Assessment of Cardiovascular Function

Overview of Anatomy and Physiology of the HeartThree layers of the heart:

EndocardiumMyocardiumEpicardium

Four chambersHeart valvesCoronary arteriesCardiac conduction systemCardiac hemodynamics

Structure of the Heart

Coronary Arteries

Cardiac Conduction System

Terms: Cardiac Action Potential Depolarization: electrical activation of a cell

caused by the influx of sodium into the cell while potassium exits the cell

Repolarization: return of the cell to the resting state caused by re-entry of potassium into the cell while sodium exits

Refractory periods:Effective refractory period: phase in which

cells are incapable of depolarizingRelative refractory period: phase in which cells

require a stronger-than-normal stimulus to depolarize

Cardiac Action Potential

Great Vessel and Heart Chamber Pressures

Terms: Cardiac Output

Stroke volume: the amount of blood ejected with each heartbeat

Cardiac output: amount of blood pumped by the ventricle in liters per minute

Preload: degree of stretch of the cardiac muscle fibers at the end of diastole

Contractility: ability of the cardiac muscle to shorten in response to an electrical impulse

Afterload: the resistance to ejection of blood from the ventricle

Ejection fraction: the percent of end-diastolic volume ejected with each heartbeat

CO= SV x HRControl of heart rate

Autonomic nervous system and baroreceptors Control of strike volume

Preload: Frank-Starling lawAfterload: affected by systemic vascular

resistance and pulmonary vascular resistanceContractility increased by catecholamines,

SNS, some medications and decreased by hypoxemia, acidosis, some medications

AssessmentHealth history

Demographic information Family/genetic historyCultural/social factors

Risk factorsSee Chart 26-2ModifiableNonmodifiable

Most Common Clinical Manifestations

Chest painDyspneaPeripheral edema and weight gainFatigueDizziness, syncope, changes in level of

consciousnessSee Chart 26-1 and Table 26-2

Assessing Chest Pain

Assessing Chest Pain

Assessing Chest Pain

Assessing Chest Pain

Assessing Chest Pain

Assessing Chest Pain

AssessmentNutritionEliminationActivity and exerciseSleep and restCognition and perceptionSelf-perception and self-conceptRoles and relationshipsSex and reproductionCoping and stress

Health Promotion, Perception, and Management Questions

Ask regarding health promotion and preventive practices.

What type of health issues do you have? Are you able to identify any family history or behaviors that put you at risk for this health problem?

What are your risk factors for heart disease? What do you do to stay healthy?

How is your health? Have you noticed any changes?

Do you have a cardiologist or primary health care provider? How often do you go for check-ups?

Do you use tobacco or alcohol?What medications do you take?

Laboratory TestsCardiac biomarkersCK and CK-MBMyoglobinTroponin T and I Lipid profileBrain (B-type) natriuretic peptideC-reactive proteinHomocysteine

Electrocardiography12-lead ECGContinuous monitoring: hardwire and

telemetrySignal-averaged ECGContinuous ambulatory monitoringTranstelephonic monitoringWireless mobile monitoringCardiac stress testing

Exercise stress testing Pharmacologic stress testing

Diagnostic TestsChest x-ray and fluoroscopyEchocardiogram and transesophageal

echocardiogramRadionuclide imagingMyocardial perfusion imagingEquilibrium radionuclide angiocardiography

(ERNA or MUGA)CT scansPET scansElectrophysiologic testing (EPS)

Cardiac CatheterizationInvasive procedure used to measure cardiac

chamber pressures and assess patency of the coronary arteries

Requires ECG and hemodynamic monitoring; emergency equipment must be available

Assessment prior to test; allergies, blood workAssessment of patient after procedure: circulation,

potential for bleeding, potential for dysrhythmias Activity restrictionsPatient education before & after procedure

See Chart 26-4

Hemodynamic MonitoringCVPPulmonary artery pressure Intra-arterial BP monitoring

Phlebostatic Level

Pulmonary Artery Catheter

Pulmonary Artery Catheter and Pressure Monitoring System

Arterial Pressure Monitoring System

Dysrhythmias

Dysrhythmias: dsiorders of the formation or conduction (or both) of the electrical impulses in the heart

These disorders can cause disturbances of:RateRhythmBoth rate and rhythm

Potentially can alter blood flow & cause hemodynamic changes

Diagnosed by analysis of ECG waveform

Relationship of ECG Complex, Lead System, and Electrical Impulse

ECG Electrode Placement

ECG Graph and Commonly Measured Components

Heart Rate Determination

Normal Sinus Rhythm

Sinus Bradycardia

Sinus Tachycardia

Sinus Arrhythmia

Premature Atrial Complexes

Atrial Flutter

Atrial Fibrillation

Multifocal PVCs-Quadrigeminy

Ventricular Tachycardia

Ventricular Fibrillation

Asystole

First-Degree AV Block

Second-Degree AV Block, Type 1

Second-Degree AV Block, Type 2

Third-Degree AV Block

Nursing Process: Patient with a Dysrhythmia: Assessment

Assess indicators of cardiac output and oxygenation, especially changes in level of consciousness.

Physical assessment includes:Rate and rhythm of apical and peripheral pulsesAssess heart sounds Blood pressure and pulse pressure Signs of fluid retention

Health history: include presence of coexisting conditions and indications of previous occurrence

Medications

Nursing Process: The Care of the Patient with a Dysrhythmia: Diagnosis

Decreased cardiac outputAnxiety Deficient knowledge

Collaborative Problems/Potential Complications

Cardiac arrestHeart failureThromboembolic event, especially with atrial

fibrillation

Nursing Process: The Care of the Patient with a Dysrhythmia: Planning

Goals may include eradicating or decreasing the occurrence of the dysrhythmia to maintain cardiac output, minimizing anxiety, and acquiring knowledge about the dysrhythmia and its treatment.

