Anatomy and Physiology

A. Anatomy1. Layers

a. pericardium: fibrous sac that encloses the heart

b. epicardium: covers surface of heartc. myocardium: muscular portion of the heartd. endocardium: lines cardiac chambers and covers surface of heart valves

2. Chambers of heart

a. right atrium: collecting chamber for incoming systemic venous systemb. right ventricle: propels blood into pulmonary systemc. left atrium: collects blood from pulmonary venous systemd. left ventricle: thick-walled, high-pressure pump that propels blood into system the systemic

circulation

Heart valves: membranous openings that allow one way blood flow

a. atrioventricular valves: prevent backflow from ventricles to atria during systolei. tricuspid - right heart valveii. mitral - left heart valve (bicuspid)

b. semilunar valves prevent backflow from aorta and pulmonary arteries into ventricles during diastolei. pulmonicii. aortic

c. Blood supply to hearti. arteries

Cardiovascular: Arteries of the Heart 

a. right coronary artery supplies right ventricle and part of left ventricleb. left coronary artery supplies mostly left ventricle

ii. veinsa. coronary sinus veinsb. thebesian veins

d. Conduction system  i. SA (sinoatrial) node - referred to as the "pacemaker" of the heart

ii. junctional tissue - often referred to as the atrioventricular node (AV node)iii. bundle branch Purkinje system

Physiology

1. Function of the heart is the transport of oxygen, carbon dioxide, nutrients and waste products2. Cardiac cycle - atria and ventricles work in an asynchronous manner

a. systole - phase of contraction during which the ventricles eject bloodb. diastole - the phase of relaxation during which the chambers fill with blood; when the heart pumps,

myocardial layer contracts and relaxes3. Blood flow

a. deoxygenated blood enters the right atrium through the superior and inferior vena cavab. enters the right ventricle via the tricuspid valvec. travels through the pulmonic valve to pulmonary arteries and lungsd. oxygenated blood returns from lungs through the pulmonary veins into left atrium and enters the left

ventricle via bicuspid (mitral) valvee. finally, the blood, from the left ventricle, goes through the aortic valve into the aorta and into the

systemic circulation

4. The vascular system is a continuous network of blood vessels.a. the arterial system consists of arteries, arterioles and capillaries and delivers oxygenated blood to

tissues

b. oxygen, nutrients and metabolic waste are exchanged at the microscopic levelc. the venous system, veins and venules, returns the blood to the heart

5. The heart itself is supplied with blood by the left and right coronary arteries 

Heart Infections

A. Pericarditis1. Definition and related terms: inflammation of the pericardial sac

a. due to a bacterial or fungal infection, collagen disease, e.g., systemic lupus erythematosus (SLE), or as a complication of an acute myocardial infarction

b. there may or may not be pericardial effusion or constrictive pericarditisc. Dressler's syndrome (also called post myocardial infarction syndrome)

i. a combination of pericarditis, pericardial effusion and constrictive pericarditis; etiology is unclear

ii. occurs several weeks to months after a myocardial infarctionB. Epidemiology

1. may be acute or chronic and may occur at any age2. pericarditis occurs in up to 15% of persons with a transmural infarction

C. Findings  1. sharp chest pain often relieved by leaning forward2. pericardial friction rub

 Listen3. dyspnea4. fever, sweating, chills5. dysrhythmias6. pulsus paradoxus7. client cannot lie flat without pain or dyspnea

D. Diagnostics 1. history and physical exam

2. serum studiesa. increased

i. white blood cellsii. sedimentation rate

b. positivei. blood culturesii. antinuclear antibody (ANA) if due to connective tissue disease

3. EKG changes on 12-lead4. echocardiography - to determine pericardial effusion or cardiac tamponade, may show pleural

thickeningE. Management

1.  pharmacologicala. antibiotics to treat underlying infectionb. corticosteroids usually reserved for clients with pericarditis due to SLE, or clients who do not

respond to NSAIDsc. NSAIDS or aspirin for pain, inflammation, and fever controld. avoid anticoagulants - may increase the possibility of cardiac tamponade from bleeding risk

2. oxygen: to prevent tissue hypoxia3. surgical

a. emergency pericardiocentesis if cardiac tamponade developsb. for recurrent constrictive pericarditis, partial pericardiectomy (pericardial window) or total

pericardiectomyF. Nursing interventions

1. manage pain and anxiety2. semi-Fowler's or high-Fowler's position

3. the cardio-care six   4. maintain a pericardiocentesis set at the bedside in case of cardiac tamponade5. observe for pericarditis complications

a. dysrhythmiasb. cardiac tamponadec. heart failure

6. assess respiratory, cardiovascular, and renal status often7. rotate IV sites often and observe for findings of infiltration or inflammation at the venipuncture site

(possible complication of long-term IV administration)

8. teach client and family the cardio five 

Myocarditis

1. Definition - an inflammatory condition of the myocardium caused bya. viral infectionb. bacterial infectionc. fungal infectiond. serum sicknesse. rheumatic feverf. chemical agentg. complication of a collagen disease, e.g., SLE

2. Epidemiologya. may be acute or chronic and may occur at any ageb. usually an acute virus and self-limited, but it may lead to acute heart failure

3. Findingsa. depends on the type of infection, degree of myocardial damage, capacity of myocardium to recover,

and host resistanceb. may be minor or unnoticed, i.e., fatigue and dyspnea, palpitations, occasional precordial discomfort

manifested as a mild chest soreness and persistent feverc. recent upper-respiratory infection with fever, viral pharyngitis, or tonsillitisd. cardiac enlargement

e. abnormal heart sounds : murmur, S3 or gallop or friction rub   

 Listenf. possible findings of congestive heart failure such as pulsus alternans, dyspnea, and cracklesg. tachycardia disproportionate to the degree of fever

4. Diagnostic  studies a. EKG for changes and arrhythmias

b.  labsi. increases erythrocyte sedimentation rate (ESR)ii. increases myocardial enzymes such as:

aspartate aminotransferase (AST) creatine kinase (CK) lactic dehydrogenase  (LDH)

c. endomyocardial biopsy (EMB)d. myocardial imaging

5. Management

a. pharmacologicali. antibiotics to treat underlying infectionii. corticosteroids to decrease inflammationiii. analgesics for pain

b. oxygen to prevent tissue hypoxia

6. Nursing interventions and assessments 

a. the cardio-care six  with modified bedrest and less help with ADLs

b. assess for edema, weigh daily; record intake and outputc. assess cardiovascular status frequentlyd. observe for findings of left-sided heart failure, e.g., dyspnea, hypotension and tachycardiae. check often for changes in cardiac rhythm or conduction; auscultate heart soundsf. evaluate arterial blood gas levels as needed to ensure adequate oxygenationg. client and family teaching

i. physical activity may be slowly increased to sitting in chair, walking in room, then outdoorsii. avoid pregnancy, alcohol, and competitive sportsiii. immunize against infectionsiv. teach client about anti-infective drugs; stress importance of taking drugs as orderedv. teach clients taking digitalis at home to

check pulse for one full minute before taking the dose, and withhold the drug if heart rate falls below 60 beats/minute

monitor for findings of digitalis toxicity, e.g., anorexia, nausea, vomiting, blurred vision, cardiac arrhythmias

vi. teach client to report rapidly beating heart

Endocarditis

1. Definition - inflammation of the endocardium; can involve any portion of the endocardial lininga. usually infectiousb. usually affects the valves

