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• Standard protocols apply to all nursing procedures

Before the Procedure

• Verify physician's orders if the procedure is a dependent or collaborative nursing intervention
• Gather necessary equipment and supplies, and account for charges per agency policy
• Wash hands for at least 10-15 seconds before each client contact.
• Verify the client's identity using their folder, ID bracelet, or by having them state their name, if possible
• Introduce yourself, including your name, title, or role, to the client and their family
• Explain the procedure to the client in detail
• Identify teaching needed and explain what the client can expect in understandable terms
• Assess the client to ensure the intervention is still appropriate before proceeding
• Adjust the bed height and lower the side rail nearest to you
• Ensure adequate lighting for the procedure
• Provide privacy, position, and drape the client as necessary
• Obtain written consent from the client
• Perform any necessary physical preparations, like shaving

During the Procedure

• Encourage client independence and involvement, when possible
• Assess client tolerance, watching for signs of discomfort and fatigue

After the Procedure

• Assist the client into a comfortable position and arrange toiletries or personal items within reach
• Ensure the client knows how to call for help and has a means to do so
• Raise the side rails and lower the bed
• Dispose of or decontaminate used supplies and equipment
• Remove and dispose of gloves, if used, and perform hand hygiene for at least 2-3 minutes
• Document and report the client's response, whether expected or unexpected

Nursing Management of Patients with Cardiovascular Conditions

• Care for people with cardiovascular disorders uses a significant amount of nursing skill and resources
• Cardiovascular diseases are one of the highest causes of morbidity and mortality worldwide (WHO 2005)

Assessment

• Cardiovascular function assessment gives data to identify actual and potential health problems, guide nursing intervention, and evaluate care
• Includes health history, physical examination, diagnostic procedures, and knowledge of cardiovascular disorder manifestations

Health History

• Helps the nurse define the patient's health problems
• The depth and manner of information collection depends on the patient's clinical status and availability of family or significant people
• Includes primary health problem, history of present illness, past health history, family history, and social/personal history

Primary Health Problem

• This is the main concern/reason for the patient contact with the healthcare system, such as chest pain, dyspnea, palpitation, etc

History of Present Illness

• Requires a detailed investigation of the patient's presenting and primary health problems
• Get a detailed picture from when the patient was last well to their current condition
• Investigate the chief complaint using OLD CARTS: Onset, Location, Duration, Character/Course, Aggravating/Associated factors, Relieving factors, Treatments tried, Severity
• Alternatively, one could use the pneumonic PQRST: Provocative/Palliative factors, Quality/Quantity, Region/Radiation, Severity, Timing

Past Health History

• Assess the patient's childhood and adult illnesses, hospitalizations, accidents, and injuries
• Determine if the patient has hypertension, diabetes mellitus, hyperlipidemia, chronic obstructive pulmonary disease (COPD), bleeding disorders, or acquired immune deficiency syndrome, because these may increase cardiac disease risk
• Review the patient's past illnesses and hospitalizations looking for trauma to the chest (possible myocardial contusion), sore throat and dental extractions (possible endocarditis), or rheumatic fever (valvular dysfunction, endocarditis), thromboembolism (myocardial infarction, pulmonary embolism)
• Ask about any drug, food, environmental, or animal allergies

Family history

• Note relatives' ages and health, because sudden death, hypertension, or diabetes history might place the patient at higher risk for heart disease

Social and Personal History

• Assess health habits like alcohol/drug/tobacco use, nutrition, obesity, weight gain after dieting, stress, sleeping patterns, and physical activity (sedentary lifestyle)

Physical Examination

• Should be complete or partial, following a comprehensive or problem-related history
• Provides a cornerstone for nurse data collection and allows for the gathering of objective data on the person’s cardiovascular system to assess changes in health status
• It is conducted in a quiet, well-lit room with consideration for patient privacy and comfort

General Appearance

• Assess if the patient is awake, alert, lethargic, stuporous, or comatose, and if they appear in acute distress
• Focus physical examination on what is essential when examining a patient in acute distress
• Observe the patient's build (thin, emaciated, obese) and skin color (pink, pale, flushed, cyanotic)
• Assess shortness of breath and jugular vein distention

Inspection

• This is the most important physical examination technique and begins at the first encounter
• It involves the organized scrutiny of the patient’s behavior and body and examiners can become highly sensitive to visual clues
• The examiner begins each examination phase by inspecting the particular part with the eyes

