Cardiovascular nursing

In short

Cardiovascular nursing is the assessment, monitoring and care of patients with disorders of the heart and blood vessels — coronary artery disease, heart failure, hypertension, valvular and rheumatic heart disease, arrhythmias and peripheral vascular disease — across prevention, acute care, surgery and rehabilitation. It matters because cardiovascular disease is India's single largest cause of death, strikes Indians roughly a decade earlier than Western populations, and rheumatic heart disease still burdens young patients in rural areas. In the B.Sc Nursing curriculum it sits in Medical-Surgical Nursing I and is examined through nursing process, drug calculations, ECG basics and emergency management. It is heavily tested in AIIMS NORCET, state staff-nurse, ESIC, RRB and military nursing recruitment, and in interviews for CCU/CTVS posts at AIIMS, PGIMER, CMC Vellore, Narayana Health, Apollo, Fortis and Medanta.

Explained

Applied physiology and haemodynamic assessment

• Cardiac cycle: systole (ventricular contraction, S1 = mitral/tricuspid closure) and diastole (filling, S2 = aortic/pulmonary closure). S3 suggests volume overload/failure; S4 suggests a stiff ventricle.
• Cardiac output (CO) = heart rate × stroke volume; normal 4–8 L/min. Stroke volume depends on preload (venous return/ventricular filling), afterload (resistance the ventricle ejects against) and contractility.
• Frank–Starling law: within limits, greater myocardial fibre stretch gives a stronger contraction; beyond that limit (a failing heart) more preload only worsens congestion.
• Normal values to quote: HR 60–100/min, BP <140/90 mmHg, MAP 70–105 mmHg (keep >65 for organ perfusion), CVP 2–8 mmHg (≈5–10 cmH₂O), ejection fraction 55–70%, SpO₂ ≥94%, urine output ≥0.5 mL/kg/h.
• Inspection and palpation: apex beat normally 5th intercostal space, mid-clavicular line (displaced in cardiomegaly); check peripheral pulses bilaterally (grade 0–4+), capillary refill <3 s, pedal oedema (pitting, graded 1+ to 4+), jugular venous pressure raised in right-sided failure, clubbing and cyanosis in congenital/chronic disease.
• Pulse abnormalities: pulsus paradoxus (tamponade), water-hammer pulse (aortic regurgitation), pulse deficit = apical minus radial rate (atrial fibrillation).

Coronary artery disease — angina and myocardial infarction

• Pathology: atherosclerotic plaque narrows a coronary artery (ischaemia, reversible); plaque rupture with thrombus occludes it (infarction, necrosis).
• Risk factors — modifiable: smoking and tobacco chewing, hypertension, diabetes, dyslipidaemia, obesity, physical inactivity, stress, high-salt/trans-fat diet. Non-modifiable: age, male sex, family history, South Asian ethnicity (higher risk at lower BMI).
• Angina types: stable (on exertion, relieved by rest/nitrate), unstable (at rest, increasing — an acute coronary syndrome), Prinzmetal/variant (spasm), silent (common in diabetics and the elderly).
• MI presentation: crushing retrosternal pain >20 min radiating to left arm, jaw or back, unrelieved by rest; sweating, nausea, dyspnoea, anxiety, sense of doom. Women, diabetics and elderly patients often present atypically with fatigue, epigastric pain or breathlessness.
• Diagnosis: 12-lead ECG within 10 minutes of arrival — ST elevation (STEMI), ST depression/T inversion (NSTEMI/unstable angina), pathological Q waves (old infarct). Cardiac markers: troponin I/T rises in 3–4 h, peaks ~24 h, stays elevated 7–14 days (most specific); CK-MB peaks ~24 h and normalises in 48–72 h, useful for re-infarction; myoglobin rises earliest but is non-specific.
• Immediate nursing management (MONA-plus, in the order actually done): assess airway-breathing-circulation, continuous ECG monitoring, IV access (two lines), oxygen only if SpO₂ <90%, aspirin 325 mg chewed, sublingual nitroglycerin 0.5 mg (hold if SBP <90 mmHg, suspected right-ventricular infarct, or sildenafil-type drug in 24–48 h), morphine for unrelieved pain, loading dose of clopidogrel/ticagrelor as prescribed, absolute bed rest, reassurance, keep defibrillator at hand.
• Reperfusion: primary PCI is preferred — target door-to-balloon ≤90 minutes; where PCI is not available, thrombolysis with streptokinase or tenecteplase — target door-to-needle ≤30 minutes. India's hub-and-spoke STEMI networks (pioneered in Tamil Nadu and Kerala) connect spoke centres that thrombolyse to PCI hubs.
• Thrombolysis nursing: confirm no absolute contraindication (active bleeding, prior intracranial haemorrhage, ischaemic stroke <3 months, aortic dissection, recent major surgery/head trauma); watch for hypotension and allergy with streptokinase; monitor for bleeding from all sites, neurological change, and reperfusion arrhythmias.
• Complications to watch: arrhythmias (commonest early cause of death — ventricular fibrillation), cardiogenic shock, heart failure, pericarditis, papillary muscle rupture, ventricular aneurysm, mural thrombus with embolism.