2. Infection can lead to vegetation or abscess formation with resultant thrombus or embolus3. Endocarditis can be classified as

a. native valve endocarditisb. endocarditis in IV drug usersc. prosthetic valve endocarditis

4. Epidemiologya. with proper treatment, majority of clients recoverb. the prognosis is worse when endocarditis damages valves severely or involves a prosthetic valvec. infective endocarditis occurs in many clients with previous valvular disordersd. systemic lupus erythematosus (SLE) often leads to nonbacterial endocarditise. in some clients with subacute endocarditis, lesions produce clots that show the findings of splenic,

renal, cerebral or pulmonary infarction, or peripheral vascular occlusion5. Findings of endocarditis

a. cardiac murmurs  in great majority of persons with infective endocarditis b. feverc. especially, a murmur that changes suddenly, or a new murmur that develops in the presence of a

feverd. pericardial friction rube. anorexia, abdominal painf. malaiseg. clubbing of fingersh. neurologic sequelae of embolusi. petechiae of the skin (especially on the chest)j. splinter hemorrhage under the nailsk. infarction of spleen: pain in the upper left quadrant, radiating to the left shoulder, and abdominal

rigidityl. infarction in kidney: hematuria, pyuria, flank pain, and decreased urine outputm. infarction in brain: hemiparesis, aphasia, and other neurologic deficitsn. infarction in lung: cough, pleuritic pain, pleural friction rub, dyspnea and hemoptysiso. peripheral vascular occlusion: numbness and tingling in an arm, leg, finger, or toe, or signs of

impending peripheral gangrene

6. Diagnostics  a. health history

b. laboratory data1. CBC - elevated WBC2. blood cultures - positive for microbe3. erythrocyte sedimentation rate (ESR) - elevated

c. chest x-ray to detect heart failure or cardiomegalyd. transesophageal echocardiogram to detect vegetation and abscesses on valvese. EKG to detect dysrhythmias

7. Management - clients at risk for prosthetic valves

a. pharmacological

1. antibiotics - to treat underlying infection (used prophylactically to prevent endocarditis, mitral valve prolapse)

2. antipyretics - to control fever3. anticoagulants - to prevent embolization

b. oxygen - to prevent tissue hypoxiac. surgical - possible valve replacement

8. Nursing interventions

a. the cardio-care six  b. observe for findings of infiltration or inflammation at venipuncture site; rotate sites oftenc. client and family teaching

1. explain all procedures in a simple and culturally sensitive manner2. involve the client and family in scheduling the daily routine activities3. allow client and family to participate in care4. teach client relaxation techniques (meditation, visualization, or guided imagery) to cope with

stress, pain, or insomnia5. explain endocarditis and the need for long-term therapy6. may need prophylactic antibiotics before dental work and other invasive procedures7. teach client to report fever, tachycardia, dyspnea and shortness of breath

Rheumatic heart disease (rheumatic endocarditis)

1. Definition and related termsa. rheumatic heart disease: damage to the heart by one or more episodes of rheumatic fever; pathogen

is group A streptococcusb. rheumatic endocarditis: damage to the heart, particularly the valves, resulting in valve leakage

(regurgitation) and/or stenosis; to compensate, the heart's chambers enlarge and walls thicken2. Epidemiology

a. fairly rare in developed countries; more common in developing countriesi. more common where malnutrition and crowded living are common, in children between ages

5 and 15 years-oldii. strikes most often during cool, damp weather

b. could be prevented by finding and treating streptococcal pharyngitisc. it is unknown how and why group A streptococcal infections cause the lesions called Aschoff bodies

i. damage depends on site of infection; most often the mitral valve in females and the aortic valve in males

ii. malfunction of these valves leads to severe pericarditis, and sometimes pericardial effusion and fatal heart failure; about 20% die within ten years

3. Findingsa. streptococcal pharyngitis

i. sudden sore throatii. throat reddened with exudateiii. swollen, tender lymph nodes at angle of jawiv. headache and fever to 104 degrees Fahrenheit

b. polyarthritis manifested by warm and swollen jointsc. carditisd. choreae. erythema marginatum (wavy, thin red-line rash on trunk and extremities)f. subcutaneous nodulesg. fever to 104 degrees Fahrenheit

h. heart murmurs  pericardial friction rub and pericardial rub   

 Listeni. no lab test confirms rheumatic fever, but some support the diagnosis

4. Diagnosticsa. antistreptolysin O (ASO) titer - increasedb. ESR - increasedc. throat culture - positive for streptococcid. WBC count - increasede. RBC parameters - normocytic, normochromic anemiaf. C-reactive protein (CRP) - positive for streptococci

5. Management

a. pharmacologicali. provide analgesics - for pain/inflammationii. oxygen to prevent tissue hypoxiaiii. give antibiotics steadily to maintain level in blood

b. surgical - commissurotomy, valvuloplasty, prosthetic heart valve

Nursing interventions

a. the cardio-care six  

b. help the client with chorea to grasp objects; prevent fallsc. encourage family and friends to spend time with client and fight boredom during the long, tedious

convalescenced. client and family teaching

i. explain all tests and treatmentsii. nutritioniii. hygienic practicesiv. to resume ADLs slowly and schedule rest periodsv. to report penicillin reaction, e.g., rash, fever, chillsvi. to report findings of streptococcal infection

sudden sore throat diffuse throat redness and oropharyngeal exudate swollen and tender cervical lymph glands pain on swallowing temperature of 101 to 104 degrees Fahrenheit headache nausea

vii. keep client away from people with respiratory infectionsviii. explain necessity of long-term antibioticsix. arrange for a visiting nurse if necessaryx. help the family and client cope with temporary chorea

Valve Disorders

A. Mitral stenosis1. Definition: mitral valve thickens and gets narrower, blocking blood flow from the left atrium to left

ventricle

2. Epidemiology a. of clients with mitral stenosis, 2/3 are femaleb. most cases of mitral stenosis are caused by rheumatic fever

B. Findings1. mild - no findings2. moderate to severe

a. dyspnea on exertionb. paroxysmal nocturnal dyspneac. orthopnead. weakness, fatigue, and palpitations

3. peripheral and facial cyanosis in severe cases4. jugular vein distention5. with severe pulmonary hypertension or tricuspid stenosis - ascites

6. edema  7. hepatomegaly

8. diastolic thrill at the cardiac apex  9. when client lies on left side, loud S1 or opening snap and a diastolic murmur at the apex10. crackles in lungs

C. Diagnostic  studies 1. history and physical exam2. EKG - note indications of left atrial enlargement and right ventricle enlargement3. echocardiogram - for restricted movement of the mitral valves and diastolic turbulence

4. cardiac catheterization5. chest x-ray

D. Management

1. antiarrhythmics if needed2. if medication fails, atrial fibrillation is treated with cardioversion

3. low-sodium diet - to prevent fluid retention4. oxygen if needed - to prevent hypoxia5. surgery - mitral commissurotomy or valvotomy

6. medications used in severe casesa. vasodilators (nitroprusside, nitrogylcerin)b. positive inotropes (dobutamine, dopamine, digoxin)c. aminophylline (decrease bronchospasm)

E. Nursing interventions and assessment 

1. the cardio-care six  2. observe closely for findings of heart failure, pulmonary edema, and reactions to drug therapy3. if client has had surgery, watch for hypotension, arrhythmias, and thrombus formation

4. monitor the cardio seven  

5. client and family  teaching a. explain the need for long-term antibiotic therapy and the need for additional antibiotics before

dental careb. report early findings of heart failure such as dyspnea or a hacking, nonproductive cough