Examination of the Head

• Includes assessment of facial traits, expressions, and skin/eye color, which can reveal underlying cardiac disease
  • Ear lobe creases in a patient younger than 45 may indicate a genetic tendency toward coronary artery disease (CAD)
  • Facial color looks for a flush, cyanotic lips or slightly jaundiced skin (rheumatic heart disease)
  • Facial edema be noted with constrictive pericarditis and associated tricuspid valve disease

Examination of the Neck

• Neck to be examined for jugular venous pulse
• Jugular vein distention is characteristic of heart failure and other cardiovascular disorders

Examination of the Skin

• Checked for variations of temperature, diaphoresis, cyanosis, pallor, or jaundice.
• Warm, dry skin = adequate cardiac output (CO)
• Cool, clammy skin = compensatory vasoconstriction due to low cardiac output
• Cyanosis may be central (tongue, buccal mucosa, lips) with lung cancer, heart failure, pulmonary edema, etc, or peripheral (distal extremities, nose/ear tips) with chronic arteriosclerosis, heart failure, cold exposure, etc
• Jaundice can indicate right-sided heart failure or chronic hemolysis from a prosthetic heart valve

Extremities Examination

• Inspect the nailbeds for color, splinter hemorrhages, clubbing, and capillary refill
  • Pale nailbeds may indicate anemia, while cyanotic nails indicate decreased oxygenation
  • Splinter hemorrhages are associated with endocarditis
  • Clubbing is associated with pulmonary or cardiovascular disease
  • Capillary refill reflects peripheral blood flow rate
• Inspect and palpate for edema, describing the depth of pitting with slight pressure (1+ or mild, 2+ or moderate, 3-4+ or severe)

Palpation

• Involves touching the region/body parts involved, noting tenderness and structure characteristics
• It should be performed in an organized manner from one region to the next
• It allows the examiner to distinguish normal from abnormal

Percussion

• Helps determine density of underlying tissues and whether it is air-filled, fluid-filled or solid
• Audible vibrations can be sensed by the examiner
• Place and apply Hyperextended middle finger of your left hand onto the surface to be percussed
• Flex the right middle finger upward and strike the extended left middle finger with the flexed right middle finger's tip
• Lift the right middle finger fast to stop vibrations and use the lightest-possible touch, moving only at the wrist instead of the finger, elbow, or shoulder, to get a clear sound

Auscultation

• This method uses the stethoscope to augment hearing
• The stethoscope has to both be well-made and fit the user
• Stethoscope earpieces should be comfortable, the tubing ~10-15in (25-28cm), and the head should have a diaphragm and bell
  • Bell for low-pitched sounds like some heart murmurs
  • Diaphragm blocks low-pitched sounds, for high-frequency sounds like breathing sounds
• Clothing, hair, and scope movement can create extraneous sounds

Cardiac Catheterization

• A catheter is inserted into the heart and surrounding vessels to get structure and function information
• Diagnostic tests and some heart disease treatments such as coronary angioplasty/stenting can be performed using this method
• A specialized form of angiography is performed where a catheter is inserted into either the left or right side of the heart to study pressures within the heart, cardiac volumes, valvular function and patency of coronary arteries
• The procedure is performed in a specially equipped lab using a thin catheter, inserted in an artery(/vein) in your groin/neck/arm and threaded to the heart
• The patient is usually awake during catheterization but is given relaxants
• Recovery is quick, and the risk of problems is low
• A contrast is inject to assess structures and functions
• The right sided catheterization uses the subclavian or femoral vein for vascular access
• Left sided heart catheterization uses the femoral or brachial arteries

Right Heart Catheterization

• Usually done before left heart catheterization
• Passage of a catheter from an antecubital or femoral vein into the RA, RV, PA, and pulmonary arterioles
• Pressures and oxygen saturations are obtained from these regions
• It is considered relatively safe, but potential complications include cardiac dysrhythmias, venous spasm, infection at the insertion site, cardiac perforation, and, rarely, cardiac arrest

Left Heart Catheterization

• Used to assess coronary artery patency and the function of the LV and the mitral and aortic valves
• Possible complications include dysrhythmias, MI, perforation of the heart or great vessels, and systemic embolization
• Done by retrograde catheterization of the LV
• The physician will insert the catheter into the right brachial or a femoral artery and into the aorta/LV
• Afterwards the catheter is removed and homeostasis maintained with manual pressure (if the physician used an arterial or venous cutdown, it is sutured, and a dressing is applied)

