A.

Coronary Arteriography (Definition/Description):

- In coronary arteriography, the catheter is introduced into the right or left brachial or femoral artery,
then passed into the ascending aorta and manipulated into the appropriate coronary artery.
Purposes:
- to evaluate the degree of atherosclerosis and to guide the selection of treatment
- to study suspected congenital anomalies of the coronary arteries
Indications:
- positive stress test, unstable angina pectoris, positive stress test following myocardial infarction,
variants of angina, ventricular aneurysm complications, and in the young coronary patient.
- to define coronary anatomy in patients who have persistent angina despite full medication
Contraindication/Precautions and interfering factors:
- Coagulopathy
- Decompensated congestive heart
failure
- Hypertensive crisis
- Stroke or CVA
- Refractory arrhythmia
- GI hemorrhage
- Pregnancy
- Inability for patient cooperation
- Active infection
- Renal failure
- Contrast medium allergy
 Equipments/Patient Preparations:
- The patient may be advised not to eat or drink anything for 8 hours before the test starts.
- They may need to stay in the hospital the night before the test. Otherwise, they will check in to the
hospital the morning of the test.
- Patient will be instructed to wear a hospital gown.
- A consent may be given form before the test and client’s health care provider will explain the
procedure and its risks.
- The client must be assessed for allergic reactions to any medications or to contrast material in the
past.
- Assess if the client is suspected to be pregnant
Normal values:
- Normal results would indicate that there is a normal supply of blood to the heart and no blockages.
Procedure:
- Coronary arteriography is a procedure in which a very thin catheter, or tube, is threaded through an
artery from the groin, neck, or arm to the coronary arteries around the heart.
- The doctor uses this catheter to put a contrast dye into the blood of the coronary arteries. The dye
shows up on X-rays and highlights the coronary arteries. The X-rays are called angiograms.
- The patient will be awake for a coronary arteriography procedure, although they may be given
medication that will help them to relax. The physician will numb the spot where the catheter is put
into the patient’s body.

Implications of abnormal results

- An abnormal result may mean you have a blocked artery due to a plaque (fatty buildup) that is
causing your coronary artery to be more narrow than normal. As plaque builds up, it is harder for
oxygen-rich blood to get to the heart through the coronary arteries. This can cause chest pain,
angina, and even heart attack. This is called coronary artery disease (CAD), also known as
coronary heart disease.
Important Nursing Responsibilities during and after the procedure:
- Observe the catheter access site for bleeding or hematoma formation, and assess the peripheral
pulses in the affected extremity (dorsalis pedis and posterior tibial pulses in the lower extremity,
radial pulse in the upper extremity) every 15 minutes for 1 hour, and then every 1 to 2 hours until
the pulses are stable.
- Evaluate temperature and color of the affected extremity and any patient complaints of pain,
numbness, or tingling sensations to determine signs of arterial insufficiency. Report changes
promptly.
- Monitor for dysrhythmias by observing the cardiac monitor or by assessing the apical and peripheral
pulses for changes in rate and rhythm.
- Inform the patient that if the procedure is performed percutaneously through the femoral artery
(and without the use of devices such as VasoSeal, Perclose, or Angio-Seal), the patient will remain on
bed rest for 2 to 6 hours with the affected leg straight and the head elevated to 30 degrees. For
comfort, the patient may be turned from side to side with the affected extremity straight. If the
cardiologist uses deployed devices, check local nursing care standards, but anticipate that the
patient will have less restrictions on elevation of the head of the bed and will be allowed to
ambulate in 2 hours or less. Analgesic medication is administered as prescribed for discomfort.
- Instruct the patient to report chest pain and bleeding or sudden discomfort from the catheter
insertion sites immediately.
- Encourage fluids to increase urinary output and flush out the dye.
- Ensure safety by instructing the patient to ask for help when getting out of bed the first time after
the procedure, because orthostatic hypotension may occur and the patient may feel dizzy and
lightheaded.