Decreased Cardiac Output

MonitoringECG monitoringAssessment of signs and symptoms

Administration of medications and assessment of medication effects

Adjunct therapy: cardioversion, defibrillation, pacemakers

Other InterventionsAnxiety

Use a calm, reassuring manner.Measures to maximize patient control to make

episodes less threateningCommunication and teaching

Teaching self-careInclude family in teaching

PacemakersAn electronic device that provides electrical

stimuli to the heart muscleTypes:

PermanentTemporary

NASPE-BPEG code for pacemaker function

Implanted Transvenous Pacemaker

Transcutaneous Pacemaker

ECG On-Demand Pacing

Complications of Pacemaker UseInfectionBleeding or hematoma formationDislocation of the leadSkeletal muscle or phrenic nerve stimulationCardiac tamponadePacemaker malfunction

See Table 27-2

Nursing Process: The Care of the Patient with an Implanted Cardiac Device: Assessment

Device function; ECGCardiac output and hemodynamic stabilityIncision siteCopingPatient and family knowledge

Nursing Process: The Care of the Patient with an Implanted Cardiac Device: Diagnosis

Risk for infectionRisk for ineffective copingKnowledge deficiency

Nursing Process: The Care of the Patient with an Implanted Cardiac Device- Planning

Goals include absence of infection, adherence to self-care program, effective coping, and maintenance of device function.

InterventionsRisk for ineffective coping

Support of patient and family copingSetting of realistic goalsAllow patient to talk, share feeling and

experiences Support groups or referralStress reduction techniques

Knowledge deficiencyPatient and family teaching

See Chart 27-3

Cardioversion and DefibrillationTreat tachydysrhythmias by delivering an

electrical current that depolarizes a critical mass of myocardial cells. When cells repolarize, the sinus node is usually able to recapture its role as heart pacemaker.

In cardioversion, the current delivery is synchronized with the patient’s ECG.

In defibrillation, the current delivery is unsynchronized.

Safety Measures Ensure good contact between skin and pads or

paddles. Use a conductive medium and 20-25 pounds of pressure.

Place paddles so that they do not touch bedding or clothing and are not near medication patches or oxygen flow.

If cardioverting, turn the synchronizer on. If defibrillating, turn the synchronizer off. Do not charge the device until ready to shock. Call “clear” three times; follow checks

required for clear and ensure that no one is in contact with the patient, bed, or equipment.

Paddle Placement for Defibrillation

Implantable Cardioverter Defibrillator (ICD)A device that detects and terminates life-

threatening episodes of tachycardia or fibrillation

NASPE-BPEG codeAntitachycardia pacing

ICD

Invasive Methods to Diagnose and Treat Recurrent Dysrhythmias

Electrophysiologic studiesCardiac conduction surgery

Maze procedureCatheter ablation therapy

Coronary Atherosclerosis

Atherosclerosis is the abnormal accumulation of lipid deposits and fibrous tissue within arterial walls and lumen.

In coronary atherosclerosis, blockages and narrowing of the coronary vessels reduce blood flow to the myocardium.

Cardiovascular disease is the leading cause of death in the United States for men and women of all racial and ethnic groups.

CAD (coronary artery disease) is the most prevalent cardiovascular disease in adults.

Pathophysiology of Atherosclerosis

Coronary Arteries

Clinical Manifestations

Symptoms are due to myocardial ischemia.Symptoms and complications are related to

the location and degree of vessel obstruction.Angina pectoris Myocardial infarctionHeart failureSudden cardiac death

The most common symptom of myocardial ischemia is chest pain; however, some individuals may be asymptomatic or have atypical symptoms such as weakness, dyspnea, and nausea.

Atypical symptoms are more common in women and in persons who are older or who have a history of heart failure or diabetes.

Angina Pectoris

A syndrome characterized by episodes of paroxysmal pain or pressure in the anterior chest caused by insufficient coronary blood flow

Physical exertion or emotional stress increases myocardial oxygen demand, and the coronary vessels are unable to supply sufficient blood flow to meet the oxygen demand.

Types of anginaSee Chart 28-3

Anginal pain varies from mild to severeMay be described as tightness, choking, or a

heavy sensationIt is frequently retrosternal and may radiate to

neck, jaw, shoulders, back, or arms (usually left).

Anxiety frequently accompanies the pain.Other symptoms may occur: dyspnea/shortness

of breath, dizziness, nausea, and vomiting.The pain of typical angina subsides with rest or

NTG. Unstable angina is characterized by increased

frequency and severity and is not relieved by rest and NTG. Requires medical intervention!

TreatmentTreatment seeks to decrease myocardial

oxygen demand and increase oxygen supply.MedicationsOxygenReduce and control risk factors.Reperfusion therapy may also be done.

MedicationsNitroglycerin

See Chart 28-5Beta-adrenergic blocking agentsCalcium channel blocking agentsAntiplatelet and anticoagulant medicationsAspirinClopidogrel and ticlopidineHeparinGlycoprotein IIB/IIIa agents

Nursing Process: The Care of the Patient with Angina Pectoris: AssessmentSymptoms and activities, especially those

that precede and precipitate attacksSee Chart 28-6Risk factors, lifestyle, and health promotion

activities Patient and family knowledgeAdherence to the plan of care

Collaborative ProblemsAcute pulmonary edemaHeart failureCardiogenic shockDysrhythmias and cardiac arrestMyocardial infarction

Nursing Process: The Care of the Patient with Angina Pectoris: DiagnosisIneffective cardiac tissue perfusionDeath anxietyDeficient knowledgeNoncompliance, ineffective management of

therapeutic regimen

Nursing Process: The Care of the Patient with Angina Pectoris: PlanningGoals include the immediate and appropriate

treatment of angina, prevention of angina, reduction of anxiety, awareness of the disease process, understanding of prescribed care, adherence to the self-care program, and absence of complications.

