NCM 102 lec cardio

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NCM 102ALTERATION IN OXYGENATION

Lecture Series 01

Anatomy And Physiology

Cardiovascular Physiology

Circulatory system includes a pump (the heart), interconnected tubes (blood vessels orvascular system), and extracellular fluid and cells (blood)

Heart and heart wall layers

The heart is located in the left side of the mediastinum.

The layer that covers the heart is the

PERICARDIUM

There are two parts- parietal and visceralpericardium

The space between the two pericardial

layers is the pericardial space

Chambers of heart

Right atrium: collecting chamber for incoming systemic venous system

Right ventricle: propels blood into pulmonary system

Left atrium: collects blood from pulmonary venous system

Left ventricle: largest thick-walled muscle that acts as a high-pressurepump which propels blood into the systemic arterial system

The heart chambers are guarded by valves

- The atrio-ventricular valves- Tricuspid and bicuspid

- The semi-lunar valves- Pulmonic and aortic valves

The Blood supply of the heart comes from the Coronary arteries

NCM 102 Med-Surg Nsg. Cardiovascular Disorders Prepared by: Lindsay CarmelleI. Nate, R.N.

The Layers of the Heart Wall

Epicardium(visceralpericardium)

Essential layer of the heart

Coronary arteries are found in this

layer

Myocardium

Middle and thickest layer of the heart

(CBQ)

Responsible for contraction of the

heart

Endocardium

Innermost layer of the heart

Lines the inside of the myocardium

Covers the heart valves


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- Right coronary artery- Left coronary artery

Blood supply for the heart:Coronary arteries supply blood to myocardiumCoronary blood flow blood flowing through the coronary arteriesCoronary sinus drainage area for the blood; empties into right atrium

The main functions of this system are:

- to transport oxygen, hormones and nutrients to the tissues

- and to transport waste products to the lungs and kidneys for excretion

The CONDUCTING SYSTEM OF THE HEARTConsists of the

1. SA node- the pacemaker2. AV node- slowest conduction3. Bundle of His branches into the Right and the Left bundle branch4. Purkinje fibers- fastest conduction

The Heart sounds

1. S1- due to closure of the AV valves2. S2- due to the closure of the semi-lunar valves3. S3- due to increased ventricular filling4. S4- due to forceful atrial contraction

Heart rate

- Normal range is 60-100 beats per minute

- Tachycardia is greater than 100 bpm

- Bradycardia is less than 60 bpm

- Sympathetic system INCREASES HR

- Parasympathetic system (Vagus) DECREASES HR (CBQ)

The Heart: Physiology

- The amount of blood the heart pumps out in each beat is called the STROKE VOLUME

- When this volume is multiplied by the number of heart beat in a minute (heart rate), it becomesthe CARDIAC OUTPUT

- When the Cardiac Output is multiplied by the Total Peripheral Resistance, it becomes the BLOODPRESSURE

Blood pressure = Cardiac output X Peripheral resistance

Blood pressure

- Control is neural (central and peripheral) and hormonal

- Baroreceptors in the carotid and aorta

- Hormones - ADH, Adrenergic hormones, Aldosterone and ANF

The Heart: Physiology

- The PRELOAD is the degree of stretching of the heart muscle when it is filled-up with blood

- The AFTERLOAD is the resistance to which the heart must pump to eject the blood



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Vascular System

- The vascular system consists of the arteries, veins and capillaries

- The arteries are vessels that carry blood away from the heart to the periphery

- The veins are the vessels that carry blood to the heart

- The capillaries are lined with squamos cells, they connect the veins and arteries

- The lymphatic system also is part of the vascular system and the function of this system is to

collect the extravasated fluid from the tissues and returns it to the blood

Cardiac Assessment

1. Health History

- Obtain description of present illness and the chief complaint

- Chest pain, SOB, Edema, etc.- Assess risk factors

2. Physical examination

- Vital signs- BP, PP, MAP

- Inspection of the skin

- Inspection of the thorax

- Palpation of the PMI, pulses- Auscultation of the heart sounds

3. Laboratory and diagnostic studies

- CBC- Cardiac catheterization

- Lipid profile

- arteriography

- Cardiac enzymes and proteins

- CXR

- CVP

- ECG



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- Holter monitoring- Exercise ECG

Laboratory Test Rationale

- To assist in diagnosing MI

- To identify abnormalities

- To assess inflammation- To determine baseline value

- To monitor serum level of medications

- To assess the effects of medications

CK- MB (creatine kinase)

- Indicates myocardial damage- Elevates in MI within 4-6 hours

- peaks in 18 hours and then declines till 3 days- 0-5% of total CK (26-174U/L)

- Normal value is 0-7 U/L

Lactate Dehydrogenase (LDH)

- Elevates in MI in 24 hours- peaks in 48-72 hours

- Normally LDH1 is greater than LDH2

- MI- LDH2 greater than LDH1 (flipped LDH pattern)- Normal value is 70-200 IU/L

Myoglobin

- Oxygen binding protein

- Found in both skeletal and cardiac

- Level rises 1 hour after cell death

- Peaks in 4-6 hours

- Returns to normal w/in 24-36 hours

- Not used alone

- Muscular and RENAL disease can have elevated myoglobin

Troponin I and T

- Troponin I has a high affinity for myocardial injury

- Elevates within 3-4 hours, peaks in 4-24 hours and persists for 7 days to 3 weeks!- Troponin I -


