Introduction to Medical-Surgical Nursing, 6th ed.
36
Lesson Plans for
Cardiac Disorders
CHAPTER LESSON PLANS & OBJECTIVES
Lesson 36.1:
2. Describe the flow of blood through the heart and coronary vessels.
4. State the order in which normal impulses are conducted through the heart.
Lesson 36.2:
5. Explain the nursing considerations for patients having procedures to detect or evaluate cardiac
disorders.
Lesson 36.3:
6. Identify nursing implications for common therapeutic measures, including drug, diet, or oxygen
Lesson 36.4:
7. Explain the pathophysiology, risk factors, signs and symptoms, complications, and treatment for
selected cardiac disorders.
9. Assist in developing nursing care plans for patients with cardiac disorders.
CHAPTER TEACHING FOCUS
• In this chapter, the student will be introduced to topics related to cardiac disorders.
• The student will have the opportunity to become acquainted with the anatomy and physiology of the
heart, coronary blood flow, the conduction system, nursing assessment of cardiac function, diagnostic
CONCEPTS
The following conceptual themes and specific concepts match those presented in Giddens, J. R. (2013).
Concepts for nursing practice. St. Louis: Elsevier. The specific exemplars chosen and listed below for
each concept have been tailored specifically to correspond to the Linton textbook.
THEME: Oxygenation and Hemostasis
• Concept: Perfusion
• Exemplar: Myocardial Infarction, p. 710
• Figure 36-8: Electrocardiographic changes with myocardial infarction, p. 713
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Introduction to Medical-Surgical Nursing, 6th ed.
CHAPTER PRETEST
Have the students answer these questions prior to covering this chapter to understand where they stand
in relation to the content.
1) The layer of the heart in which the coronary arteries are embedded is the __________.
a) myocardium
b) endocardium
c) epicardium
d) pericardium
2) Which of the following normally initiates the cardiac electrical impulse?
a) AV node
b) SA node
c) Myocardium
d) Cardiac output
3) Cardiac output is best defined as the amount of __________.
a) blood ejected by the heart per minute
b) blood remaining in the ventricle at the end of diastole
c) blood remaining in the ventricle at the end of systole
d) pressure the ventricles must overcome to eject the blood volume
4) Which of the following drugs is a glycoprotein IIb/IIIa inhibitor used in combination with heparin and
aspirin to treat unstable angina and myocardial infarction?
a) Gemfibrozil (Lopid)
b) Verapamil (Calan)
c) Abciximab (ReoPro)
d) Amiodarone (Cordarone)
5) Which of the following is a cardiac enzyme that rises in the serum within 4 to 6 hours after an acute
myocardial infarction?
a) Lactic dehydrogenase (LDH)
b) Creatine phosphokinase (CPK)-MB
c) High-density lipids (HDLs)
d) Low-density lipids (LDLs)
6) Which of the following is an example of an antianginal drug?
a) Nifedipine (Procardia)
b) Digoxin (Lanoxin)
c) Nicotinic acid (Niacin)
d) Amrinone (Inocor)
7) Which of the following complications of an acute myocardial infarction is always fatal?
a) Cardiogenic shock
b) Thromboembolism
c) Ventricular rupture
d) Cardiac failure
8) Which of the following assessment data would indicate adequate cardiac output in a patient with
congestive heart failure?
a) Increased heart rate
b) Increased respiratory rate
c) Decreased urinary output
d) Heart rate and rhythm returned to baseline
9) Patients with valvular disease may need to be treated prophylactically with antibiotics before invasive
procedures to prevent __________.
a) rheumatic fever
b) infective endocarditis
c) heart failure
d) rejection
10) On an ECG, what does a P wave before every QRS complex indicate?
a) Heart block
b) Bradycardia
c) Rhythm originates from the SA node
d) Tachycardia
_______________________________________________________________ Chapter 36Cardiac Disorders 3
Introduction to Medical-Surgical Nursing, 6th ed.
Chapter Pretest Answers
CHAPTER BACKGROUND ASSESSMENT
Discuss these questions with your students prior to covering this chapter to understand where they stand
in relation to the content.
Question: What are the four valves of the heart? Where is each located?