Treatment of Anginal Pain

Treatment of anginal pain is a priority nursing concern.

Patient is to stop all activity and sit or rest in bed.

Assess the patient while performing other necessary interventions. Assessment includes VS, observation for respiratory distress, and assessment of pain. In the hospital setting, the ECG is assessed or obtained.

Administer oxygen.Administer medications as ordered or by

protocol, usually NTG.

AnxietyUse a calm mannerStress-reduction techniquesPatient teachingAddressing patient spiritual needs may assist

in allaying anxietiesAddress both patient and family needs

Patient TeachingLifestyle changes and reduction of risk factors Explore, recognize, and adapt behaviors to

avoid to reduce the incidence of episodes of ischemia.

Teaching regarding disease processMedicationsStress reductionWhen to seek emergency careSee Chart 28-7

Myocardial InfarctionMyocardium is permanently destroyed.Caused by reduced blood flow in a coronary

artery due to rupture of an atherosclerotic plaque and subsequent occlusion of the artery by a thrombus.

In unstable angina, the plaque ruptures but the artery is not completely occluded.

Unstable angina and acute myocardial infarction are considered the same process but at different point on the continuum.

The term “acute coronary syndrome” includes unstable angina and myocardial infarction.

Effects of Ischemia, Injury, and Infarction on ECG

Clinical Manifestations and DiagnosisChest pain, other symptoms

See Chart 28-8ECGLaboratory tests--biomarkers

See Table 28-3CK-MBMyoglobinTroponin T or I

Treatment of Acute MI (See Chart 28-9)Obtain diagnostic tests including ECG within

10 minutes of admission to the ED.OxygenAspirin, nitroglycerin, morphine, beta-blockersAngiotensin-converting enzyme inhibitor within

24 hoursEvaluate for percutaneous coronary

intervention or thrombolytic therapy.As indicated; IV heparin or LMWH, clopidogrel

or ticlopidine, glycoprotein IIb/IIIa inhibitorBed rest

Nursing Process: The Care of the Patient with ACS: AssessmentA vital component of nursing care!See Chart 28-8.Assess all symptoms carefully and compare to

previous and baseline data to detect any changes or complications.

Assess IVs.Monitor ECG.

Nursing Process: The Care of the Patient with ACS: DiagnosisIneffective cardiac tissue perfusionRisk for fluid imbalanceRisk for ineffective peripheral tissue

perfusionDeath anxietyDeficient knowledge

Collaborative ProblemsAcute pulmonary edemaHeart failureCardiogenic shockDysrhythmias and cardiac arrestPericardial effusion and cardiac tamponade

Nursing Process: The Care of the Patient with ACS: Planning

Goalsrelief of pain or ischemic signs and symptoms, prevention of further myocardial damage, absence of respiratory dysfunction, maintenance of or attainment of adequate

tissue perfusion, reduced anxiety, adherence to the self-care program, absence or early recognition of complications.

Percutaneous Coronary Intervention

Coronary Artery Bypass Grafts

Greater and lesser saphenous veins are commonly used for bypass graft procedures.

Cardiopulmonary Bypass System

Postoperative Care of the Cardiac Surgical Patient

Valvular DisordersRegurgitation: the valve does not close

properly and blood backflows through the valve

Stenosis: the valve does not open completely and blood flow through the valve is reduced

Valve prolapse: the stretching of an atrioventricular valve leaflet into the atrium during diastole

Specific Valvular DisordersMitral valve prolapseMitral regurgitationMitral stenosisAortic regurgitationAortic stenosis

Pathophysiology: Left Heart Failure as a Result of Aortic and Mitral Valvular Heart Disease

Valve Repair and Replacement ProceduresValvuloplasty

Commissurotomy: open or closedBalloon valvuloplasty: open or closedAnnuloplastyLeaflet repairChordoplasty

Valve replacement

Balloon Valvuloplasty

Annuloplasty Ring Insertion

Valve Leaflet Resection and Repair with Ring Annuloplasty

Valve Replacement

Types of Replacement ValvesMechanical valves

Do not deteriorate or become infected as easily, but are thrombogenic and require life-long anticoagulation therapy.

Tissue (biologic) valvesXenograft (heterograft): pig or cow valveHomograft (allograft): human valveAutograft: patient’s own valve

Mechanical Valves

CardiomyopathyCardiomyopathy is a series of progressive

events that culminates in impaired cardiac output and can lead to heart failure, sudden death, or dysrhythmias.

Types: Dilated cardiomyopathyHypertrophic cardiomyopathyRestrictive cardiomyopathyArrhythmogenic cardiomyopathyUnclassified cardiomyopathies

Types of Cardiomyopathy

Infectious Diseases of the HeartAny of the layers of the heart may be affected

by an infectious process.Diseases are named by the layer of the heart

that is affected.Diagnosis is made by patient symptoms and

echocardiogram.Blood cultures may be used to identify the

infectious agent and to monitor therapy.Treatment is with appropriate antimicrobial

therapy. Patients need to be instructed to complete the course of appropriate antimicrobial therapy, and require teaching about infection prevention and health promotion.

Rheumatic EndocarditisOccurs most often in school-age children, after

group A beta-hemolytic streptococcal pharyngitisInjury to heart tissue is caused by inflammatory

or sensitivity reaction to the streptococci.Myocardial and pericardial tissue is also

affected, but endocarditis results in permanent changes in the valves.

