Sub: Advanced Nursing Practice

A Demonstration On
Pacemaker

Submitted to, Submitted by,

Madam M Tamang Shreya Putatunda
Senior Lecturer MSC Nursing Part 1
CON, NBMC&H CON, NBMC&H
A cardiac pacemaker is an electronic device that delivers direct electrical stimulation to
stimulate the myocardium to depolarize, initiating a mechanical contraction. The pacemaker
initiates and maintains the heart rate when the heart's natural pacemaker is unable to do so.
Pacemakers can be used to correct bradycardias, tachycardia, sick sinus syndrome, and
second- and third-degree heart blocks, and for prophylaxis. Pacing may be accomplished
through a permanent implantable system, a temporary system with an external pulse
generator and percutaneously threaded leads, or a transcutaneous external system with
electrode pads placed over the chest.
An artificial pacemaker is a mechanical device that electronically stimulates impulse
initiation within the heart. Temporary or permanent cardiac pacing in which an electrical
impulse depolarizes cardiac tissue is indicated when bradycardia causes symptoms of
cerebral hypoperfusion or hemodynamic decompensation. The artificial pacing system
consists of a pulse generator and a placing wire that delivers the stimulus to the heart to
control rate. The pacing unit initiates and maintains the heart rate when the natural
pacemakers of the heart unable to do so. The purpose of artificial pacing is to control the
heart. Pacemakers can be permanent or temporary. Temporary pacing is done after MI or an
open heart surgery to support patient until he improves or receives a permanent pacemaker.
Permanent pacemakers are used for irreversible complete heart block.

 Components of Pacemakers

 Pacing lead: It is an insulated wire which transmits the electric current from the pulse
generator to the myocardium.

 Pulse generator: It contains the battery cell power. Lithium batteries lasting 6 years or
more are used in most pacemakers. Nuclear-powered pacemakers (plutonium-238 source)
can last 20 years or more. Other pacemakers can have their batteries recharged; externally
when the generator battery fails the implantable unit that contains the batteries must be
replaced surgically. The pulse generator has several controls. They are energy output,
heart rate and pacing leads. Energy output refers to the intensity of the electrical impulse
delivered by the pule generator to the myocardium. The amount of output measured in
milli amperes (mA).
The mA setting is regulated by the physician at the time of pacemaker insertion and is set
at the lowest level the will produce depolarization. A setting of 1.5 mA usually sufficient
to cause depolarization.
 Components of Pacemaker

 Heart rate: It is set according to the desired therapeutic aim and the clinical
condition of the patient. Heart rate is usual set at 70-80 beats/min. If the purpose
of pacemaker is suppress dysrhythmias, the rate usually is set higher often 100-
120 beats/min.

 Clinical Indications

1. Symptomatic brady-dysrhythmias.
2. Symptomatic sinus bradycardia that results from required drug therapy.
3. Symptomatic heart block.
a. Mobitz II second-degree heart block.
b. Complete heart block.
c. Bifascicular and trifascicular bundle-branch blocks.
4. Hypersensitive carotid sinus syndrome and neurocardiogenic syncope.
5. Prophylaxis.
a. After acute Ml; dysrhythmia and conduction defects.
b. Before or after cardiac surgery.
c. Severing cardiac resynchronization therapy in patients with systolic heart failure.
 d. During diagnostic testing.
i. Cardiac catheterization.
ii. EPS.
iii. PTCA.
iv. Stress testing.
v. Before permanent pacing.
6. Tachydysrhythmias; to override rapid rhythm disturbances
a. Supraventricular tachycardia.
b. Ventricular tachycardia.

 Types of Pacing :

 Permanent Pacemakers
1. Used to treat chronic heart conditions; surgically placed utilizing a local anesthetic, the
leads are placed transvenously in the appropriate chamber of the heart and then anchored
to the endocardium.
2. The pulse generator is placed in a surgically made pocket in sub- cutaneous tissue
under the clavicle or in the abdomen. Choices for types of generators include single or
dual chamber devices, biventricular devices, unipolar of bipolar pacing/sensing
configuration, and various types of sensors for rate response. 3. Once placed, it can be
programmed externally as needed.