Mitral insufficiency (or regurgitation)

1. Definition and related termsa. a damaged mitral valve allows blood from the left ventricle to flow back into the left atrium during

systoleb. to handle the back flow, the atrium enlarges; the left ventricle also enlarges, in part to make up for its

lower output of blood2. Epidemiology

a. follows birth defects such as transposition of the great arteries

b. in older clients, the mitral annulus may have become calcifiedc. cause unknown; may be linked to a degenerative processd. occurs in 5 to 10% of adults

3. Findingsa. client may be asymptomaticb. orthopnea, dyspnea, fatigue, weakness, weight lossc. chest pain and palpitationsd. jugular vein distentione. peripheral edemaf. hepatomegaly

4. Diagnostics  a. EKG for arrhythmias and changes of left atrial enlargementb. echocardiogram - to visualize regurgitant jets and flail chordae/leafletsc. cardiac catheterization shows regurgitation of blood from left ventricle to left atriumd. chest x-ray shows cardiomegaly, pulmonary congestion

5. Management

a. low-sodium diet - to prevent fluid retentionb. oxygen as needed - to prevent tissue hypoxia

c. antibiotics - to treat infection (prophylactic antibiotics - to prevent infection)d. surgery - mitral valvuloplasty or valve replacement

6. Nursing interventions and assessment 

a. the cardio-care six  

b. monitor the cardio seven c. monitor for left-sided heart failure, pulmonary edema, adverse reactions to drug therapy, and cardiac

dysrhythmias (especially atrial and ventricular fibrillation)d. if client has surgery, monitor postoperatively for hypotension, arrhythmias and thrombus formatione. client and family teaching

1. diet restrictions and drugs2. explain tests and treatments3. prepare client for long-term antibiotic and follow-up care4. stress the need for prophylactic antibiotics during dental care5. teach client and family to report findings of heart failure, i.e., dyspnea and hacking,

nonproductive cough

Tricuspid stenosis

1. Definition: narrowing of the tricuspid valve between right atrium and right ventricle2. Epidemiology

a. relatively uncommonb. usually associated with lesions of other valvesc. caused by rheumatic fever

3. Findingsa. dyspnea, fatigue, weakness, syncopeb. peripheral edemac. jaundice with severe peripheral edema and ascites can mean that tricuspid stenosis has led to right

ventricular failured. may appear malnourishede. distended jugular vein

4. Diagnostics  a. EKG - for arrhythmiasb. echocardiogram - right ventricular dilation and paradoxical septal motion

5. Management: surgery - valvulotomy or valve replacement; valvuloplasty

6. Nursing interventions and assessment 

a. the cardio-care six  

b. monitor the cardio seven c. monitor for findings of heart failure, pulmonary edema, and adverse reactions to the drug therapyd. post valve surgery, monitor client for hypotension, arrhythmias and thrombus formatione. when client sits, elevate legs to prevent dependent edemaf. client and family teaching

i. teach the cardio five 

ii. client must comply with long-term antibiotic and follow up careiii. emphasize the need for prophylactic antibiotics during dental care

Tricuspid insufficiency (regurgitation)

1. Definition - tricuspid valve lets blood leak from the right ventricle back into the right atrium2. Epidemiology

a. results from dilation of the right ventricle and tricuspid valve ringb. most common in late stages of heart failure from rheumatic or congenital heart disease

3. Findingsa. dyspnea, fatigue, weakness and syncopeb. peripheral edema may cause discomfort

4. Diagnostics  - echocardiogram for abnormal valve movement 5. Management: surgical - valve replacement

6. Nursing interventions and assessment 

a. the cardio-care six  

b. monitor the cardio seven c. monitor for findings of heart failure, pulmonary edema, and adverse reactions to the drug therapyd. post-op monitor client for hypotension, arrhythmias and thrombus formatione. when sitting, client should raise legs to prevent dependent edemaf. client and family teaching

i. the cardio five  ii. emphasize the need for prophylactic antibiotics during dental careiii. instruct client to raise legs when sitting - to prevent dependent edema

Pulmonic stenosis

1. Definition - obstructed right ventricular outflow resulting in right ventricular hypertrophy2. Epidemiology

a. usually congenital, often with other birth defects such as Tetralogy of Fallot

b. rare among the elderlyc. may result from rheumatic fever

3. Findingsa. dyspnea, fatigue, chest pain and syncopeb. peripheral edema may cause discomfort

4. Diagnostics  - echocardiogram for abnormal valve or blood movement 5. Management: surgical - replace the valve via balloon and cardiac catheter6. Nursing interventions

a. same as tricuspid stenosis and tricuspid insufficiencyb. monitor for findings of heart failure, pulmonary edema, and adverse reactions to to the drug therapyc. post-op: monitor client for hypotension, dysrhythmias and thrombus formation

d. monitor the cardio seven e. client and family teaching - same as tricuspid stenosis and tricuspid insufficiency

Pulmonic insufficiency (regurgitation)

1. Definition - pulmonary valve fails to close, so that blood flows back into the right ventricle2. Epidemiology

a. a birth defect, or a result of pulmonary hypertensionb. rarely, result of prolonged use of a pressure-monitoring catheter in the pulmonary artery

3. Findingsa. dyspnea, fatigue, chest pain and syncopeb. peripheral edema may cause discomfortc. if advanced: jaundice with ascites and peripheral edemad. possible malnourished appearance

4. Diagnostics  - echocardiogram for abnormal blood or valve movement 5. Management

a. pharmacologicali. diuretics - to mobilize edematous fluid to reduce pulmonary venous pressureii. anticoagulants - to prevent blood clotsiii. digitalis - to increase the force or strength of cardiac contractions (inotropic action)

b. sodium-restricted diet - to control underlying heart diseasec. surgery for severe cases: valvulotomy or valve replacement

6. Nursing interventions and assessment 

a. the cardio-care six  

b. monitor the cardio seven c. monitor for findings of heart failure, pulmonary edema, and adverse reactions to drug therapyd. post-op: monitor client for hypotension, arrhythmias and thrombus formatione. provide rest periodsf. when client sits, elevate legsg. client and family teaching - same as tricuspid stenosis, tricuspid insufficiency, and pulmonic stenosis

i. the cardio five teaching plan  ii. client's dentist must give client prophylactic antibiotics to prevent infectioniii. instruct client to raise legs when sitting to prevent dependent edema

Aortic stenosis

1. Definition - aortic valve stiffens to narrow opening

2. Epidemiologya. most significant valvular lesion seen among elderly people. It usually leads to left-sided heart failureb. incidence increases with agec. occurs in 1% of the populationd. about 80% of these people are malee. 20% of them die suddenly, around age 60

3. Findings

a. classic triad: dyspnea, syncope, angina (see assessing clients with cardiovascular disorders)b. fatiguec. palpitationsd. left-sided heart failure may bring on orthopnea, paroxysmal nocturnal dyspnea, and peripheral

edemae. systolic murmur that radiates into carotid arteries and the apex of the heartf. EKG - findings of left ventricular hypertrophy

4. Management

a. pharmacological1. nitroglycerin to relieve chest pain2. digitalis - to increase the force or strength of cardiac contractions (inotropic action)3. diuretics - to mobilize edematous fluid and to reduce pulmonary venous pressure

b. low-sodium diet - to prevent fluid retentionc. oxygen - to prevent hypoxiad. surgery - percutaneous balloon valvuloplasty, then valve replacement

5. Nursing interventions and assessment 

a. the cardio-care six  

b. monitor the cardio seven c. monitor for findings of heart failure, pulmonary edema, and adverse reactions to the drug therapyd. post-op: monitor client for hypotension, arrhythmias and clotse. when client sits, elevate legs to prevent dependent edemaf. client and family teaching: (same as tricuspid stenosis, tricuspid insufficiency, pulmonic stenosis and

pulmonic insufficiency)

1. the cardio five teaching plan  2. client's dentist must administer prophylactic antibiotics3. client should elevate legs when sitting

Aortic insufficiency (regurgitation)

1. Definitiona. blood flows back into the left ventricle during diastole overloading the ventricle and causing it to

hypertrophy.b. extra blood also overloads the left atrium and, eventually, the pulmonary system.