Need to promptly recognize and treat “strep” throat to prevent rheumatic fever. See Chart 29-1.

Infective EndocarditisA microbial infection of the endothelial surface

of the heart. Vegetative growths occur and may embolize to tissues throughout the body.

Usually develops in people with prosthetic heart valves or structural cardiac defects. Also occurs in patients who are IV drug abusers and in those with debilitating diseases, indwelling catheters, or prolonged IV therapy. See Chart 29-2.

Types:Acute Subacute

PericarditisInflammation of the pericardiumMany causes

See Chart 29-3Nursing diagnosis: pain Potential complications

Pericardial effusionCardiac tamponade

Antibiotic ProphylaxisMechanical valve replacements including annuloplasty

or other prosthetic materialValvular defects including mitral click and murmur or

mitral regurgitation, mitral stenosis, aortic stenosis, and aortic regurgitation

A history of rheumatic heart disease, endocarditis, or myocarditis

Antibiotic prophylaxis is required for dental procedures and surgical interventions, including GU and GI procedures, to prevent endocarditis.

Heart FailureThe inability of the heart to pump sufficient blood to

meet the needs of the tissues for oxygen and nutrientsA syndrome characterized by fluid overload or

inadequate tissue perfusionThe term HF indicates myocardial disease, in which

there is a problem with the contraction of the heart (systolic failure) or filling of the heart (diastolic failure).

Some cases are reversible.Most HF is a progressive, lifelong disorder managed

with lifestyle changes and medications.

Pathophysiology of HF

Clinical Manifestations (See Chart 30-1)Right-sided failure

RV cannot eject sufficient amounts of blood, and blood backs up in the venous system. This resuts in perpheral edema, hepatomegaly, ascites, anorexia, nausea, weakness, and weight gain.

Left-sided failureLV cannot pump blood effectively to the systemic

circulation. Pulmonary venous pressures increase, resulting in pulmonary congestion with dyspnea, cough, crackles, and impaired oxygen exchange.

Chronic HF is frequently biventricular.

Classification of Heart FailureNYHA classification of HF

Classification I, II, III, IVACC/AHA classification of HF

Stages A, B, C, DTreatment guidelines are in place for each

stage.

Medical Management of HFEliminate or reduce etiologic or contributory

factors.Reduce the workload of the heart by reducing

afterload and preload.Optimize all therapeutic regimens.Prevent exacerbations of HF.Medications are routinely prescribed for HF.

MedicationsAngiotensin-converting enzyme inhibitorsAngiotensin II receptor blockersBeta-blockersDiureticsDigitalisOther medications

Nursing Process: The Care of the Patient with HF: AssessmentHealth historySleep and activityKnowledge and coping Physical exam

Mental statusLung sounds: crackles and wheezesHeart sounds: S3Fluid status/signs of fluid overload

Daily weight and I&OAssess responses to medications

Nursing Process: The Care of the Patient with HF: DiagnosisActivity intolerance and fatigueExcess fluid volumeAnxietyPowerlessnessNoncompliance

Collaborative Problems/Potential ComplicationsCardiogenic shockDysrhythmiasThromboembolismPericardial effusion and cardiac tamponade

Nursing Process: The Care of the Patient with HF: PlanningGoals may include promoting activity and

reducing fatigue, relieving fluid overload symptoms, decreasing anxiety or increasing the patient’s ability to manage anxiety, encouraging the patient to make decisions and influence outcomes, teaching the patient about the self-care program.

Activity IntoleranceBed rest for acute exacerbationsEncourage regular physical activity; 30-45 minutes daily Exercise training Pacing of activitiesWait 2 hours after eating before doing physical activity. Avoid activities in extremely hot, cold, or humid weather. Modify activities to conserve energy.Positioning; elevation of HOB to facilitate breathing and

rest, support of arms

Fluid Volume ExcessAssessment for symptoms of fluid overload Daily weightI&O Diuretic therapy; timing of medsFluid intake; fluid restrictionMaintenance of sodium restriction

See Chart 30-4

Patient TeachingMedicationsDiet: low-sodium diet and fluid restrictionMonitoring for signs of excess fluid, hypotension, and

symptoms of disease exacerbation, including daily weight

Exercise and activity programStress managementPrevention of infectionKnow how and when to contact health care providerInclude family in teaching

Pulmonary EdemaAcute event in which the LV cannot handle an overload of

blood volume. Pressure increases in the pulmonary vasculature, causing fluid to move out of the pulmonary capillaries and into the interstitial space of the lungs and alveoli.

Results in hypoxemiaClinical manifestations: restlessness, anxiety, dyspnea, cool

and clammy skin, cyanosis, weak and rapid pulse, cough, lung congestion (moist, noisy respirations), increased sputum production (sputum may be frothy and blood-tinged), decreased level of consciousness

Management of Pulmonary EdemaPreventionEarly recognition: monitor lung sounds and for

signs of decreased activity tolerance and increased fluid retention

Place patient upright and dangle legs.Minimize exertion and stress. OxygenMedications

MorphineDiuretic (furosemide)

Cardiogenic ShockA life-threatening condition with a high

mortality rateDecreased CO leads to inadequate tissue

perfusion and initiation of shock syndrome.Clinical manifestations: symptoms of HF,

shock state, and hypoxia

Pathophysiology of Cardiogenic Shock

Management of Cardiogenic ShockCorrect underlying problemMedications

Diuretics Positive inotropic agents and vasopressors

Circulatory assist devicesIntra-aortic balloon pump (IABP)

Intra-Aortic Balloon Pump

ThromboembolismDecreased mobility and decreased circulation

increase the risk for thromboembolism in patients with cardiac disorders, including those with HF.