Purpose of Cardiac Catheterization

• To obtain a clear picture of the cardiac structure and function prior to heart surgery
• To obtain a pressure within the heart chambers and the great vessels
• To inject contrast into the heart chambers and great vessels for X-rays (angiocardiography)
• To diagnose congenital abnormalities like atrial/ventricular septal defects (ASD/VSD)
• Locate narrowing/blockages in blood vessels to see the cause of chest pain (angiogram)
• Measure pressure and oxygen levels in different parts of the heart (hemodynamic assessment)
• Check heart pumping function (right/left ventriculogram)
• Sample a tissue from the heart (biopsy)
• Measure cardiac output
• Confirm heart diagnoses, and determine the extent the disease has affected its structure and function
• To detect pulmonary/mediastinal abnormalities and vessel displacement from emboli or congenital defects

Cardiac Catheterization Used to Treat Heart Disease

• Close holes in the heart and fix congenital defects
• Widen narrow arteries (angioplasty) with or without a stent
• Repair or replace heart valves
• Open narrow heart valves (balloon valvuloplasty)
• Treat irregular heart rhythms with ablation
• Close off parts of the heart to prevent blood clots
• Perform coronary angiograms; dye is injected through a catheter, and X-rays of heart arteries are taken. In some cases, catheters are first placed in the artery of your wrist or groin
• Perform right heart catheterization to measure pressure and blood flow in the right side of your heart; a catheter having special sensors is inserted in the vein of your neck or groin
• Perform heart biopsies; if the provider is sampling heart tissue, a catheter will be placed in a vein and a small jaw-like tip will grab a small piece A patient may feel pressure as the catheter is being used, but likely sensation of tissue being snipped

Balloon Angioplasty with/without Stenting

• A procedure which opens a narrowed artery in or near the heart using a catheter inserted in the wrist/groin
• A balloon catheter is fed through the arteries, inflated at the narrowed area to open it, and potentially kept open with a mesh coil
• Close holes in the heart by inserting a device to close the hole, and the cases of valve leak repair, may use clip/plug to stop leak
• Balloon Valvuloplasty is a procedure to open narrowed heart valves, where the catheter insertion site depends on valve problem

Contraindications for Cardiac Catheterization

• Clients who refuse surgery if needed
• Iodine contrast allergy
• Uncooperative clients who cannot lie still
• Pregnancy
• Severe cardiomyopathy
• Severe dysrhythmias
• Uncontrolled congestive cardiac failure
• Anticoagulant therapy

Nursing Responsibilities Before Cardiac Catheterization

• Instruct patient to fast for 8-12 hours pre-op, and make sure an outpatient has a ride home
• Inform the patient of anticipated procedure duration (~2hrs lying on a hard table)
• Reassure the patient IV medications will be given for comfort
• Tell the patient any potential sensations during the procedure
  • A pounding chest sensation can be sensed b/c of extra heartbeats, and more especially when the tip touches the endocardium
  • The patient may be asked to cough and breathe deeply, especially after contrast is injected because that coughing might help disrupt a dysrhythmia & breathing helps lower the diaphragm for better visualization of heart structures.
  • Contrast injection may cause flushing/feeling to void that usually resolves quickly (1min)
  • The nurse is to encourage/allow the patient to express all emotions while listening, and the patient must be reassured of their fears to reduce apprehension
• Diabetics must provide the nurse instructions about medicine administration
• You may need to stop blood thinning medications (warfarin, aspirin, apixaban, dabigatran, rivaroxaban)
• It's best if all medication bottles are taken with you so the doctor knows the exact dose you take"
• Check BP and pulse, and have the patient empty bladder
• Have them remove dentures and jewelry, then wait in a pre-op room and offer companionship if needed

Requirements for Procedure

• Protective supplies- mask, goggles, sterile gown and gloves
• Special catheter packs
• IV access equipment
• Diazepam, midazolam, or other sedative agents
• Emergency equipment such as oxygen, defibrillator, cardiac monitor, pulse oximeter