2. Epidemiologya. by itself, most common among malesb. with mitral valve disease, more common among femalesc. may accompany marfan's syndrome, ankylosing spondylitis, syphilis, essential hypertension or a

defect of the ventricular septum3. Findings

a. uncomfortable awareness of heartbeatb. palpitations along with a pounding headc. dyspnea with exertiond. paroxysmal nocturnal dyspnea, with diaphoresis, orthopnea and coughe. fatigue and syncope with exertion or emotionf. anginal chest pain unrelieved by sublingual nitroglycering. heartbeat that seems to jar the client's entire bodyh. client's nail beds appear to be pulsatingi. if nail tip is pressed, the root will flush and then pale (Quincke's sign)j. if left ventricle fails, client may show ankle edema and ascitesk. pulsus bisferiens: a double-beat pulse (palpated over the carotid or brachial arteries)

4. Diagnostics a. chest x-rayb. echocardiogramc. cardiac catherization

5. Management

a. pharmacological1. digitalis - increases the heart's contractility (inotropic action)2. diuretics - to mobilize edematous fluids and to reduce pulmonary venous pressure3. anticoagulant agents - to prevent blood clots4. ACE inhibitors - decrease cardiac workload and assist to increase oxygenation

b. sodium-restricted diet - to prevent fluid retentionc. surgical - valve replacement, however, aortic insufficiency often damages the ventricle before it is

detected

6. Nursing interventions and assessment a. same as all other valve disorders - the cardio-care six except don't need to elevate head unless

pulmonary problems have begun

b. monitor the cardio seven c. monitor for signs of heart failure, pulmonary edema, and drug reactionsd. post-op: monitor client for hypotension, arrhythmias and clotse. client and family teaching

1. same as all other valve disorders - the cardio five teaching plan 2. emphasize the need for prophylactic antibiotics during dental care3. instruct client to raise legs when sitting

Failures of the Heart Muscle

A. Myocardial infarction (MI)1. Definition - insufficient oxygen supply kills (causes necrosis of) myocardial tissue; may be sudden or

gradual and total event may take 3 to 6 hours

2. Epidemiologya. almost equal for men and womenb. client history of smoking, obesity, high cholesterol/low density lipoprotein diet,

physical/emotional stressc. a common killer in North America and Western Europed. mortality

i. mortality about 25%; of the sudden deaths from MI, more than half happen within an hour

ii. of those who survive the initial MI and recover, up to 10% die within the first yeariii. factors affecting mortality: age, number of occluded vessels, previous history of MI,

presence of cardiogenic shock

Findings

a. classic findings: persistent, crushing substernal chest paini. pain that may radiate to the left arm, jaw, neck and shoulder blades, with a feeling of impending

doomii. pain does not resolve with restiii. some clients report no pain or call it mild indigestion

more likely in the elderly or clients with diabetes

clues suggesting "silent" MI (acute or sudden): heart failure, change in mental status, unexplained abdominal pain, dyspnea, fatigue

iv. some clients (especially older women) report only fatigue, nausea or vomiting, shortness of breath, or flu-like symptoms

b. sudden deathc. within the first hour after an anterior MI, about 25% of clients experience tachycardia or hypertensiond. up to 50% of clients with an inferior MI experience the opposite, i.e., bradycardia or hypotension

4. Diagnostics  a. history and physicalb. EKG - monitor for changes, arrhythmias

c. serum cardiac markersi. isoenzymes - CK-MB isoenzyme: rises 4 to 6 degrees after acute MI; returns to normal in 3 to 4

daysii. muscle proteins - Troponin rises quickly but remains elevated for two weeks

5. Managementa. cardiac monitoring for arrhythmiasb. oxygen - to prevent tissue hypoxiac. induced hypothermia (target temperature of 32 to 34 degrees Celsius) - initiated as soon as possible

after return of spontaneous circulationd. bed rest - to decrease the workload of the heart

e. pharmacologic agents - to stabilize clienti. stool softeners - to decrease the workload of the heart caused by straining, which can cause

vagal stimulation producing bradycardia and arrhythmiasii. narcotic analgesics - to reduce pain, anxiety and fear and decrease the workload of the heartiii. beta-blocking agents - to slow heart rate, decrease contractility, and decrease workload of heartiv. sedatives - to decrease anxiety and fear and to decrease the workload of the heartv. antiarrhythmics - only used if serious arrhythmia develops or client is symptomatic with

arrhythmiavi. thrombolytic agents - to dissolve the thrombus in the coronary artery and re-perfuse the

myocardiumvii. nitrates- to decrease pain and decrease preload and afterload while increasing the myocardial

oxygen supplyviii. anticoagulants - to prevent blood clots

f. pulmonary artery (Swan-Ganz) catheter to monitor pressure in pulmonary artery (measures functioning of left ventricle)

g. intra-aortic balloon counterpulsation may be used for cardiogenic shockh. cardiac catheterization may be performed for percutaneous transluminal coronary angioplasty (PTCA),

i.e.,  stent insertion   

i. surgery - coronary atherectomy or graft of a coronary artery bypass

Therapeutic treatment for MI: " O BATMAN! "

 O =Oxygen B =Beta blocker A =ASA (aspirin) T =Thrombolytics (heparin) M =Morphine A =ACE (especially for those with heart failure or a lower EF) N =Nitroglycerin

Nursing interventions

a. the cardio-care six  plus monitor the following to prevent heart failure, infections and complicationsi. temperatureii. daily weightiii. intake and outputiv. respiratory ratev. breath soundsvi. blood pressurevii. serum enzyme levelsviii. EKG readingsix. peripheral pulses

x. heart sounds  especially S3 and gallop   

Listenb. assess pain and administer analgesics as ordered; record the severity, location, type, and duration of painc. do  not  give intramuscular injections (or CK will be falsely elevated)d. watch for crackles, cough, tachypnea, and edema, which may predict left ventricle is failing

 Listene. use anti-embolism stockings to prevent venostasis and thrombophlebitisf. assistance with range-of-motion exercisesg. client and family teaching

i. cardio five teaching plan  ii. explain the intensive care (or coronary care) unit routine and machineryiii. ask dietitian to speak with the client and family to reinforce teachingiv. encourage client to join the cardiac rehab exercise programv. counsel gradual resumption of sexual activity; taking nitroglycerin before sex may prevent chest painvi. advise the client to report typical or atypical chest painvii. describe post-myocardial infarction syndrome; have client report it to physicianviii. stress that client must modify high-risk behaviors

h. Heart failurei. Definition

a. heart fails to pump enough blood to support the body's functionsb. types of CHF depend on which part of the heart is failing: the left half that pumps to the body

or the right half that pumps to the lungsii. Etiology

a. coronary artery disease b. myocarditis

c. cardiomyopathyd. infiltrative disorders, i.e., amyloidosis, tumors, sarcoidosise. collagen-vascular disease: systemic lupus erythematosus, sclerodermaf. dysrhythmias that reduce cardiac filling timeg. disorders that increase cardiac workload: hypertension, valve disease, anemia,

hyperthyroidismh. cardiac tamponade

iii. Findings

Heart Failure symptoms listed in order of earliest to later findings

Right Bilateral Left

Nocturia

Bulging neck veins (JVD)