Pulmonary embolism: blood clot from the legs moves to obstruct the pulmonary vesselsThe most common thromboembolic problem with

HFPreventionTreatmentAnticoagulant therapy

Pulmonary Emboli

Pericardial Effusion and Cardiac TamponadePericardial effusion is the accumulation of fluid in the pericardial sac.Cardiac tamponade is the restriction of heart function due to this fluid, resulting in decreased venous return and decreased CO.Clinical manifestations: ill-defined chest pain or fullness, pulsus parodoxus, engorged neck veins, labile or low BP, shortness of breath Cardinal signs of cardiac tamponade: falling systolic BP, narrowing pulse pressure, rising venous pressure, distant heart soundsSee Chart 30-6

Assessing for Cardiac Tamponade

Medical ManagementPericardiocentesisPericardiotomy

Sudden Cardiac Death/Cardiac ArrestEmergency management: cardiopulmonary

resuscitationA- airwayB- breathingC- circulationD- defibrillation for VT and VF

Vascular SystemArteries and arteriolesCapillariesVeins and venulesLymphatic vesselsFunction of the vascular system

Systemic and Pulmonary Circulation

Peripheral Blood FlowFlow rate = ΔP/RMovement of fluid across the capillary wall;

hydrostatic and osmotic forceHemodynamic resistance

Blood viscosityVessel diameter

Regulation of peripheral vascular resistance

Assessment Characteristics of arterial and venous

insufficiencySee Table 31-1

Intermittent claudicationRest painChanges in skin and appearancePulsesAging changes

Assessing Peripheral Pulses

Peroneal, Dorsalis Pedis, and Posterior Tibial Pulse Sites

Continuous-wave Doppler ultrasound detects blood flow, combined with computation of ankle or arm pressures; this diagnostic technique helps characterize the nature of peripheral vascular disease.

Color Flow Duplex Image

Nursing Process: The Care of the Patient with Peripheral Arterial Insufficiency: AssessmentHealth history Medications Risk factorsSigns and symptoms of arterial insufficiencyClaudication and rest painColor changesWeak or absent pulsesSkin changes and skin breakdown

Nursing Process: The Care of the Patient with Peripheral Arterial Insufficiency: DiagnosisAltered peripheral tissue perfusionChronic painRisk for impaired skin integrityKnowledge deficiency

Nursing Process: The Care of the Patient with Peripheral Arterial Insufficiency: PlanningMajor goals include increased arterial blood

supply, promotion of vasodilatation, prevention of vascular compression, relief of pain, attainment or maintenance of tissue integrity, and adherence to self-care program.

Improving Peripheral Arterial CirculationExercises and activities: walking, graded

isometric exercises. Consult primary health care provider before prescribing an exercise routine.

Positioning strategiesTemperature; effects of heat and coldSmoking cessationStress reduction

Maintaining Tissue IntegrityProtection of extremities and avoidance of

traumaRegular inspection of extremities with

referral for treatment and follow-up for any evidence of infection or inflammation

Good nutrition, low-fat dietWeight reduction as necessary

Progression of Atherosclerosis

Common Sites of Atherosclerotic Obstruction

Risk Factors for Atherosclerosis and PVD Modifiable NonmodifiableNicotineDietHypertensionDiabetesObesity StressSedentary lifestyleC-reactive proteinHyperhomcysteinemia

Age GenderFamilial

predisposition/genetics

Medical ManagementPreventionExercise programMedicationsPentoxifylline (Trental) and cilostazol (Pletal) Use of antiplatelet agentsSurgical management

Buerger’s Disease: Thromboangiitis ObliteransRecurring inflammatory process of the small and

intermediate vessels of (usually) the lower extremities; probably an autoimmune disorder

Most often occurs in men ages 20-35Risk or aggravating factor: tobacco Progressive occlusion of vessels results in pain,

ischemic changes, ulcerations, and gangrene.

Raynaud's DiseaseIntermittent arterial vaso-occlusion, usually of the fingertips or toesRaynaud's phenomenon is associated with other underlying disease, such as scleroderma.Manifestations: sudden vasoconstriction results in color changes, numbness, tingling, and burning painEpisodes are usually brought on by a trigger such as cold or stress.Occurs most frequently in young womenProtect from cold/other triggers. Avoid injury to hands/fingers.

Other DisordersAortoiliac diseaseAneurysms

Thoracic aortic aneurysmAbdominal aortic aneurysm

Aortic dissection

Aortoiliac Endarterectomy

Characteristics of Arterial Aneurysms

Repair of an Ascending Aortic Aneurysm

AneuRx Endograft Repair of Abdominal Aortic Aneurysm

Venous ThrombusPathophysiologyRisk factors

See Chart 31-6Endothelial damageVenous stasisAltered coagulation

ManifestationsDeep veinsSuperficial veins

Blood flow and function of valves in veins. Note impaired blood return due to incompetent valve.

Preventive MeasuresElastic hosePneumatic compression devicesSubcutaneous heparin or LMWH, warfarin

(Coumadin) for extended therapy Positioning: periodic elevation of lower

extremitiesExercises: active and passive limb exercises,

deep-breathing exercisesEarly ambulationAvoid sitting/standing for prolonged periods;

walk 10 minutes every 1-2 hours.

Nursing Process: The Care of the Patient with Leg Ulcers: AssessmentHistory of the conditionTreatment depends upon the type of ulcer.Assess for presence of infection.Assess nutrition.

Arterial Ulcer, Gangrene Due to Arterial Insufficiency, and Ulcer Due to Venous Stasis

Medical ManagementAnti-infective therapy is dependent upon

infecting agent.Oral antibiotics are usually prescribed.