B. Electrophysiologic testing (Definition/Description):

- Electrophysiology studies (also known as bundle of His electrography) permit measurement of
discrete conduction intervals by recording electrical conduction during the slow withdrawal of a
bipolar or tripolar electrode catheter from the right ventricle through the bundle of His to the
sinoatrial node. The catheter is introduced into the femoral vein, passing through the right atrium
and across the septal leaflet of the tricuspid valve.
Purposes:
- To diagnose arrhythmias and conduction anomalies
- To determine the need for an implanted pacemaker, an internal cardioverterdefibrillator, and
cardioactive drugs and to evaluate their effects on the conduction system and ectopic rhythms
 - To locate the site of a bundle-branch block, especially in an asymptomatic patient with conduction
disturbances
- To determine the presence and location of accessory conducting structures
Indications:
- Identification and diagnosis of cause of arrhythmias as revealed by abnormal wave deflections
- Determination of heart rate
- Determination of conduction defects or diseases revealed by delay of electric impulses, with
abnormal time duration and amplitude of waves and intervals recorded on the strip
- Determination of the site and extent of myocardial or pulmonary infarction and myocardial ischemia
revealed by abnormal wave and interval times and amplitudes
- Determination of hypertrophy of chambers of the heart (atrial and ventricular) or heart hypertrophy
- Determination of the position of the heart in the thoracic cavity
- Diagnosis of pericarditis and Wolff-Parkinson- White syndrome revealed by ventricular pre-
excitation caused by accelerated AV conduction and changes in the QRS complex
- Suspected electrolyte imbalances of potassium, calcium, and magnesium and their effect on the
heart
- Evaluation of drugs such as digitalis preparations and antiarrhythmics, vasodilators, and
antihypertensives
- Evaluation of cardiac pacemaker function Monitoring of myocardial infarction during
- recovery
- Differentiation between possible causes of intraventricular conduction abnormalities and ventricular
hypertrophy by vectorcardiography
- Suspected ventricular abnormalities
Contraindication/Precautions and interfering factors:
- Patients whom are suspected to be pregnant.
- Patient whom are taking medications, physicians may advice the client to stop certain medicines
before the procedure
- Patients with bleeding disorders
- Patients with kidney disorders
- Patients with pacemaker or any other implanted cardiac devices.
- Patients with low blood pressure
Equipments/Patient Preparations:
- Patients receive nothing to eat or drink for 8 hours before the procedure.
- Antiarrhythmic medications are withheld for at least 24 hours before the initial study, and the
patient’s cardiac rate and rhythm are carefully monitored for dysrhythmias. Other medications may
be taken with sips of water.
- Ensure that the patient understands the reason for the study and is able to describe the common
sensations and experiences expected during and after the study.
Normal values:
- Normal EP/His bundle procedure
- Normal conduction intervals, refractory periods, and recovery times
- Controlled, induced arrhythmias
Procedure:
- A nurse will put an IV (intravenous line) in your arm. You’ll get medicine (a sedative) that will help
you relax. But you’ll be awake and able to follow instructions during the test.
- Your nurse will clean and shave the part of your body where the doctor will be working. This is
usually in the groin but may be the arm or neck.
- You’ll be given a shot – a local anesthetic will be given — to make the area numb. Your doctor will
make a needle puncture through your skin and into your blood vessel. A small straw-sized tube
called a sheath will be inserted into your artery or vein. The doctor will gently guide several
specialized EP catheters into your blood vessel through the sheath and advance them to your heart.
A video screen will show the position of the catheters. You may feel some pressure in the area
where the sheath was inserted, but you shouldn’t feel any pain.
- Your doctor will send small electric pulses through the catheters to make your heart beat at
different speeds. You may feel your heart beat stronger or faster.
- Electrical signals produced by your heart will be picked up by the special catheters and recorded.
This is called cardiac mapping and allows the doctor to locate where arrhythmias are coming from,
- Your doctor will remove the catheters and the IV line. Your nurse will put pressure on the puncture
site to stop any bleeding.
- EPS usually last 1 to 4 hours.
Implications of abnormal results
Abnormal EP results will reveal the following conditions:
- Conduction intervals longer or shorter than normal
- Refractory periods longer than normal
 - Prolonged recovery times
- Induced dysrhythmia in a normal subject
Abnormal results indicate the following conditions:
- Long atrial His (AH) bundle intervals indicate disease in the atrioventricular (AV) node if s ympathetic
and vagal influences on the AV node have been eliminated.
- Long ventricular His (VH) bundle intervals indicate disease in the His-Purkinje system.
- Prolonged sinus node recovery times indicate sinus node dysfunction such as sick sinus syndrome.
- Prolonged sinoatrial conduction times can indicate sinus exit block.
- A wide or split His bundle deflection indicates a His bundle lesion.
- Induction of a sustained ventricular and supraventricular tachycardia confirms the diagnosis of
recurrent ventricular tachycardia
Important Nursing Responsibilities during and after the procedure:
- the patient needs to be aware that the nurses in the EPS laboratory will be monitoring carefully for
signs of discomfort and will offer intravenous medications to reduce discomfort or anxiety. Patients
should be reminded to request these medications if necessary.
- Postprocedure interventions include careful monitoring for complications. The nurse takes vital
signs, reviews tracings of continuous ECG monitoring, assesses the apical pulse, auscultates for
pericardial friction rub (which indicates bleeding into the pericardial sac), and inspects the catheter
insertion sites for bleeding or hematoma formation.
- In addition, the nurse assists the patient to maintain bed rest with the affected extremity kept
straight and the head of the bed elevated to 30 degrees for 4 to 6 hours. The frequency of
assessments and the duration of bed rest may vary based on institutional policy and physician
preference.
C. Arteriogram (Definition/Description)
- An arteriogram is a procedure that produces an image of your arteries. During the procedure, your
doctor will use contrast material, or dye, and X-rays to observe the flow of blood through your arteries
and note any blockages.
Purposes:
- An arteriogram is done to see how blood moves through the arteries.
- It is also used to check for blocked or damaged arteries.
- It can be used to visualize tumors or find a source of bleeding.
Indications:
- Allow infusion of thrombolytic drugs into an occluded coronary
- Detect narrowing of coronary vessels or abnormalities of the great vessels in patients with angina,
syncope, abnormal electrocardiogram, hypercholesteremia with chest pain, and persistent chest
pain after revascularization
- Evaluate cardiac muscle function
- Evaluate cardiac valvular and septal defects
- Evaluate disease associated with the aortic arch
- Evaluate previous cardiac surgery or other interventional procedures
- Evaluate ventricular aneurysms
- Monitor pulmonary pressures and cardiac output
- Perform angioplasty, perform atherectomy, or place a stent
- Quantify the severity of atherosclerotic, occlusive coronary artery disease
Contraindication/Precautions and interfering factors:
- Patients with allergies to shellfish or iodinated contrast medium. The contrast medium used may
cause a life-threatening allergic reaction. Patients with a known hypersensitivity to contrast medium
may benefit from premedication with corticosteroids or the use of nonionic contrast medium.
- Patients with bleeding disorders.
- Patients who are pregnant or suspected of being pregnant, unless the potential benefits of the
procedure far outweigh the risk of radiation exposure to the fetus.
- Elderly and compromised patients who are chronically dehydrated before the test, because of their
risk of contrast-induced renal failure.
- Patients who are in renal failure.
Equipments/Patient Preparations:
- Inform the patient that the procedure assesses cardiovascular function.
- Obtain a history of the patient’s complaints, including a list of known allergens (especially allergies
or sensitivities to latex, iodine, seafood, anesthetics or contrast medium).
- Obtain a history of results of the patient’s cardiovascular and respiratory system, symptoms, and
results of previously performed laboratory tests and diagnostic and surgical procedures. Ensure
results of coagulation testing are obtained and recorded prior to the procedure; BUN and creatinine
results are also needed if contrast medium is to be used.
 - Note any recent procedures that can interfere with test results, including examinations using iodine-
based contrast medium or barium. Ensure that barium studies were performed more than 4 days
before angiography.
- Record the date of last menstrual period and determine the possibility of pregnancy in
perimenopausal women.
Normal values:
- Normal great vessels and coronary arteries
Procedure:
- The test is done in a medical facility designed to perform this test. You will lie on an x-ray table.
Local anesthetic is used to numb the area where the dye is injected. Most of the time, an artery in
the groin will be used. In some cases, an artery in your wrist may be used.
- Next, a flexible tube called a catheter (which is the width of the tip of a pen) is inserted into the
groin and moved through the artery until it reaches the intended area of the body. The exact
procedure depends on the part of the body being examined.
- You will not feel the catheter inside of you.
- You may ask for a calming medicine (sedative) if you are anxious about the test.
- For most tests:
o A dye (contrast) is injected into an artery.
o X-rays are taken to see how the dye flows through your bloodstream.

Implications of abnormal results:

- Aortic atherosclerosis
- Aortic dissection
- Aortitis
- Aneurysms
- Cardiomyopathy
- Congenital anomalies
- Coronary artery atherosclerosis and degree of obstruction
- Graft occlusion
- Pulmonary artery abnormalities
- Septal defects
- Trauma causing tears or other disruption
- Tumors
- Valvular disease
Important Nursing Responsibilities during and after the procedure:
- Ensure that the patient has removed external metallic objects from the area to be examined prior to
the procedure.
- If the patient has a history of allergic reactions to any substance or drug, administer ordered
prophylactic steroids or antihistamines before the procedure. Use nonionic contrast medium for the
procedure.
- Have emergency equipment readily available.
- Instruct the patient to cooperate fully and to follow directions. Instruct the patient to remain still
throughout the procedure because movement produces unreliable results.
- Record baseline vital signs, and continue to monitor throughout the procedure.
- Establish an IV fluid line for the injection of emergency drugs and of sedatives.
- Administer an antianxiety agent, as ordered, if the patient has claustrophobia. Administer a sedative
to a child or to an uncooperative adult, as ordered.
- Place electrocardiographic electrodes on the patient for cardiac monitoring. Establish a baseline
rhythm; determine if the patient has ventricular arrhythmias.
- Using a pen, mark the site of the patient’s peripheral pulses before angiography; this allows for
quicker and more consistent assessment of the pulses after the procedure.
- Place the patient in the supine position on an exam table. Cleanse the selected area, and cover with
a sterile drape.
- A local anesthetic is injected at the site, and a small incision is made or a needle inserted under
fluoroscopy.
- The contrast medium is injected, and a rapid series of images is taken during and after the filling of
the vessels to be examined. Delayed images may be taken to examine the vessels after a time and to
monitor the venous phase of the procedure.
 - Ask the patient to inhale deeply and hold his or her breath while the x-ray images are taken, and
then to exhale after the images are taken.
- Instruct the patient to take slow, deep breaths if nausea occurs during the procedure.
- Monitor the patient for complications related to the procedure (e.g., allergic reaction, anaphylaxis,
bronchospasm).
- The needle or catheter is removed, and a pressure dressing is applied over the puncture site.
- Observe the needle/catheter insertion site for bleeding, inflammation, or hematoma formation.
- Obtain a list of the patient’s current medications, including anticoagulants, aspirin and other
salicylates, herbs, nutritional supplements, and nutraceuticals, especially those known to affect
coagulation. Such products should be discontinued by medical direction for the appropriate number
of days prior to a surgical procedure. Note the last time and dose of medication taken.
- If contrast medium is scheduled to be used, patients receiving metformin (Glucophage) for non-
insulin dependent (type 2) diabetes should be instructed as ordered to discontinue the drug on the
day of the test and continue to withhold it for 48 hours after the test. Failure to do so may result in
lactic acidosis.
- Review the procedure with the patient. Address concerns about pain and explain that there may be
moments of discomfort and some pain experienced during the test. Inform the patient that the
procedure is usually performed in a radiology or vascular suite by a HCP and takes approximately
30–60 min.
- Instruct the patient to resume usual diet, fluids, medications, and activity as directed by the HCP.
Renal function should be assessed before metformin is resumed.
- Monitor vital signs and neurologic status every 15 min for 1 hr, then every 2 hr for 4 hr, and then as
ordered by the HCP. Take temperature every 4 hr for 24 hr. Compare with baseline values. Protocols
may vary from facility to facility.
- Observe for delayed allergic reactions, such as rash, urticaria, tachycardia, hyperpnea, hypertension,
palpitations, nausea, or vomiting.
- Instruct the patient to immediately report symptoms such as fast heart rate, difficulty breathing,
skin rash, itching, or decreased urinary output.
- Assess extremities for signs of ischemia or absence of distal pulse caused by a catheter-induced
thrombus.
- Instruct the patient in the care and assessment of the site and to observe for bleeding, hematoma
formation, bile leakage, and inflammation.
- Instruct the patient to apply cold compresses to the puncture site as needed, to reduce discomfort
or edema.
- Instruct the patient to maintain bed rest for 4 to 6 hr after the procedure or as ordered.
D. Venogram (Definition/Description):
- A venogram is an x-ray test that involves injecting contrast material into a vein to shows how blood
flows through your veins. This allows a physician to determine the condition of your veins
Purposes:
- To confirm a diagnosis of DVT
- To distinguish clot formation from venous obstruction (for example, a large tumor of the pelvis impinging
on the venous system)
- To evaluate congenital venous abnormalities
- To assess deep vein valvular competence (especially helpful in identifying underlying causes of leg
edema)
- To locate a suitable vein for arterial bypass grafting
Indications:
- Confirm a diagnosis of DVT
- Distinguish clot formation from venous obstruction
- Evaluate congenital venous malformations
Contraindication/Precautions and interfering factors:
- Patients with severe edema of the legs
- Patients who are uncooperative
- Patients who are allergic to iodinated dye or shellfish
- Patients with renal failure, because the iodinated dye isnephrotoxic
- Inability of the patient to cooperate or remain still during the procedure because of age, significant pain,
or mental status
- Patients who are very obese, who may exceed the weight limit for the equipment
- Incorrect positioning of the patient, which may produce poor visualization of the area to be examined
- Improper adjustment of the radiographic equipment to accommodate obese or thin patients, which can
cause overexposure or underexposure and a poor-quality study
 - Metallic objects within the examination field (e.g., jewelry or body rings), which may inhibit organ
visualization and can produce unclear images
Equipments/Patient Preparations:
- Explain to the patient that lower limb venography helps detect abnormal conditions in the veins of the
legs.
- Instruct the patient to restrict food and to drink only clear liquids for 4 hours before the test.
- Describe the test, including who will perform it and where it will take place. Tell the patient pretest blood
work for coagulation and kidney function may be needed.
- Warn the patient that he may feel a burning sensation in his leg on injection of the contrast medium and
some discomfort during the procedure.
- Make sure that the patient or a responsible family member has signed an informed consent form.
- Check the patient’s history for hypersensitivity to iodine or iodine-containing foods or to contrast media.
Mark any sensitivities on the chart and notify the physician.
- Reassure the patient that contrast media complications are rare, but tell him to report nausea, severe
burning or itching, constriction in the throat or chest, or dyspnea immediately. Restrict anticoagulant
therapy, if ordered.
- Just before the test, instruct the patient to void, to remove all clothing below the waist, and to put on a
gown.
- If ordered, administer a prescribed sedative to an anxious or uncooperative patient.
Normal values:
- No evidence of venous thrombosis or obstruction

