Module 1: Understanding the Cardiovascular System.

After successfully completing this module, students will be able to do the following:

 Discuss the necessary steps that nurses must take to develop a positive relationship with clients.
 Describe the anatomy and physiology of the cardiovascular system.
 Discuss the general preparatory measures that must be taken prior to cardiovascular surgery.
 Describe the various diagnostic procedures that can be used to determine whether or not a
patient is suffering from a cardiovascular disorder.
 Describe the symptoms and causes of a range of cardiovascular system disorders.

Introduction
A patient is not a passive object on which we perform nursing care procedures. A patient should never
be thought of, or discussed, as merely a condition or injury. It is not acceptable to think of, or refer to
your patient as “the gallbladder” or “the fractured hip”. A patient is much more than the condition that
brought him to the hospital. A patient is a human being, possessing physical and emotional needs and
wants.

The relationship between the patient and the nursing staff is extremely dynamic and personal. The
patient places his trust in the nursing staff and they, in return, must utilize all their knowledge and skills
to ensure the patient’s well-being and assist in his return to good health and independence. This is
accomplished by developing a therapeutic relationship between the patient, his family, and the health
care professionals.

The Role of the Nurse

The nursing paraprofessional relates very closely with the patient and his family by virtue of his
participation in providing nursing care and his presence at the bedside. It is often the nursing
paraprofessional who makes the initial observation that something is not as it should be.
Nursing paraprofessionals who are responsible, educated, and observant are assets to the therapeutic
environment necessary for patient recovery.

Fostering a Therapeutic Environment

To foster a therapeutic environment, the nursing professionals must do the following;

 Assess the patient’s ability to express himself.

 Assess the patient’s mechanisms for coping.
 Assess the patient’s level of understanding about his condition and the teaching provided by the
health care professionals.
 Assist the patient to established a trusting relationship with the health care providers.
 Utilize the nursing process to provide the best possible care.
 Continue to pursue his own education in order to sustain and enhance professional knowledge
and skills.

The Cardiovascular and Lymphatic System.

The circulatory system has two major fluid transportation systems,
the cardiovascular (CV) system and the lymphatic system.

The cardiovascular system, which contains the heart and blood vessels, is a closed system, transporting
blood to all parts of the body. Blood flowing through the circuit formed by the heart and blood vessels
brings oxygen, food and other chemical elements to tissue cells and removes carbon dioxide and other
waste products resulting from cell activity.
The lymphatic system provides drainage for tissue fluid and is an auxiliary part of the circulatory system. Commented [MM1]: A network of lymph vessels and
It returns an important amount of tissue fluid to the blood stream through its own system of lymphatic lymph nodes that transport fluid, fats, proteins, and
lymphocytes to the blood stream as lymph, and remove
vessels.
microorganisms and other debris from tissues.

The Heart
The heart, designed to be a highly efficient pump, is a four-chambered muscular organ, lying within the
chest, with about 2/3 of its mass to the left of the midline. It lies in the pericardial space in the thoracic
cavity between the two lungs. Commented [MM2]: A chamber located within the upper
human torso(the part of the body from the neck to the
In size and shape, it resembles a man’s closed fist. Its lower point, the apex, lies just above the left groin) which contains the heart and lungs.
diaphragm.

Heart Layers
The pericardium is a double walled sac enclosing the heart. The outer
fibrous surface gives support, and the inner lining prevents friction as the
heart moves within its protecting jacket.

The lining surfaces of the pericardial sac produce a small amount of

pericardial fluid needed for lubrication facilitate the normal movements of
the heart.
Heart Wall
The walls of the heart are composed of three distinct layers:
 The outer layer, the epicardium—which corresponds to the visceral
pericardium it protects the heart by reducing friction.

 The middle layer—the myocardium—which consists mostly of cardiac

muscle tissue that pumps blood out to the heart chambers.

 The inner layer—the endocardium—which consists of epithelium and

connective tissue that contains many elastic and collagenous fibers.

Heart Chambers
There are four chambers in the heart. These chambers are essentially
the same size. The upper chambers, called the atria, are seemingly
smaller than the lower chambers, the ventricles. The apparent
difference in total size is due to the thickness of the myocardial layer.

The right atrium communicates with the right ventricle; the left atrium
communicates with the left ventricle. The septum (partition), dividing
the interior of the heart into right and left sides, prevents direct
communication of blood flow from right to left chambers or left to
right chambers.