Ankle & foot edema

Liver enlargement (hepatomegaly with abdominal pain, anorexia, and nausea)

Fatigue in adults and decreased play activity in children

Tachycardia

Hypotension

Restlessness, irritability, hostility, agitation, anxietyCough (often dry initially)Weight gainShortness of breath/orthopneaTachypneaCracklesS3 heart soundPulmonary edemaFrothy, sputum (may be blood-tinged)DiaphoresisCyanosis

4. Diagnostics  - the primary goal is to determine the underlying cause of the heart failurea. history and physical examb. chest x-ray to determine heart size and pleural effusionsc. EKG for changes, arrythmiasd. echocardiogram to measure valvular abnormalitiese. nuclear imaging - to determine myocardial contractility, myocardial perfusion, and acute cell injuryf. hemodynamic monitoring of arterial blood pressure, pulmonary artery pressure, pulmonary artery

wedge pressure and cardiac output5. Management - objective is to restore balance between myocardial oxygen supply and demand

a. oxygen

b. pharmacological: positive inotropes, e.g., digitalis, vasodilators, nitrates, antihypertensives, cardiac glycosides, diuretics

c. intra-aortic balloon counterpulsation, ventricular assist pumping, pacemaker6. Nursing interventions

a. the cardio care six  b. administer medications as orderedc. administer oxygen as ordered - to prevent tissue hypoxiad. monitor hemodynamic indicatorse. monitor for findings of hyponatremia, hypokalemiaf. restrict fluids and assess for findings of fluid retentiong. client and family teaching

i. medications and side effectsii. how to conserve energy and thus oxygeniii. teach client to report

weight gain of more than 2 pounds in 24 hours (equals 1 liter) or 5 pounds in 1 week dyspnea - sudden or progressive with ADLs decreased exercise tolerance

iv. importance of sodium-restricted diet

Cardiac tamponade

1. Definition: fluid fills pericardial sac and limits cardiac output; a medical emergency  

2. Etiologya. acute pericarditisb. post-op after cardiac surgeryc. pericardial effusionsd. chest traumae. myocardial rupturef. aortic dissectiong. anticoagulant therapy

3. Findings: classic triad of findingsa. hypotension withb. muffled heart sounds withc. high jugular venous pressure (increased CVP)

4. Diagnostics  5. Management: pericardiocentesis (needle aspiration of pericardial sac)6. Nursing interventions

a. bed rest with elevated head of bedb. prepare client for pericardiocentesisc. provide emotional supportd. prepare for surgery if pericardiocentesis is ineffective

Disorders of the Circulatory System

A. Hypertension   1. Definitions 

a. hypertension - systolic blood pressure of 140 mm Hg or greater, diastolic blood pressure of 90 mm Hg or greater, or taking antihypertensive medication

b. chronic hypertension of pregnancy - high blood pressure already present before week 20 of gestation

c. accelerated hypertension - a hypertensive crisis when blood pressure rises very rapidlyi. threat of immediate vascular necrosis and target organ damage, particularly to the

heart, kidneys, retina and brainii. blood pressure is usually greater than 180/120 mm Hg or a mean arterial pressure of

more than 150 mm Hg

Etiology and epidemiology 

a. essential hypertension: cause unknown.b. possible risk factors

i. family history - immediate family, including mother, father, sister, brotherii. race - African American, Hispanic, Native American, more susceptibleiii. stressiv. obesity - 20% more than ideal weightv. a diet high in sodium or saturated fatvi. use of tobaccovii. use of hormonal contraceptivesviii. sedentary life/lack of exerciseix. aging process

c. besides hypertension, most individuals have other risk factors for cardiovascular disease (CVD)d. secondary hypertension may result from

i. renovascular disease

ii. renal parenchymal diseaseiii. Cushing's syndromeiv. diabetes mellitusv. dysfunction of the thyroid, pituitary, or parathyroidvi. coarctation of the aortavii. pregnancyviii. neurologic disorders

e. Findingsi. often asymptomaticii. findings reflect the effect of hypertension on organ systemsiii. occipital headache, blurred vision, dizzinessiv. weakness, fatigue, and impotencev. epistaxisvi. nocturia, hematuriavii. chest pain, palpitations, and dyspnea, if heart is involved

f. Diagnosticsi. based on the average of two or more blood pressure readings, two minutes apart, at each of two or

more visits after an initial screening visit (measuring blood pressure)

ii. classification of adult hypertension iii. hypertension is classified according to its cause:

a. primary or essential hypertension (about 90% of clients)b. secondary hypertension (results from another disease; about 5% to 10% of clients)c. pregnancy-induced hypertension (PIH)d. accelerated hypertension - a hypertensive crisis

5. Management: initial treatment for prehypertension and uncomplicated stage 1 hypertension is lifestyle modifications; if life changes fail to decrease the BP to an acceptable level than medication is added

a. initial treatment for prehypertension and uncomplicated stage 1 hypertension - lifestyle modifications

b. pharmacological - if life changes fail to decrease the blood pressure to an acceptable level, medication is added

i. initial therapy includes one of the following classification of medications: thiazide diuretic, beta-adrenergic blocking agent, or angiotensin converting enzyme (ACE) inhibitor

ii. angiotensin-converting enzyme (ACE) inhibitors are the first choice for clients with left-sided heart failure and diabetics

iii. antilipemicsc. goals of treatment: to prevent end organ damage

i. BP <130/85 mm Hgii. control dyslipidemia, obesity, inactivityiii. control diabetes mellitus, if indicatediv. increase activity

6. Nursing interventions - reinforce client and family teaching regarding:a. use of self-monitoring blood pressure cuffb. the need to record blood pressure readings at least twice weekly in a journal or calendar (for review by

care provider during visits)c. a routine or schedule for taking antihypertensive medicationsd. the need to avoid high-sodium antacids and cold or sinus remedies with vasoconstrictors, e.g.,

antihistamines

e. a diet that is low sodium, cholesterol and saturated fatf. when to report extremely high blood pressure readingsg. lifestyle modifications

i. optimizing body weightii. drinking alcohol based on current guidelinesiii. reducing dietary sodium, e.g., 2 gram sodium dietiv. participating in regular and moderately intense aerobic activityv. avoiding tobacco productsvi. managing stress trigger and responses to triggers

Complementary and Alternative Medicine

Garlic, ginseng dried root, hawthorn, and snakeroot have been used to treat hypertension; however, there’s not enough research to support the efficacy and safety of these herbal therapies.

Supplements: Coenzyme Q10 (CoQ10) supplements may cause small decreases in blood

pressure; low blood levels of CoQ10 have been found in people with hypertension

Omega-3 fatty acids supplements may lower blood pressure

Complementary and Alternative Medicine

Amino acid L-arginine diet supplements may temporarily lower blood pressure Alternative systems of care

Traditional Chinese medicine Avurveda

Note: Licorice and ephedra should not be used by people with hypertension because they can increase blood pressure.