Procedure:
- The patient is positioned on a tilting radiographic table inclined 40 to 60 degrees so that the leg being
tested doesn’t bear any weight. He’s instructed to relax this leg and keep it still; a tourniquet may be tied
around the ankle to expedite venous filling.
- A superficial vein in the dorsum of the patient’s foot is injected with normal saline solution.
- When needle placement is correct, 100 to 150 ml of the contrast medium is slowly injected over 90
seconds to 3 minutes and the presence of extravasation is checked.
- If a suitable superficial vein can’t be found (due to edema), a surgical cutdown of the vein may be
performed.
- Using a fluoroscope, the distribution of the contrast medium is monitored, and spot films are taken from
the anteroposterior and oblique projections and over the thigh and femoroiliac regions. Then, overhead
films are taken of the calf, knee, thigh, and femoral area.
- After filming, the patient is repositioned horizontally, the leg is quickly elevated, and normal saline
solution is infused to flush the contrast medium from the veins.
- The fluoroscope is checked to confirm complete emptying. Then the needle is removed.
- Apply an adhesive bandage to the injection site.
- Monitor the patient’s vital signs until he’s stable; check his pulse rate and quality on the dorsalis pedis,
popliteal, and femoral arteries.
- Administer prescribed analgesics, as ordered, to counteract the irritating effects of the contrast medium.
- If the venogram indicates DVT, initiate the prescribed therapy (heparin infusion, bed rest, leg elevation or
support, or blood chemistry tests).
- Tell the patient that he may resume his usual diet and medications, as ordered.
- Observe the patient for signs and symptoms of a latent reaction to the dye. Encourage fluids to flush the
dye from the kidneys.
Implications of abnormal results
- Obstructed venous systems
- Acute deep vein thrombosis
Important Nursing Responsibilities during and after the procedure:
- Note the following procedural steps:
o The patient is taken to the radiology department and placed in a supine position on the x-ray
table.
o Catheterization of a superficial vein on the foot is performed. This may require a surgical cut
down.
o An iodinated, radiopaque dye is injected into the vein.
o X-ray images are taken to follow the course of the dye up the leg.
o A tourniquet is frequently placed on the leg to prevent filling of the superficial saphenous vein.
As a result, all of the dye goes toward filling the deep venous system, which contains the most
clinically significant thrombosis that can embolize.
- Note that a radiologist performs this study in approximately 30 to 90 minutes.
 o Tell the patient that the venous catheterization is only as uncomfortable as a cutaneous heel
stick.
o The dye may cause the patient to feel a warm flush. Occasionally, mild degrees of nausea,
vomiting, or skin itching also may occur
- Continue appropriate hydration of the patient.
- Observe the puncture site for infection, cellulitis, or bleeding.
- Assess the patient’s vital signs for signs of bacteremia.

E. Hemodynamic monitoring (CVP, pulmonary artery pressure, intra-arterial BP monitoring)

(Definition/Description):
- Hemodynamic monitoring measures the blood pressure inside the veins, heart, and arteries. It also
measures blood flow and how much oxygen is in the blood. It is a way to see how well the heart is
working.
Purposes:
Central Venous Pressure Monitoring
- The CVP, the pressure in the vena cava or right atrium, is used to assess right ventricular function and
venous blood return to the right side of the heart.
- Because the pressures in the right atrium and right ventricle are equal at the end of diastole (0 to 8 mm
Hg), the CVP is also an indirect method of determining right ventricular filling pressure (preload). This
makes the CVP a useful hemodynamic parameter to observe when managing an unstable patient’s fluid
volume status.
- CVP monitoring is most valuable when pressures are monitored over time and are correlated with the
patient’s clinical status.

Pulmonary Artery Pressure Monitoring

- Pulmonary artery pressure monitoring is an important tool used in critical care for assessing left
ventricular function, diagnosing the etiology of shock, and evaluating the patient’s response to medical
interventions
Intra-arterial Blood Pressure Monitoring
- Intra-arterial BP monitoring is used to obtain direct and continuous BP measurements in critically ill
patients who have severe hypertension or hypotension.
- Arterial catheters are also useful when arterial blood gas measurements and blood samples need to be
obtained frequently.
Indications:
- Pulmonary artery monitoring is preferred for the patient with HF
- Intra-arterial BP monitoring is used to obtain direct and continuous BP measurements in critically ill
patients who have severe hypertension or hypotension.
Contraindication/Precautions and interfering factors:
- CVP monitoring is not clinically useful in a patient with HF in whom left ventricular failure precedes right
ventricular failure, because in these patients an elevated CVP is a very late sign of HF
Equipments/Patient Preparations:
To perform invasive monitoring, specialized equipment is necessary and includes the following:
- A CVP, pulmonary artery, or arterial catheter, which is introduced into the appropriate blood vessel
or heart chamber
- A flush system composed of intravenous solution (which may include heparin), tubing, stopcocks,
and a flush device, which provides for continuous and manual flushing of the system
- A pressure bag placed around the flush solution that is maintained at 300 mm Hg of pressure; the
pressurized flush system delivers 3 to 5 mL of solution per hour through the catheter to prevent
clotting and backflow of blood into the pressure monitoring system
- A transducer to convert the pressure coming from the artery or heart chamber into an electrical
signal
- An amplifier or monitor, which increases the size of the electrical signal for display on an
oscilloscope
Central Venous Pressure Monitoring
- Before the insertion of a CVP catheter, the site is prepared by shaving if necessary and by cleansing
with an antiseptic solution.
- A local anesthetic may be used.