Answer: The four valves of the heart are the mitral, tricuspid, aortic, and pulmonic. The mitral valve is
Question: What three factors affect stroke volume of the heart? Define each one.
4 Chapter 36Cardiac Disorders ________________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 36.1
Textbook Objectives Covered
2. Describe the flow of blood through the heart and coronary vessels.
4. State the order in which normal impulses are conducted through the heart.
Lesson Preparation Checklist
• Prepare lecture from TEACH lecture slides available on Evolve.
• Student performance evaluation of all entry-level skills required for student comprehension of
principles underlying cardiac disorders, including:
• Anatomy and physiology of the heart
Materials and Supplies
• computer and PowerPoint
projector
• overhead of unlabeled
diagram of the heart and
overhead projector
Key Terms
• afterload (p. 685)
• arteriosclerosis (p. 708)
• preload (p. 685)
• regurgitation (p. 726)
_______________________________________________________________ Chapter 36Cardiac Disorders 5
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 36.1
Student Preparation
Assignments 2 hours
1
READ – Textbook (pp. 681-682)
REVIEW
• Figure 36-1: Anatomic location of the heart (p. 682)
ANSWER – Study Guide
2
READ – Textbook (pp. 682-684)
REVIEW
• Figure 36-2: Normal circulation through the heart (p. 682)
• Figure 36-3: Coronary arteries and veins (p. 684)
ANSWER – Study Guide
3
READ – Textbook (pp. 684-685)
ANSWER – Text
• Review Questions for the NCLEX Examination: 1 (p. 735)
ANSWER – Study Guide
• Part IB: 2, 6, 7, 11, 12 (p. 218)
• Part IM: A-E (p. 221)
4
READ – Textbook (pp. 684-686)
REVIEW
ANSWER – Text
• Review Questions for the NCLEX Examination: 2, 3 (p. 735)
ANSWER – Study Guide
• Part IA: 7, 12, (p. 217)
SIMCHART
• Simulation: Scenario 9 – Keola Akana: Heart Failure, Digoxin Toxicity and Hypokalemia
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Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 36.1
Lecture Outline 20 minutes
Slide 1
Chapter 36
Cardiac Disorders
1
Slide 2
Anatomy
• Chambers
• Two upper atria (right and left)
• Two lower ventricles (right and left)
• Muscle layers
• Endocardium, myocardium, and epicardium
TALKING POINTS:
• What separates the four chambers?
• Valves separate the atria from the ventricles.
Heart Sounds
• The first heart sound (S1), referred to as lub, occurs when the ventricles contract during
2
Coronary Blood Flow
• Left coronary artery and the right coronary artery
TALKING POINTS:
• What are collateral arteries?
Coronary Blood Flow (cont.)
• Venous system parallels the arterial system: the great cardiac vein follows the left anterior
_______________________________________________________________ Chapter 36Cardiac Disorders 7
LESSON 36.1
3
&
4
Slide 6
Conduction
• SA node, called the pacemaker, initiates the impulse
• The impulse is carried throughout the atria to the AV node, located on the floor of the RA
• Impulse is delayed in the AV node, then transmitted to the ventricles through the bundle of
His
• The bundle of His is made up of Purkinje cells and is located where the atrial and
ventricular septa meet
TALKING POINTS:
• For the heart to pump blood through the chambers, nerves must stimulate muscle
contractions in an orderly fashion.
• What are depolarization and repolarization?
Slide 7
Conduction (cont.)
• Cardiac innervation
• Heart innervated by sympathetic and parasympathetic fibers of the autonomic
nervous system
• Sympathetic fibers distributed throughout the heart
• Sympathetic stimulation results in increased heart rate, increased speed of
4
Slide 8
Cardiac Function
• Cardiac cycle
• Contraction and relaxation of the heart make up one heartbeat
• Cardiac output
• Amount of blood (in liters) ejected per minute
TALKING POINTS:
• When the ventricles are at rest (relaxation phase), they are filling up with blood coming
from the atria; this is called diastole.
• At the end of diastole, the atria contract to eject blood into the ventricles.