Malignant Hypertension

1. Definition: a sudden and rapid development of extremely high blood pressure; systolic is greater than 180 mm Hg and the diastolic is higher than 120 mm Hg

2. Etiology: the most common cause is suddenly when client stops taking antihypertensive medication3. Findings: headache, confusion, blurred vision, restlessness, motor sensory deficits4. Management

a. goal: to reduce blood pressure by no more than 25% within minutes to one hour, then toward 160/100 within 2 to 6 hours; must avoid rapidly dropping blood pressure because this could cause ischemia to body systems

b. pharmacologicali. sodium nitroprussideii. nitroglycerin

5. Nursing interventionsa. monitor for end organ damageb. monitor urine output; assess level of consciousness

c. monitor BUN, creatinine, arterial blood gases, urinalysisd. continuous cardiac monitoringe. vital signs every 5 to 30 minutes (while titrating medication)

Coronary artery disease (CAD) 

1. Definition - fatty deposits in coronary arteries (atheroma or plaque) narrow the artery (by 75% or more) and cut flow of blood and oxygen to the heart muscle

2. Epidemiology and etiologya. CAD is epidemic in the western worldb. more than 30% of men age 60 or older show signs of CAD on autopsyc. most common cause: Atherosclerosisd. risk factors:

i. over 40 white maleii. family history of CADiii. high blood pressureiv. high cholesterol v. smokers are twice as likely to have a myocardial infarction and four times as likely to die

suddenly; the risk drops sharply within one year after smoking cessationvi. obesity, particularly waist circumference; added weight increases the risk of diabetes,

hypertension and high cholesterol

vii. sedentary life style3. Findings: angina 

4. Diagnostics  

a. serum elevationsi. homocysteine levelsii. C-reactive proteiniii. LDH cholesteroliv. triglycerides

b. cardiac catherization

Management

a. pharmacologicali. nitrates such as nitroglycerin, isosorbide dinitrate (Isordil), or beta-adrenergic neuron-blocking

agentsii. diuretics and beta-adrenergic blocking agentsiii. antiplatelet agents (aspirin [81 mg daily]) - reduces platelet aggregation and decreases platelet

aggregationiv. antilipemics- to decrease circulating lipids

b. oxygen - to prevent hypoxia

c. diet: reduce calories, salts, fats, cholesterold. cardiac catheterization

e. rotational ablationf. laser coronary angioplastyg. surgical treatment - cardiovascular bypass graft surgery (CABG) 

Nursing interventions 

a. help client with ADL (activities of daily living)b. partial bed restc. reassure clientd. assist with turning, deep breathing and coughing exercisese. relieve chest pain by oxygen and medication as orderedf. during angina attacks, monitor blood pressure, heart rate, pain, medications, symptoms; get

electrocardiogramg. keep nitroglycerin available for immediate useh. post cardiac catheterization and percutaneous transluminal coronary angioplasty

i. maintain heparinizationii. observe for bleeding systemically at the siteiii. keep the affected leg straight and immobile for 6 to 12 hoursiv. check for distal pulsesv. to counter the diuretic effect of the dye, increase IV fluids and make sure client drinks plenty of fluidsvi. assess potassium level and observe for dysrhythmiasvii. observe findings of hypotension, bradycardia, diaphoresis, dizziness; give atropine and lay the client

flati. post rotational ablation

i. monitor the client for chest pain, hypotension, coronary artery spasm and bleeding from the catheter site

ii. provide heparin and antibiotic therapy for 24 to 48 hours or as orderedj. client and family teaching

i. risks teach the risk factors for coronary artery disease (CAD) encourage client to lose excess weight; review low-fat, low-cholesterol diet teach smoking cessation teach side effects of drugs for CAD stress - teach stress reduction techniques

ii. avoid activities known to cause angina physical activities for two hours after meals very cold and very hot weather alcohol and caffeine drinks diet pills, nasal decongestants, or any remedy that can raise heart rate or blood pressure

iii. use nitroglycerin tablets and carry at all times if necessary nitroglycerin patch

iv. report angina go to clinic or hospital when angina lasts more than 15 minutes  

Shock

1. Definition - a clinical syndrome marked by inadequate perfusion and oxygenation of cells, tissues and organs.

2. Four physiologic components for homeostatic regulation - if one or more of these components malfunctions shock may follow

a. adequate cardiac outputb. uncompromised vascular system

c. adequate blood volumed. ability of tissue to extract and use oxygen

3. Major categories or types of shocka. cardiogenic (pump failure)b. obstructive (mechanical interference with ventricular filling or ventricular emptying)c. distributive (vasogenic)

i. septicii. anaphylactic

d. hypovolemic (intravascular volume loss)

Findings: progression of shock (you will note there are many terms used to describe the stages of shock)

a. stage I - reversible, compensatory, initial, "warm"i. characterized by decreased cardiac output and perfusion; anaerobic metabolism begins

(development of lactic acidosis)ii. compensatory mechanisms (neural, chemical, and hormonal) act to maintain perfusion

neural compensation baroreceptors in carotid sinus aortic arch activate sympathetic nervous system (NS),

which contracts blood vessels so that skin cools sympathetic NS stimulates heart, so tachycardia sets in; it cuts blood flow to kidneys

and gastrointestinal system and dilates pupils hormonal compensation

decreased blood flow to kidneys releases angiotensin, which constricts vessels and increases BP

angiotensin stimulates the secretion of aldosterone; aldosterone makes kidneys retain sodium, which increases serum osmolality, which in turn stimulates antidiuretic hormone (ADH)

ADH causes water retention increased sodium and water retention results in increased BP, decreased urine

volume and increased urine specific gravity anterior pituitary is stimulated to secrete adrenocorticotropic hormone (ACTH); ACTH

acts on adrenal cortex to increase secretion of glucocorticoids, which increase serum glucose

chemical compensation decreased pulmonary blood flow causes hypoxemia hypoxemia is sensed by chemoreceptors that increase rate and depth of respirations,

which results in respiratory alkalosisiii. clinical findings at this stage are vague because of compensatory mechanisms

anxiety, restlessness tachypnea skin cool and clammy thirst pupils dilated slight tachycardia weak or normal peripheral pulses decreased bowel sounds normal to decreased urine output concentrated urine

b. progressive stage of shock - compensatory mechanisms can no longer maintain perfusioni. severe hypoperfusionii. massive cell deathiii. organs begin to failiv. severe lactic acidosis and metabolic acidosisv. findings of progressive stage of shock

consciousness - LOC depressed lungs - tachypnea with hypoventilation and adventitious lung sounds (crackles and wheezes) cardiovascular

decreased cardiac output and decreased BP with systolic below 90 mm Hg narrowing pulse pressure tachycardia and irregular pulse weak and thready peripheral pulses

elimination urine volume below 20 mL/hour dilute urine osmolality absent bowel sounds

c. refractory stage - shock irreversiblei. death from multi-organ dysfunction syndrome (MODS)ii. findings of refractory stage of shock

cardiac failure respiratory failure renal shutdown liver dysfunction loss of consciousness

d. Diagnostics - bedside data collection based on etiology of shocke. Management - objective is to correct underlying cause and prevent progression

i. many treatments listed are used for all shock syndromes, e.g., vasopressors, positive inotropic support, oxygen therapy (intubation), fluid replacement

ii. cardiogenic shock

pharmacologic treatments  positive inotropic agents: increase myocardial contractility and improve systolic

ejection, e.g., dobutamine (Dobutrex), amrinone lactate (Inocor) vasodilators: improve heart's pumping action by reducing its workload;