Compression therapyDébridement of woundDressingsOther

Nursing Process: The Care of the Patient with Leg Ulcers: DiagnosisImpaired skin integrityImpaired physical mobilityImbalanced nutrition

Collaborative Problems/Potential ComplicationsInfection Gangrene

Nursing Process: The Care of the Patient with Leg Ulcers: PlanningMajor goals include restoration of skin

integrity, improved physical mobility, adequate nutrition, and absence of complications.

MobilityWith leg ulcers, activity is usually initially

restricted to promote healing.Gradual progression of activityActivity to promote blood flow; encourage

patient to move about in bed and exercise upper extremities.

Diversional activitiesPain medication prior to activities

Other InterventionsSkin integrity

Skin care/hygiene and wound carePositioning of legs to promote circulationAvoidance of trauma

NutritionMeasures to ensure adequate nutritionAdequate protein, vitamins C and A, iron, and zinc

are especially important for wound healing.Include cultural considerations and patient

teaching in the dietary plan.

Cellulitis and Lymphatic DisordersCellulitis: infection and swelling of skin tissues Lymphangitis: inflammation/infection of the

lymphatic channelsLymphadenitis: inflammation/infection of the

lymph nodes Lymphedema: tissue swelling related to

obstruction of lymphatic flowPrimary: congenitalSecondary: acquired obstruction

Blood Pressure = Cardiac Output x Peripheral Resistance

Cardiac Output = Heart Rate x Stroke Volume

Hypertension AKA High blood pressureDefined by the Seventh Report of the Joint National

Commission on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) as a systolic pressure greater than 140 mm Hg and a diastolic pressure greater than 90 mm Hg, based on the average of two or more accurate blood pressure measurements taken during two or more contacts with a health care provider (Chobanian, Bakris, Black, et al., 2003).

Classification of Blood Pressure for Adults Age 18 and Older

Incidence of Hypertension- “The Silent Killer”Primary hypertensionSecondary hypertension28-31% of the adult population of the U.S.

have hypertension. 90-95% of this population with hypertension

have primary hypertension.Incidence is greater in southeastern U.S. and

among African-Americans.

Factors Involved in the Control of Blood Pressure

Factors that Influence the Development of Hypertension Increased sympathetic nervous system

activityIncreased reabsorption of sodium, chloride

and water by the kidneysIncreased activity of the renin-angiotensin

systemDecreased vasodilatationInsulin resistance

Manifestations of HypertensionUsually NO symptoms other than elevated

blood pressureSymptoms seen related to organ damage are

seen late and are serious: Retinal and other eye changesRenal damage Myocardial infarctionCardiac hypertrophyStroke

Major Risk Factors HypertensionSmokingObesityPhysical inactivityDyslipidemiaDiabetes mellitusMicroalbuminuria or GFR <60Older ageFamily history

Patient AssessmentHistory and PhysicalLaboratory tests

UrinalysisBlood chemistryCholesterol levels

ECG

Recommendations for Follow-up Based on Initial Blood Pressure Readings

Persons with diabetes mellitus or chronic renal disease as evidenced by a reduced GFR or an elevated serum creatinine have a lower goal pressure of 130/80 (JNC 7).

JNC 7 Treatment Algorithm

Lifestyle ModificationsWeight lossReduced alcohol intakeReduced sodium intakeRegular physical activityDiet: high in fruits, vegetables, and low-fat

dairyDASH diet

DASH Diet

Medication TreatmentUsually initial medication treatment is a diuretic,

a beta blocker, or both.Low doses are initiated and the medication

dosage is increased gradually if blood pressure does not reach target goal.

Additional medications are added if needed.Multiple medications may be needed to control

blood pressure.Lifestyle changes initiated to control BP must be

maintained.

Medication Therapy for HypertensionDiuretic and related drugs

Thiazide diureticsLoop diureticsPotassium-sparing diureticsAldosterone receptor blockers

Central Alpha2-Agonists and other centrally acting drugs

Beta blockersBeta blockers with intrinsic sympathomimetic

activityAlpha and beta blockers

Medication Therapy for Hypertension (continued)VasodilatorsAngiotensin-converting enzyme (ACE)

inhibitorsAngiotensin II antagonistsCalcium channel blockers

NondihydropyridinesDihydropyridines

Nursing History and AssessmentHistory and risk factorsAssess potential symptoms of target organ

damageAngina, shortness of breath, altered speech, altered

vision, nosebleeds, headaches, dizziness, balance problems, nocturia

Cardiovascular assessment: apical and peripheral pulses

Personal, social, and financial factors that will influence the condition or its treatment

Goals:Patient understanding of disease process.Patient understanding of treatment regimen.Patient participation in self-care.Absence of complications.

Nursing DiagnosesKnowledge deficit regarding the relation of

the treatment regimen and control of the disease process.

Noncompliance with therapeutic regimen related to side effects of prescribed therapy.

InterventionsPatient teachingSupport adherence to the treatment regimenConsultation/collaboration Follow-up careEmphasize control rather than cure Reinforce and support lifestyle changesA lifelong process

Gerontologic ConsiderationsNoncomplianceInclude familyUnderstanding of therapeutic regimen

Reading instructionsMonotherapy

Hypertensive CrisesHypertensive emergency

Blood pressure >180/120 and must be lowered immediately to prevent damage to target organs.

Hypertensive urgency Blood pressure is very high but no evidence of

immediate or progressive target organ damage.