Procedure Steps

• Perform hand hygiene and wear protective equipment.
• Enforce that the patients empty the bladder
• Prepare monitoring equipment, including cardiac monitor, pulse oximeter, and blood pressure cuff
• Provide IV access with large-bore cannula, then remove gloves
• Monitor vitals, obtain weight, and palpate peripheral pulses
• Place patient in a comfortable supine position (possibly Trendelenburg) on the examination table and immobilize the extremity to be injected
• Verify the patient's name, procedure type, and the procedure site with the patient
• Tell the patient that dye injection might cause intense chest pain and a severe hot flash for only a few seconds
• Physicians cleanse site with antiseptic
• Asepsis- All team members apply mask, goggles, sterile gown, cap, & gloves, and the patient is draped with a sterile drape leaving the arterial puncture site exposed
• Anesthetize the skin overlying the arterial puncture site
• Next, a physician performs needle puncture of artery, inserts needle guide wire through needle and angiographic catheter threaded over the wire, advances catheter to desired artery/cardiac chamber/injects contrast medium
• Take a rapidsequence of x-ray films during dye injection.
• Watch the patient for anaphylaxis, like resp distress, palpitations, itching and diaphoresis while assisting with measuring the cardiac volumes and pressure
• Monitor sedation/consciousness level
• Physician applies 5-15 min pressure to puncture site after catheter withdrawal
• Remove and discard gloves
• Immobilize the affected extremity for 6-8 hours post-sheath removal per agency protocol, using an orthopedic bedpan for female patients on bed rest
• Emphasize the need to lay flat for 6-12 hours and encourage patient to drink 1-2L of fluid after the procedure
• Be prepared to end the cardiac catheterization procedure early in the event of severe unrelieved chest pain, neurological symptoms of a cardiovascular accident, cardiac dysrhythmias, or haemodynamic changes

Groin Pain Management

• Manual pressure applied to the groin can stimulate the baroreceptors and cause a vaso vagal reaction in which the patient becomes bradycardic and hypotensive
• Lower the head of the bed (flat) and giving a bolus of intravenous fluids

Nursing Responsibilities After Cardiac Catheterization

• The cardiac catheter access site should be observed looking for bleeding/hematoma formation
• Peripheral extremity pulses are checked every 15mins for 1hr, and then every 1-2 hours until stable
• The temperature, color, and cap refill of the affected extremities are frequently evaluated, per local nursing standards.
• Assess extremity pain, numbness, or tingling feelings which may indicate arterial insufficiency, and any changes are to be reported to promptly assess & relieve pt nausea/back pain w meds
• Be aware of and carefully screen any Dysrhythmias by continuous cardiac monitor & palpating apical pulse
• Vasovagal reactions of bradycardia, hypotension, and nausea can be due to distended bladder/pressure in which case one should elevate LE> heart level, infusion intravenous fluid, and administer IV atropine
• Maintain Bed rest for 2-6 hours, the patient needs to be laying flat and straight
• A pt can shift side to side
• Analgesic medication is given if discomfort occurs
• Review discharge orders with the patient/family Educate them about signs/symptoms of complications and notify about potential blood work

Cardiac Catheterization Complications

• Irregular heart rhythms (cardiac arrhythmias)
• Venous spasm
• Artery or heart damage at insertion site
• Thrombo-, phlebitis
• Myocardial infarction
• Heart failure
• Bruising
• Bleeding
• Stroke
• Allergic reaction
• Kidney damage
• Infection
• Blood clots
• Inform doctors of pregnancy/plans beforehand

Echocardiography

• Echocardiography can show the problems with the patient's heart
• This is a diagnostic tool with which you can utilize ultrasound to visualize the structures of the heart
• It is a recording of high frequency sound vibrations that have been sent into the heart through the chest wall
• The cardiac structures return the echoes derived from the ultrasound
• Traced with an Oscilloscope, recorded on film or outputted to a digital screen to produce visible images of the heart beating and pumping

Echocardiography Purpose

• You can use this test to check for any signs of defects or irregular rhythms of the heart

Echocardiogram Advantages

• Non-invasive; comfortable
• Convenient
• Diagnostic
• Time to run the test between 20 to 40 minutes
• Almost no contraindications of performing the test
• No special preparation needed
• ReliableTest

Transthoracic Echocardiogram

• In this echocardiogram, a technician (sonographer) spreads gel on a device (transducer)
• The sonographer presses the transducer firmly against your chest, aiming an ultrasound beam through your chest to your heart.
• The transducer records the sound wave echoes from your heart.
• A computer converts the echoes into moving images on a monitor.
• If your lungs or ribs block the view, you may need a small amount of an enhancing agent injected through an intravenous (IV) line.
• The enhancing agent, which is generally safe and well tolerated, will make your heart's structures show up more clearly on a monitor.

Transesophageal Echocardiogram

• This process is more detailed and the doctor or clinician may struggle to get the more direct picture of what they're looking to get to tell, for any signs of any potential cardiac problems or issues
• Your throat will be numbed, and you'll be given medications to help you relax
• A flexible tube containing a transducer is guided down your throat and into the esophagus.
• The transducer records the sound wave echoes from your heart.
• A computer converts the echoes into detailed moving images of your heart, which your doctor can view on a monitor.

