1. X- RAY

To find location of the heart and hypertrophy

  1. ECHO cardio gram

To identify structural abnormality of heart and no need of any preparation


  1. MYOGLOBIN: – An oxygen binding protein found in cardiac and skeletal muscle. Level rise with in 1 hr after cell death, peak in 4 to 6 hr and return in 24 to 36 hr: normal value for male  10 to 95 ng/ml and female 10 to 65ng/ml
  2. CK-MB (creating kinase, myocardial muscle) :-an increased value indicate myocardial damage and increase occur within 4 to 6 hrs and peek within 24hr following MI ; normal value is : 0 – 7 U/L
  3. LACTIC DEHYDROGENASE (LDH) :- elevation of LDH occur 24 hour following MI and peak in 24 -72 hr normal value is 140 to 280 IU/L
  4. TROPONIN :- composed of Three proteins , cardiac troponin, Troponin I, Troponin T
    • Troponin I :- it rise with in 3 hrs and persist for 7 days normal value is less than 0.6ng/ml
    • Troponin T :-normal value is 0 to 0.2ng/ml, thus any change indicate myocardial injury
  5. CBC count
    1. RBC :- increased RBC indicate inadequate tissue perfusion: decreased RBC indicate Anemia, infective heart diseases, and rheumatic heart diseases
    2. HCT (hematocrit) :- increased HCT indicate ischemia or vascular volume depletion: decreased HCT indicate anemia
  6. WBC :- increase indicate infection, and after MI
  1. lipids :-cholesterol normal value : <200mg/dl
  1. Lipoprotein
    1. LDL (low density lipoprotein) bad cholesterol normal value  :<130mg/dl
    2. HDL(high density lipoprotein)good cholesterol normal value:30-70 mg/dl
    3. Triglycerides : normal value :<200mg/dl
  1. HOLTER MONITORING :- it is a non-invasive procedure in which the client wear a holter monitor and an ECG tracking is recorded continually over a period of 24 hr or more

Nursing responsibility

  • Instruct the client that, record all activity in a diary
  • Do not discontinue wire
  • Do not wet and don’t use electrical blanket
  • Avoid electromagnetic interference
  1. EXERCISE TESTING (STRESS TEST)A noninvasive test that study the heart during activity and detect and evaluates coronary artery diseases.

Method: – TMT (treadmill testing ), Bicycle erigometry , step climbing.

Nursing responsibility

  • Consent should take before procedure
  • Adequate rest before procedure
  • Take light meals
  • Avoid stimulants, alcohol, coffee, and smoking.
  • Wear loose fitting cloths and well-fitting shoes
  • Instruct the patient to notify if chest pain occur
  • Keep emergency equipment at bed side

After procedure

  • Rest for 2 to 4 hr
  • Check vital sign every 15 minutes
  • Avoid hot drinks, hot water bath and driving for 3 to 4 hr to reduce vasodilatation
  • Report any unusual symptoms
  1. ANGIOGRAM: – contract medium is injected into the heart through blood vessel to outline the heart and blood vessel. Serious X ray are taken to identify structural deformity of blood vessel

Nursing responsibility pre-operative

  • Take consent
  • NPO from mid night
  • Assess allergy to iodine or sea food
  • Check base-line vital signs
  • Monitor color, temperature, and distal pulse of extremity through which die is injected

After procedure

  • Monitor vita sign every 15 minutes
  • Increase fluid intake
  • Monitor color ,temperature, pulse, of the extremity
  • Monitor for bleeding, infection and hematoma
  • Keep the leg straight for 8hr to prevent hematoma, bleeding.
  • Keep tight dressing over the inserted site and place ice pack or sand bag
  1. CARDIAC CATHETERIZATION :- insertion of catheter into the heart and surrounding  vessels


  • To measure oxygen concentration
  • To assess pressure in various chamber
  • To detect the patency of shunt
  • To inject contract medium
  • To monitor cardiac output
  • To assess pulmonary out flow


  • Rt cardiac catheterization and Lt cardiac catheterization

Rt cardiac catheterization:-A catheter is passed from femoral or anti cubital vein in to the Rt atrium, Rt ventricle and pulmonary artery

Lt cardiac catheterization:-methods are , Retrograde approach, and Tran septal approach

  • Retrograde approach :-a catheter is introduced in to the femoral or brachial artery in to aorta , coronary artery, Lt ventricle, and Lt atrium
  • Trans septal :- when catheter reaches Rt atrium a needle is used to break the atrial septum and the catheter is advanced in to the left atrium

Nursing responsibility

  • Take consent
  • Keep NPO
  • Assess any allergy to sea food or iodine
  • Monitor vital signs and peripheral pulses
  • Measure height and weight to determine the amount of die
  • Monitor s. creatinine and urea
  • Instruct the client that, when the catheter reaches the heart pt may feel desire to cough and may feel palpitation
  • Maintain patent IV line

After procedure

  • Monitor vital signs every 15 to30 minute
  • Provide bed rest 8 to 12 hr. if femoral artery is used. If vein is used 6 to 8 hr.
  • Apply pressure over the site by using a sand bag
  • Apply cold pack to reduce bleeding and edema
  • Avoid flexion
  • Do not elevate head more than 30degree
  • Monitor for complication


  • Cardiac dysrhythmias
  • Venous spasm
  • Thrombophlebitis
  • Cardiac perforation
  • Cardiac tamponade
  • Infection

Heart rate :- a pulsation of the heart, including one complete systole and diastole

Cardiac output :- total amount of blood pumping from heart in a minute . cardiac output = stroke volume  * pulse