Heart failure, hypertension and rheumatic/valvular disease

• Heart failure: inability to pump enough blood for metabolic needs. Left-sided → pulmonary congestion: dyspnoea, orthopnoea, paroxysmal nocturnal dyspnoea, fine crackles, pink frothy sputum, S3. Right-sided → systemic congestion: raised JVP, pedal oedema, ascites, hepatomegaly, weight gain, anorexia. HFrEF (EF ≤40%) versus HFpEF (EF ≥50% with diastolic dysfunction).
• NYHA classification: I — no limitation; II — slight limitation, symptoms on ordinary activity; III — marked limitation, symptoms on less-than-ordinary activity; IV — symptoms at rest.
• Heart-failure nursing: Fowler's position, oxygen, daily weight at the same time on the same scale (gain >2 kg in 2 days = fluid retention, report), strict intake–output, fluid restriction usually 1.5–2 L/day and salt <5 g/day as prescribed, monitor for digoxin and diuretic side effects, energy conservation, pacing of activity, DVT prophylaxis.
• Acute pulmonary oedema: sit upright with legs dependent, high-flow oxygen/NIV, IV furosemide, morphine, nitrates, continuous monitoring — a medical emergency.
• Hypertension: usually asymptomatic; may cause headache, epistaxis, dizziness. Indian practice generally defines hypertension as ≥140/90 mmHg (the India Hypertension Control Initiative and NP-NCD use this), while ACC/AHA uses ≥130/80 — state which standard you are applying. Hypertensive emergency = severe BP elevation with target-organ damage (encephalopathy, pulmonary oedema, dissection) needing controlled IV reduction; urgency has no organ damage.
• BP measurement technique (examined): patient seated 5 min, back supported, arm at heart level, correct cuff size (bladder ≈80% of arm circumference), no caffeine/smoking for 30 min, average of two readings, measure in both arms initially, check postural drop in the elderly and diabetics.
• Rheumatic fever and RHD: autoimmune sequel of untreated group A streptococcal throat infection, appearing about 2–3 weeks after the sore throat and commonest in children aged 5–15 years; modified Jones criteria (major: carditis, polyarthritis, chorea, erythema marginatum, subcutaneous nodules). Secondary prophylaxis — injection benzathine penicillin G 1.2 million units IM every 3–4 weeks (600,000 units if <27 kg), continued for years as prescribed; test dose for penicillin sensitivity per institutional policy. Mitral stenosis is the commonest lesion.
• Valve surgery nursing: mechanical valves need lifelong warfarin (target INR usually 2.5–3.5); bioprosthetic valves may not. Teach infective-endocarditis prevention — dental hygiene and antibiotic prophylaxis before specified dental/surgical procedures.