 Temporary Pacemakers
1. Temporary pacemakers are usually placed during an emergency, such as when a patient
demonstrates signs of decreased CO.
2. Indicated for patients with high-grade AV blocks, bradycardia, or low CO. They serve as a
bridge until the patient becomes stable enough for placement of a permanent pacemaker.
3. Can be placed transvenously, epicardially, transcutaneously, and transthoracically.
a. Transvenous pacemakers are inserted transvenously (into a vein, usually the subclavian,
internal jugular, antecubital, or femoral) into the right ventricle (or right atrium and right
ventricle for dual-chamber pacing) and then attached to an external pulse generator. This
procedure may be done at the bedside or under fluoroscopy.
b. Epicardial pacemaker wires are attached to the endocardium, brought out through a
surgical incision in the thorax. These wires are then connected to an external pulse generator.
This is commonly seen after cardiac surgery.
c. With Transcutaneous pacing, noninvasive multifunction electrode pads are placed either
anterior-posteriorly (anterior chest wall under left nipple, slightly midaxillary, and on the
patient's back directly behind anterior pad) or anterior-laterally (anterior chest wall under left
nipple, slightly midaxillary, and on patient's upper right chest wall below the clavicle). The
multifunction electrode pads are connected to an external energy source (defibrillator with
pacing ability). The electrical impulses flow through the multifunction electrode pads and
subcutaneous skin to the heart, thereby pacing the heart.
d. The Transthoracic pacemaker is a type of temporary pace maker that is placed only in an
emergency via a long needle, using a sub-xiphoid approach. The pacer wire is then placed
directly into the right ventricle.

Temporary Transvenous Pacer Wire with External Pulse Generator

 Biventricular Pacemakers

1. Biventricular pacemakers are also referred to as cardiac resynchronization therapy.

2. Biventricular pacing is used to treat moderate to severe heart failure as a result of
left ventricular dyssynchrony
3. Intraventricular conduction defects result in an un-coordinated contraction of the
left and right ventricle, which causes a wide QRS complex and is associated with
worsening heart failure and increased mortality.
4. Biventricular pacemakers utilize three leads (one in the right atrium, one in the
right ventricle, and one in the left ventricle via the coronary sinus) to coordinate
ventricular contraction and improve CO.
 5. Biventricular pacemakers can incorporate implantable cardioverter defibrillators or
be used alone.

Temporary Introduction Sites,

• Subclavian vein
• Antecubital vein
• Femoral vein
• Jugular Vein
•
 Pacemaker Function

Cardiac pacing refers to the ability of the pacemaker to stimulate either the atrium, the
ventricle, or both heart chambers in sequence and initiate electrical depolarization and cardiac
contraction. Cardiac pacing is evidenced on the ECG by the presence of a "spike" or "pacing
artifact."
Pacing Functions
1. Atrial pacing direct stimulation of the right atrium producing a "spike" on the ECG
preceding a P wave.
2. Ventricular pacing-direct stimulation of the right or left ventricle producing a "spike" on
the ECG preceding a QRS complex.
3. AV pacing-direct stimulation of the right atrium and either ventricle in sequence; mimics
normal cardiac conduction, allowing the atria to contract before the ventricles. ("Atrial kick"
received by the ventricles allows for an increase in CO.)

Sensing Functions
Cardiac pacemakers have the ability to "see" intrinsic cardiac activity occurs when it
(sensing).
1. Demand- ability "sense" intrinsic cardiac activity and deliver a pacing stimulus only if the
heart rate falls below a preset rate limit.
2. Fixed-no ability to "sense" intrinsic cardiac activity; the pacemaker can't "synchronize"
with the heart's natural activity and consistently delivers a pacing stimulus at a preset rate.
3. Triggered-ability to deliver pacing stimuli in response to "sensing" a cardiac event.
a. "Sees" atrial activity (P waves) and deliver a pacing spike to the ventricle after an
appropriate delay (usually 0.16 second, similar to PR interval).
b. Maintains AV synchrony and increases heart rate based on increases in the body demands
that occur with exercise or during stress.
c. "Physiologic" sensors are being developed as alternatives to "trigger" a ventricular
response because many patients have atrial dysfunction.
d. "Sensor-driven" rate-responsive pacemakers do not sense atrial activity; a triggered
ventricular beat occurs when the pacemaker senses either increases in muscle activity,
temperature, oxygen utilization, or changes in blood pH.

Capture Functions
1. The pacemaker's ability to generate a response from the heart (contraction) after electrical
stimulation is referred to as capture. Capture is determined by the strength of the electrical
stimulus, measured in milliamperes (mA), the amount of time the stimulus is applied to the
heart (pulse width), and by contact of the distal tip of the pacing lead to healthy myocardial
tissue.
a. "Electrical" capture is indicated by a P wave or QRS following and corresponding to a
pacemaker spike.
b. "Mechanical" capture of the ventricles is determined by a palpable pulse corresponding to
the electrical event.