This is important, because the right side of the heart receives un-oxygenated blood returning from the
systemic (body) circulation. The left side of the heart receives oxygenated blood returning from the
pulmonary (lung) circulation. The special structure of the heart keeps the blood flowing in its proper
direction to and from the heart chambers.

Heart Valves
The four chambers of the heart are lined with endocardium. At each opening from the chambers this
lining folds on itself and extends into the opening to form valves. These valves allow the blood to pass
from a chamber but prevent its return.

Semilunar Valves

 The pulmonary semilunar (half-moon shaped) valve is located at the opening into the pulmonary
artery that arises from the right ventricle. The aortic semilunar valve is located at the opening
into the aorta that arises from the left ventricle.

Atrioventricular Valves

 The tricuspid valve is located between the right atrium and right ventricle. It has three flaps or
cusps. The bicuspid valve or mitral valve is located between the left atrium and left ventricle. It
has two flaps or cusps.
(Anatomy and Physiology)
Flow of Blood through the Heart.
It is helpful to follow the flow of blood through the heart in order to understand the relationship of the
heart structures. Remember, the heart is the pump and is also the connection between the systemic
circulation and pulmonary circulation.

Flow of Blood through the Heart- Step by Step.

All the blood returning from the systemic circulation must flow through the pulmonary circulation for
exchange of carbon dioxide for oxygen. Blood from the upper part of the body enters the heart through
the superior (anterior) vena cava and blood from the lower part of the body enters through the inferior
(posterior) vena cava.

It is helpful to follow the flow of blood through the heart in order to understand the relationship of the
heart structures.

Step by step account of how blood flows through the heart.

Step 1
Blood from the superior vena cava and inferior vena cava enters the heart at the right atrium.
The right atrium contracts, and blood is forced through the open tricuspid valve into the relaxed
right ventricle.
Step 2
As the right ventricle contracts, the tricuspid valve is closed, preventing back flow into the
atrium. The pulmonary semilunar valve opens as a result of the force and movement of the
blood, and the right ventricle pumps the blood into the pulmonary artery.
Step 3
The blood is carried through the lung tissues, exchanging its carbon dioxide for oxygen in the
alveoli. This oxygenated blood is collected from the main pulmonary veins and delivered back Commented [MM3]: (anatomy) a small air sac in the
to the left side of the heart to the left atrium. lungs, where oxygen and carbon dioxide are exchange with
the blood.
Step 4
As the left atrium contracts, the oxygenated blood flows through the open bicuspid (mitral)
valve into the left ventricle.
Step 5

As the left ventricle contracts, the bicuspid valve is closed. The aortic semilunar valve opens as a result
of the force and movement of the blood, and the left ventricle pumps oxygenated blood through the
aortic semilunar valve into the aorta, the main artery of the body. Oxygenated blood now starts its flow
to all of the body cells and tissues.

Blood and Nerve Supply of the Heart

The heart gets its blood supply from the right and left
coronary arteries. These arteries branch off from the
aorta just above the Aortic Valve, then subdivide into
many smaller branches within the heart muscle.

If any part of the heart muscle is deprived of its blood supply through interruption of blood flow through
the coronary arteries and their branches, the muscle tissue deprived of blood cannot function and will
die. This is called myocardial infarction (MI).
Blood from the heart tissue is returned by coronary veins to the right atrium via the coronary sinus.

Nerve Supply
The nerve supply to the heart is from two sets of nerves originating in the medulla of the brain. The
nerves are part of the involuntary (autonomic) nervous system. One set, the branches from the vagus
nerve, keeps the heart beating at a slow, regular rate. The other set, the cardiac accelerator nerves, Commented [MM4]: Either of the tenth pair of cranial
speeds up the heart. The heart muscle has a special ability; it contracts automatically, but the nerve nerves, which extends from the brainstem down into the
abdomen. Branches of these important nerves supply the
supply is needed to provide an effective contraction for blood circulation.
tongue, larynx, lungs, gut, and heart.

Blood Vessels
The blood vessels are the closed system of tubes through which the blood flows. The arteries and
arterioles are distributors. The capillaries are the vessels through which all exchange of fluid, oxygen, Commented [MM5]: One of the small branches of artery,
and carbon dioxide takes place between the blood and tissue cells. especially one that connects with capillaries.

The capillaries are the smallest of these vessels but are of greatest importance functionally in the
circulatory system. The venules and veins are collectors, carrying blood back to the heart. Commented [MM6]: A small vein, especially one that
connects capillaries to a larger vein.