ECG basics and arrhythmia nursing

• Paper: small box = 0.04 s and 1 mm (0.1 mV); large box = 0.20 s. Rate = 300 ÷ number of large boxes between R waves, or 1500 ÷ small boxes; for irregular rhythms count QRS complexes in a 6-second strip × 10.
• Normal intervals: P wave <0.12 s, PR 0.12–0.20 s, QRS <0.12 s, QT varies with rate (use QTc).
• Lead placement: V1 — 4th ICS right sternal border; V2 — 4th ICS left sternal border; V3 — between V2 and V4; V4 — 5th ICS mid-clavicular line; V5 — anterior axillary line level with V4; V6 — mid-axillary line level with V4. Limb leads by colour code (right arm red, left arm yellow, left leg green, right leg black in the IEC convention).
• Localisation: II, III, aVF — inferior (right coronary); V1–V4 — anteroseptal (LAD); I, aVL, V5–V6 — lateral (circumflex).
• Arrhythmias: sinus bradycardia (<60 — atropine if symptomatic), sinus tachycardia (>100 — treat the cause), atrial fibrillation (irregularly irregular, no P waves; rate control + anticoagulation, stroke risk), atrial flutter (saw-tooth), SVT (vagal manoeuvres, adenosine rapid push with immediate flush), ventricular tachycardia (wide QRS — pulseless = shock), ventricular fibrillation (chaotic, no output — immediate defibrillation), asystole and PEA (CPR + adrenaline, not shockable), heart blocks (first degree, Mobitz I/II, complete block needing pacing).
• Defibrillation versus cardioversion: defibrillation is unsynchronised, for VF/pulseless VT (biphasic ~120–200 J per device instruction); synchronised cardioversion is for unstable AF/flutter/SVT/VT with a pulse, delivered on the R wave with sedation. Safety: "I'm clear, you're clear, all clear", remove oxygen from the chest, dry the skin, avoid pacemaker site.
• BLS (adult, current guidelines): check response and breathing, activate help and get AED/defibrillator, compressions 100–120/min, depth 5–6 cm, full recoil, ratio 30:2, minimise interruptions, change compressor every 2 minutes.
• Pacemaker nursing: post-insertion limit arm abduction above shoulder, watch the site for haematoma, monitor for failure to capture/sense, teach pulse self-checking, carry the pacemaker ID card, avoid strong electromagnetic fields, inform the MRI team.

Cardiac drugs, procedures and rehabilitation

• Antiplatelets: aspirin (give with food, watch GI bleed), clopidogrel, ticagrelor, prasugrel. Anticoagulants: unfractionated heparin (monitor aPTT 1.5–2.5 × control, antidote protamine sulphate), LMWH (enoxaparin, subcutaneous into the abdomen, do not expel the air bubble, do not aspirate or rub), warfarin (monitor INR 2–3 for most indications, antidote vitamin K, counsel on consistent green-leafy-vegetable intake), DOACs such as dabigatran/rivaroxaban (no routine INR).
• Nitrates: sublingual GTN — one dose, repeat up to three at 5-minute intervals, seek emergency care if pain persists; store in a dark glass bottle; patches given with a nitrate-free interval to prevent tolerance; side effect is headache and hypotension.
• Beta blockers (metoprolol, carvedilol): check apical pulse and BP, hold if HR <60 or SBP <90 as ordered; never stop abruptly (rebound angina); caution in asthma; may mask hypoglycaemia in diabetics.
• ACE inhibitors (enalapril, ramipril): dry cough and hyperkalaemia, first-dose hypotension, contraindicated in pregnancy; ARBs (losartan, telmisartan) if cough intolerable.
• Diuretics: furosemide — give in the morning, monitor potassium (hypokalaemia potentiates digoxin toxicity), weight, and hearing at high IV doses; spironolactone is potassium-sparing — avoid potassium supplements.
• Digoxin: count the apical pulse for one full minute before each dose; withhold and report if <60/min in adults (<70 in children, <100 in infants). Therapeutic level ~0.5–2 ng/mL. Toxicity: anorexia, nausea, visual halos/yellow vision, bradycardia, arrhythmia — risk rises with hypokalaemia and renal impairment.
• Statins: at night (short-acting agents), report unexplained muscle pain (rhabdomyolysis); monitor liver enzymes as prescribed.
• Cardiac catheterisation/PCI nursing: pre — consent, NBM as ordered, check allergy to iodine/contrast and renal function, mark pedal pulses, hold metformin as per protocol. Post — bed rest with the limb straight for the prescribed hours (femoral route), pressure dressing, check the puncture site for bleeding/haematoma, distal pulses, colour, temperature and sensation every 15 min initially, encourage oral fluids to clear contrast, monitor urine output and for chest pain. Radial access allows earlier mobilisation.
• Post-CABG/open-heart nursing: haemodynamic monitoring, chest-drain care (report drainage >100 mL/h for consecutive hours — suspect tamponade), pain control, early extubation and ambulation, incentive spirometry and splinted coughing, sternal precautions for 6–8 weeks (no lifting >5 kg, no pushing/pulling), leg-wound care for the saphenous graft site, glycaemic control.
• Cardiac rehabilitation: Phase I in-hospital mobilisation, Phase II supervised outpatient exercise, Phase III maintenance. Teach DASH-style low-salt diet adapted to Indian meals, tobacco cessation, 150 min/week moderate activity, weight and waist control (Asian-Indian cut-offs: BMI ≥23 overweight, ≥25 obese; waist ≥90 cm men, ≥80 cm women), medication adherence, and sexual-activity guidance.