e.g., nitroglycerin (Corobid), nitroprusside sodium (Nipride); usually limited to clients with failing ventricular function

vasopressors: increase peripheral vascular resistance and elevate blood pressure, e.g., norepinephrine (Levophed), DOPamine hydrochloride (Intropin)

oxygen therapy - titrated based on ABG analysis and respiratory effort supportive treatments

intra-aortic balloon pump (counterpulsation) left and right ventricular assist pumping

iii. hypovolemic shock: rapid fluid replacement therapy to replace lost volume crystalloids- 2/3 moves out of vascular space, e.g. normal saline or ringers lactate colloids (not for sepsis or burn)– 1/3 to 1/2 moves out of vascular space, e.g. dextran, blood,

hetastarch, FFP, albumin hemoglobin based oxygen carriers, e.g. PolyHeme, Hemopure, Hemolink blood products: whole blood (autotransfusion an option if they go to surgery/chest tube)

iv. anaphylactic shock epinephrine (adrenalin) antihistamines aminophylline (Truphylline)

v. neurogenic: depends on causative agentvi. septic shock

fluid replacement

antiinfective agents based on culture results

improve cardiac output with positive inotropes and vasopressors

Nursing interventions for shock: the cardio-care six  except  

a. do  not  elevate or lower head: maintain complete bed rest in flat position or with legs slightly raised to increase venous return (modified trendelenburg)

b. bed restc. turn patient every two hours as toleratedd. keep client warme. administer parenteral therapy, medicationsf. monitor mean hemodynamic indicators as orderedg. blood plasma expanders or packed cells if hematocrit and hemoglobin low

Dysrhythmias and Lesser Vascular Disorders

A. Dysrhythmias1. Definition: disturbance in heart rate or rhythm2. Types of dysrhythmia

a. supraventricular: sinus, atrial, and junctionali. sinus tachycardiaii. sinus bradycardiaiii. sinus arrhythmiaiv. premature atrial complexesv. atrial tachycardiavi. atrial fluttervii. atrial fibrillationviii. premature junctional complexix. junctional tachycardia

b. ventriculari. premature ventricular contractionii. ventricular tachycardiaiii. ventricular fibrillationiv. asystolev. atrioventricular blockvi. first degree A-V blockvii. second degree A-V block Mobitz one (type one)viii. second degree A-V block Mobitz two (type two)ix. third degree A-V block

Nursing interventions - always check your client for symptoms of an arrythmia (the number and degree of findings will often dictate the treatment)

a. supraventricular dysrhythmiasi. asymptomatic - no nursing interventions indicatedii. symptomatic

vagal stimulation

administer medications as ordered  (slow rate of administration) adenosine (Adenocard) calcium channel blockers beta blockers

procedures cardioversion ablation

provide emotional support teach client

about medications and side effects to decrease stimulant use, i.e., caffeine, nicotine to control reactions to stress to reduce alcohol intake about importance of sleep

b. ventricular dysrhythmiasi. administer medications as orderedii. monitor hemodynamic indicators as orderediii. administer oxygen as orderediv. provide a restful environmentv. prepare the client for cardioversionvi. initiate cardiopulmonary resuscitation as indicatedvii. provide emotional supportviii. teach client

medications and side effects importance of wearing MedicAlert® identification

c. atrio-ventricular (AV) conduction disturbancesi. asymptomatic: no nursing interventions indicatedii. symptomatic

administer medications as ordered

prepare client for pacemaker insertion care of the client undergoing surgery provide emotional support provide a restful environment

Aneurysms

1. Definition: dilation of an artery due to a weakness in the arterial wall2. Etiology - atherosclerosis3. Types

a. four types of aneurysmsi. saccular: out-pouching of one wall in a circumscribed areaii. fusiform: involves complete circumference of arteryiii. dissecting: accumulation of blood separating the layers of the arterial walliv. pseudoaneurysm: tear of the full thickness of the arterial wall, leading to a collection of blood

contained in the connective tissueb. common locations

i. location one: abdominal aortic aneurysm

findings of abdominal aortic aneurysm usually asymptomatic vague abdominal or back pain tenderness on palpation hypotension diminished pulses in lower extremities commonest site: just below renal arteries and above iliac arteries

diagnostics - arteriography management - surgical repair nursing interventions

postop care  of client  after surgery, watch for back pain, a sign of retroperitoneal hemorrhage monitor perfusion provide comfort measures provide emotional support teach client - to avoid prolonged sitting and lifting of heavy objects

ii. location two: thoracic aortic aneurysm findings of thoracic aortic aneurysm

may be asymptomatic vague chest pain dyspnea distended neck veins

diagnostics - arteriography management - surgical repair nursing interventions

care of the client undergoing surgery

postop care  of client 

Arterial occlusive disease

1. Definition: insufficient blood supply in the arteries, usually in legs; may be acute or chronic

2. Acute arterial occlusive diseasea. etiology

i. embolism, thrombosis, and trauma ii. femoral artery most often affected

b. findings  i. pain in affected limbii. cyanosis in affected limbiii. paresthesia in affected limbiv. if untreated, gangrene

c. management

i. anticoagulants

ii. IV hepariniii. surgical treatment

embolectomy bypass of affected artery amputation of limb percutaneous transluminal coronary angioplasty

Chronic arterial occlusive disease

a. etiologyi. arteriosclerosis obliterans, aneurysms, hypercoagulability states, tobacco useii. slow, progressive arteriosclerotic changes give collateral circulation a chance to formiii. collateral circulation cannot give tissues enough oxygen; result is hypoperfusioniv. hypoperfusion leads to ischemiav. usually affects legs

b. findingsi. intermittent claudication indicates mild to moderate obstructionii. pain at rest indicates severe obstructioniii. affected limb will show

edema paresthesia weak pulses skin: waxy, hairless, cool, pale, cyanotic

iv. in men, impotencec. management

i. physical activityii. dietiii. smoking cessation

iv. pharmacologic anticoagulants - to prevent blood clots vasodilators antiplatelet drugs - to prevent platelet aggregation pentoxifylline (Trental): increases blood flow by thinning blood

v. surgical treatment endarterectomy femoral-popliteal bypass sympathectomy amputation of affected limb for gangrene laser coronary angioplasty

peripheral angioplasty

Both acute and chronic arterial occlusive disease

a. nursing interventionsi. administer medications as orderedii. monitor peripheral pulses and blanch testiii. provide comfort measuresiv. help client develop an exercise program

v. postop care  of client vi. provide foot care

b. teach clienti. to change positions frequentlyii. to avoid crossing legsiii. to avoid any constrictive clothing on legsiv. to avoid trauma to lower extremitiesv. foot carevi. to place legs in dependent position to increase blood flow

Raynaud's phenomenon (arteriopastic disease)

1. Definitiona. episodic vasospasm of the small cutaneous arteries that results in intermittent pallor or cyanosis of

the skin - usually affects the fingers bilaterally, but occasionally affects the toes, nose, or tongue that result in intermittent pallor or cyanosis of the skin

b. the process involves a severe constriction of cutaneous vessels followed by vessel dilation and then a reactive hyperemia (blue, white, red)

2. Etiologya. unknownb. frequently occurs in womenc. may be triggered by stress, cold

3. Findings  4. Diagnostics

a. clinical patternb. digital plethysmographyc. peripheral arteriography

5. Management

a. pharmacologic agentsi. calcium channel blockers: nifedipine (Procardia), diltiazem (Cardiazem)ii. alpha-adrenergic blocking agents: prazosin (Minipress)iii. vasodilators

b. surgeryi. sympathectomy in advanced stagesii. amputation of fingers showing gangrene