Normal values:
Central Venous Pressure Monitoring
 - The range for a normal CVP is 0 to 8 mm Hg with a pressure monitoring system or 3 to 8 cm H2O
with a water manometer system.
Pulmonary Artery Pressure Monitoring
- Normal pulmonary artery pressure is 25/9 mm Hg, with a mean pressure of 15 mm Hg
Procedure:
Central Venous Pressure Monitoring
- The CVP can be continuously measured by connecting either a catheter positioned in the vena cava
or the proximal port of a pulmonary artery catheter to a pressure monitoring system. The
pulmonary artery catheter, described in greater detail later, is used for critically ill patients. Patients
in general medical-surgical units who require CVP monitoring may have a single-lumen or multi
lumen catheter placed into the superior vena cava. Intermittent measurement of the CVP can then
be obtained with the use of a water manometer.
Pulmonary Artery Pressure Monitoring
- Pulmonary artery pressure monitoring is achieved by using a pulmonary artery catheter and
pressure monitoring system. Catheters vary in their number of lumens and their types of
measurement (ex. cardiac output, oxygen saturation) or pacing capabilities. All types require that a
balloon-tipped, flow-directed catheter be inserted into a large vein (usually the subclavian, jugular,
or femoral vein); the catheter is then passed into the vena cava and right atrium. In the right atrium,
the balloon tip is inflated, and the catheter is carried rapidly by the flow of blood through the
tricuspid valve, into the right ventricle, through the pulmonic valve, and into a branch of the
pulmonary artery. When the catheter reaches a small pulmonary artery, the balloon is deflated and
the catheter is secured with sutures. Fluoroscopy may be used during insertion to visualize the
progression of the catheter through the heart chambers to the pulmonary artery. This procedure
can be performed in the operating room or cardiac catheterization laboratory or at the bedside in
the critical care unit. During insertion of the pulmonary artery catheter, the bedside monitor is
observed for waveform and ECG changes as the catheter is move through the heart chambers on
the right side and into the pulmonary artery. After the catheter is correctly positioned, the following
pressures can be measured: CVP or right atrial pressure, pulmonary artery systolic and diastolic
pressures, mean pulmonary artery pressure, and pulmonary artery wedge pressure. If a
thermodilution catheter is used, the cardiac output can be measured and systemic vascular
resistance and pulmonary vascular resistance can be calculated.
Intra-arterial Blood Pressure Monitoring
- This technique involves direct measurement of arterial pressure by inserting a cannula needle in a
suitable artery. The cannula must be connected to a sterile, fluid-filled system, which is connected to
an electronic patient monitor. Once an arterial site is selected (radial, brachial, femoral, or dorsalis
pedis), collateral circulation to the area must be confirmed before the catheter is placed. If no
collateral circulation exists and the cannulated artery became occluded, ischemia and infarction of
the area distal to that artery could occur. Collateral circulation to the hand can be checked by the
Allen test to evaluate the radial and ulnar arteries or by an ultrasonic Doppler test for any of the
arteries.
Implications of abnormal results
Central Venous Pressure Monitoring
- A rising pressure may be caused by hypervolemia or by a condition, such as HF, that results in a
decrease in myocardial contractility.
- Decreased CVP indicates reduced right ventricular preload, most often caused by hypovolemia.
Pulmonary Artery Pressure Monitoring
- Complications of pulmonary artery pressure monitoring include infection, pulmonary artery rupture,
pulmonary thromboembolism, pulmonary infarction, catheter kinking, dysrhythmias, and air
embolism.
Intra-arterial Blood Pressure Monitoring
- Complications include local obstruction with distal ischemia, external hemorrhage, massive
ecchymosis, dissection, air embolism, blood loss, pain, arteriospasm, and infection.
Important Nursing Responsibilities during and after the procedure:
Central Venous Pressure Monitoring
- Once the CVP catheter is inserted, it is secured and a dry, sterile dressing is applied.
- Catheter placement is confirmed by a chest x-ray, and the site is inspected daily for signs of
infection.
- In general, the dressing is to be kept dry and air occlusive. Dressing changes are performed with the
use of sterile technique.
 - To measure the CVP, the transducer (when a pressure monitoring system is used) or the zero mark
on the manometer (when a water manometer is used) must be placed at a standard reference
point, called the phlebostatic axis. After locating the phlebostatic axis, the nurse may make an ink
mark on the patient’s chest to indicate the location.

Pulmonary Artery Pressure Monitoring

- The nurse who obtains the wedge reading ensures that the catheter has returned to its normal
position in the pulmonary artery by evaluating the pulmonary artery pressure waveform.
- Catheter site care is essentially the same as for a CVP catheter. As in measuring CVP, the transducer
must be positioned at the phlebostatic axis to ensure accurate readings
Intra-arterial Blood Pressure Monitoring
- Site preparation and care are the same as for CVP catheters.
- A transducer is attached, and pressures are measured in millimeters of mercury (mm Hg).

F. CABG (Definition/Description):
- Coronary artery bypass grafting (CABG) is a type of surgery that improves blood flow to the heart.
It's used for people who have severe coronary heart disease (CHD), also called coronary artery
disease.
Purposes:
- to treat coronary artery disease
Indications:
- patients with significant narrowings and blockages of the heart arteries (coronary artery disease)
Contraindication/Precautions and interfering factors:
- Patients whom are suspected to be pregnant
- Patients with bleeding disorders
- Patients with kidney disorders
- Patients whom have a sensitivity to or are allergic to any medicines, iodine, latex, tape, or anesthetic
medicines (local and general).
- Patients with pacemaker or any other implanted cardiac device.
- Patients who are smoking
Equipments/Patient Preparations:
- Explain the procedure thoroughly and be open to questions and concerns given by the patient.
- A consent may be given to the client for the permission to do the test.
- Conduct a health history and complete physical examination to ensure that the patient is in good
health before having the procedure. Blood tests or other diagnostic tests may be needed to find out
how long it takes your blood to clot.
- Patients may be asked to not eat or drink for 8 hours before the procedure, generally after midnight.
- Assess if the patient is suspected to be pregnant
- Assess for any sensitivity to or allergic reactions to any medicines, iodine, latex, tape, or anesthetic
medicines (local and general).
- Inquire about all medications (prescription and over-the-counter), vitamins, herbs, and supplements
that the patient is taking.
- Assess for a history of bleeding disorders or if the patient is taking any blood-thinning medicines,
aspirin, or other medicines that affect blood clotting. Patients may be advised to stop some of these
medicines before the procedure.
- Patient will be asked to remove any jewelry or other objects that may interfere with the procedure
and change into a hospital gown and empty your bladder if needed.
Normal values:
- Normal results would indicate an improved blood flow to the heart.
Procedure:
- A healthcare professional will insert an intravenous (IV) line in your arm or hand. Other catheters
will be put in your neck and wrist to monitor your heart and blood pressure, as well as to take blood
samples.
- You will lie on your back on an operating table.
- The anesthesiologist will continuously monitor your heart rate, blood pressure, breathing, and blood
oxygen level during the surgery. Once you are sedated (put into a deep sleep), a breathing tube will
be put into your throat and you will be connected to a ventilator, which will breathe for you during
the surgery.
- A catheter will be put into your bladder to drain urine.
- The skin over the surgical site will be cleaned with an antiseptic solution.
- Once all the tubes and monitors are in place, your doctor will make incisions (cuts) in one or both of
your legs or one of your wrists to access the blood vessel(s) to be used for the grafts. He or she will
remove the vessel(s) and close those incision(s).
 - The doctor will make an incision (cut) down the center of your chest from just below the Adam's
apple to just above the navel.
- The doctor will cut the sternum (breastbone) in half lengthwise. He or she will separate the halves of
the breastbone and spread them apart to expose your heart.
Coronary artery bypass graft surgery--on-pump procedure
- To sew the grafts onto the very small coronary arteries, the doctor will need to stop the patient’s
heart temporarily. Tubes will be put into the heart so that blood can be pumped through their body
by a heart-lung bypass machine.

- Once the blood has been diverted into the bypass machine for pumping, the doctor will stop the
heart by injecting it with a cold solution.

- When the heart has been stopped, the doctor will do the bypass graft procedure by sewing one end
of a section of vein over a tiny opening made in the aorta, and the other end over a tiny opening
made in the coronary artery just below the blockage. If the doctor uses the internal mammary artery
inside the patient’s chest as a bypass graft, the lower end of the artery will be cut from inside the
chest and sewn over an opening made in the coronary artery below the blockage.