Doppler Echocardiogram

• This test measures the speed and direction of blood flow in your heart using the sound waves
• Doppler signals can help your doctor measure
• Doppler techniques is generally used in both transthoracic and transesophageal echocardiograms
• Doppler techniques can also be used to check blood flow problems and blood pressure in the arteries of your heart—which traditional ultrasound might not detect. The blood flow shown on the monitor is colorized to help your doctor pinpoint any problems.

Stress Echocardiogram

• Some heart problems - particularly those involving the arteries that supply blood to your heart muscle (coronary arteries) occur only during physical activity
• an echocardiogram can't provide information about any blockages in the heart's arteries.
• Ultrasound images of your heart are taken before and immediately after you walk on a treadmill or ride a stationary bike
• If you're unable to exercise, you may get an injection of a. medication to make your heart pump as hard as you were if you were exercising

Risks of Echocardiograms

• There are little to no risks in a standard transthoracic echocardiogram
• The firmness is necessary to produce the best images of your heart
• In a transesophageal echocardiogram, your throat may be sore for a few hours afterward
• Rarely, the tube may scrape the inside of your throat
• Your oxygen level will be monitored during the exam to check for any breathing problems caused by the sedation medication
• During a stress echocardiogram, exercise or the medication - (not itself the echocardiogram) - may temporarily cause an irregular heartbeat

Preparation for Echocardiograms

• No special preparations are necessary for a standard trans thoracic echocardiogram
• Eat, drink and take medications as you normally would
• Doctor asking to not eat for several hours beforehand in most tests, like a transesophageal echocardiogram
• Patient is unable to drive immediately after the procedure because of the medications that often receive. Make sure to arrange a ride home
• Echocardiograms either can be done in the doctor's office or at a hospital
• Standard echocardiogram has the staff start by helping undress the patient from the waist up and have them get on an examination table or bed
• Followed by the attaching of leads to the body's to help regulate the test
• To record, images they will the transducer may move back and forth against the patient chest
• With the esophageal version, The throat will be numbed with a spray or gel
• Patients given sedation to help relax the entire body but still follow instructions or listen the proctors

After Echocardiograms

• The patient is expected to return to daily activities
• In addition to a standard exam, transesophageal echocardiogram. may require several hours for after to test for any sign of test effects or irregular rhythm issues

Electrocardiography/ECG/EKG

• A test often performed with the intent to measure heart of the electricity which can be helpful to identify a arrhythmia, heart, or electrical heart condition
• As you might know, heart problems can often affect affect of the electrical activity of the heart, to make it easier to test the health and the electricity that travels throughout the body
• An Electrocardiogram is a graphic record of the electrical impulses that are generated by depolarization and repolarization of the myocardium
• These impulses are conducted to the surface of the body to which they are detected, where electrodes and measuring equipment such as an ECG are placed on the patient's body
• After this testing happens, one has a visible output of the hearts condition where the heart is initiating each heart beat of the pulse
• Most hearts beat and function regularly with the help of the (Electrical, which impulses travel to the upper-half-Section of the heart, and then down to the bottom (60-100 a min

Electrocardiography Indications and Purpose

• Doctor or clinician may recommend an (EKD) if symptoms suggest an experience issue with the heart itself, to rule or confirm a specific medical condition is true and proper Potential Heart ECG testing - chestpain, trouble breathing, feeling tired/weak heart fluttering, heart feels uneven, doctors hearing unusual sounds in certain heart parts or blood vessels
• With 2 sets of data this test, a medical expert can quickly determine if an area takes to to travel from the body and to help spot problems, or determine if the body has issues that create large parts or an overworked heart

ECG Prep

• Avoid the consumption of cold drinking-water or exercising beforehand, and take a quick rest (5mins)

What to expect during an ECG

• (This is Quick, and Painless)
• 12-to-15 soft electrodes are hooked with a gel to your chest, and limbs, and have the electrodes stay properly against the skin, the provider may need to shave particular areas for an optimal procedure
• (Lie still to make sure there are no problems)
• After the testing, the tech or nurse is going to apply a wet rag, remove the electrodes and then discard the machines
• (Takes a few weeks)

Types of Cardio Grams

• Stress test, Holter

Stress Testing

• Usually, and typically are most seen heart problems can appear during normal exercise
• As such you'll have an EKG as they exercise, normally on a treadmill or by standard bike

Holter Testing

(AKA an Amulatory ECG Monitor) is done through (24to48) hours where the goal is to help record any heart potential issues or issues and the patient may feel inside

• The doctor is to inform of daily diary keeping or note potential symptoms
• Holter is battery to operate monitor, could be portable carry, can place a device to shoulder/belt/pocket/ and follow instructions