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Holter Monitoring

- A non-invasive test in which the client wears a Holter monitor and an ECG tracing recordedcontinuously over a period of 24 hours

- Instruct the client to resume normal activities and maintain a diary of activities and anysymptoms that may develop

Echocardiogram

Non-invasive test that studies the structural and functional changes of the heart with the use of

ultrasound

No special preparation is needed

Stress Test

A non-invasive test that studies the heart during activity and detects and evaluates CAD

Exercise test, pharmacologic test and emotional test

Treadmill testing is the most commonly used stress test

Used to determine CAD, Chest pain causes, drug effects and dysrhythmias in exercise

Pre-test: consent may be required, adequate rest , eat a light meal or fast for 4 hours and avoid

smoking, alcohol and caffeine Post-test: instruct client to notify the physician if any chest pain, dizziness or shortness of breath

Instruct client to avoid taking a hot shower for 10-12 hours after the test

Pharmacological stress test

Use of dipyridamole

Maximally dilates coronary artery

Side-effect: flushing of face

Pre-test: 4 hours fasting, avoid alcohol, caffeine

Post test: report symptoms of chest pain

Cardiac Catheterization

Insertion of a catheter into the heart and surrounding vessels

Obtains information about the structure and performance of the heart valves and surrounding

vessels Used to diagnose CAD, assess coronary artery patency and determine extent of atherosclerosis

PRE PROCEDURE

Ensure Consent

assess for allergy to seafood and iodine

Withhold solid food 6-8 hours and liquids for 4 hours

document weight and height, baseline VS, blood tests and document the peripheral pulses



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inform client that a local anesthetic will be administered before insertion

Client may feel fatigued because of the need to lie for 2 hours

Prepare IV line if prescribed

Prepare insertion site by shaving and cleaning with an antiseptic solution if prescribed

Administer pre medication

INTRATEST inform patient of a fluttery feeling as the catheter passes through the heart

inform the patient that a feeling of warmth and metallic taste may occur when dye isadministered.

POST TEST

Monitor VS and cardiac rhythm

Monitor dysrrhytmia and chest pain

Monitor peripheral pulses, color and warmth and sensation of the extremity distal to insertionsite

Apply sandbag or compression device to insertion site if required to maintain pressure

Maintain strict bed rest for 6-12 hours

Client may turn from side to side but bed should not be elevated more than 15 degrees

Notify physician if client complains of tingling, cool, pale, cyanosis and loss of peripheral pulsesKeep the leg straight to prevent occlusion

Monitor for bleeding and hematoma formation

Encourage fluid intake to flush out the dye

Immobilize the arm if the antecubital vein is used

Monitor for dye allergy

Encourage fluid intake to promote renal excretion of dye

Monitor nausea, vomiting, rash and other sign of HPS rxn

CVP

The CVP is the pressure within the SVC

Reflects the pressure under which blood is returned to the SVC and right atrium

is measured with a central venous line in the SVC and balloon flotation catheter in the pulmonary

artery Normal CVP is 3 to 8 mmHg/ 4-10 cm H2O

Increased CVP

1. increase in blood volume as a result of Na and water retention, excessive IVF or heart/renalfailure

Decreased CVP

2. May indicate decrease in circulating blood volume and may be to hypovolemia, hemorrhageand severe vasodilatation

Measuring CVP

1. Position the client supine with bed elevated at 45 degrees (CBQ)2. Position the zero point of the CVP line at the level of the right atrium. Usually this is at the MAL,

4th ICS

3. Instruct the client to be relaxed and avoid coughing and straining.note disease that activity that increases intra-thoracic pressure such as coughing and straining

If the client is on the ventilator reading should be taken at the point of end expiration



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Cardiac Implementation1. Assess the cardio-pulmonary status

- VS, BP, Cardiac assessment2. Enhance cardiac output

- Establish IV line to administer fluids3. Promote gas exchange

- Administer O2

- Position client in SEMI-Fowlers- Encourage coughing and deep breathing exercises

4. Increase client activity tolerance

- Balance rest and activity periods

- Assist in daily activities

- Provide strict bed rest if indicated

- Soft foods

- Assistance in self-care5. Promote client comfort

- Assess the clients description of pain and chest discomfort

- Administer medication as prescribedMorphine for MI

Nitroglycerine for Angina

Diuretics to relieve congestion (CHF)6. Promote adequate sleep7. Prevent infection

- Monitor skin integrity of lower extremities

- Assess skin site for edema, redness and warmth

- Monitor for fever

- Change position frequently8. Minimize patient anxiety

Encourage verbalization of feelings, fears and concernsAnswer client questions. Provide information about procedures and medications

CARDIOVASCULAR DISORDERS

Cardiac Diseases

Coronary Artery Disease

Myocardial Infarction

Congestive Heart Failure

Infective Endocarditis

Cardiac Tamponade

Vascular Diseases

Hypertension

Buergers disease

Aneurysm

Varicose veins

Deep vein thrombosis

Cardiac Diseases

Coronary Artery Disease (CAD)

- results from the focal narrowing of the large and medium-sized coronary arteries due to depositionof atheromatous plaque in the vessel wall

Risk Factors

1. Age above 45/55 and Sex- Males and post-menopausal females

2. Family History

3. Hypertension

4. DM

5. Smoking

6. Obesity7. Sedentary lifestyle

8. Hyperlipedimia

Most important MODIFIABLE factors:

- Smoking

- Hypertension

- Diabetes



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- Cholesterol abnormalities

Pathophysiology

- There is decreased perfusion of myocardial tissue and inadequate myocardial oxygen supply

- If 50% of the left coronary arterial lumen is reduced or 75% of the other coronary artery, thisbecomes significant

- Potential for Thrombosis and embolism

Artery walls have three layers.