- The patient may need more than one bypass graft done, depending on how many blockages they
have and where they are located. After all the grafts have been completed, the doctor will closely
check them as blood runs through them to make sure they are working.

- Once the bypass grafts have been checked, the doctor will let the blood circulating through the
bypass machine back into patient’s heart and he or she will remove the tubes to the machine. The
patient’s heart may restart on its own, or a mild electric shock may be used to restart it.
- The doctor may put temporary wires for pacing into the patient’s heart. These wires can be attached
to a pacemaker and your heart can be paced, if needed, during the initial recovery period.
Coronary artery bypass surgery--off-pump procedure
- Once the doctor has opened the chest, he or she will stabilize the area around the artery to be
bypassed with a special instrument.

- The rest of the heart will continue to function and pump blood through the body.

- The heart-lung bypass machine and the person who runs it may be kept on stand-by just in case the
procedure need to be completed on bypass.

- The doctor will do the bypass graft procedure by sewing one end of a section of vein over a tiny
opening made in the aorta, and the other end over a tiny opening made in the coronary artery just
below the blockage.

- The patient may have more than one bypass graft done, depending on how many blockages they
have and where they are located.

- Before the chest is closed, the doctor will closely examine the grafts to make sure they are working.
Implications of abnormal results
- Abnormal results would indicate further narrowing of arteries, impending the flow of blood towards
the heart.
Important Nursing Responsibilities during and after the procedure:
- Patient preparation is the primary role of the nurse for these tests.
- Explain the procedure thoroughly and be open to questions and concerns given by the patient.
- Prior to the procedure an informed consent may be given to the client for the permission to do the
test.
- The nurse should instruct and assist the client to lie on their back on an operating table.
- Frequent monitoring of the patient's vitals is essential during and after the procedure.
- Observe for signs or symptoms fever, rapid heart rate, new or worsened pain around the chest
wound, reddening around the chest wound or bleeding, or other discharge from the chest wound
- Assist the client in developing a treatment plan that includes lifestyle changes to help them stay
healthy and reduce the chance of CHD getting worse.

G. Gallium Scan (Definition/Description)

 - Gallium imaging is a nuclear medicine study that assists in diagnosing neoplasm and inflammation
activity. Gallium, which has 90 percent sensitivity for inflammatory disease, is readily distributed
throughout plasma and body tissues.
Purposes:
- To detect primary or metastatic neoplasms and inflammatory lesions when the site of the disease
hasn’t been clearly defined
- To evaluate malignant lymphoma and identify recurrent tumors following chemotherapy or
radiation therapy
- To clarify focal defects in the liver when liver-spleen scanning and ultrasonography prove
inconclusive
- To evaluate bronchogenic carcinoma
Indications:
- Aid in the diagnosis of infectious or inflammatory diseases
- Evaluate lymphomas
- Evaluate recurrent lymphomas or tumors after radiation therapy or chemotherapy
- Perform as a screening examination for fever of undetermined origin
Contraindication/Precautions and interfering factors:
- Patients who are pregnant, unless the benefits outweigh the risks of fetal damage
- Recent barium studies will interfere with visualization of gallium within the abdomen.
Equipments/Patient Preparations:
- Explain to the patient that gallium scanning helps detect abnormal or inflammatory tissue.
- Tell the patient that he need not restrict food and fluids.
- Explain to the patient that the test requires a total body scan (usually performed 24 to 48 hours
after the I.V. injection of 67Ga citrate).
- Tell the patient who will perform the test and where it will take place.
- Warn the patient that he may experience transient discomfort from the needle puncture during
injection of the 67Ga citrate. Reassure him, however, that the dosage is only slightly radioactive and
isn’t harmful.
- If a gamma scintillation camera is to be used, assure the patient that although the uptake probe and
detector head may touch his skin, he’ll experience no discomfort.
- If a rectilinear scanner is to be used, mention to the patient that it makes a soft, irregular clicking
noise as it registers the radiation emissions.
- Make sure that the patient or a responsible family member has signed an informed consent form.
- Administer a laxative, an enema, or both, as ordered.
Normal values:
- Normal distribution of gallium. Some localization of the radionuclide within the liver, spleen, bone,
nasopharynx, lacrimal glands, breast, and bowel is expected.
Procedure:
- The patient may be positioned erect or recumbent or in an appropriate combination of these
positions, depending on his physical condition.
- Scans or scintigrams of the patient are taken 24 to 48 hours after 67Ga citrate injection, from
anterior and posterior views and, occasionally, lateral views.
- If the initial gallium scan suggests bowel disease and additional scans are necessary, give the patient
a cleaning enema before continuing the test.
Implications of abnormal results
- Abscess
- Infection
- Inflammation
- Lymphoma
- Tumor
Important Nursing Responsibilities during and after the procedure:
- Note the following procedural steps:
o The unsedated patient is injected with gallium.
o A total-body scan may be performed 4 to 6 hours later by slowly passing a radionuclide
detector over the body.
o Additional scans are usually taken 24, 48, and 72 hours later.
o During the scanning process, the patient is placed in the supine position and occasionally in
the lateral position.
- Note that a nuclear medicine technologist performs each scan in approximately 30 to 60â•›minutes.
Repeated scanning is required. Repeated injections are not necessary.
- Inform the patient that test results are interpreted by a physician trained in nuclear medicine and
are usually available 72 hours after the injection
- Assure the patient that only tracer doses of radioisotopes have been used and that no precautions
against radioactive exposure to others are necessary.
H. Thallium Scan (Definition/Description):
- Cardiac scanning is a nuclear medicine study that reveals clinical information about coronary blood
flow, ventricular size, and cardiac function. Thallium-201 chloride rest or stress studies are used to
evaluate myocardial blood flow to assist in diagnosing or determining the risk for ischemic cardiac
disease, coronary artery disease (CAD), and myocardial infarction (MI).
- This procedure is an alternative to angiography or cardiac catheterization in cases where these
procedures may pose a risk to the patient.
Purposes:
- To assess myocardial scarring and perfusion
- To demonstrate the location and extent of acute or chronic MI, including transmural and
postoperative infarction (resting imaging)
- To diagnose CAD (stress imaging)
- To evaluate the patency of grafts after CABG
- To evaluate the effectiveness of antianginal therapy or balloon angioplasty (stress imaging)
Indications:
- Aid in the diagnosis of or risk for CAD
- Evaluate the extent of CAD and determine cardiac function
- Assess the function of collateral coronary arteries
- Evaluate bypass graft patency and general cardiac status after surgery
- Evaluate the site of an old MI to determine obstruction to cardiac muscle perfusion
- Determine rest defects and reperfusion with delayed imaging in unstable angina
- Evaluate the effectiveness of medication regimen and balloon angioplasty procedure on narrow
coronary arteries
Contraindication/Precautions and interfering factors:
- Patients who are uncooperative or medically unstable
- Patients with severe cardiac arrhythmia.
- Patients who are pregnant, (unless the benefits outweigh the risks) because of fetal exposure to
radionuclide material (unless the benefits outweigh the risks)
- Myocardial trauma
- Cardiac flow studies can be altered by excessive alterations in chest pressure (as exists with
excessive crying in children).
- Recent nuclear scans (e.g., thyroid or bone scan)
- Drugs, such as long-acting nitrates, may only temporarily improve coronary perfusion and cardiac
function.
Equipments/Patient Preparations:
- Explain to the patient that thallium imaging helps determine if any areas of the heart muscle aren’t
receiving an adequate blood supply.
- If the patient is undergoing stress imaging, instruct him to restrict alcohol, tobacco, and
nonprescribed medications for 24 hours before the test and to have nothing by mouth for 3 hours
before the test.
- Describe the test, including who will perform it and where it will take place. Explain that additional
scans may be required.
- Tell the patient that he’ll receive an I.V. radioactive tracer and that multiple images of his heart will
be scanned.
- Explain to the patient that it’s important to lie still when images are taken.
- Warn the patient that he may experience discomfort from skin abrasion during preparation for
electrode placement. Assure him that the test involves minimal radiation exposure.
- Make sure that the patient or a responsible family member has signed an informed consent form.
- Tell the patient undergoing stress imaging to wear walking shoes during the treadmill exercise and
to report fatigue, pain, or shortness of breath immediately.
Normal values:
- Normal wall motion, coronary blood flow, tissue perfusion, and ventricular size and function
Procedure:
- Resting imaging
o Optimally, within the first few hours of symptoms of a MI, the patient receives an injection of
I.V. thallium or Cardiolite and scanning begins after 10 minutes.
o If further scanning is required, have the patient rest and restrict food and beverages other
than water.
- Stress imaging
o The patient, wired with electrodes, walks on a treadmill at a regulated pace that’s gradually
increased, while the electrocardiogram (ECG), blood pressure, and heart rate are monitored.
 o When the patient reaches peak stress, the examiner injects 1.5 to 3 millicuries of thallium
into the antecubital vein and then flushes it with 10 to 15 ml of normal saline solution or an
infusion of Cardiolite.
o The patient exercises an additional 45 to 60 seconds to permit circulation and uptake of the
isotope, and then lies on his back under the scintillation camera.
o If the patient is asymptomatic, the precordial leads are removed. Scanning begins after 10
minutes with the patient in the anterior, left anterior oblique, and left lateral positions.
o Additional scans may be taken after the patient rests and, rarely, after 24 hours. Taking a scan
after the patient rests is helpful in differentiating between an ischemic area and an infarcted
or scarred area of the myocardium.
Implications of abnormal results
- Abnormal stress images with normal resting images, indicating transient ischemia
- Abnormal stress and resting images, indicating previous MI
- Cardiac hypertrophy, indicated by increased radionuclide uptake in the myocardium
- Enlarged left ventricle
- Heart chamber disorder
- Ventricular septal defects
Important Nursing Responsibilities during and after the procedure:
- Take the patient to the nuclear medicine department. Depending on the type of nuclear myocardial
scan, each scanning protocol is different.
- Note the following general procedural steps:
o One or more intravenous (IV) injection of radionuclide material is performed.
o Electrocardiographic (EKG) leads may be applied.
o Depending on the radionuclide used, scanning is performed 15 minutes to 4 hours later.
o SPECT camera is placed at the level of the precordium.
o If a single gamma camera is used, the patient is placed in a supine position, then may be
repositioned to the lateral position or in the right and left oblique positions. In some
departments, the detector can be rotated around the patient, who remains in the supine
position.
o The gamma ray scanner records the image of the heart, and an image is immediately
developed.
o For an exercise stress test, additional radionuclide is injected during exercise when the
patient reaches a maximum heart rate. The patient then lies on a table, and scanning is
done. A repeat scan may be done 3 to 4 hours later.
o If an isonitrile stress test is needed, the radionuclide material is injected and a scan
performed 30 to 60 minutes later for the resting phase. Four hours later, cardiac stress
testing is done. After a second injection, scanning is repeated.
- Note that myocardial scans are usually performed in less than 30 minutes by a nuclear medicine
technician.
- If nuclear cardiac stress testing is performed, follow routine protocol described on page 225.
- Inform the patient that because only tracer doses of radioisotopes are used, no precautions need to
be taken against radioactive exposure to personnel or family.
- Instruct the patient to drink fluids to aid in the excretion of the radioactive substance.
- Apply pressure or a pressure dressing to the venipuncture site.
- Assess the venipuncture site for bleeding.