Hypertensive EmergencyReduce BP 25% in first hourReduce to 160/100 over 6 hoursThen gradual reduction to normal over a period

of daysExceptions are ischemic stroke and aortic

dissectionMedications

IV vasodilators: sodium nitroprusside, nicardipine, fenoldopam mesylate, enalaprilat, nitroglycerin

Need very frequent monitoring of BP and cardiovascular status

Hypertensive UrgencyPatient requires close monitoring of blood

pressure and cardiovascular status.Assess for potential evidence of target organ

damage. Medications

Fast-acting oral agents: beta-adrenergic blocker- labetalol; angiotensin-converting enzyme inhibitors: captopril or alpha2-agonists-clonidine

Hematologic SystemThe blood and the blood forming sites, including the

bone marrow and the reticuloendothelial system

Blood

Plasma

Blood cells

Hematopoiesis

Blood Cells Erythrocyte: RBCLeukocyte: WBC

NeutrophilMonocyteEosinophil Basophil Lymphocyte: T lymphocyte and B lymphocyte

Thrombocyte: platelet

Blood Smear

Hematopoiesis

Hemostasis

AnemiasLower-than-normal hemoglobin and fewer-than-normal

circulating erythrocytes are signs of an underlying disorderHypoproliferative: defect in production of RBCs

Due to iron, vitamin B12 or folate deficiency, decreased erythropoietin production, and cancer

Hemolytic: excess destruction of RBCs Due to altered erythropoiesis, or other causes such as

hypersplenism, drug-induced or autoimmune processes, mechanical heart valves

May also be due to blood loss

ManifestationsDepend upon the rapidity of the development of the

anemia, duration of the anemia, metabolic requirements of the patient, concurrent problems, and concomitant features

Fatigue, weakness, and malaisePallor and jaundice Cardiac and respiratory symptomsTongue changesNail changes Angular cheilosis Pica

Medical ManagementCorrect or control the causeProvide transfusion of packed RBCsTreatment is specific to the type of anemia:

Dietary therapy Iron or vitamin supplementation: iron, folate, B12 BMT or PBSCT Immunosuppressive therapy Other

Nursing Process—Assessment of the Patient With Anemia

Health history and physical examLaboratory dataPresence of symptoms and impact of those

symptoms on the patient’s life: fatigue, weakness, malaise, pain

Nutritional assessment MedicationsCardiac and GI assessments Blood loss: menses and potential GI lossNeurologic assessment

Nursing Process—Diagnosing the Patient With Anemia

Fatigue

Altered nutrition

Altered tissue perfusion

Noncompliance with prescribed therapy

Collaborative Problems/Potential Complications

Heart failure

Angina

Paresthesias

Confusion

Nursing Process—Planning the Care of the Patient With Anemia

Major goals include decreased fatigue, attainment or maintenance of adequate nutrition, maintenance of adequate tissue perfusion, compliance with prescribed therapy, and absence of complications

InterventionsBalance physical activity, exercise, and rest

Maintain adequate nutrition

Provide patient education to promote compliance with medications and nutrition

Monitor VS and pulse oximetry and provide supplemental oxygen as needed

Monitor for potential complications

Leukemia Hematopoietic malignancy with unregulated

proliferation of leukocytes

Types:

Acute myeloid leukemia

Chronic myeloid leukemia

Acute lymphocytic leukemia

Chronic lymphocytic leukemia

Acute Myeloid Leukemia (AML)Defect in the stem cells that differentiate into all myeloid

cells: monocytes, granulocytes, erythrocytes, and platelets

Most common nonlymphocytic leukemiaAffects all ages with peak incidence at age 60Prognosis is variableManifestations: fever and infection, weakness and

fatigue, bleeding tendencies, pain from enlarged liver or spleen, hyperplasia of gums, and bone pain

Treatment is aggressive chemotherapy: induction therapy, BMT, and PBSCT

Chronic Myeloid Leukemia (CML) Mutation in myeloid stem cell with uncontrolled proliferation of

cells: Philadelphia chromosome Stages: chronic phase, transformational phase, blast crisis Uncommon in people under 20; incidence increases with age;

mean age is 55 to 60 years Life expectancy is 3 to 5 years Manifestations (initially may be asymptomatic): malaise; anorexia;

weight loss; confusion or shortness of breath due to leukostasis; enlarged, tender spleen; enlarged liver

Treatment: imatinib mesylate (Gleevec) blocks signals in leukemic cells that express BCR-ABL protein; chemotherapy, BMT, and PBSCT

Acute Lymphocytic LeukemiaUncontrolled proliferation of immature cells from lymphoid

stem cellMost common in young children, boys more often than girlsPrognosis is good for children; 80% event-free after 5 years,

but survival drops with increased ageManifestations: leukemic cell infiltration is more common

with this leukemia with symptoms of meningeal involvement and liver, spleen, and bone marrow pain

Treatment: chemotherapy, imatinib mesylate (if Philadelphia chromosome positive), BMT or PBSCT, and monoclonal antibody therapy

Chronic Lymphocytic LeukemiaMalignant B lymphocytes, most of which are

mature, may escape apoptosis, resulting in excessive accumulation of cells

Most common form of leukemiaMore common in older adults and affects men

more oftenSurvival varies from 2 to 14 years depending

upon stage

Chronic Lymphocytic Leukemia (cont.)

Manifestations: lymphadenopathy, hepatomegaly, splenomegaly; in later stages, anemias and thrombocytopenia; autoimmune complications with RES destroying RBCs and platelets may occur; B symptoms include fever, sweats, and weight loss

Treatment: early stage may require no treatment, chemotherapy, or monoclonal antibody therapy

Nursing Process—Assessment of the Patient With Leukemia

Health historyAssess for symptoms of leukemia and complications

of anemia, infection, and bleeding Weakness and fatigue See Charts 33-8 and 33-9

Laboratory tests Leukocyte count, ANC, hematocrit, platelets,

electrolytes, and cultures reports

Nursing Process—Diagnosis of the Patient With Leukemia

Risk for bleedingRisk for impaired skin integrityImpaired gas exchangeImpaired mucous membraneImbalanced nutritionAcute painHyperthermiaFatigue and activity intoleranceImpaired physical mobility

Nursing Process—Diagnosis of the Patient With Leukemia (cont.)