• Once the ventricles have filled with blood and the electrical impulse has reached the
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Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 36.1
Slide 9
Age-Related Changes
• Heart
• Increased density of connective tissue and decreased elasticity
• Number of pacemaker cells in the SA node decreases, as does the number of nerve
fibers in the ventricles
TALKING POINTS:
• Cardiac dysrhythmias are more common in older people, but should still be evaluated
because they can be dangerous.
• What commonly happens to the valves in the older adult?
Slide 10
Question 1
• Which of the following statements is true about heart valves?
A. The mitral and tricuspid valves are called semilunar valves.
B. The tricuspid and mitral valves are open during systole and closed in diastole.
C. The aortic and pulmonic valves are called atrioventricular valves.
D. The semilunar valves separate the ventricles from the aorta and the pulmonary
artery.
TALKING POINTS:
and are closed during diastole.
Slide 11
Question 2
• Which of the following is the pacemaker of the heart?
A. AV node
B. Bundle of His
C. Purkinje fibers
D. SA node
_______________________________________________________________ Chapter 36Cardiac Disorders 9
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 36.1
Activities
Classroom Choose from below to make 30 minutes
Online
1
ASSESS BASELINE
• Have the class complete the Pretest. Collect
their work and use the results to guide how
you teach the class.
DISCUSS
• Discuss the anatomy and physiology of the
four chambers, three muscle layers, and four
valves of the heart.
PRACTICE
• Project an unlabeled diagram of the heart on
the board or the overhead screen. Ask
ASSESS BASELINE
• Post the Pretest and the Background
Assessment online and have your class
complete them. Use the results to guide how
you teach the class
POST & COMMENT
• Post the following discussion topic online
and have students comment. Ask students
to create and post a video describing the
anatomy and physiology of the four
chambers, three muscle layers and four
valves of the heart. Ask students to post
2
DISCUSS
• Discuss the normal circulation through two
major coronary arteries, the collateral
arteries, and the venous system.
PRACTICE
• Divide the class into small groups. Ask each
group to create an illustration of the blood
POST & COMMENT
• Post the following discussion topic online
and have students comment. Ask students
to create and post a video demonstrating the
blood flow through the heart and coronary
vessels. Ask students to view each other’s
videos and post constructive comments.
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Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 36.1
3
DISCUSS
• Discuss the conduction system of the heart.
PRACTICE
• Divide the class into pairs. Have each pair
develop a set of flash cards that list each
element of the heart’s conduction system
and its function. Have the students quiz
each other using the flash cards.
POST & COMMENT
• Post the following discussion topic online
and have students comment. Ask students
to create their own 10-question pop quiz
regarding the conduction system. Ask
students to answer each other’s quizzes.
4
DISCUSS
• Discuss the normal conduction of electrical
impulses through the heart.
• Discuss the cardiac cycle and the three
factors affecting stroke volume (preload,
contractility, and afterload).
• Discuss age-related changes in the heart
muscle and blood vessels.
PRACTICE
• In pairs, have students make flash cards for
the following terms: SA node, AV node,
POST & COMMENT
• Post the following discussion topic online
and have students comment. Ask students
to post a blog describing three changes in
the cardiovascular system related to aging
and how these changes would affect
everyday life. Ask students to read and post
constructive comments on each other’s
blogs.
_______________________________________________________________ Chapter 36Cardiac Disorders 11
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 36.1
Critical Thinking Question
What are several age-related changes that you would expect to see in a 78-year-old man’s
heart? What would indicate that the change is related to something other than age?
Discussion Guidelines: As a person ages, the heart muscle changes, which includes increased
density of connective tissue and decreased elasticity. As a result, the contractility of the heart
Instructor Notes/Student Feedback
12 Chapter 36Cardiac Disorders ________________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 36.2
Textbook Objectives Covered
8. List the data to be obtained in assessing the patient with a cardiac disorder?
5. Explain the nursing considerations for patients having procedures to detect or evaluate cardiac
disorders.
Lesson Preparation Checklist
• Prepare lecture from TEACH lecture slides available on Evolve.