I. Technetium (Definition/Description):
- Technetium-99m stannous pyrophosphate (PYP) scanning, also known as myocardial infarct imaging,
reveals the presence of myocardial perfusion and the extent of myocardial infarction (MI). This
procedure can distinguish new from old infarct when a patient has had abnormal
electrocardiograms (ECGs) and cardiac enzymes have returned to normal.
Purposes:
- To confirm a recent MI
- To help define the size and location ofan MI
- To assess the prognosis after an acute MI
Indications:
- Aid in the diagnosis of (or confirm and locate) acute MI when ECG and enzyme testing do not
provide a diagnosis
- Evaluate possible reinfarction or extension of the infarct
- Obtain baseline information about infarction before cardiac surgery
- Aid in the diagnosis of perioperative MI
- Differentiate between a new and old infarction
Contraindication/Precautions and interfering factors:
 - Patients who are uncooperative or medically unstable
- Patients with severe cardiac arrhythmia.
- Patients who are pregnant, (unless the benefits outweigh the risks) because of fetal exposure to
radionuclide material (unless the benefits outweigh the risks)
Equipments/Patient Preparations:
- Explain to the patient that technetium pyrophosphate scanning helps assess if the heart muscle is
injured.
- Inform the patient that he need not restrict food and fluids. Tell him who will perform the test and
where it will take place.
- Inform the patient that he’ll receive an I.V. tracer isotope 2 or 3 hours before the procedure and
that multiple images of his heart will be made.
- Reassure the patient that the injection causes only slight discomfort, that the scan itself is painless,
and that the test involves less exposure to radiation than does a chest X-ray.
- Instruct the patient to remain quiet and motionless while he’s being scanned.
- Make sure that the patient or a responsible family member has signed an informed consent form.
Normal values:
- Normal coronary blood flow and tissue perfusion, with no PYP localization in the myocardium
- No uptake above background activity in the myocardium (note: when PYP uptake is present, it is
graded in relation to adjacent rib activity)
Procedure:
- Usually, 20 millicuries of 99mTc pyrophosphate are injected I.V. into the antecubital vein.
- After 2 or 3 hours, the patient is placed in a supine position and electrocardiography electrodes are
attached for continuous monitoring during the test.
- Generally, scans are taken with the patientin several positions, including anterior, left anterior
oblique, right anterior oblique, and left lateral. Each scan takes 10 minutes
Implications of abnormal results
- MI, indicated by increased PYP uptake in the myocardium
Important Nursing Responsibilities during and after the procedure
- Ensure that emergency equipment is readily available during the procedure.
- Ask the patient to void before the procedure. Have the patient put on a hospital gown.
- Inform the patient that movement during the procedure affects the results and makes
interpretation difficult.
- Images of the patient’s heart begin 2 to 4 hours after injection of the radionuclide.
- Images of the heart are taken from a minimum of three angles: anterior, left anterior oblique, and
left lateral. In most circumstances, however, SPECT is done so that the heart can be viewed from
multiple angles an dplanes.
- Instruct the patient to resumenormal activity and diet, unless otherwise indicated.
- If the patient must return for additional imaging, advise the patient to rest in the interim and restrict
diet to liquids before redistribution studies.
- Observe the injection site for redness, swelling, or hematoma.
- Advise patient to drink increased amounts of fluids for 24 to 48 hours to eliminate the radionuclide
from the body, unless contraindicated. Tell the patient that radionuclide is eliminated from the body
within 6 to 24 hours.
- Observe patient for up to 60 minutes after the study for a possible anaphylactic reaction to the
radionuclide, such as rash, tightening of throat, or difficulty breathing.
- Instruct the patient to flush the toilet immediately after each voiding following the procedure and to
wash hands meticulously with soap and water after each voiding for 24 hours after the procedure.
- Tell all caregivers to wear gloves when discarding urine for 24 hours after the procedure. Wash
gloved hands with soap and water before removing gloves. Then wash hands after the gloves are
removed.
- A physician specializing in this branch of medicine sends a written report to the ordering provider,
who discusses the results with the patient.
- Evaluate test results in relation to the patient’s symptoms and other tests performed. Related
diagnostic tests include electrocardiogram, echocardiogram, myocardial perfusion scan, and
computed tomography and magnetic resonance imaging of the chest.