Fig: A magnified illustration of a vein and

artery.

Veins
Veins have thin walls and valves. Formed from the inner vein lining, these valves prevent blood from
flowing back toward the capillaries. Venules, the smallest veins, unite into veins of larger and larger size
as the blood is collected for return to the heart.

The superior vena cava, collecting blood from all regions above the diaphragm and the inferior vena
cava, collecting blood from all regions below the diaphragm, return the venous blood to the right atrium
of the heart. Superficial veins lie close to the surface of the body and can be seen through the skin.

Capillaries
Microscopic in size, capillaries are so numerous that there is at least one or more near every living cells.
A single layer of endothelial cells forms the walls of a capillary. Capillaries are the essential link between
arterial and venous circulation.

The vital exchange of substances between the capillary blood and the tissue cells takes place through
the capillary wall. Blood starts its route back to the heart as it leaves the capillaries.

Arteries
The system of arteries and arterioles is like a tree, with the large trunk, the aorta, giving off branches
that repeatedly divide and subdivide. Arterioles are very small arteries, about the diameter of a hair. By
way of comparison, the aorta is more than one inch in diameter.

An artery wall has a layer of elastic, muscular tissue that allows it to dilate and constrict. When an artery
is cut, this wall does not collapse, and bright red blood escapes from the artery in spurts.

Pulse and Blood Pressure

Pulse is defined as the alternate expansion and recoil of an artery.

Pulse is a characteristic associated with the heartbeat and the subsequent wave of expansion and recoil
set up in the wall of an artery. With each heartbeat, blood is forced into arteries causing them to dilate
(expand).

Then the arteries contract (recoil) as the blood moves further along in the circulatory system. The pulse
can be felt at certain points in the body where an artery lies close to the surface. The most common
location for feeling the pulse is at the wrist, proximal to the thumb on the palm side of the hand (radial
artery). Alternate locations are in front of the ear (temporal artery), at the side of the neck (carotid
artery), and on the top (dorsum) of the foot (dorsalis pedis). Commented [MM7]: Either of a pair of arteries, each side
of the neck, which branch from the aorta and supply blood
Blood Pressure to the head.

The force that blood exerts on the walls of vessels through which it flows is called blood pressure. All
parts of the blood vascular system are under pressure, but the term blood pressure usually refers to
arterial pressure.

Pressure in the arteries is highest when the ventricles contract during systole. Pressure is lowest when
the ventricles relax during diastole. The brachial artery, in the upper arm, is the artery usually used for
blood pressure measurement.

The Lymphatic System

Unlike the cardiovascular system, the lymphatic system has no pump to move the
fluid that collects, but muscle contractions and breathing movements aid in the
movement of lymph through its channels and its return to the blood stream.
The lymphatic system consists of lymph, lymph vessels, and lymph nodes. The spleen belongs, in part, to
the lymphatic system.

Lymph, fluid found in the lymph vessels, is clear and watery and is similar to tissue fluid, which is the
colorless fluid that fills the space between tissues, between the cells of organs, and between cells and
connective tissues. Tissue fluid serves as the “middleman” for the exchange between blood and body
cells. Formed from plasma, it seeps out of capillary walls. The lymphatic system collects tissue fluid, and
as lymph, the collected fluid is started on its way for return to the circulating blood.

Lymph Vessels
Starting as small blind duets within the tissues, the lymphatic vessels enlarge to form lymphatic
capillaries. Theses capillaries unite to form larger lymphatic vessels, which resemble veins in structure
and arrangement. Valves in lymph vessels prevent backflow.

Superficial lymph vessels collect lymph from the skin and subcutaneous tissue; deep vessels collect Commented [MM8]: Pertaining to the fatty layer under
lymph from all parts of the body. The two largest collecting vessels are the thoracic duct receives lymph the skin.
from all parts of the body except the upper right side. The lymph from the thoracic duct drains into the
left subclavian vein, at the root of the neck on the left side. The right lymphatic duct drains into a
corresponding vein on the right side.

Spleen
The largest collection of lymphoid tissue in the body, the spleen is located high in the abdominal cavity
on the left side, below the diaphragm and behind the stomach. It is somewhat long and ovoid (egg-
shaped).

Although it can be removed (splenectomy) without noticeable harmful effects, the spleen has useful
functions, such as serving as a reservoir for blood and red blood cells.

Infection and the Lymphatic System

Lymph vessels and lymph nodes often become inflamed as the result of infection. An infection in the
hand may cause inflammation of the lymph vessels as high as the axilla (armpit).