 Assessment Of a Patient with Pacemaker

KEY TERMS
• Assessment
• Health history
• Physical Examination

ARTICLES
• A tray containing vital sign monitoring articles
• Pacing Kit
• Assessment recording sheet
• ECG Machine with lids
• Intake Output Chart

HISTORY TAKING
• Name
• Age
• Gender
• Ward
• DOA
• Diagnosis
• Surgery/ Cardiac intervention:
 • Address
• Religion:
• Educational status:
• Occupation:
• Income
• Marital status:

IMPORTANT HEALTH INFORMATION

 Chief complaints on admission with duration.

 Chief complaints at the time of assessment.

SYMPTOM ANALYSIS
 Chest pain-
o Provocation
o Location
o Severity
o Duration
o Quality
o Radiation
o Associated manifestations

 Palpitation: Associated activity

 Fatigue
o Current activities and limitation?
o How long the patient can walk?
o Can the patient participate in sports?
o Do any activities lead to breathlessness or chest pain?

 Respiratory Manifestation
• Dyspnea
• Dyspnea on exertion
• Orthopnea
• Paroxysmal nocturnal dyspnea
• Dyspnea or exertion
• No. of pillows used for sleep
• Cough

 Syncope:
 • Associated activity
• Duration
• Frequency

 Edema:
• Weight gain
• Edema grading
• Does patient wake up in night to urinate?
• Pitting edema
• Skin appearance (glossy/shiny)

 Leg pain

PAST HEALTH HISTORY

Diseases Affecting Cardiovascular System
• Congenital heart disease
• Anemia
• Rheumatic fever
• Chest pain
• Diabetes
• Hypertension
• Chronic obstructive pulmonary disease (COPD)
• Renal disorders
• Stroke
• Varicosities
• Deep vein thrombosis (DVT)
• Others

SURGERY OR OTHER TREATMENT

o Medications
• Antihypertensives
• Antianginals
• Vasopressors
• Anticoagulants
• Platelet aggregation inhibitors
• Hypolipidemics
• Diuretics
• Steroids
• Hormone replacement therapy (HRT)
• Thyroid hormone
 • Insulin/oral hypoglycemic agents
• OTC
• Others

Head to Toe Physical Examination

 Nursing Assessment and Preprocedure Care for Permanent

Pacemaker
1. Assess patient's knowledge level of procedure.
2. Instruct patient that he or she may have nothing by mouth before the procedure
3. Facilitate IV line insertion.
4. Explain to patient that pacemaker insertion will be performed in an operating or
special procedures room with fluoroscopically and continuous ECG monitoring.
5. Describe local anesthetic that will be used to minimize discomfort; sedation.
6. Explain to patient that the usual placement for a permanent pacemaker is in the left
upper chest
7. The incision will be closed with Steri-strips (suture or staples may also be used).

 Nursing Diagnoses

• Decreased Cardiac Output related to potential pacemaker malfunction and

dysrhythmias.
• Risk for Injury related to pneumothorax, hemothorax, bleeding, microshock, and
accidental malfunction.
• Risk for Infection related to surgical implantation of pacemaker generator and/or
leads.
• Anxiety related to pacemaker insertion, fear of death lack knowledge, and role
change.
• Impaired Physical Mobility related to imposed restrictions of arm movement.
• Acute Pain related to surgical incision and transcutaneous external pacing stimuli.
• Disturbed Body Image related to pacemaker implantation.
  Nursing Interventions

o Maintaining Adequate Cardiac Output

1. Record the following information after insertion of the pace maker:
a. Pacemaker manufacturer, model, and lead type.
b. Operating mode
c. Programmed settings: lower rate limit; upper rate limit; AV delay; pacing
thresholds.
d. Patient's underlying rhythm.
e. Patient's response to procedure.
2. Attach ECG electrodes for continuous monitoring of heart rate and rhythm.
a. Set alarm limits 5 beats below lower rate limit and 5 to 10 beats above upper
rate limits (ensures immediate detection of pacemaker malfunction or failure).
b. Keep alarms on at all times.
3. Monitor vital signs as per facility protocol, and as necessary.
4. Monitor urine output and level of consciousness ensures adequate cardiac output
achieved with paced rhythm.
5. Observe for dysrhythmias (ventricular ectopic activity can occur because of irritation
of ventricular wall by lead wire).
a. Monitor for competitive rhythms, such as runs of atrial fibrillation or flutter,
ventricular tachycardia.
b. Report dysrhythmias.
c Administer antidysrhythmic therapy, as directed.
6. Obtain 12-lead ECG, as ordered.