1. The inner layer provides a slippery surface.

2. The middle layer is strong, elastic and muscular.3. The outer, fibrous, layer adds strength and contains tiny blood vessels that supply blood to the

arteries themselves.

Narrowing or obstruction of the coronary arteries is the main cause of a group of disorders knownas ischaemic heart disease.

Coronary Artery Disease.

- Acute Coronary Syndrome (ACS) is the phrase used when referring to any cardiac conditioninvolving the coronary arteries.

- Angina is a feeling of tightness or pain across the chest that may spread outwards to theshoulders, upper arms and back.May occur with exercise or strong emotion and can be worse after a meal or in cold weather.Symptoms usually disappear after 1-2 minutes rest.

- Heart attack (myocardial infarction or MI) is when part of the heart muscle dies. This isusually caused by a blood clot (coronary thrombosis), which has blocked one of the coronaryarteries supplying the heart and depriving the tissues of oxygen.

Coronary Artery Disease treatment

Angioplasty & Stent

Coronary Artery Bypass Graft.

- Treatment for C.A.D involves the removal or treatment of risk factors.- Sometimes procedures to enlarge or bypass coronary artery narrowing are required.

- If Coronary Disease is not treated and the coronary artery becomes blocked the result may be aheart attack.

Angioplasty

- Coronary angioplasty involves inserting a balloon into a diseased (blocked/narrowed) coronaryartery through an artery in the groin or arm.

- Commonly a metal support (stent) is inserted into the artery to help keep it open.



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C. A. B. G.

- Veins and sometimes arteries are grafted from the aorta to a point on the coronary artery beyondthe area of disease. This enables an adequate blood supply to reach those parts of the heart

suffering from ischaemia

Valve Replacements

- Aortic Valve Replacement (AVR)

- Mitral Valve Replacement (MVR)

Angina Pectoris

- Chest pain resulting from coronary atherosclerosis or myocardial ischemia

Angina Pectoris: Clinical Syndromes

Three Common Types of Angina1. Stable Angina

- The typical angina that occurs during exertion, relieved by rest and drugs and the severitydoes not change

2. Unstable angina

- Occurs unpredictably during exertion and emotion, severity increases with time and pain maynot be relieved by rest and drug

3. Variant angina

- Prinzmetal angina, results from coronary artery VASOSPASMS, may occur at rest

ASSESSMENT FINDINGS1. Chest pain - ANGINA

- The most characteristic symptom- PAIN is described as mild to severe retrosternal pain, squeezing, tightness or burning sensation

- Radiates to the jaw and left arm- Precipitated by Exercise, Eating heavy meals, Emotions like excitement and anxiety and

Extremes of temperature

- Relieved by REST and Nitroglycerin2. Diaphoresis3. Nausea and vomiting4. Cold clammy skin5. Sense of apprehension and doom

6. Dizziness and syncope

LABORATORY FINDINGS1. ECG may show normal tracing if patient is pain-free. Ischemic changes may show ST

depression and T wave inversion



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2. Cardiac catheterization3. Provides the MOST DEFINITIVE source of diagnosis by showing the presence of the

atherosclerotic lesions

- Decreased cardiac output- Impaired gas exchange

- Activity intolerance- Anxiety

Nursing Management1. Administer prescribed medications

Nitrates- to dilate the venous vessels decreasing venous return and to some extent dilate thecoronary arteries

Aspirin- to prevent thrombus formation

Beta-blockers- to reduce BP and HR

Calcium-channel blockers- to dilate coronary artery and reduce vasospasm2. Teach the patient management of anginal attacks

Advise patient to stop all activities

Put one nitroglycerin tablet under the tongue

Wait for 5 minutes

If not relieved, take another tablet and wait for 5 minutes

Another tablet can be taken (third tablet)

If unrelieved after THREE tablets seek medical attention

3. Obtain a 12-lead ECG4. Promote myocardial perfusion

Instruct patient to maintain bed rest

Administer O2 @ 3 lpm

Advise to avoid valsalva maneuvers

Provide laxatives or high fiber diet to lessen constipation

Encourage to avoid increased physical activities5. Assist in possible treatment modalities

PTCA- percutaneous transluminal coronary angioplasty

To compress the plaque against the vessel wall, increasing the arterial lumen

CABG- coronary artery bypass graft

To improve the blood flow to the myocardial tissue

6. Provide information to family members to minimize anxiety and promote family cooperation7. Assist client to identify risk factors that can be modified8. Refer patient to proper agencies

Myocardial infarction

- Death of myocardial tissue in regions of the heart with abrupt interruption of coronary bloodsupply



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FIGURE 13-1 Different degrees of damage occur to the heart muscle after a

myocardial infarction. The diagram shows the zones of necrosis, injury, and ischemia.