Risk for excess fluid volume

DiarrheaRisk for deficient fluid

volumeSelf-care deficitAnxietyDisturbed body imagePotential for spiritual

distressGrieving diagnosesDeficient knowledge

Collaborative Problems/Potential Complications

InfectionBleedingRenal dysfunctionTumor lysis syndromeNutritional depletionMucositisDepression

Nursing Process—Planning the Care of the

Patient With LeukemiaMajor goals include absence of complications,

attainment and maintenance of adequate nutrition, activity tolerance, ability for self-care and to cope with the diagnosis and prognosis, positive body image, and an understanding of the disease process and its treatment

InterventionsSee Charts 33-8 and 33-9 for interventions

related to risk of infection and bleedingMucositis

Frequent, gentle oral hygieneSoft toothbrush, or if counts are low, sponge-

tipped applicatorsRinse only with NS, NS and baking soda, or

prescribed solutions Perineal and rectal care

Improving NutritionProvide oral care before and after meals

Administer analgesics before meals

Provide appropriate treatment of nausea

Provide small, frequent feedings with soft foods that are moderate in temperature

Provide a low-microbial diet

Provide nutritional supplements

LymphomaNeoplasm of lymph origin

Hodgkin’s lymphoma

Non-Hodgkin’s lymphoma

Hodgkin’s DiseaseUnicentric originReed–Sternberg cell Suspected viral etiology; familial pattern; incidence

occurs in early 20s and again after age 50Excellent cure rate with treatmentManifestations: painless lymph node enlargement;

pruritus; B symptoms such as fever, sweats, and weight loss

Treatment is determined by stage of the disease and may include chemotherapy and/or radiation therapy

Non-Hodgkin's Lymphoma (NHL)Lymphoid tissues become infiltrated with malignant

cells that spread unpredictably; localized disease is rare

Incidence increases with age; the average age of onset is 50 to 60

Prognosis varies with the type of NHLTreatment is determined by type and stage of disease

and may include interferon, chemotherapy, and/or radiation therapy

Multiple MyelomaMalignant disease of plasma cells in the bone marrow with

destruction of boneM protein and Bence-Jones proteinMedian survival is 3 to 5 years; there is no cureManifestations: bone pain, osteoporosis, fractures,

elevated serum protein hypocalcemia, renal damage, renal failure, symptoms of anemia, fatigue, weakness, increased serum viscosity, and increased risk for bleeding and infection

Treatment may include chemotherapy, corticosteroids, radiation therapy, and biphosphonates

Bleeding DisordersPrimary thrombocythemiaThrombocytopeniaIdiopathic thrombocytopenia purpura (ITP)HemophiliaAcquired coagulation disorders: liver disease,

anticoagulants, and vitamin K deficiencyDisseminated intravascular coagulation (DIC)Bleeding precautions

See Chart 33-9

Disseminated Intravascular CoagulationNot a disease but a sign of an underlying disorderSeverity is variable; may be life-threatening Triggers may include sepsis, trauma, shock, cancer abruptio

placentae, toxins, and allergic reactionsAltered hemostasis mechanism causes massive clotting in

microcirculation; as clotting factors are consumed, bleeding occurs; symptoms are related to tissue ischemia and bleeding

Laboratory tests; see Table 33-5 Treatment: treat underlying cause, correct tissue ischemia,

replace fluids and electrolytes, maintain blood pressure, replace coagulation factors, and use heparin

Nursing Process—Assessment of the Patient With DIC

Be aware of patients who are at risk for DIC and assess for signs and symptoms of the condition

Assess for signs and symptoms and progression of thrombi and bleeding

See Chart 33-13

Nursing Process—Diagnosis of the Patient With DIC

Risk for fluid volume deficiency

Risk for impaired skin integrity

Risk for imbalanced fluid volume

Ineffective tissue perfusion

Death anxiety

Collaborative Problems/Potential Complications

Renal failure

Gangrene

Pulmonary embolism or hemorrhage

Acute respiratory distress syndrome

Stroke

Nursing Process--Planning the Care of the Patient With DIC

Major goals include maintenance of hemodynamic status, maintenance of intact skin and oral mucosa, maintenance of fluid balance, maintenance of tissue perfusion, enhanced coping, and absence of complications

InterventionsAssessment and interventions should target

potential sites of organ damage

Monitor and assess carefully

Avoid trauma and procedures that increase the risk of bleeding, including activities that increase intracranial pressure

See Chart 33-14

Therapies for Blood DisordersAnticoagulant therapy

Splenectomy

Therapeutic apheresis

Therapeutic phlebotomy

Blood component therapy

Blood Transfusion AdministrationSee Charts 33-17 and 33-18Review patient history including history of

transfusions and transfusion reactions; note concurrent health problems and obtain baseline assessment and VS

Perform patient teaching and obtain consentEquipment: IV (20 gauge or greater for PRBCs),

appropriate tubing, and normal saline solutionProcedure to identify patient and blood productMonitoring of patient and VS Postprocedure careNursing management of adverse reactions

ComplicationsFebrile nonhemolytic reactionAcute hemolytic reactionAllergic reactionCirculatory overloadBacterial contaminationTransfusion-related acute lung injuryDelayed hemolytic reactionDisease acquisitionComplications of long-term transfusion therapy