A sore throat may cause inflammation and swelling of lymph nodes in the neck (submandibular nodes
below the jaw and cervical nodes posteriorly).

Lymph Nodes
Occurring in groups up to a dozen or more, lymph nodes lie along the course of lymph vessels. Although
variable in size, they are usually small oval bodies that are composed of lymphoid tissue.

Lymph nodes acts as filters for removal of infective organisms from the lymph stream. Important groups
of these nodes are located in the axilla, the cervical region, the sub maxillary region, the inguinal (groin)
region, and the mesenteric (abdominal) region. Commented [MM9]: Mesentery—the membrane that
attaches the intestines to the wall of the abdomen,
Diagnostic Procedures maintaining their position in the abdominal cavity, and
supplying them with blood vessels, nerves, and lymphatics.
Introduction
Cardiovascular diagnostic tests and examinations are conducted by order of the physician to help
determine the nature of the specific disease condition. Many of these tests or examinations may be
repeated at intervals to determine the patient’s progress or response to prescribed treatment. While
some are performed on the nursing unit, many others are conducted only in special laboratories and
hospital clinics.

The nursing paraprofessional’s role in assisting with diagnostic tests and collection of specimens will
vary, depending upon the test, the specimen, the condition of the patient, and the local situation and
policy.

Although they may seldom perform any part of the test themselves, they should be acquainted with
those commonly performed in order to give intelligent patient care and appropriate assistance to the
doctor, nurse, or technician.

The general nursing knowledge required when performing a cardiovascular diagnostic

procedure.
Nurses should know;
1. How and why the procedure is done and what, if any, reaction is expected from it.
2. What explanation and physical care the patient should have before, during, and after the
procedure. The informed, prepared patient is more apt to cooperate and to tolerate any
inconvenience or discomfort incidental to the test.
3. What equipment, clean or sterile, must be provided when assisting with the procedure and how
to care for used equipment following the procedure.
4. The role of the assistant is relation to that of the doctor, nurse, or technician performing the
test.

General Preparatory Measures for Procedures

Caution: Always verify with the nurse or doctor what
information you may give to the patient.

Procedures vary from one hospital to another concerning nursing unit preparation of patients who are
to be sent or escorted to clinics, laboratories, or operating rooms.

These various departments set their own standing operating procedure in accordance with local
directives and issue instructions and the doctor’s orders for the particular patient must be carried out
carefully to ensure the best results for the patient.

Additional Tips. Some additional tips to help prepare a patient for a procedure are outlined below:

Prepare the Patient Mentally. Tell the patient briefly what to expect and explain his role in the
preparation. Mental preparation of the patient gives him emotional security and gains his confidence
and cooperation.
Prepare the Patient Physically. Have the patient clean, properly dressed, and protected from exposure
or drafts. Make sure that any specific preparation ordered has been accomplished, such as medication,
rest for a required period, or restriction on food or liquid.

General Preparation Measure for Procedures

Additional Tips. Some additional tips to help prepare a patient for a procedure are outlined below:

Have the Right Patient in the Right Place at the Right Time. If he is an ambulatory patient, give him
specific directions on how to reach the clinic or laboratory. Transport an otherwise ambulatory patient
who has received a sedative or other pretreatment medication in a wheelchair or on a stretcher. The
responsibility of nursing unit personnel who are to perform the procedure.

In addition to the general rules mentioned in the previous paragraph, you should:

 Assist the physician as required. This may involve obtaining equipment, opening sterile trays,
preparing a sterile field, pouring solutions, preparing the patient’s skin, positioning the patient,
drafting the patient, and assisting the physician in the performance of the procedure.
 Reassure the patient and make him as comfortable as possible. NOTE: For some patients and
some procedures, two assistants will be needed one to support and observe the patient and one
to assist the doctor.
 If a specimen is taken, attach to the specimen container a prepared label identifying the patient
by name and register number, ward, date, and text. Forward the specimen to the laboratory
immediately with the proper laboratory request slip.

General Nursing Care following Diagnostic Procedures

When a diagnostic procedure has been completed, nurses should complete the following duties:

 Return the patient to his bed by the means ordered.