• Student performance evaluation of all entry-level skills required for student comprehension of
principles underlying cardiac disorders, including:
Materials and Supplies
• computer and PowerPoint
projector
Key Terms
• afterload (p. 685)
• arteriosclerosis (p. 708)
• atherosclerosis (p. 708)
• preload (p. 685)
• regurgitation (p. 726)
• syncope (p. 686)
_______________________________________________________________ Chapter 36Cardiac Disorders 13
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 36.2
Student Preparation
Assignments 2 hours
8
READ – Textbook (pp. 686-688)
REVIEW
• Figure 36-5: Auscultation of the heart (p. 687)
• Table 36-2: Grading of Heart Murmurs (p. 688)
• Box 36-1: Assessment of Patients with Cardiac Disorders (p. 688)
ANSWER – Study Guide
• Part IA: 1, 2, 5, 10, 11 (p. 217)
5
READ – Textbook (pp. 688-696)
REVIEW
• Table 36-3: Diagnostic Tests and Procedures (pp. 689-691)
• Figure 36-6: Right sided and Left sided Heart catheterization (p. 693)
ANSWER – Study Guide
• Part IB: 1, 10 (p. 218)
• Part IG: 1-17 (pp. 219-220)
• Part IIN: 8-10, 15-17, 21, 28 (pp. 222-223)
Lecture Outline 20 minutes
8
Slide 12
Chief Complaint and History of Present Illness
• Symptoms related to cardiac disorders include fatigue, edema, palpitations, dyspnea, and
pain
• Note when symptoms occur, what aggravates them, and what relieves them
Slide 13
Medical History
• Hypertension, kidney disease, pulmonary disease, stroke, rheumatic fever, streptococcal
sore throat, and scarlet fever
• Document previous cardiac disorders and hospitalizations. List recent and current
medications and note allergies in appropriate records
Slide 14
Family History
Review of Systems
• Systematically assess whether the patient has experienced the following: weight gain,
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Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 36.2
Slide16
Functional Assessment
• Determine how this illness has affected the patient’s ability to carry out usual activities
• Activity and rest patterns and usual diet
• Ask about sources of stress and coping strategies
Slide 17
Physical Examination
• Vital signs
• Blood pressure, pulse, and respirations
• Skin
5
Slide 18
Diagnostic Tests and Procedures
• Electrocardiogram (ECG)
• Ambulatory ECG (Holter monitor)
• Implantable loop monitor/recorder (ILR)
Slide 19
Diagnostic Tests and Procedures (cont.)
• Stress test (exercise tolerance test)
• Perfusion imaging
• Thallium imaging
Slide 20
Laboratory Tests
• Arterial blood gases
• Pulse oximetry
• Cardiac enzymes
• Creatine phosphokinase
• Cardiac protein markers
_______________________________________________________________ Chapter 36Cardiac Disorders 15
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 36.2
Activities
Classroom Choose from below to make 30 minutes
Online
8
DISCUSS
• Discuss the elements of the health history
and the physical examination for a patient
with a cardiac disorder.
• Discuss the physiology of systole and
diastole. Discuss how to assess for heart
murmurs and describe the recommended
pattern of auscultation.
PRACTICE
• Ask the students to form groups of 3. Ask
one student to role play the nurse obtaining
a health history, another student to role play
DISCUSS
• Discuss elements of a nursing care plan for
a patient with coronary artery disease.
• Discuss the elements of a nursing care plan
for a patient with acute myocardial infarction.
• Discuss the elements of a nursing care plan
for a patient with congestive heart failure.
• Discuss the elements of a nursing care plan
for a patient who has an ICD.
POST & COMMENT
• Post the following discussion topic online
and have students comment. Ask students
to blog their comments on how to best
approach a patient with to obtain a health
history regarding their cardiac problems. Ask
students to post constructive comments on
each other’s blogs.
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Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 36.2
5
DISCUSS
• Discuss diagnostic tests and procedures for
patients with cardiac disorders.
• Discuss each component of the complete
blood count.
PRACTICE
• Make a list of these procedures and their
characteristics on the board. Some
questions to ask the students might be: Is
the testing invasive or noninvasive? What
disorder is the procedure used to evaluate?
Is this a common procedure? Who will
perform the procedure?
• Divide the class into small groups, and
POST & COMMENT
• Post the following discussion topic online
and have students comment. Ask students
to blog their comments on how a patient who
is to undergo a cardiac catheterization
education for sensations the patient will
experience during the procedure. Ask
students to post constructive comments on
each other’s blogs.