Nursing process, Indian programmes and legal-professional context

• Common nursing diagnoses: acute pain related to myocardial ischaemia; decreased cardiac output related to altered contractility; excess fluid volume related to reduced renal perfusion; activity intolerance related to imbalance between oxygen supply and demand; ineffective peripheral tissue perfusion; anxiety; deficient knowledge of the therapeutic regimen; risk of bleeding related to anticoagulant therapy.
• Documentation and handover: record pain using PQRST (Provocation, Quality, Region/radiation, Severity 0–10, Timing) and hand over with SBAR. Timed, signed entries are the nurse's legal record.
• Indian programmes and systems: NP-NCD (National Programme for Prevention and Control of Non-Communicable Diseases — the renamed/expanded NPCDCS) runs NCD clinics and population-based screening for hypertension and diabetes from age 30 through Ayushman Arogya Mandirs; the India Hypertension Control Initiative standardises treatment protocols; Ayushman Bharat PM-JAY funds cardiac packages including stenting and bypass surgery; the National Pharmaceutical Pricing Authority caps coronary stent and orthopaedic-implant prices, and essential cardiac drugs sit in the National List of Essential Medicines under the Drugs (Prices Control) Order.
• Professional regulation: nursing education and registration were governed by the Indian Nursing Council Act, 1947; the National Nursing and Midwifery Commission Act, 2023 provides for its replacement and the transition is still being implemented — state the Act, and note that the commission's regulations are in transition rather than quoting a disputed clause. Practice follows the council's code of ethics and professional conduct, and hospital accreditation standards (NABH) govern crash-cart checks, code-blue response and medication safety.
• Crash cart and code blue: check and document the crash cart every shift (defibrillator self-test, adrenaline, atropine, amiodarone, lignocaine, sodium bicarbonate, airway equipment, suction), seal after restocking, and know the hospital's code-blue number and the nurse's role in the team.

Key points

• Cardiac output - HR × SV, 4–8 L/min; falls when rate is too fast to fill or contractility fails.
• Preload, afterload, contractility - the three determinants of stroke volume that every cardiac drug manipulates.
• MAP ≥65 mmHg - the perfusion threshold used in shock management.
• Troponin - most specific MI marker; rises 3–4 h, peaks ~24 h, elevated up to 14 days.
• ECG in 10 minutes - the first target for any patient with chest pain.
• Door-to-needle ≤30 min, door-to-balloon ≤90 min - reperfusion time targets in STEMI.
• Nitroglycerin hold rule - SBP <90 mmHg, right-ventricular infarct, or recent phosphodiesterase-5 inhibitor.
• Oxygen in MI - only when SpO₂ <90%; routine oxygen is no longer recommended.
• Apical pulse for one minute before digoxin - withhold if <60/min in an adult and report.
• Hypokalaemia potentiates digoxin toxicity - watch patients on furosemide plus digoxin.
• INR 2–3 for most anticoagulation; 2.5–3.5 for mechanical valves; antidote vitamin K.
• aPTT 1.5–2.5 × control on heparin; antidote protamine sulphate.
• Daily weight - the most reliable bedside measure of fluid status in heart failure; >2 kg in 2 days is significant.
• Left failure = lungs, right failure = body - crackles and orthopnoea versus raised JVP, oedema and hepatomegaly.
• VF and pulseless VT are shockable; asystole and PEA are not - the latter get CPR and adrenaline.
• Benzathine penicillin every 3–4 weeks - secondary prophylaxis that prevents recurrent rheumatic carditis.
• Asian-Indian obesity cut-offs - BMI ≥23 overweight; waist ≥90 cm (men), ≥80 cm (women).
• Post-catheterisation checks - site bleeding, distal pulses, colour, warmth, sensation, and chest pain.