 Check the orders of the physician who performed the procedures. Observe and report any
unusual reactions of the patient. If there are no orders pertaining to taking vital signs,
accomplish this nursing measure according to standard nursing unit procedures.
 Use appropriate measure to relieve discomfort or pain.
 If the patient has been sedated or anesthetized, ensures bed rest until he has completely
reacted. Tell him to stay in bed and to signal for any needs. Use side rails according to standard
procedures. Ensure the call light is within reach of the patient.
 If the procedure involves the patient’s diet, notify food service to serve, modify, or cancel his
meal as appropriate.
 Explain to the patient that he will notified when he may resume his normal regime. When this
time arrives, inform him promptly.

Fluoroscopy
Fluoroscopy is used to look for abnormal configuration, tumors, and
calcifications in the heart, aorta, and pulmonary vessels, to find
congestion of the lungs, and to detect pleural or pericardial effusions.
Fluoroscopy shows the heart in action and is used more often than x-ray methods in cardiologic
examinations. During examination of the heart under fluoroscopy, barium is given by mouth so the
outline of the esophagus can be seen.

An enlarge left atrium pushes the esophagus aside as it becomes larger. There is no preparation of the
patient for this examination.

Summary:

The aorta and its branches are studied by the injection of a contrast medium through a plastic catheter Commented [MM10]: A small tube inserted into a body
or with a needle directly into the aorta. Terms used in connection with the aortogram are retrograde cavity to remove fluid, create an opening, distend a
passageway or administer a drug.
aortogram (retrograde meaning against the direction of blood flow) and translumbar aortogram
(meaning the injection is made below the twelfth rib and to the left of the spine). No preparation of the
patient is necessary.

Intravenous Angiocardiography
This is a procedure in which an opaque medium is injected into a vein followed by a rapid series of x-ray
pictures taken of the course of the medium through the heart, to the lungs, back to the heart, and out
through the aorta. The dosage of contrast media is calculated according to the kilograms of body weight.
The solution is injected through a large bore (12 gauge) needle held in position in the vein, usually by a
“cut down”.

Speed of injection is imperative, since the solution must pass through the heart in a large bolus to make Commented [MM11]: A round mass of something. Like a
possible a good examination. The solution is injected after the patient has been instructed to inhale single, large dose of a drug, especially one in that form.
deeply. The inspiration is held for the entire series of x-rays.
Additional Information:

This diagnostic method is recognized for precision in detecting congenital cardiac defects. Individual
chambers of the heart are visualized, pathways for the blood stream are demonstrated, and chamber
enlargement can be seen. The opaque medium may cause a flushing sensation as it flows through the
body. If necessary, the studies may be conducted under mild anesthesia. After one complete circulation,
the opaque media is so diluted that it is no longer visible by x-ray. No special preparation of the patient
is necessary unless anesthesia is to be given. In that event, food may be withheld prior to the studies. A
record of the patient’s weight should be sent to the x-ray department with him.

Cardiac Catheterization
This is a procedure in which a radiopaque catheter is manipulated through the heart under fluoroscopic
observation. The exterior end of the catheter is connected by a three-way stopcock to a saline filled Commented [MM12]: Containing salt.
regulated drip system that also contains a pressure gauge (strain gauge) and a camera.

During the procedure the blood pressures within the heart are automatically transmitted to the strain
gauge that, in turn, transmits the pressure to the camera recording the findings on photographic film.

Samples of blood are also withdrawn from the heart chambers and great vessels. The samples are
analyzed for oxygen content.

Electrocardiogram
The electrocardiogram (ECG) is a graphic recording of the electrical
impulses produced in association with the heartbeat. Impulse
formation and conduction produce weak electrical currents that
spread throughout the entire body.

By connecting certain points on the body to a recording instrument, these currents can be recorded as a
graphic representation of the heartbeat, measured against time. Time is expressed on the special ECG
graph paper by vertical and horizontal lines.

The ECG provides quite a bit of valuable information for the small amount of effort involved in obtaining
an ECG recording. It is a procedure that is completely noninvasive and without risk to the patient. It is
easily performed by anyone with the proper training. The ECG provides information about the heart
 rate, rhythm, the condition of the myocardium, the presence of ischemia or necrosis conduction Commented [MM13]: Local disturbance in blood
abnormalities, the presence of certain drugs, and the effects of disturbed electrolytes. circulation due to mechanical obstruction of the blood
supply.

Stress Test Commented [MM14]: The localized death of cells or

tissues through injury, disease, or the interruption of blood
Stress testing or exercise testing is done to assess cardiac function. Stress testing is accomplished by supply.
having the patient climb stairs, pedal a stationary bicycle, or walk a treadmill. The exercise is gradually
increased (climb or walk faster, pedal harder) while the patient is monitored.