ETIOLOGY and Risk factors1. CAD2. Coronary vasospasm3. Coronary artery occlusion by embolus and thrombus4. Conditions that decrease perfusion- hemorrhage, shock

Risk factors1. Hypercholesterolemia2. Smoking3. Hypertension4. Obesity

5. Stress6. Sedentary lifestyle

Pathophysiology

- Interrupted coronary blood flow myocardial ischemia anaerobic myocardial metabolism forseveral hours myocardial death depressed cardiac function triggers autonomic nervous

system response further imbalance of myocardial O2 demand and supply

Assessment Findings1. Chest Pain

- Chest pain is described as severe, persistent, crushing substernal discomfort

- Radiates to the neck, arm, jaw and back- Occurs without cause, primarily early morning

- NOT relieved by rest or nitroglycerin- Lasts 30 minutes or longer2. Dyspnea3. Diaphoresis4. cold clammy skin5. N/V6. restlessness, sense of doom7. tachycardia or bradycardia8. hypotension9. S3 and dysrhythmias

Laboratory Findings1. ECG- the ST segment is ELEVATED, T wave inversion, presence of Q wave

2. Myocardial enzymes- elevated CK-MB, LDH and Troponin levels



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3. CBC- may show elevated WBC count4. Test after the acute stage - Exercise tolerance test, thallium scans, cardiac catheterizationPain

- Decreased cardiac output

- Impaired gas exchange

- Activity intolerance

- Altered tissue perfusion- Constipation

Nursing Intevention1. Provide Oxygen at 2 lpm, Semi-fowlers2. Administer medications

- Morphine to relieve pain

- Nitrates, thrombolytics, aspirin and anticoagulants

- Stool softener and hypolipidemics3. Minimize patient anxiety

- Provide information as to procedures and drug therapy- Allow verbalization of feelings

- Morphine can be administered

4. Provide adequate rest periods- Bed rest during acute stage

5. Minimize metabolic demands

- Provide soft diet

- Provide a low-sodium, low cholesterol and low fat diet6. Assist in treatment modalities such as PTCA and CABG7. Monitor for complications of MI- especially dysrhythmias, since ventricular tachycardia can

happen in the first few hours after MI8. Provide client teaching

Medical Management1. Analgesic

- The choice is MORPHINE

- It reduces pain and anxiety- Relaxes bronchioles to enhance oxygenation

2. ACE inhibitors

- Prevents formation of angiotensin II

- Limits the area of infarction3. Thrombolytic therapy

- Streptokinase, Alteplase

- Dissolve clots in the coronary artery allowing blood to flow

Nursing Interventions After Acute Episode1. Maintain bed rest for the first 3 days2. Provide passive ROM exercises3. Progress with dangling of the feet at side of bed4. Proceed with sitting out of bed, on the chair for 30 minutes TID

5. Proceed with ambulation in the room toilet hallway TID6. Cardiac rehabilitation

- To extend and improve quality of life

- Physical conditioning

- Patients who are able to walk 3-4 mph are usually ready to resume sexual activities

Infective endocarditis

- Infection of the heart valves and the endothelial surface of the heartCan be acute, sub-acute or chronic



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Etiologic factors1. Bacteria- Organism depends on several factors2. Fungi

Risk factors

1. Prosthetic valves

2. Congenital malformation

3. Cardiomyopathy

4. IV drug users

5. Valvular dysfunctions

Assessment findings1. Intermittent high grade fever2. anorexia, weight loss3. cough, back pain and joint pain4. splinter hemorrhages under nails5. Oslers nodes- painful nodules on fingerpads6. Roths spots- pale hemorrhages in the retina7. Heart murmurs

8. Heart failure= usually acute heart failure

Prevention

- Antibiotic prophylaxis if patient is undergoing procedures like dental extractions, bronchoscopy,surgery, etc.

- Any invasive procedure that is associated with transient bacteremia may cause themicrorganism to lodge in the damaged, irregular valves

Laboratory Exam

- Blood Cultures to determine the exact organismUsually, 3 culture specimens are obtained and antibiotic sensitivity done

Nursing management1. Regular monitoring of temperature, heart sounds

2. Manage infection3. Long-term antibiotic therapy is given to ensure eradication of bacteria

Medical management1. Pharmacotherapy

- IV antibiotic for 2-6 weeks

- Antifungal agents are given amphotericin B2. Surgery3. Valvular replacement

Congestive Heart Failure (CHF)

- A syndrome of congestion of both pulmonary and systemic circulation caused by inadequatecardiac function and inadequate cardiac output to meet the metabolic demands of tissues

- Inability of the heart to pump sufficiently- The heart is unable to maintain adequate circulation to meet the metabolic needs of the body

This can happen acutely or chronically

- Acute in Myocardial infarction

- Chronic cardiomyopathies

Classified according to the major ventricular dysfunction1. Left Ventricular failure2. Right ventricular failure

Etiology of CHF1. CAD2. Valvular heart diseases

3. Hypertension4. MI5. Cardiomyopathy6. Lung diseases7. Post-partum8. Pericarditis and cardiac tamponade

Class 1

- Ordinary physical activity does NOT cause chest pain and fatigue



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- No pulmonary congestion- Asymptomatic

- NO limitation of ADLs

Class 2

- SLIGHT limitation of ADLs

- NO symptom at rest- Symptoms with INCREASED activity

- Basilar crackles and S3

Class 3

- Markedly limitation on ADLs

- Comfortable at rest BUT symptoms present in LESS than ordinary activity

Class 4

- SYMPTOMS are present at rest

PATHOPHYSIOLOGYLEFT Ventricular pump failure

back up of blood into the pulmonary veins

increased pulmonary capillary pressure

pulmonary congestion (edema)