o Avoiding Injury

1. Note that a post pacemaker insertion chest x-ray has been taken to ensure correct lead wire
position and that no fluid is in lungs,
2. Monitor for signs and symptoms of hemothorax inadvertent punctures of the subclavian
vein or artery, which can cause fatal hemorrhage, observe for diaphoresis, hypotension
shortness of the breath , chest deviation, and restlessness; immediate surgical intervention
may be necessary.
3. Monitor for signs and symptoms of pneumothorax- inadvertent puncture of the lung;
observe for acute onset of dyspnea, cyanosis, chest pain, absent breath sounds over involved
lung, acute anxiety, hypotension. Prepare for chest tube insertion.
4. Evaluate continually for evidence of bleeding.
a. Check incision site frequently for bleeding.
 b. Apply manual pressure carefully without pushing against pacemaker generator box.
c. Palpate for pulses distal to insertion site. (Swelling of tis sues from bleeding may
impede arterial flow.)
5. Monitor for evidence of lead migration and perforation of heart.
a. Observe for muscle twitching and/or cough (may indicate chest wall or
diaphragmatic pacing).
b. Evaluate patient's complaints of chest pain (may indicate perforation of pericardial
sac).
c. Auscultate for pericardial friction rub.
d. Observe for signs and symptoms of cardiac tamponade: distant heart sounds,
distended jugular veins, pulsus paradoxus, and hypotension.

6. Provide an electrically safe environment for patient. Stray electrical current can enter the
heart through temporary pacemaker lead system and induce dysrhythmias.
a. Protect exposed parts of electrode lead terminal in temporary pacing systems per
manufacturer recommendations.
b. Wear rubber gloves when touching temporary pacing leads. (Static electricity from
your hands can enter the patient's body through the lead system.)
c. Make sure all equipment is grounded with three-prong plugs inserted into a proper
outlet when using an external pacing system.
d. Epicardial pacing wires should have the terminal needles protected by a plastic
tube; place tube in rubber glove to protect it from fluids or electrical current.

7. Be aware of hazards in the facility that can interfere with pacemaker function or cause
pacemaker failure and permanent pacemaker damage.
a. Avoid use of electric razors.
b. Avoid direct placement of defibrillator paddles over pace maker generator; anterior
placement of paddles should be 4 to 5 inches (10 to 12.5 cm) away from pacemaker,
always evaluate pacemaker function after defibrillation.
c. Electrocautery devices and transcutaneous electrical stimulator (TENS) units pose a
risk.
d. Recent studies have shown that patients may safely have an MRI with a permanent
pacemaker. Check with cardiologist.
8. Prevent accidental pacemaker malfunctions.
o Use clear plastic covering over external temporary generators at all times (eliminates
potential manipulation of programmed settings).
o Secure temporary pacemaker generator to patient's chest or waist; never hang it on an IV
pole.
o Transfer of patient from bed to stretcher should only be attempted with an adequate number
of personnel so that patient can remain passive; caution personnel to avoid underarm lifts.
o Evaluate transcutaneous pacing electrode pads every 2 hours for secure contact to chest wall;
change electrode pads every 24 hours or if pads do not have complete con- tact with skin.
o Note: Transcutaneous pacing should not be utilized continuously for more than 2 hours.
Transvenous pacing should then be initiated.
9. Monitor for electrolyte imbalances, hypoxia, and myocardial ischemia. (The amount of
energy the pacemaker needs to stimulate depolarization may need adjustment if any of these
are present.)

o Preventing Infection

Permanent Pacemaker

1. Take temperature every 4 hours; report elevations. (Suspect permanent pacemaker as

infection source if temperature elevation occurs.)
2. Observe incision site for signs and symptoms of local infection: redness, purulent drainage,
warmth, soreness.
3. Be alert to manifestations of bacteremia. (Patients with endocardial leads are at risk for
endocarditis.)
4. Clean incision site, as directed, using sterile technique.
5. Instruct patient to keep incision site dry, which means no showers for 24 hours.
6. Evaluate patient's complaints of increasing tenderness and discomfort at incision site.
7. Administer antibiotic therapy, as prescribed, after permanent pacemaker insertion.