Electrocardiogram electrodes attached to the patient record tracings before, during, and after exercise.
Additionally, blood pressure, physical appearance, and chest pain levels are monitored closely.

Blood Pressure
Blood pressure is defined as the pressure exerted by the blood on the walls of the blood vessels. When
speaking of blood pressure, it is the arterial blood pressure that we are concerned with. When taking a
patient’s blood pressure with a sphygmomanometer and stethoscope , it is the arterial blood pressure Commented [MM15]: A medical instrument used for
that is being measured. listening to sounds produced within the body.

Blood pressure is registered by two numbers that represent the pressures exerted during contraction
and relaxation of the heart.

 Systolic pressure is the maximum pressure occurring during systole, or contraction, of the ventricles. It
is the higher of the two numbers. Normal systolic pressure for the average resting adult is between 100-
150 mmHg.

 Diastolic pressure is the pressure occurring during diastole, the period of relaxation and filling of the
ventricles. This is the lowest pressure. Normal diastolic pressure for the average resting adult is between
60-90 mmHg.

Additional Information

Blood pressure is best measured over a large artery. The most commonly used is the brachial artery. The
cuff is wrapped around the upper arm and auscultation is done over the brachial artery in the
antecubital space. In patients with hypertension or other cardiovascular disease, it is best to measure
blood pressure in both the right and left arms. There should be no more than 5 mmHg difference
between the two readings. A greater difference is indicative of vascular disease. The physician may
order blood pressure checks to be done with the patient lying down, sitting, and standing. The
corresponding rise or fall in pressure with the change of position may give the physician valuable
information about the nature of the cardiovascular disease.

Coronary Artery Disease

Coronary artery disease (CAD) is the condition in which the coronary
arteries cannot deliver adequate blood supply to the heart muscle to
meet the tissue demand.
 This condition is characterized by obstruction or narrowing
of the vessel lumen. Coronary artery disease has been linked
with certain “risk factors.” In general, the more risk factors
associated with an individual, the greater the chance for
development for CAD.

Some risk factors cannot be changed, while other risk

factors can be modified or eliminated. Patient education is
an important aspects of the nursing care of patients with
CAD because the education patient can take steps to
improve his condition.

Risk Factors promoting Coronary Artery Disease:

 Risk factors that cannot be changed (non-modified) are age, sex, race, genetic make-up, and family
history.
 The major risk factors, however, fall into the category of modifiable risk factors. Hypertension, elevated
serum cholesterol levels, and cigarette smoking have been identified as the three major risk factors.
These factors can be modified and controlled by taking prescribed blood pressure medication, modifying
eating habits, and giving up cigarettes.
 Additional modifiable risk factors include weight, activity level, and stress levels. These factors can be
controlled by maintaining an appropriate weight, making life style adjustments to reduce stress, and
increasing physical activity.

Arteriosclerosis
Arteriosclerosis is the primary cause of CAD. Arteriosclerosis is defined as hardenings or thickening of the
arteries. Arteriosclerotic disease is characterized by thickening and loss of elasticity of the arterial walls.

Atherosclerosis is the most common form of arteriosclerosis. Deposits of yellowish plaques (called
atheroma) are formed within the medium and large sized arteries.

These atheroma’s are made up of cholesterol, lipoid material, and lipophages (cells that ingest or absorb
fat).

Coronary Heart Disease

Coronary heart disease (CHD) is a collective name for a number of ischemic diseases of the myocardium.
Coronary heart disease is the eventual clinical manifestation of the effects of coronary artery disease.

The major diseases of CHD are:

 Angina Pectoris: A clinical syndrome of ischemic heart disease.
 Myocardial Infraction: An imbalance between oxygen demand and oxygen supply to the
myocardium.
 Congestive Heart Failure: A condition in which the heart’s function as a pump is inadequate to
meet the body’s needs.
 Sudden Cardiac Death: The sudden cessation of the heartbeat and circulation.

Angina Pectoris

Angina pectoris is a clinical syndrome of ischemic heart

disease, manifested by paroxysmal pain in the chest and
adjacent areas.
The main cause for this inability to meet oxygen demand is the presence of atherosclerosis that causes Commented [MM16]: Hardening, narrowing or loss of
advanced occlusion or stenosis of one or more of the three major branches of the coronary artery tree. elasticity in arteries or blood vessels.
Commented [MM17]: Anything that obstructs or closes a
This disorder is considered to be an early warning of CV deterioration. The symptoms occur as a result vessel or canal.
myocardial oxygen demand that exceeds the ability of the coronary arteries to deliver oxygen. (The
coronary arteries supply the myocardium with the oxygenated blood it needs to work effectively.)