Formulas and examples

Example 1 — Cardiac output and index. A patient has HR 78/min, stroke volume 70 mL, body surface area 1.60 m².

• CO = 78 × 70 = 5,460 mL/min = 5.46 L/min (normal).
• CI = 5.46 ÷ 1.60 = 3.41 L/min/m² (normal 2.5–4.0) — perfusion is adequate.
• If the same patient goes into AF at HR 150 with SV falling to 40 mL, CO = 150 × 40 = 6,000 mL/min = 6.0 L/min, but filling time is halved and the patient may still decompensate — rate alone is not the whole story.

Example 2 — Ejection fraction and MAP. Echo shows EDV 140 mL, ESV 80 mL; BP is 160/90 mmHg.

• SV = 140 − 80 = 60 mL; EF = (60 ÷ 140) × 100 = 42.9% → HFrEF, below the normal 55–70%.
• PP = 160 − 90 = 70 mmHg; MAP = 90 + (70 ÷ 3) = 90 + 23.3 = 113.3 mmHg — hypertensive, perfusion pressure is not the problem.

Example 3 — Dopamine infusion. Order: dopamine 5 mcg/kg/min for a 60 kg patient. Stock: 200 mg in 250 mL 5% dextrose.

• Concentration = 200 mg ÷ 250 mL = 0.8 mg/mL = 800 mcg/mL.
• Dose per minute = 5 × 60 = 300 mcg/min → per hour = 300 × 60 = 18,000 mcg/h.
• Rate = 18,000 ÷ 800 = 22.5 mL/h on the syringe/infusion pump.

Example 4 — Heparin and drip-rate calculations.

• Heparin 25,000 units in 500 mL normal saline = 50 units/mL. Order 1,000 units/h → 1,000 ÷ 50 = 20 mL/h.
• Separately, 500 mL to run over 8 hours with a macro set of 15 drops/mL: (500 × 15) ÷ 480 = 7,500 ÷ 480 = 15.6 → 16 drops/min.

Example 5 — ECG rate and QTc. R–R interval measures 20 small boxes; QT measures 0.44 s.

• Rate = 1500 ÷ 20 = 75 beats/min; RR = 20 × 0.04 = 0.80 s.
• QTc = 0.44 ÷ √0.80 = 0.44 ÷ 0.894 = 0.49 s (492 ms) — prolonged (>440 ms men, >460 ms women); review QT-prolonging drugs and potassium/magnesium.

Where it is used

• CCU, ICCU and cardiac ICU nursing in tertiary hospitals — AIIMS, PGIMER, CMC Vellore, SCTIMST Thiruvananthapuram, Narayana Health, Apollo, Fortis, Medanta — monitoring, titrating inotropes and running code blue.
• Cath-lab and CTVS nursing — scrub/circulating roles in angiography, PCI, valve surgery and CABG, plus post-operative sternal and chest-drain care.
• Emergency department and ambulance services (108/112 EMS, STEMI hub-and-spoke networks) — triage of chest pain, pre-hospital ECG transmission, thrombolysis at spoke centres.
• Community and public-health nursing — NP-NCD screening camps, India Hypertension Control Initiative clinics, RHD registers and benzathine penicillin follow-up, school screening for rheumatic fever.
• Cardiac rehabilitation, dialysis and geriatric units — exercise supervision, fluid and BP management, lifestyle and drug-adherence counselling.
• Non-bedside roles — clinical research coordinator in cardiology trials, medical-device and stent company clinical specialist, insurance/TPA claim review for PM-JAY cardiac packages, nursing education and NORCET coaching.