Temporary Pacemaker

1. Monitor temperature every 4 hours; report elevations.

2. Assess central IV site (where temporary pacing wire is inserted) for signs and symptoms of
infection, such as redness and drainage.

o Relieving Anxiety

1. Offer careful explanations regarding anticipated procedures and treatments, and answer the
patient's questions with concise explanations.
2. Use sedation, as necessary, when inserting temporary pacemaker.
3. When using transcutaneous pacing, always sedate the patient because the level of mA used
is high, and the patient may feel the uncomfortable stimulus (twitching).
4. Encourage patient and family to use coping mechanisms to overcome anxieties-talking,
crying, and walking.
 5. Encourage patient to accept responsibility for care.
a. Review care plan with patient and family.
b. Encourage patient to make decisions regarding a daily schedule of self-care
activities.
c. Engage patient in goal-setting. Establish with patient priorities of care and time
frames to accomplish goals up until discharge.

6. Monitor for unwarranted fears expressed by patient and family (commonly, pacemaker
failure) and provide explanation to alleviate fear. Explain to patient life expectancy of
batteries and the measures taken to check for failure.

o Minimizing the Effects of Immobility

1. Encourage patient to take deep breaths frequently each how (promotes pulmonary
function); however, caution against vigorous coughing because this could cause lead
dislodgement.

2. Instruct patient in dorsiflexion exercises of ankles and tightening of calf muscles. This
promotes venous return and pre- vents venous stasis. Exercises should be done hourly.
3. Restrict movement of affected extremity.

a. Place arm nearest to permanent pacemaker implant in sling as directed. Sling use can range
from 6 to 24 hours, according to prescribed order.

b. Instruct patient to gradually resume range of motion (ROM) of extremity as directed

(usually 24 hours for permanent implants); avoid over-the-head motions for approximately 5
days and limit the weight of carried items to less than 3 pounds.

c. Evaluate patient's arm movements to ensure normal ROM progression; assist patient with
passive ROM of extremity as necessary (prevents development of shoulder stiffness caused
by prolonged joint immobility); consult physical therapy as directed if stiffness and pain
occur.

4. Assist patient with activities of daily living (ADLs) as appropriate.

o Relieving Pain

1. Prepare patient for the discomfort he or she may experience after pacemaker implant.
a. Explain to patient that incisional pain will occur after procedure; pain will subside
after the first week, but he or she may have some soreness for up to 4 weeks.
2. Administer analgesics as directed; attempt to coincide peak analgesic effect with
performance of ROM exercises and ADLs
3 . Offer back rubs to promote relaxation.
4. Provide patient with diversional activities.
5. Evaluate effectiveness of pain-relieving modalities.
 6. Explain to the patient about the potential for discomfort dur ing transcutaneous placing;
however, assure patient that the lowest energy possible will be used and
analgesics/anxiolytics will be given.

o Maintaining a Positive Body Image

1. Encourage patient and family to express concerns regarding self-image and pacemaker
implant.
2. Reassure patient and significant other that sexual activity and modes of dressing will not be
altered with pacemaker implantation.
3. Offer pacemaker support group information to the patient
4. Encourage spouse or significant other to discuss concerns of self-image with patient.

o Termination:
 Documents to be kept in patients’ file thoroughly and carefully
 Box to be handed over to family members
 ECG leads to be discarded in red BMW bucket

Patient Teaching

The following information concerning pacemaker function and care should be given to the
patient:

 Check pulse daily for 1 full minute at relatively the same time.
 Report any sudden slowing or increase in pulse rate.
 Notify physician of any pain or redness over incision site.
 Wear loose fitting clothing around the pacemaker area for increased comfort.
 Have pacemaker function checked at special centers.
 Carry an identification card. Avoid closeness to magnetic fields or microwave oven.
 Maintain follow-up care with the physician. Keep the site dry for 4 days after insertion.
 Avoid lifting the arm above the shoulder level.
 Avoid direct blows to the site.
 Report any signs of infection such as redness, swelling, discharge.

Care of Pacemaker Site

1. Advise patient to wear loose-fitting clothing around the area of pacemaker implantation
until it has healed.
2. Watch for signs and symptoms of infection around generator and leads-fever, heat, pain,
and skin breakdown at implant site.
3. Advise patient to keep incision clean and dry. Encourage tub baths rather than showers for
the first 10 days after pacemaker implantation.
a. Instruct patient not to scrub incision site or clean site with bath water.
b. Teach patient to clean incision site with antiseptic, as directed.
4. Explain to patient that healing will take approximately 3 months.