The pain of angina pectoris occurs when the heart is stressed or worked to a point where the oxygen
demand is greater than the amount of oxygen that can be delivered. This usually occurs with some type
of exertion, such as mowing the lawn, climbing stairs, or doing heavy housework. In the affected patient,
the onset of pain will occur with exertion, and relief will normally occur with rest. Rest will decrease the
workload on the heart, thereby decreasing the heart’s oxygen demand and relieving the pain.

Unstable angina pectoris is a term used to describe the

exacerbation of the symptoms of angina pectoris.

This syndrome is characterized by increased severity of symptoms, increased ease in provoking attacks
of angina, and less predictability in controlling angina attacks. Symptoms may be severe enough to
mimic an acute myocardial infarction. Crescendo angina and acute coronary insufficiency are also terms
used to describe unstable angina.

In either case, medical management is the same. The patient is educated about the nature of the
disease so that it may be controlled with diet, medication, exercise, and risk factor modification. When
the condition advances to the stage where it can no longer be controlled in this manner, surgical
intervention may be indicated.
 Acute Myocardial Infarction

Acute myocardial infarction (AMI) results from

an imbalance between oxygen demand and
oxygen supply to the myocardium.

In 90 percent of the cases of AMI, this imbalance is preceded by atherosclerosis and decreased blood
flow in the coronary arteries. The inadequate blood flow results in decreased oxygen delivery to the
heart muscle, which causes ischemia, injury, and death of a portion of the myocardium (infarction).

Myocardial infarctions are described as being anterior, inferior, or posterior, depending upon the
location of the infarcted area of the heart muscle. Infarcts can be further classifies as being transmural
or non-transmural. A transmural infarct (Non Q-Wave MI) is one that involves damage to the full
thickness of the myocardium. A non-transmural MI involves only a partial thickness of the muscle.

In the majority of patients with AMI, chest pain is the major presenting symptom. The pain is usually
substernal and may radiate to the neck, shoulders, arms, or epigastric area. The pain is described as
heaviness, constriction, burning, or similar to ingestion. It is important to remember, however, that
there may be little or no pain present at all. AMI can be very subtle, and often difficult to distinguish
from angina. In addition to chest pain, symptoms of MI include shortness of breath, diaphoresis,
weakness, fatigue, anxiety, nausea, vomiting, abnormal blood pressure, and abnormal heart rate.

Pain, anxiety, and arrhythmias occur in the early stages of MI. Ventricular fibrillation is the greatest
threat to life in the first hours after MI. Medical management includes ECG monitoring, bedrest to
reduce the workload of the heart, and intravenous therapy. Medications include morphine to reduce
pain and relieve anxiety, vaso-dialators, beta blocker, calcium channel blockers and lidocaine as
antiarrhythmic therapy.

Additional Information

 This diagnostic method is recognized for precision in detecting congenital cardiac defects. Individual
chambers of the heart are visualized, pathways for the blood stream are demonstrated, and chamber
enlargement can be seen.

 The opaque medium may cause a flushing sensation as it flows through the body. If necessary, the
studies may be conducted under mild anesthesia. After one complete circulation, the opaque media is so
diluted that is no longer visible by x-ray.

 No special preparation of the patient is necessary unless anesthesia is to be given. In that event, food
may be withheld prior to the studies. A record of the patient’s weight should be sent to the x-ray
department with him.

Heat Failure
Heart failure is the clinical state in which there is inadequate
cardiac output, resulting in poor perfusion of all organ
systems.
In left sided heart failure, the pumping action of the left ventricle is compromised, but the right
ventricle continues to function normally. There is an imbalance between the out-put of each ventricle.
The right heart continues to pump blood into the lungs to be oxygenated. The failing left heart,
however, is unable to return that same volume of blood to the systemic circulation.

The result is an accumulation of blood in the pulmonary blood vessels. Increased pressure in the
pulmonary vessels causes fluid to leak into the interstitial lung tissue, compromising gas exchange. This
condition is called pulmonary edema.