Pulmonary manifestations

LEFT ventricular failure

Decreased cardiac output

Decreased perfusion to the brain, kidney and other tissues

Cerebral anoxia, fatigue, oliguria, dizziness

RIGHT ventricular failure

blood pooling in the venous circulation

increased hydrostatic pressure

peripheral edema

RIGHT ventricular failure

Venous blood pooling

venous congestion in the kidney, liver and GIT

Left Sided CHF Assessment Findings1. Dyspnea on exertion, activity intolerance

2. PND3. Orthopnea4. Pulmonary crackles/rales5. Cough with Pinkish, frothy sputum6. Tachycardia7. Cool extremities8. Cyanosis9. decreased peripheral pulses10. Fatigue

11. Oliguria12. signs of cerebral anoxia

Right Sided CHF Assessment Findings1. Peripheral dependent, pitting edema2. Weight gain3. Distended neck vein4. hepatomegaly5. Ascites



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6. Body weakness7. Anorexia, nausea8. Pulsus alternans

9. Nocturia= urination at night at frequent intervals as the blood moves from interstitial space tothe intravascular space and is excreted

Laboratory Findings

1. CXR may reveal cardiomegaly2. ECG may identify Cardiac hypertrophy3. Echocardiogram may show hypokinetic heart4. ABG and Pulse oximetry may show decreased O2 saturation5. PCWP is increased in LEFT sided CHF and CVP is increased in RIGHT sided CHF

Nursing Interventions1. Assess patient's cardio-pulmonary status2. Assess VS, CVP and PCWP. Weigh patient daily to monitor fluid retention3. Administer medications- usually cardiac glycosides are given- DIGOXIN or DIGITOXIN,

Diuretics, vasodilators and hypolipidemics are prescribed

CardiotonicsPositive inotropic agents

To increase cardiac contractility

Diuretics To decrease the intravascular volume in thecirculation

Low Sodium Diet To minimize water retention

Hypolipidemics To decrease the lipid levels of high risk patients

Digoxin Health teaching

- Oral tablet usually once a day

- Increases force of contraction- DECREASES heart rate

- Assess: Apical pulse, ECG, hypokalemia- Withhold the drug if apical pulse is less than 60

- Note for early signs of toxicity: NAVDA

- Provide potassium supplements

4. Provide a LOW sodium diet. Limit fluid intake as necessary5. Provide adequate rest periods to prevent fatigue

6. Position on semi-fowlers to fowlers for adequate chest expansion7. Prevent complications of immobility

Nursing Intervention after the Acute Stage1. Provide opportunities for verbalization of feelings2. Instruct the patient about the medication regimen- digitalis, vasodilators and diuretics

3. Instruct to avoid OTC drugs, Stimulants, smoking and alcohol4. Provide a LOW fat and LOW sodium diet5. Provide potassium supplements

6. Instruct about fluid restriction7. Provide adequate rest periods and schedule activities8. Monitor daily weight and report signs of fluid retention

CARDIAC TAMPONADE

- A condition where the heart is unable to pump blood due to accumulation of fluid in the pericardialsac (pericardial effusion)

- This condition restricts ventricular filling resulting to decreased cardiac output- Acute tamponade may happen when there is a sudden accumulation of more than 50 ml fluid in

the pericardial sac

Causative factors1. Cardiac trauma2. Complication of Myocardial infarction

3. Pericarditis4. Cancer metastasis

Assessment Findings1. BECKs Triad- Jugular vein distention, hypotension and distant/muffled heart sound2. Pulsus paradoxus3. Increased CVP4. decreased cardiac output5. Syncope



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6. anxiety7. dyspnea8. Percussion- Flatness across the anterior chest

Laboratory Findings1. Echocardiogram= shows accumulate fluid in the pericardial sac2. Chest X-ray

Nursing Interventions

1. Assist in PERICARDIOCENTESIS2. Administer IVF3. Monitor ECG, urine output and BP4. Monitor for recurrence of tamponade

Pericardiocentesis

- Patient is monitored by ECG- Maintain emergency equipments

- Elevate head of bed 45-60 degrees- Monitor for complications- coronary artery rupture, dysrhythmias, pleural laceration and

myocardial trauma

Vascular Diseases

General Measures to Improve Peripheral Circulation1. Implement Regular Physical Activity to facilitate movement of venous blood2. Eliminate cigarette smoking- to prevent vasoconstriction3. Control hyperlipidemia and cholesterol levels- to prevent the progression of atherosclerosis4. Avoid cold environmental temperature5. Teach clients to assess fingers and toes daily for circulatory adequacy: Check the peripheral

pulses, capillary refill and temp6. Report break in the skin

Hypertension

- A systolic BP greater than 140 mmHg and a diastolic pressure greater than 90 mmHg over asustained period, based on two or more BP measurements.

Types of Hypertension1. Primary or Essential

- Most common type2. Secondary

- Due to other conditions like Pheochromocytoma, renovascular hypertension, Cushings, Conns ,SIADH

CLASSIFICATION OF BP FOR ADULTS 18 YRS AND OLDER (PHIL. SOCIETY OF HPN)Optimal

o


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o 140-159 mmHg / 90-99 mmHgConfirm in 2 months.