Stroke volume :- amount of blood ejected from the heart, with each heart beat normal  is 70 ml

BP monitoring :-5 – 10 mmofhg difference between both arm can be seen when taking BP.More than 10mmofhg show subclavian artery steel syndrome, or aortic aneurism

Pulse pressure:-

  • it is the difference between systolic BP and diastolic BP:
  • Normal is 40 mmofhg.
  • If it is less than 30 hypotension or decreased cardiac output .
  • if it is more than 50 hypertension

Orthostatic hypotension

  • BP changes when position changes suddenly Systolic pressure decreases 15 mmofhg, diastolic pressure decreases 5mmofhg and heart rate increased by 15b/m
  • Take 3 minute  between position changes
  • If adequate cardiac output – warm and flushed skin
  • If decreased cardiac output – cold and clammy skin

Cyanosis –

  • Central cyanosis :- due to decrease blood supply or o2 saturation to artery
    • Cyanosis will be at lips, buccal mucosa, and tongue
  • Peripheral cyanosis :- due to decrease blood supply to the peripheral vessel
    • Cyanosis will be at nail, ears, and tipoff the nose

Pulse alternate:-

  • It is the hallmark sign of LVF with regular alternation of strong and weak pulse

Pulse paradoxes:-

  • Fall of systolic pressure (10mmof hg) during inhalation. It is the hallmark sign of cardiac tamponade
  1. PCWP (pulmonary capillary wedge pressure) :- is equal to the pressure in the left atrium and the normal value is  8 to 12 mmofhg.  PCWP is the pressure inside the pulmonary capillary at wedge position  and the pressure is equal to the pressure in the Lt atrium or lung


Introduce swan ganz catheter through the vein in  Rt atrium or SVC the balloon is inflated with 1ml air so that it guide the further passage of catheter. Pressure is monitor when the inflated balloon is in pulmonary artery

  • PCWP is decrease in hypovolemia and shock
  • PCWP is increase in hypervolemia , LVF, and pulmonary edema


CVP (central venous pressure):- pressure inside the SVC or Rt atrium


A central venous catheter is introduced in to the SVC or Rt atrium another end is attached to manometer the Rt atrium is located at the mid axillary line at the 4th intercostal space and zero point on the transducer need to be at the level of Rt atrium.

  • The client need to be supine with head of the bed elevated at 45 degree
  • The client need to be relax , note that activity that increases intrathoraxic pressure such as cough, straining , or deep breath which may cause false reading
  • If the client is in ventilator the reading should be taken at the end of the respiration
  • To maintain patency of line , a constant small amount of fluid is delivered to the patient
  • Normal CVP is 5 to 10 mmofhg
  • CVP decreases in hypovolemia, and cardiogenic shock
  • CVP increases in congestive HF, hypervolemia, excess fluid infusion, PHT


  • Air embolism
  • Pneumothorax
  • Haemothorax
  • Infection
  • Cardiac tamponade
  1. ECG

Electro cardio gram. It is a common noninvasive diagnostic test that evaluate the heart function

By recording electrical activity

P wave­ : fist +ve deflation. it represent atrial depolarization (contraction). Time is 0-12sec

PR interval:- it is represent the time it taken an impulse from the AV node to the bundle of Hiss, and to bundle branch to the purkinje fiber,. Normal PR interval duration ranges from 0.12 to 0.20sec

QRS complex: – represent ventricle depolarization normal duration ranges from 0.08 to 0.12sec

ST segment: – begin at the end of an S- wave and up to the beginning of T-wave. It represent the part of ventricle repolarization. Normal time of ST segment is less than 0.20sec

T-wave: – indicate ventricular repolarization. Time taken for this is less than 0.20sec

U-wave: – may follow T-wave, prominent U wave may indicate hypokalemia

Measuring heart rate from ECG

  1. Count the no of QRS complex in 6sec ECG *10 (6sec ECG means 30 large square in ECG)
  2. Count the no of large square between two consecutive QRS complex or between two R-wave and divided by 300
  3. Count the no of small square b/w 2 QRS complex and divided by 1500

A large square =5 small square

A large square = 0.20 sec

A small square = 0.04sec


  • 3 standard bi polar leads, L1 , L2, L3
  • 3 unipolar limp leads , aVR, aVL, aVF
  • 6 unipolar chest lead, V1, V2, V3, V4, V5, V6.
  • L1 – it is a potential difference b/w Lt arm and Rt arm
  • L2 – it is a potential difference b/w Rt arm and Lt leg
  • L3 – it is a potential difference b/w Lt leg and Lt arm
  • aVR (augmented voltage right) – is a the electrical potential b/w Rt arm and central terminal
  • aVL –it is a the electrical potential b/w Lt arm and central terminal
  • aVF- it is a the electrical potential b/w Lt leg and central terminal

Placement of chest leads

V1:-     Rt side 4th intercostal space near to sternum

V2:-     Lt side 4th intercostal space near to sternum

V3:-     middle of the V2 and V4

V4:-     Lt side 5th intercostal space at mid-clavicle line

V5:-     Lt side 5th intercostal space at anterior axillary  line

V6:-     Lt side 5th intercostal space at mid axillary line near to V5

Chest lead records difference of electrical potential b/w central of heart and various part of chest

  • V1 and aVR represent -: Rt side of the heart
  • L1, aVL, V5,and V6 represent -: Lt side of the heart
  • L2, L3, and aVF represent -; inferior portion of the heart
  • V2,V3,and V4 represent -: trans section  b/w Rt and Lt of the heart


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