Follow-Up

1. Make sure that the patient has a copy of ECG tracing (according to facility policy) for
future comparisons. Encourage patient to have regular pacemaker checkups for monitoring
function and integrity of pacemaker.
2. Inform patient that trans telephonic evaluation of implanted cardiac pacemakers for battery
and electrode failure is available.
3. Review medications with patient before discharge.
4. Inform patient that the pulse generator will have to be surgically removed to replace
battery and that it is a relatively simple procedure performed under local anesthesia.

Evaluation: Expected Outcomes

• Vital signs stable; pacing spikes rated on ECG tracing.

• Breath sounds noted throughout; respirations unlabored.
• Incision without drainage.
• Asks questions and participates in care.
• Affected arm and pacer site show decreased edema.
• Reports pain relief,
• Verbalizes acceptance of pacemaker.

 Conclusion
A pacemaker is used to control or increase the heartbeat. It stimulates the heart as needed
to keep it beating regularly. The heart's electrical system typically controls the heartbeat.
Electrical signals, called impulses, move through the heart chambers. They tell the heart
when to beat. Changes in heart signaling may happen if the heart muscle is damaged. A
pacemaker only works when it senses trouble with the heartbeat. For example, if the heart
beats too slowly, the pacemaker sends electrical signals to correct the beat.
 Bibliography
o Nettina, Sandra M, ‘Manual of Medical-Surgical Nursing’ , Lippincott
Williams and Wilkins; 10th Edition(2013); Philadelphia Page: 348-56
o Kuruvilya S, ‘Critical Care Nursing’; CBS Publishers & Distributors Pvt Ltd,
2nd Edition(2018) New Delhi; Page: 216-21
o Woods LS, Froelicher SSE, Motzer US, Bridges EJ. Cardiac Nursing. 6th
edition. Baltimore: Wolters Kluwer Publication; 2010,Page : 445-70
o Pacemaker - American Heart Association
www.heart.org/HEARTORG/Conditions/.../Pacemaker_UCM_448480_Articl
e.jsp
 Assessment Of a Patient with Pacemaker

KEY TERMS
• Assessment
• Health history
• Physical Examination

ARTICLES
• A tray containing vital sign monitoring articles
• Pacing Kit
• Assessment recording sheet
• ECG Machine with lid
• Intake Output Chart

HISTORY TAKING
• Name
• Age
• Gender
• Ward
• DOA
• Diagnosis
• Surgery/ Cardiac intervention:
• Address
• Religion:
• Educational status:
• Occupation:
• Income
• Marital status:

IMPORTANT HEALTH INFORMATION

 Chief complaints on admission with duration.

 Chief complaints at the time of assessment.

SYMPTOM ANALYSIS
 Chest pain-
o Provocation
 o Location
o Severity
o Duration
o Quality
o Radiation
o Associated manifestations

 Palpitation: Associated activity

 Fatigue
o Current activities and limitation?
o How long the patient can walk?
o Can the patient participate in sports?
o Do any activities lead to breathlessness or chest pain?

 Respiratory Manifestation
• Dyspnea
• Dyspnea on exertion
• Orthopnea
• Paroxysmal nocturnal dyspnea
• Dyspnea or exertion
• No. of pillows used for sleep
• Cough

 Syncope:
• Associated activity
• Duration
• Frequency

 Edema:
• Weight gain
• Edema grading
• Does patient wake up in night to urinate?
• Pitting edema
• Skin appearance (glossy/shiny)

 Leg pain

PAST HEALTH HISTORY

Diseases Affecting Cardiovascular System
• Congenital heart disease
• Anemia
• Rheumatic fever
• Chest pain
• Diabetes
• Hypertension
• Chronic obstructive pulmonary disease (COPD)
• Renal disorders
• Stroke
• Varicosities
• Deep vein thrombosis (DVT)
• Others

SURGERY OR OTHER TREATMENT

o Medications
• Antihypertensives
• Antianginals
• Vasopressors
• Anticoagulants
• Platelet aggregation inhibitors
• Hypolipidemics
• Diuretics
• Steroids
• Hormone replacement therapy (HRT)
• Thyroid hormone
• Insulin/oral hypoglycemic agents
• OTC
• Others

Head to Toe Physical Examination