Right Sided Heart Failure:

 Right sided heart failure usually follows left sided failure. The increased pressure in the
pulmonary vessels causes “back pressure” to the right side of the heart. This interferes with
venous return, and consequently, the organs of the body become congested. This condition,
known as congestive heart failure (CHF), is manifested by neck vein distention and body edema.
 Right sided failure may occur without left sided failure. This condition, called cor-pulmonale, Commented [MM18]: A change in structure and function
may be caused by pulmonary hypertension secondary to lung disease or by the pressure of of the right ventricle of the heart as a result of a respiratory
disorder.
pulmonary emboli.
Commented [MM19]: (Plu) Embolus –an obstruction
Hypertension causing an embolism: a blood clot, air bubble or other
matter carried by the blood stream and causing a blockage
or occlusion of a blood vessel.
Hypertension (HTN) is defined as persistent levels of blood
pressure with the systolic pressure greater than 150 mmHg and
the diastolic pressure greater than 90 mmHg. Hypertension is a
major cause of heart failure, kidney failure, and stroke.
Hypertension is classified as primary and secondary.

 Primary (or essential) HTN has no identifiable cause. Increased peripheral resistance is the basic
cause for the elevated blood pressure, but the cause of the increased resistance is not
understood. Drug therapy is aimed at decreasing the peripheral resistance, thereby lowering the
blood pressure.
 Secondary HTN is the result of a specific cause or disease process. Kidney disease, adrenal
tumors, thyrotoxicosis, and preeclampsia are just a few examples. Therapy is aimed at both
treating the elevated pressures and treating the primary cause.

Additional Information:

 Hypertension is called the “silent killer” because it is often symptom free. When symptoms do
occur, they are often mistakenly associated with other causes. Symptoms include headache,
fatigue, nervousness, irritability, dyspnea, and edema.
  Continued HTN is damaging to the body. Medical management is aimed at lowering the blood
pressure to alleviate the symptoms and to slow the progression of damage to the body.

Nursing management of a patient with hypertension involves intensive patient education to help the
patient understand the nature of his disease and his role in keeping it under control. The nursing staff
should reinforce the importance of the following:

 Taking medications as prescribed and decreasing the use of tobacco and stimulants, such as
caffeine.
 Eliminating table salt and avoiding foods high in sodium, such as pickles, potato chips, cold cuts,
and processed foods.
 Controlling serum cholesterol levels by modifying the diet to avoid saturated fats.
 Maintaining a weight appropriate to height and body type.
 Altering one’s lifestyle to minimize stress and following a regular exercise program.

The key points from this module are the following:

The nursing paraprofessional relates very closely with the patient and his family by virtue of his
participation in providing nursing care and his presence at the bedside.
The circulatory system has two major fluid transportation systems, the cardiovascular (CV)
system and the lymphatic system.
The cardiovascular system, which contains the heart and blood vessels, is a closed system,
transporting blood to all parts of the body.
The lymphatic system provides drainage for tissue fluid and is an auxiliary part of the circulatory
system.
The heart, designed to be a highly efficient pump, is a four-chambered muscular organ, lying
within a chest, with about 2/3 of its mass to the left of the midline.
There are four chambers in the heart. These chambers are essentially the same size. The upper
chambers, called the atria, are seemingly smaller than the lower chambers, the ventricles.
The heat gets its blood supply from the right and left coronary arteries.
Pulse is defined as the alternate expansion and recoil of an artery.
Always verify with the nurse or doctor what information you may give to the patient.
Fluoroscopy is used to look for abnormal configuration, tumors, and calcifications in the heart,
aorta, and pulmonary vessels, to find congestion of the lungs, and to detect pleural or
pericardial effusions.
The electrocardiogram (ECG) is a graphic recording of the electrical impulses produced in
association with the heartbeat.
Blood pressure is defined as the pressure exerted by the blood on the walls of the blood vessels.
Coronary artery disease (CAD) is the condition in which the coronary arteries cannot deliver
adequate blood supply to the heart muscle to meet the tissue demand.
Arteriosclerosis is the primary cause of CAD. Arteriosclerosis is defined as hardening or
thickening of the arteries. Arteriosclerotic disease is characterized by thickening and loss of
elasticity of the arterial walls.
Angina pectoris is a clinical syndrome of ischemic heart disease, manifested by paroxysmal pain
in the chest and adjacent areas.
Unstable angina pectoris is a term used to describe the exacerbation of the symptoms of angina
pectoris.
Acute myocardial infarction (AMI) results from an imbalance between oxygen demand and
oxygen supply to the myocardium.
Heart failure is the clinical state in which there is inadequate cardiac output, resulting in poor
perfusion of all organ systems.