6. Nursing interventionsa. administer medications as orderedb. care of the client undergoing surgeryc. teach client

i. to manage stressii. to stop smoking, avoid caffeineiii. to avoid temperature extremesiv. how to protect self from the coldv. medications and their side effects

Thromboangiitis obliterans (Buerger's disease)

1. Definition: blocking of the medium and small arteries, usually in the legs and feet2. Etiology

a. affects men more than womenb. 25 to 40 age group who smokec. the disease only occurs in smokers

3. Findings  a. intermittent claudicationb. numbness and tingling of toesc. weak or absent peripheral pulsesd. ischemic ulcerations may occure. can lead to gangrene

4. Diagnostics - angiography

Varicose veins 

1. Definition: dilation of superficial veins of the legs and feet2. Etiology

a. usually found in greater saphenous vein (leg)b. incompetent valves (incompetence, valvular) in the superficial veinsc. increased pressure in veins causing them to distendd. risk factors: standing for long periods, pregnancy

3. Findings   a. pain after period of standingb. foot and ankle swelling at end of dayc. distended leg veins

4. Diagnostics - venography5. Management

a. objective - to reduce pain and halt underlying conditionb. medical - sclerotherapy (injection of sclerosing agent that causes vein thrombosis)c. surgical - vein ligation (vein stripping)

6. Nursing interventionsa. care of the client undergoing surgeryb. post-operative care includes

i. application of elastic stocking or bandagesii. elevation of leg

c. teach clienti. not to cross legsii. to elevate legs as much as possibleiii. to avoid prolonged sitting or standingiv. avoid anything that impedes venous returnv. overweight clients should lose weight

Thrombophlebitis

1. Definition: a thrombus (clot) accompanied by the inflammation of the wall of a superficial blood vessel

2. Etiologya. traumab. intravenous cathetersc. prolonged immobilityd. IV drug use

3. Findingsa. rednessb. swellingc. tendernessd. warmth

4. Diagnosticsa. history and physicalb. ultrasonographyc. plethysmography

5. Managementa. bed rest, with elastic stockingsb. elevation of affected extremity

c. anticoagulants - to prevent clot formation

d. analgesics - to control discomfort6. Nursing interventions

a. keep leg elevatedb. monitor

i. for findings of pulmonary embolism, i.e., sudden pain, cyanosis, hemoptysis, shockii. vital signs, including peripheral pulsesiii. for findings of vascular impairment, i.e., pallor, cyanosis, coolness

c. administer analgesics as orderedd. client teaching

i. avoid tight or constricting clothingii. stop cigarette smokingiii. avoid maintaining one position for long periods

Deep venous thrombosis

1. Definition: clot formation in a deep vein (upper or lower extremity)2. Etiology and risk:

a. Virchow's triad, e.g., hypercoagulability, hemodynamic changes (stasis, burbulence), endothelial injury/dysfunction

b. immobilizationc. sepsisd. hematological disorders and clotting disorderse. malignanciesf. congestive heart failureg. myocardial infarctionh. obesityi. pregnancyj. fracturesk. venipuncturel. surgeries, i.e., orthopedic, neurologic, urologic and gynecologicm. risk of pulmonary embolus

3. Findings  unilateral edema of extremity 4. Diagnostics - venography5. Management

a. objective: to eliminate the clot and prevent complicationsb. bed rest

c. pharmacologicali. anticoagulant therapy - to prevent new clotsii. thrombolytic therapy - to dissolve thrombus

d. compression stockingse. surgery - thrombectomy

6. Nursing interventionsa. monitor for findings of pulmonary embolusb. maintain bed restc. administer medications as ordered

d. monitor drug therapy (aPTT for heparin, PT/INR for warfarin) and know therapeutic levelse. observe for evidences of bleeding, i.e., bruises, nosebleeds, bleeding gums, blood in urine or stoolf. teach client

i. medications and side effectsii. to avoid prolonged immobilityiii. to maintain adequate fluid intake

Venous stasis ulcers

1. Definition: skin and subcutaneous ulcers usually found on legs, ankles or feet (often is a chronic symptom for clients with chronic venous insufficiency)

2. Etiologya. chronic venous insufficiencyb. venous stasis is caused by incompetent valves in either perforating veins or in deep veinsc. pressure of blood pooling causes capillaries to leakd. ulcer begins as small, inflamed, tender areae. any trauma causes tissue to break or it may break spontaneouslyf. site: pretibial and medial supramalleolar areas of the ankle

3. Findings  a. open skin lesion with irregular borderb. skin around ulcer usually brown and leatheryc. pain in affected area

4. Diagnostics - history and physical exam of site5. Management

a. objective: to correct venous hypertension and both prevent and correct ulcerationb. local wound care

c. antibiotics and analgesics as indicatedd. surgery

1. debridement2. skin grafting3. removal of veins with incompetent valves

6. Nursing interventionsa. keep legs elevated, with feet above level of heart at all timesb. compression dressings (e.g. elastic bandages)c. cleanse and dress ulcer as orderedd. administer drugs as orderede. teach client

1. to report any signs of inflammation immediately2. to avoid trauma to affected limb3. to provide skin care4. to apply elastic bandages

Points to Remember

Cardiovascular disease is the leading cause of death among Americans.

Measure blood pressure  correctly  give client 5 minutes rest, with 2 to 3 minutes between checks take blood pressure while client is lying, sitting, and standing ask client if s/he has recently smoked, drank a beverage containing caffeine or was emotionally

upset; if s/he answers yes to any of the questions, repeat blood pressure in 30 minutes use the correct size BP cuff ensure the client's arm is supported and does not have legs crossed

Rarely, the heart may lie on the right side instead of the left (this is called  dextrocardia ). Valves control the direction of the blood flow through the heart; flow is unidirectional. When the atria contract, the atrioventricular valves swing open, allowing the blood to flow down into the

ventricles. When the ventricles contract the valves snap shut preventing blood from flowing back up into the atria;

semilunar valves open allowing blood to eject during ventricular contraction. If the SA node fails to generate an impulse, the AV node takes over, generating a slower rate. If the AV node

fails to generate an impulse, the Bundle of His takes over, generating an even slower rate. If the Bundle of His fails to generate an impulse, the Purkinje fibers take over and generate an even slower rate.

More Points to Remember

Damaged areas of the heart may also stimulate contractions and produce arrhythmias. Rapid, short-term control of blood pressure is achieved by cardiac and vascular reflexes that are initiated by

stretch receptors (baroreceptors) in the walls of the carotid sinus and the aortic arch. Many clients with angina or who have experienced a heart attack benefit from involvement in a structured

cardiac rehabilitation program to assist clients to increase their activity level in a monitored environment. Current research suggests that cardiovascular changes once related aging can now be attributed to lifestyle

and personal habits. The elderly are less able to physically adapt to stressful physical and emotional conditions, because their

hearts do three things less quickly: the myocardium contracts less easily the left ventricle ejects blood less quickly the heart is slower to conduct the impulse for a heartbeat

Because different enzymes are released into the blood at varying periods after a myocardial infarction, it is important to evaluate enzyme levels in relation to the onset of the physical symptoms, e.g., chest pain.

Clients who are in postoperative recovery, on bed rest, obese, taking hormonal contraceptives or had knee or hip surgery should be monitored closely for the development of thrombophlebitis.