Interview questions

• Q: What is the first nursing action for a patient reporting crushing chest pain? A: Assess airway-breathing-circulation and vital signs while placing the patient on a cardiac monitor, obtain a 12-lead ECG within 10 minutes, secure IV access and alert the physician — oxygen only if SpO₂ is below 90%.
• Q: Why is routine oxygen no longer given in myocardial infarction? A: Hyperoxia causes coronary vasoconstriction and increases oxidative injury without improving outcome, so oxygen is reserved for hypoxaemic patients (SpO₂ <90%).
• Q: When would you withhold sublingual nitroglycerin? A: If systolic BP is below 90 mmHg, the patient has a right-ventricular (inferior) infarct that is preload-dependent, or has taken a phosphodiesterase-5 inhibitor such as sildenafil in the last 24–48 hours.
• Q: How do you check a patient before giving digoxin? A: Count the apical pulse for one full minute; withhold the dose and inform the physician if it is below 60/min in an adult, and look for anorexia, nausea, visual halos and hypokalaemia.
• Q: Differentiate defibrillation from synchronised cardioversion. A: Defibrillation is an unsynchronised shock for ventricular fibrillation and pulseless VT; cardioversion is synchronised to the R wave, given with sedation for unstable rhythms that still have a pulse.
• Q: Which cardiac arrest rhythms are shockable? A: Ventricular fibrillation and pulseless ventricular tachycardia; asystole and pulseless electrical activity are managed with high-quality CPR and adrenaline.
• Q: How do you distinguish left- from right-sided heart failure at the bedside? A: Left-sided failure produces pulmonary signs — dyspnoea, orthopnoea, PND, crackles; right-sided failure produces systemic congestion — raised JVP, pedal oedema, ascites and hepatomegaly.
• Q: What is the most reliable daily indicator of fluid status in heart failure? A: Daily weight measured at the same time on the same scale in similar clothing; a gain of more than about 2 kg in two days signals fluid retention.
• Q: What teaching does a patient on warfarin need? A: Take it at the same time daily, attend INR monitoring, keep green-leafy-vegetable intake consistent rather than avoiding it, report bleeding gums, black stools or unusual bruising, and inform every doctor and dentist before procedures.
• Q: What are your priority observations after femoral cardiac catheterisation? A: Puncture-site bleeding or haematoma, distal pulses with colour, warmth and sensation of the limb, vital signs, chest pain, urine output and adequate hydration to clear contrast, with the limb kept straight for the ordered period.
• Q: Why is secondary prophylaxis important in rheumatic heart disease? A: Each streptococcal reinfection can trigger fresh carditis and worsen valve damage, so benzathine penicillin every 3–4 weeks is continued for the prescribed years.
• Q: A patient in atrial fibrillation has an apical rate of 96 and a radial rate of 78 — what does that mean? A: A pulse deficit of 18, meaning some ventricular contractions are too weak to produce a palpable peripheral pulse; always take the apical rate in AF.

Common mistakes

• Giving routine oxygen to every chest-pain patient, or withholding it when SpO₂ is genuinely below 90%.
• Taking the radial pulse instead of the apical pulse in atrial fibrillation or before digoxin, and so missing the pulse deficit or a bradycardia.
• Confusing shockable with non-shockable rhythms — attempting defibrillation in asystole, or delaying it in VF.
• Errors in infusion calculations: using mg instead of mcg, forgetting to multiply by 60 for an hourly rate, or using the wrong drop factor for a micro set.
• Measuring BP with the wrong cuff size, the arm unsupported or below heart level, and reporting a falsely high reading.
• Telling a warfarin patient to avoid all green vegetables instead of keeping intake consistent, and failing to teach INR follow-up.
• Writing nursing diagnoses as medical diagnoses ("myocardial infarction") instead of patient responses with related factors ("decreased cardiac output related to altered contractility").

Related topics

Critical care nursing · Respiratory nursing · Diabetes and endocrine nursing · Perioperative nursing · Pharmacology for nurses · Health assessment and nursing process