J. Phonography (Definition/Description):
- Phonocardiography is an electrophysiologic study performed to identify, amplify, and record heart
sounds and murmurs. The sounds of blood flowing through the heart and great vessels are recorded
from sites on the chest by a microphone containing a transducer that converts the sounds into
electric impulses.
Purposes:
- The phonocardiogram allows to provide data on the timing, relative intensity, frequency, quality,
tone, timbre and precise location of the different components of the cardiac sound, in an objective
 and repeatable manner. In this way, the specialist can identify and analyze the sounds that make up
the heart sound separately to later make a synthesis of the characteristics that have been extracted
Indications:
- Detecting valvular defects revealed by abnormal heart sounds: increased intensity of the first sound
(S1), heard in tricuspid or mitral stenosis, or lower frequency of the fourth sound (S4), heard in
aortic stenosis
- Differentiating between mitral and tricuspid opening snaps from the third sound (S3) as revealed by
a higher frequency of the snaps in phonocardiography
- Differentiating among early, mid, and late systolic murmurs
- Diagnosing hypertrophic cardiomyopathies and pulmonary hypertension revealed by the presence
of the fourth sound (S4) and murmurs
- Diagnosing abnormal left ventricular function revealed by changes in systolic time interval ratio, that
is, left ventricular ejection and pre-ejection time
Contraindication/Precautions and interfering factors:
- Anatomic variation of the heart (i.e., the heart may be rotated in both the horizontal and frontal
planes)
- Distortion of cardiac cycles due to age, gender, weight, or a medical condition (e.g., infants, women
[may exhibit slight ST segment depression], obese patients, pregnant patients, patients with ascites)
- High intake of carbohydrates or electrolyte imbalances of potassium or calcium
- Improper placement of electrodes or inadequate contact between skin and electrodes because of
insufficient conductive gel or poor placement, which can cause ECG tracing problems
- Inability of the patient to remain still during the procedure, because movement, muscle tremor, or
twitching can affect accurate test recording
- Increased patient anxiety, causing hyperventilation or deep respirations •Medications such as
barbiturates and digitalis
- Strenuous exercise before the procedure
Equipments/Patient Preparations:
- Obtain a history of the patient’s complaints, including a list of known allergens, especially allergies
or sensitivities to latex, iodine, seafood, anesthetics, or contrast mediums. Ask if the patient has had
a heart transplant or pacemaker implanted.
- Obtain a history of the patient’s cardiovascular system, symptoms, and results of previously
performed laboratory tests and diagnostic and surgical procedures.
- Obtain a list of the patient’s current medications, including herbs, nutritional supplements and
nutraceuticals.
- Review the procedure with the patient. Address concerns about pain related to the procedure and
explain that there should be no discomfort related to the procedure. Inform the patient that the
procedure is performed by a health care provider (HCP) and takes approximately 15 min.
- Ensure the patient has complied with pretesting preparations.
- Ensure the patient has removed all external metallic objects from the area to be examined prior to
the procedure.
- Instruct the patient to void prior to the procedure and to change into the gown, robe, and foot
coverings provided.
Normal values:
- Normal heart sounds; no cardiac valvular disease
Procedure:
- The client is placed on the examination table in a supine position with the head elevated on a pillow
in a quiet room.
- The ECG leads are placed on the appropriate skin sites, and the monitors for the pulse, using a cuff
around the neck and respiration recordings, are prepared.
- The microphones are then placed over the apex and pulmonary region and strapped in place.
- The client is requested to inhale and then exhale, while stopping the expiration as the recording is
obtained.
- The microphone is moved from the pulmonary region to the aortic region and the procedure is
repeated to obtainthe recording. These recordings are followed by recordings made with the cuff
removed from the neck and the recorder placed at the V2 position (fourth intercostal space at the
border of the left sternum) while the client is requested to hold the breath after exhaling.
- Heart sounds can also be recorded with the client in a different position (left side-lying) and while
breathing slowly or performing exercises.
Implications of abnormal results
- Arrhythmias.
- Atrial or ventricular hypertrophy.
- Bundle branch block.
- Electrolyte imbalances.
- MI or ischemia.
 - Pericarditis.
- Pulmonary infarction.
- P wave: An enlarged P wave deflection could indicate atrial enlargement. An absent or altered P
wave could suggest that the electrical impulse did not come from the SA node.
- P-R interval: An increased interval could imply a conduction delay in the AV node.
- QRS complex: An enlarged Q wave may indicate an old infarction; an enlarged deflection could
indicate ventricular hypertrophy. Increased time duration may indicate a bundle branch block.
- ST segment: A depressed ST segment indicates myocardial ischemia. An elevated ST segment may
indicate an acute MI or pericarditis. A prolonged ST segment may indicate hypocalcemia or
hypokalemia (short segment).
- T wave: A flat or inverted T wave may indicate myocardial ischemia, infarction, or hypokalemia. A
tall T wave may indicate hyperkalemia.
Important Nursing Responsibilities during and after the procedure
- Ensure the patient has complied with pretesting preparations.
- Record baseline values.
- Expose and appropriately drape the chest, arms, and legs.
- Prepare the skin surface with alcohol and remove excess hair. Shaving may be necessary. Dry skin
sites.
- Monitor vital signs and compare with baseline values.
- Instruct the patient to immediately notify a HCP of chest pain, changes in pulse rate, or shortness of
breath.
- Recognize anxiety related to the test results and be supportive of perceived loss of independence
and fear of shortened life expectancy.

K. Myocardial nuclear perfusion Imaging (Definition/Description):

- Also known as chemical stress imaging, radiopharmaceutical myocardial perfusion imaging is an
alternative method of assessing coronary vessel function in the patient who can’t tolerate exercise
electrocardiography (ECG).
Purposes:
- To assess the presence and degree of coronary artery disease (CAD)
- To evaluate therapeutic procedures, such as bypass surgery or coronary angioplasty
- To evaluate myocardial perfusion
Indications:
- Aid in the diagnosis of CAD or risk for CAD
- Determine rest defects and reperfusion with delayed imaging in unstable angina
- Evaluate the extent of CAD and determine cardiac function
- Assess the function of collateral coronary arteries
- Evaluate bypass graft patency and general cardiac status after surgery
- Evaluate the site of an old MI to determine obstruction to cardiac muscle perfusion
- Evaluate the effectiveness of medication regimen and balloon angioplasty procedure on narrow
coronary arteries
Contraindication/Precautions and interfering factors:
- Patients who are uncooperative or medically unstable
- Patients with severe cardiac arrhythmia.
- Patients who are pregnant, (unless the benefits outweigh the risks) because of fetal exposure to
radionuclide material (unless the benefits outweigh the risks)
- Myocardial trauma
- Cardiac flow studies can be altered by excessive alterations in chest pressure (as exists with
excessive crying in children).
- Recent nuclear scans (e.g., thyroid or bone scan)
- Drugs, such as long-acting nitrates, may only temporarily improve coronary perfusion and cardiac
function.
Equipments/Patient Preparations:
- Describe to the patient what the radiopharmaceutical myocardial perfusion imaging test is, including
who will perform it and where it will take place.
- Tell the patient that he’ll need to arrive 1 hour before the test and that an I.V. line will be initiated
before it begins.
- If the patient will receive adenosine or dipyridamole (Persantine), instruct him to avoid taking all
theophylline medications for 24 to 36 hours and all caffeinated drinks for 12 hours before the test.
- If the patient will receive dobutamine (Dobutrex), instruct him to withhold betaadrenergic blockers
for 48 hours before the test. Also tell him not to eat for 3 to 4 hours before the test, although he
may have water. Instruct him to take his other medications, as prescribed, with sips of water.
 - Tell the patient to continue taking antihypertensive medications. If his systolic blood pressure is
higher than 200 mm Hg, the dobutamine stress test can’t be done until his blood pressure is under
control.
- Tell the patient that a cardiologist, a nurse, an ECG technician, and a nuclear medicine technologist
will be present for the medication infusion. Advise him that he’ll be weighed first to determine the
proper drug dose.
- Inform the patient that he may experience flushing, shortness of breath, dizziness, headache, chest
pain, and increased heart rate during the infusion, but that these will end as soon as the infusion
ends and that emergency equipment will be available, if needed.
- Screen the patient for bronchospastic lung disease or asthma. Adenosine and dipyridamole are
contraindicated in these cases; use dobutamine instead. Weigh the patient to determine the
appropriate dosage.
- Make sure that the patient or a responsible family member has signed an informed consent form.
Normal values:
- Heterogeneous uptake of radionuclide throughout the myocardium of the left ventricle
- Left ventricular end-diastolic volume ≤70â•›mL
- Left ventricular end-systolic volume ≤25â•›mL
- Left ventricular ejection fraction >50%
- Right ventricular ejection fraction >40%
- Normal cardiac wall motion
- No muscle wall thickening
Procedure:
- Place the patient on a bed or an examination table in the ECG or medical imaging department and
start an I.V. line.
- Apply 12 ECG leadwires to appropriate sites and obtain baseline ECG and blood pressure readings.
- The selected chemical stress medication is infused, and blood pressure, pulse, and cardiac rhythm
are monitored continuously.
- Tell the patient to report the symptoms he’s feeling.
- At the appropriate time, the selected radiopharmaceutical is injected.
- Depending on which radiopharmaceutical is used, the patient either undergoes imaging immediately
or is instructed to return for imaging 45 minutes to 2 hours later. Resting imaging may be done
before stress imaging or 3 to 4 hours afterward, depending on the radiopharmaceutical used.
- Tell the patient when he needs to return and whether he should continue to fast.
- Remove the I.V. line after the images are completed.
- When all scans are completed, tell the patient that he may resume his usual diet.
- If the patient must return for further scanning, tell him to rest; he may also need to restrict foods
and fluids in the interim.