Stage 2 (moderate) HPNo 160-179 mmHg / 100-109 mmHg

Evaluate within a month.Stage 3 (severe) HPN

o 180-209 mmHg / 110-119mmHg

Evaluate within a week.Stage 4 (very severe) HPN

o 210 mmHg / >/=120 mmHg Evaluate

Pathophysiology

- Multi-factorial etiologyo BP= CO (SV X HR) x TPR

Any increase in the above parameters will increase BP

Risk factors for Cardiovascular Problems in Hypertensive patientsMajor Risk factors

1. Smoking2. Hyperlipidemia3. DM4. Age older than 605. Gender- Male and post menopausal women6. Family History

Any increase in the above parameters will increase BP1. Increased sympathetic activity2. Increased absorption of Sodium, and water in the kidney

3. Increased activity of the RAAS4. Increased vasoconstriction of the peripheral vessels5. Insulin resistance

Assessment Findings1. Headache2. Visual changes3. chest pain4. dizziness5. N/V

Diagnostic Studies1. Health history and PE2. Routine laboratory- urinalysis, ECG, lipid profile, BUN, serum creatinine , FBS3. Other lab- CXR, creatinine clearance, 24-huour urine protein

Medical Management1. Lifestyle modification2. Diet therapy

3. Drug therapy

MEDICAL MANAGEMENTDrug therapy

- Diuretics- Beta blockers

- Calcium channel blockers- ACE inhibitors

- A2 Receptor blockers



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- VasodilatorsNursing Interventions

1. Provide health teaching to patient

- Teach about the disease process

- Elaborate on lifestyle changes

- Assist in meal planning to lose weight

- Provide list of LOW fat , LOW sodium diet of less than 2-3 grams of Na/day- Limit alcohol intake to 30 ml/day

- Regular aerobic exercise

- Advise to completely Stop smoking2. Provide information about anti-hypertensive drugs

- Instruct proper compliance and not abrupt cessation of drugs even if pt becomes asymptomatic/improved condition

- Instruct to avoid over-the-counter drugs that may interfere with the current medication3. Promote Home care management

- Instruct regular monitoring of BP

- Involve family members in care

- Instruct regular follow-up4. Manage hypertensive emergency and urgency properly

Aneurysm

- Dilation involving an artery formed at a weak point in the vessel wall

- Saccular= when one side of the vessel is affected- Fusiform= when the entire segment becomes dilatedRisk Factors

1. Atherosclerosis2. Infection= syphilis3. Connective tissue disorder4. Genetic disorder= Marfans Syndrome

Pathophysiology

- Damage to the intima and media weakness outpouching of vessel wall

- Dissecting aneurysm tear in the intima and media with dissection of blood through the layers

Assessment1. Asymptomatic2. Pulsatile sensation on the abdomen3. Palpable bruit

Laboratory:

- CT scan- Ultrasound

- X-ray- Aortography

Medical Management:

- Anti-hypertensives- Synthetic graft

Nursing Management:

- Administer medications- Emphasize the need to avoid increased abdominal pressure

- No deep abdominal palpation- Remind patient the need for serial ultrasound to detect diameter changes.

Peripheral Arterial Occlusive Disease

- Refers to arterial insufficiency of the extremities usually secondary to peripheral atherosclerosis.

- Usually found in males age 50 and above

- The legs are most often affected

Risk factors for Peripheral Arterial occlusive diseaseNon-Modifiable1. Age2. gender3. family predisposition

Modifiable1. Smoking2. HPN



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3. Obesity4. Sedentary lifestyle5. DM6. Stress

Assessment Findings

1. INTERMITTENT CLAUDICATION- the hallmark of PAOD- This is PAIN described as aching, cramping or fatiguing discomfort consistently reproduced with

the same degree of exercise or activity

- This pain is RELIEVED by REST- This commonly affects the muscle group below the arterial occlusion

2. Progressive pain on the extremity as the disease advances3. Sensation of cold and numbness of the extremities4. Skin is pale when elevated and cyanotic and ruddy when placed on a dependent position5. Muscle atrophy, leg ulceration and gangrene

Diagnostic Findings1. Unequal pulses between the extremities2. Duplex ultrasonography3. Doppler flow studies

Medical Management1. Drug therapy

- Pentoxyfylline (Trental) reduces blood viscosity and improves supply of O2 blood to muscles- Cilostazol (Pletaal) inhibits platelet aggregation and increases vasodilatation

2. Surgery- Bypass graft and anastomoses

Nursing Interventions1. Maintain Circulation to the extremity

- Evaluate regularly peripheral pulses, temperature, sensation, motor function and capillary refilltime

- Administer post-operative care to patient who underwent surgery

- Administer heat modalities to the leg cautiously to promote vasodilatation2. Monitor and manage complications

- Note for bleeding, hematoma, and decreased urine output

- Elevate the legs to diminish edema

- Encourage exercise of the extremity while on bed

- Teach patient to avoid leg-crossing3. Promote Home management

- Encourage lifestyle changes- Instruct to AVOID smoking

- Instruct to avoid leg crossing

BUERGERS DISEASEThromboangiitis obliterans

- A disease characterized by recurring inflammation of the medium and small arteries and veins ofthe lower extremities

- Occurs in MEN ages 20-35- RISK FACTOR: SMOKING!

