemodynamic Monitoring
• Central venous catheter
• Placed through the skin, into a venous access
(brachial, femoral, subclavian, or jugular sites), and
threaded into the RA
• Catheter may have 1 to 3 lumens
• Mixed venous oxygen saturation
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Hemodynamic Monitoring
• Pulmonary artery catheter
• Swan-Ganz catheter
• Longer than the central venous catheter
• Inserted like the central venous catheter and is
threaded through the RA, tricuspid valve, RV,
pulmonic valve, and into pulmonary artery
• Cardiac output
• Measured continuously or by thermodilution
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Hemodynamic Monitoring
• Arterial line
• Provides a direct measurement of systolic and
diastolic blood pressures
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