Implications of abnormal results

- Coronary artery occlusive disease
- Decreased myocardial function associated with ischemia, myocarditis, cardiomyopathy, or
congestive heart failure
- Decreased cardiac output
Important Nursing Responsibilities during and after the procedure:
- Take the patient to the nuclear medicine department. Depending on the type of nuclear myocardial
scan, each scanning protocol is different.
- Note the following general procedural steps:
o One or more intravenous (IV) injection of radionuclidematerial is performed.
o Electrocardiographic (EKG) leads may be applied.
o Depending on the radionuclide used, scanning is performed 15 minutes to 4 hours later.
o SPECT camera is placed at the level of the precordium.
o If a single gamma camera is used, the patient is placed in a supine position, then may be
repositioned to the lateral position or in the right and left oblique positions. In some
departments, the detector can be rotated around the patient, who remains in the supine
position.
o The gamma ray scanner records the image of the heart, and an image is immediately
developed.
o For an exercise stress test, additional radionuclide is injected during exercise when the
patient reaches a maximum heart rate. The patient then lies on a table, and scanning is
done. A repeat scan may be done 3 to 4 hours later.
 o If an isonitrile stress test is needed, the radionuclide material is injected and a scan
performed 30 to 60 minutes later for the resting phase. Four hours later, cardiac stress
testing is done. After a second injection, scanning is repeated.
- Note that myocardial scans are usually performed in less than 30 minutes by a nuclear medicine
technician.
- Inform the patient that because only tracer doses of radioisotopes are used, no precautions need to
be taken against radioactive exposure to personnel or family.
- Instruct the patient to drink fluids to aid in the excretion of the radioactive substance.
- Apply pressure or a pressure dressing to the venipuncture site.
- Assess the venipuncture site for bleeding. If stress testing was performed, evaluate the patient’s
vital signs at frequent intervals (as indicated).
- Remove any applied EKG leads.

L. Lymphography (Definition/Description):
- Lymphangiography (or lymphography) is the radiographic examination of the lymphatic system after
the injection of an oilbased contrast medium into a lymphatic vessel in each foot or, less commonly,
in each hand. This test is no longer used widely.
Purposes:
- To detect and stage lymphomas and to identify metastatic involvement of the lymph nodes
(Computed tomography [CT] is used more commonly for staging.)
- To distinguish primary from secondary lymphedema
- To suggest surgical treatment or evaluate the effectiveness of chemotherapy and radiation therapy
in controlling malignancy
- To investigate enlarged lymph nodes detected by CT or ultrasonography
Indications:
- Suspected pathology of the lymphatics, such aslymphoma or tumor metastasis to lymph nodes,
revealed by node size and filling defects
- Determination of the stage of lymphoma between stage I and stage IV to identify extent of
involvement ranging from a single node to diffuse metastasis, especially in Hodgkin’s lymphoma40
- Diagnosis of testicular tumor, prostatic carcinoma, and cervical carcinoma when performed in
association with ultrasonography, computerized scanning, and node biopsy procedures41
- Differentiation between primary and secondary lymphedema in an extremity Evaluation of nodal
involvement before treat-ment regimen and possible surgical intervention
- Evaluation of effectiveness of therapy (chemotherapy or radiation) or progression of the disease
Contraindication/Precautions and interfering factors:
- Pregnancy, unless the benefits of performing the procedure outweigh the risks to the fetus
- Allergy to the contrast medium, unless prophylactic medications are administered before the study
- Poor or severely impaired pulmonary, cardiac, renal, or hepatic function
Equipments/Patient Preparations:
- Explain to the patient that lymphangiographypermits examination of thelymphatic system through
X-ray films taken after the injection of a contrast medium.
- Inform the patient that he need not restrict food and fluids.
- Tell the patient who will perform the procedure and where it will take place.
- Mention to the patient that additional X-ray films are also taken the following day, but that these
take less than 30 minutes.
- Inform the patient that blue contrast medium will be injected into each foot to outline the lymphatic
vessels, that the injection causes transient discomfort, and that the contrast medium discolors urine
and stool for 48 hours and may give his skin and vision a bluish tinge for 48 hours.
- Tell the patient that a local anesthetic will be injected before a small incision is made in each foot.
- Inform the patient that the contrast medium is then injected for the next 11⁄4 hours using a catheter
inserted into a lymphatic vessel.
- Advise the patient that he must remain as still as possible during injection of the contrast medium
and that he may experience some discomfort in the popliteal or inguinal areas at the beginning of
the injection.
- If this test is performed on an outpatient basis, advise the patient to have a friend or relative
accompany him.
- Warn the patient that the incision site may be sore for several days after lymphangiography.
- Make sure that the patient or a responsible family member has signed an informed consent form.
- Check the patient’s history to determine if he’s hypersensitive to iodine, seafood, or the contrast
media used in other diagnostic tests such as excretory urography. Alert the physician to any
sensitivities.
- Just before the procedure, instruct the patient to void and check his vital signs for a baseline. If
prescribed, administer a sedative and an oral antihistamine (if hypersensitivity to the contrast
medium is suspected).
Normal values:
- Normal structure and patency of lymphatic system and nodes; no filling defects, obstruction, or
hyperplasia
Procedure:
- A preliminary X-ray of the chest is taken with the patient in an erect or a supine position.
- The skin over the dorsum of each foot is cleaned with antiseptics.
- Blue contrast dye is injected intradermally into the area between the toes, usually the first and
fourth toe webs.
- The contrast medium infiltrates the lymphatic system, and within 15 to 30 minutes, the lymphatic
vessels appear as small blue lines on the upper surface of the instep of each foot.
- A local anesthetic is then injected into the dorsum of each foot and a transverse incision is made to
expose the lymphatic vessel.
- Each vessel is cannulated with a 30G needle attached to polyethylene tubing and a syringe filled
with ethiodized oil.
- After the needles are positioned, the patient is instructed to remain still throughout the injection
period to avoid dislodging the needles.
- The syringe is then placed within an infusion pump that injects the contrast medium at a constant
rate of 0.1 to 0.2 ml/minute for about 11⁄2 hours to avoid injury to delicate lymphatic vessels.
- Fluoroscopy may be used to monitor filling of the lymphatic system.
- The needles are removed, the incisions are sutured, and sterile dressings are applied.
- X-ray films of the legs, pelvis, abdomen, and chest are taken.
- The patient is then taken to his room, but must return 24 hours later for additional films.
- Check the patient’s vital signs every 4 hours for 48 hours.
Implications of abnormal results
- Enlarged, foamy-looking nodes indicate Hodgkin’s disease or malignant lymphoma.
- Filling defects or lack of opacification indicates metastatic involvement of the lymph nodes.
- The number of nodes affected, unilateral or bilateral involvement, and the extent of extranodal
involvement help determine staging of lymphoma. However, definitive staging may require
additional diagnostic tests, such as CT, ultrasonography, selective biopsy, and laparotomy.
- In differential diagnosis of primary and secondary lymphedema, shortened lymphatic vessels and a
deficient number of vessels indicate primary lymphedema.
- Abruptly terminating lymphatic vessels, caused by retroperitoneal tumors impinging on the vessels,
inflammation, filariasis, and trauma resulting from surgery or radiation, indicate secondary
lymphedema.
Important Nursing Responsibilities during and after the procedure:
- Monitor the extremity for sensation changes and the site for possible infection.
- Apply warm compresses to the sites if ordered for discomfort.
- Remind the client to return in 24 hours for more films.
- Inform the client that the skin, urine, and feces can be blue tinged for about 2 days.
- Pulmonary emboli, lipid pneumonia: Note and report dyspnea, chest pain, or hypotension.
- Monitor vital signs, respiratory pattern, and breath sounds. Administer ordered oxygen and
- medications.