Pathophysiology

- Cause is UNKNOWN

- Probably an Autoimmune disease

- Inflammation of the arteries and veins thrombus formation occlusion of the vesselAssessment Findings

1. Leg PAIN

- Foot cramps in the arch

- (INSTEP CLAUDICATION) after exercise- Relieved by rest

- Aggravated by smoking, emotional disturbance and cold chilling2. Digital rest pain not changed by activity or rest

3. Intense RUBOR (reddish-blue discoloration), progresses to CYANOSIS as disease advances4. Paresthesias

Diagnostic Studies1. Duplex ultrasonography

2. Contrast angiography

Nursing Interventions



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1. Assist in the medical and surgical management

- Bypass graft

- amputation2. Strongly advise to AVOID smoking3. Manage complications appropriately

Post-operative care: after amputation

- Elevate stump for the FIRST 24 HOURS to minimize edema and promote venous return

- Place patient on PRONE position after 24 hours several times a day- Assess skin for bleeding and hematoma

- Wrap the extremity with elastic bandage

Raynauds Disease

- A form of intermittent arteriolar VASOCONSTRICTION that results in coldness, pain and pallor ofthe fingertips or toes

- Cause : UNKNOWN

- Most commonly affects WOMEN, 16- 40 years old

Assessment Findings1. Raynauds phenomenon

- A localized episode of vasoconstriction of the small arteries of the hands and feet that causes colorand temperature changes

W-B-R is the acronym for the color change

- Pallor- due to vasoconstriction, then

- Blue- due to pooling of Deoxygenated blood- Red- due to exaggerated reflow or hyperemia

2. Tingling sensation3. Burning pain on the hands and feet

Medical management

- Drug therapy with the use of CALCIUM channel blockers

To prevent vasospasms

Nursing Interventions1. Instruct patient to avoid situations that may be stressful2. Instruct to avoid exposure to cold and remain indoors when the climate is cold3. Instruct to avoid all kinds of nicotine4. Instruct about safety. Careful handling of sharp objects

Venous diseases

Varicose Veins

- THESE are dilated veins usually in the lower extremities

Predisposing Factors

Pregnancy

Prolonged standing or sitting

Incompetent venous valves

Pathophysiology

Factors venous stasis increased hydrostatic pressure edema

Assessment findings

- Tortuous superficial veins on the legs- Leg pain and Heaviness

- Dependent edema

Laboratory findings

- Venography

- Duplex scan pletysmography

Medical management

- Pharmacological therapy

- Leg vein stripping and ligation- Anti-embolic stockings

Nursing management1. Advise patient to elevate the legs with pillow to increase venous return2. Caution patient to avoid prolonged standing or sitting



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3. Provide high-fiber foods to prevent constipation4. Teach simple exercise to promote venous return5. Caution patient to avoid constrictive clothing6. Apply anti-embolic stockings as directed7. Avoid massage on the affected area

DVT- Deep Vein Thrombosis

- Inflammation of the deep veins of the lower extremities and the pelvic veins- The inflammation results to formation of blood clots in the areaPredisposing factors

- Prolonged immobility

- Varicosities

- Traumatic procedures

- Increased age

- Malignancy- Estrogen therapy

- SmokingComplication

- PULMONARY thromboembolism

Assessment findings

- Leg tenderness

- Leg pain and edema

- Positive HOMANs SIGNHOMANs SIGN

The foot is FLEXED upward (dorsiflexed) , there is a sharp pain felt in the calf of the legindicative of venous inflammation

Laboratory findings

- Venography

- Duplex scan

Medical management

- Antiplatelets- aspirin- Anticoagulants

- Vein stripping and grafting

- Anti-embolic stockings

Nursing management1. Provide measures to avoid prolonged immobility

- Repositioning Q2

- Provide passive ROM

- Early ambulation2. Provide skin care to prevent the complication of leg ulcers3. Provide anti-embolic stockings4. Administer anticoagulants as prescribed

5. Monitor for signs of pulmonary embolism sudden respiratory distress

Blood disordersAnemia

Nutritional anemia

Hemolytic anemia

Aplastic anemia

Sickle cell anemia

Anemia

- A condition in which the hemoglobin concentration is lower than normal



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Three broad categories1. Loss of RBC- occurs with bleeding2. Decreased RBC production3. Increased RBC destruction

Hypoproliferative Anemia

Iron Deficiency Anemia- Results when the dietary intake of iron is inadequate to produce hemoglobinEtiologic Factors1. Bleeding- the most common cause2. Mal-absorption3. Malnutrition4. Alcoholism

Pathophysiology

- The body stores of iron decrease, leading to depletion of hemoglobin synthesis- The oxygen carrying capacity of hemoglobin is reduced tissue hypoxia

Assessment Findings1. Pallor of the skin and mucous membrane2. Weakness and fatigue3. General malaise4. Pica5. Brittle nails6. Smooth and sore tongue7. Angular cheilosis

Laboratory findings1. CBC- Low levels of Hct, Hgb and RBC count2. Low serum iron, low ferritin3. Bone marrow aspiration- MOST definitive

Medical management

1. Hematinics2. Blood transfusion

Nursing Management1. Provide iron rich-foods

- Organ meats (liver)

- Beans- Leafy green vegetables

- Raisins and molasses

2. Administer iron

- Oral preparations tablets- Fe fumarate, sulfate and gluconate

- Advise to take iron ONE hour before meals

- Take it with vitamin C

- Continue taking it for several months- Oral preparations- liquid

- It stains teeth- Drink it with a straw

- Stool may turn blackish- dark in color- Advise to eat high-fiber diet to counteract constipation

- IM preparation- Administer DEEP IM using the Z-track method

- Avoid vigorous rubbing- Can cause local pain and staining

Aplastic Anemia

- A condition characterized by decreased number of RBC as well as WBC and platelets

