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Chapter 35
Cardiac Disorders
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Pathway of Blood
Electrical Conduction??
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 INITIATION OF IMPULSE
 RATE
 Sinoatrial (SA) node-60-100 beats per minute (bpm)
 Atrioventricular (AV) node-40-60 bpm
 Ventricle -15-40 bpm
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 Preload is the amount of blood remaining in a ventricle
at the end of diastole or the pressure generated at the
end of diastole. Increased preload results in increased
stroke volume and thus increased cardiac output.
Factors that increase preload include increased venous
return to the heart and overhydration. Factors that
decrease preload include dehydration, hemorrhage,
and venous vasodilation.
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 Afterload is the amount of pressure the ventricles must
overcome to eject the blood volume. It is determined
primarily by the pressure in the arterial system.
Afterload is decreased by vasodilation and increased
by vasoconstriction.
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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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 A, Aortic valve at the second
intercostal space to the right
of the sternum.
 B, Pulmonic valve at the
second intercostal space to
the left of the sternum.
 C, Tricuspid valve at the fifth
intercostal space to the left of
the sternum.
 D, Mitral valve at the fifth
intercostal space in the
midclavicular line.
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Diagnostic Tests and
Procedures
 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 cont’d
 Stress test (exercise tolerance test)
 Perfusion imaging
 Thallium imaging
 Ultrafast computed tomography
 Cardiac catheterization
 Electrophysiology study (EPS)
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Laboratory Tests
 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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Drug Therapy
 Cardiac glycosides-Digoxin
 Antianginals- Nitroglycerin--verapamil
 Antidysrhythmics-Cordarone--propranolol
 Angiotensin-converting enzyme (ACE) inhibitors
(ACEIs)--captopril -- enalapril
 Diuretics—hydrochlorothiazide—spironolactone(K+
sparing) –lasix (K+ wasting)
 Anticoagulants—Heparin--enoxaparin --warfarin
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Drug Therapy cont’d
 Antiplatelet agents—Plavix—ASA 81 mg
 Fibrinolytic agents (also called thrombolytics)
 Streptokinase
 Lipid-lowering agents-statins
 Analgesics—demerol, morphine
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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 cont’d
 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 cont’d
 Postoperative nursing care
 Interventions






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) cont’d
 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 nitroglycerin (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 cont’d
 Medical treatment
 Initial therapy for patients with angina





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
(AMI)
 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
cont’d
 Pathophysiology
 Begins with occlusion of a coronary artery
 Over 4 to 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
cont’d
 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
cont’d
 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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Acute Myocardial Infarction
cont’d
 Medical treatment
 Drug therapy
 Sublingual or intravenous nitroglycerin
 Morphine or Demerol
 Oxygen
 Fibrinolytic therapy
 Aspirin and beta-adrenergic blockers
 Percutaneous coronary intervention (PCI)
 Intracoronary stents
 Coronary atherectomy
 Laser angioplasty
 Radiation therapy
 Coronary artery bypass graft surgery
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Acute Myocardial Infarction
cont’d
 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 (HF)
 Cause 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, chronic obstructive
pulmonary disease (COPD), pulmonary hypertension,
anemia, disease of the heart valves, and fluid volume
overload
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Heart Failure cont’d
 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




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 cont’d
 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
 Anasarca
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Heart Failure
 Medical diagnosis
 History, physical examination, radiographs, and
laboratory test results
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Heart Failure cont’d
 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
 Intraaortic 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 cont’d
 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 cont’d
 Interventions
 Decreased Cardiac Output
 Impaired Gas Exchange
 Fluid Volume Excess
 Activity Intolerance
 Anxiety
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Infective Endocarditis (IE)
 Cause 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 cont’d
 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 cont’d
 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 nodes on the patient’s fingertips or toes
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Infective Endocarditis cont’d
 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 cont’d
 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 cont’d
 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
 Cause 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
syndrome)
 Chronic pericarditis caused by tuberculosis,
radiation, or metastases
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Pericarditis cont’d
 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 cont’d
 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 cont’d
 Medical diagnosis
 Serial ECGs
 Echocardiogram
 Creatine kinase-MB fraction (CK-MB)
 Blood cultures
 Medical treatment
 Analgesics, antipyretics, antiinflammatory agents, and
antibiotics
 Surgical creation of a pericardial window for chronic
pericarditis with effusion
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Pericarditis cont’d
 Assessment
 Assessment of heart sounds especially important
 Interventions





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
antiinflammatory agents
 Monitor the ECG for dysrhythmias
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Cardiomyopathy (CMP)
 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 cardiomyopathy (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 CMP
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Cardiomyopathy cont’d
 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 cont’d
 Signs and symptoms
 Dilated cardiomyopathy: dyspnea, fatigue, leftsided heart failure, and moderate to severe
cardiomegaly
 Hypertrophic cardiomyopathy: dyspnea, orthopnea,
angina, fatigue, syncope, palpitations, ankle edema,
and S4 sounds
 Restrictive cardiomyopathy: dyspnea, fatigue,
right-sided HF, S3 and S4 sounds, and mitral valve
regurgitation
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Cardiomyopathy cont’d
 Medical diagnosis
 Echocardiography
 Chest radiography
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Cardiomyopathy cont’d
 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 cont’d
 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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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 cont’d
 Implantable cardioverter/defibrillator (ICD)
 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
cont’d
 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
cont’d
 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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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 cont’d
 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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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
cont’d
 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
cont’d
 Arterial line
 Provides a direct measurement of systolic and diastolic
blood pressures
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