Critical Thinking Question
While obtaining a health history from a patient during a routine physical examination, the
nurse notes that the patient has a family history of heart disease. What data should the
nurse collect from this patient related to his heart function?
Discussion Guidelines: The nurse should perform a review of systems to collect data regarding
signs and symptoms of heart disease, including weight gain, shortness of breath, fatigue,
Instructor Notes/Student Feedback
_______________________________________________________________ Chapter 36Cardiac Disorders 17
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 36.3
Textbook Objectives Covered
6. Identify nursing implications for common therapeutic measures, including drug, diet, or oxygen
therapy; pacemakers and cardioverters; cardiac surgery; and cardiopulmonary resuscitation.
Lesson Preparation Checklist
• Prepare lecture from TEACH lecture slides available on Evolve.
• Guest speaker: cardiac nurse practitioner
• Guest speaker: registered dietitian
• Student performance evaluation of all entry-level skills required for student comprehension of
principles underlying cardiac disorders, including:
Materials and Supplies
• computer and PowerPoint
projector
Key Terms
• contractility (p. 685)
• tachycardia (p. 687)
• afterload (p. 685)
• arteriosclerosis (p. 708)
• preload (p. 685)
• regurgitation (p. 726)
Student Preparation
Assignments 2 hours
6
READ – Textbook (pp. 696-708)
REVIEW
• Table 36-7: Cardiac Medications (pp. 697-702)
ANSWER – Text
ANSWER – Study Guide
• Part IIN: 31-35, 38-43, 46-47 (pp. 224-225)
• Part IIO: 1-21 (p. 225)
• Part IIIP: 7 (p. 227)
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Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 36.3
Lecture Outline 20 minutes
6
Slide 21
Drug Therapy
• Cardiac glycosides
• Antianginals
• Antidysrhythmics
• Angiotensin-converting enzyme (ACE) inhibitors (ACEIs)
• Diuretics
• Anticoagulants
TALKING POINTS:
• The cardiac glycosides slow the heart rate (negative chronotropic effect) and increase the
force of myocardial contraction (positive inotropic effect), causing increased stroke volume
and cardiac output.
Slide 22
Drug Therapy (cont.)
• Heparin
• Low-molecular-weight heparin (LMWH)
• Warfarin
• Antiplatelet agents
TALKING POINTS:
• Heparin interferes with factor III in the clotting process.
• The advantage of using LMWH is that the anticoagulant effect is more predictable.
• Antiplatelet therapy is often used after an acute myocardial infarction (AMI) to prevent
additional myocardial infarction and strokes.
_______________________________________________________________ Chapter 36Cardiac Disorders 19
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 36.3
Slide 23
Diet Therapy (cont.)
• Low-fat, high-fiber diet
• Well-balanced diet
• Emphasis on fruits, vegetables, grains, and proteins low in fat (fish, legumes, poultry,
TALKING POINTS:
• How does the reduction of body weight help the heart?
Slide 24
Diet Therapy (cont.)
• Sodium
• Sodium restriction of 1500 mg/day is recommended if the patient has fluid retention
• Potassium
• Patients taking potassium-wasting diuretics need adequate potassium in the diet
Slide 25
Other Therapeutic Measures
• Oxygen therapy
• Pacemakers
• Temporary
• Permanent
• Cardioversion
TALKING POINTS:
• Any patient complaining of chest pain unrelieved by nitroglycerin (NTG) should have
Slide 26
Other Therapeutic Measures (cont.)
• Cardiopulmonary resuscitation
• Defibrillation
Cardiac Surgery
• Common surgical procedures
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Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 36.3
Slide 28
Cardiac Surgery (cont.)
• Preoperative nursing care
• Interventions
• Fear
• Anxiety
TALKING POINTS:
• Encourage the patient to identify feelings and then explore the basis of those feelings. Do
not assume you know how the patient feels.
• What important nursing intervention is important to relieve anxiety?
Slide 29
Cardiac Surgery (cont.)
• Postoperative nursing care
• Interventions
• Ineffective breathing pattern