Causative Factors1. Environmental toxins- pesticides, benzene

2. Certain drugs- Chemotherapeutic agents, chloramphenicol, phenothiazines, Sulfonamides3. Heavy metals4. Radiation

PathophysiologyToxins cause a direct bone marrow depression



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Acellular bone marrow

decreased production of blood elementsPANCYTOPENIA

Assessment Findings

- fatigue- pallor- dyspnea

- bruising- splenomegaly

- retinal hemorrhages

Laboratory Findings1. CBC- decreased blood cell numbers

2. Bone marrow aspiration confirms the anemia- hypoplastic or acellular marrow replaced by fats

Medical Management1. Bone marrow transplantation

2. Immunosupressant drugs3. Rarely, steroids4. Blood transfusion

Nursing management1. Assess for signs of bleeding and infection2. Instruct to avoid exposure to offending agents

Megaloblastic Anemias

- Anemias characterized by abnormally large RBC secondary to impaired DNA synthesis due todeficiency of Folic acid and/or vitamin B12

Folic Acid deficiencyCausative factors

1. Alcoholism2. Mal-absorption

3. Diet deficient in uncooked vegetables

Pathophysiology of Folic acid deficiencyDecreased folic acid

impaired DNA synthesis in the bone marrow

Impaired RBC development, impaired nuclear maturation but CYTOplasmic maturation continues

large size

Vitamin B12 deficiency

Causative factors1. Strict vegetarian diet2. Gastrointestinal mal-absorption3. Crohn's disease4. Gastrectomy

Vitamin B12 deficiency: Pernicious Anemia

- Due to the absence of intrinsic factor secreted by the parietal cells

- Intrinsic factor binds with Vit. B12 to promote absorption

Assessment findings1. weakness2. fatigue3. listless4. neurologic manifestations are present only in Vit. B12 deficiency

Assessment findingsPernicious Anemia

- Beefy, red, swollen tongue

- Mild diarrhea

- Extreme pallor

- Paresthesias in the extremities



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Laboratory findings1. Peripheral blood smear- shows giant RBCs, WBCs with giant hyper-segmented nuclei2. Very high MCV3. Schillings test4. Intrinsic factor antibody test

Medical Management

1. Vitamin supplementation2. Folic acid 1 mg daily3. Diet supplementation4. Vegetarians should have vitamin intake5. Lifetime monthly injection of IM Vit B12

Nursing Management1. Monitor patient2. Provide assistance in ambulation

3. Oral care for tongue sore4. Explain the need for lifetime IM injection of vit B12

Hemolytic Anemia: Sickle Cell

- A severe chronic incurable hemolytic anemia that results from heritance of the sicklehemoglobin gene.

Causative factor

- Genetic inheritance of the sickle gene- HbS genePathophysiology

Decreased O2, Cold, Vasoconstriction can precipitate sickling process

Factors cause defective hemoglobin to acquire a rigid, crystal-like C-shaped configuration Sickled RBCs will adhere to endothelium pile up and plug the vessels ischemia resultspain, swelling and fever

Assessment Findings1. jaundice (hemolytic jaundice)2. enlarged skull and facial bones3. tachycardia, murmurs and cardiomegaly

- Primary sites of thrombotic occlusion: spleen, lungs and CNS- Chest pain, dyspnea

Assessment Findings1. Sickle cell crises

- Results from tissue hypoxia and necrosis2. Acute chest syndrome

- Manifested by a rapidly falling hemoglobin level, tachycardia, fever and chest infiltrates inthe CXR

Medical Management1. Bone marrow transplant2. Hydroxyurea3. Increases the HbF

4. Long term RBC transfusion

Nursing Management1. manage the pain

Support and elevate acutely inflamed jointRelaxation techniquesanalgesics

2. Prevent and manage infectionMonitor status of patientInitiate prompt antibiotic therapy

3. Promote coping skills

- Provide accurate information

- Allow patient to verbalize her concerns about medication, prognosis and future pregnancy4. Monitor and prevent potential complications

- Provide always adequate hydration- Avoid cold, temperature that may cause vasoconstriction

- Leg ulcerAseptic technique

- PriapismSudden painful erection

Instruct patient to empty bladder, then take a warm bath



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Polycythemia

Refers to an INCREASE volume of RBCs

The hematocrit is ELEVATED to more than 55%

Classified as Primary or Secondary

Primary Polycythemia

- A proliferative disorder in which the myeloid stem cells become uncontrolled

Causative factor

- unknown

Pathophysiology

- The stem cells grow uncontrollably

- The bone marrow becomes HYPERcellular and all the blood cells are increased in number

- The spleen resumes its function of hematopoiesis and enlarges

- Blood becomes thick and viscous causing sluggish circulation

- Overtime, the bone marrow becomes fibrotic

Assessment findings

- Skin is ruddy

- Splenomegaly- headache

- dizziness, blurred vision- Angina, dyspnea and thrombophlebitis

Laboratory findings1. CBC- shows elevated RBC mass2. Normal oxygen saturation3. Elevated WBC and Platelets

Complications1. Increased risk for thrombophlebitis, CVA and MI2. Bleeding due to dysfunctional blood cells

Medical Management

1. To reduce the high blood cell mass- PHLEBOTOMY

2. Allopurinol

3. Dipyridamole

4. Chemotherapy to suppress bone marrow

Nursing Management1. Primary role of the nurse is EDUCATOR2. Regularly asses for the development of complications3. Assist in weekly phlebotomy4. Advise to avoid alcohol and aspirin5. Advise tepid sponge bath or cool water to manage pruritus

NCM 102 lec cardio

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