Microsoft Power Point Cardiovascular Disorders Ebi

CARDIOVASCULAR CARDIOVASCULAR CARDIOVASCULAR CARDIOVASCULAR CARDIOVASCULAR CARDIOVASCULAR CARDIOVASCULAR CARDIOVASCULAR

DISORDERSDISORDERSDISORDERSDISORDERSDISORDERSDISORDERSDISORDERSDISORDERSDISORDERSDISORDERSDISORDERSDISORDERSDISORDERSDISORDERSDISORDERSDISORDERS

NIO C. NOVENO, RN, MANNIO C. NOVENO, RN, MANNIO C. NOVENO, RN, MANNIO C. NOVENO, RN, MANNIO C. NOVENO, RN, MANNIO C. NOVENO, RN, MANNIO C. NOVENO, RN, MANNIO C. NOVENO, RN, MAN

FOR HANDOUTS: www.slideshare.com/nionoveno

Overview Overview

Anatomy & Physiology Review

Physical Assessment

Diagnostics/Procedures

Psychosocial Impact of CV Disorders

2

Psychosocial Impact of CV Disorders

Risk Factors

Nursing Diagnoses

CV Disorders

Evaluation

II♥♥U:U: The human heartThe human heart

� Pericardium

� Fibrous

� Serous: Parietal &

3

Serous: Parietal & visceral

� Pericardial cavity with fluid


� Apex

� Downward, forward, &

� 5th left ICS, 9 cm from the midline

to the leftto the left

4

5 left ICS, 9 cm from the midline

� Wall Layers

� Epicardium

� Myocardium

� Endocardium

Somebody tell me..

Does the heartDoes the heart

rest on its base?rest on its base?

5

rest on its base?rest on its base?

I’ve been told..

The heart does not rest on its baseThe heart does not rest on its base

but on its diaphragmaticbut on its diaphragmatic

6

but on its diaphragmaticbut on its diaphragmatic

(inferior) surface.(inferior) surface.


� Right atrium� Main cavity & an auricle

� Openings: Venae cavae & coronary

sinus

7

sinus

� Fossa ovalis ☺

� SA & AV nodes?


� Right ventricle� Crescentic in x/s

� Trabeculae carneae: Papillary muscles

8

� Chordae tendinae

� Infundibulum

� Tricuspid & pulmonary valves


� Left atrium� Main cavity & an auricle

� Behind the right atrium

9

� Forms the greater part of the base

� Openings: Pulmonary veins ☺


� Left ventricle� Walls 3x thicker than the right’s

� Internal pressure 6x greater

� Circular in x/s

10

� Circular in x/s

� Trabeculae carneae

� Chordae tendinae

� Aortic vestibule

� Mitral & aortic valves


NVS

� Cardiac plexuses: Sympathetic & parasympathetic fibers

11

� Coronary aa. off the aortic sinuses of the ascending aorta

� Cardiac vv. into the coronary sinus

Pop Quiz, Hotshot!Pop Quiz, Hotshot!

Which of the following structures doesNOT form the anterior surface ofthe heart?

12

A. Left atrium

B. Right atrium

C. Right auricle

D. Left ventricle

E. Right ventricle

Pop Quiz, Hotshot!Pop Quiz, Hotshot!

Which of the following structures doesNOT form the anterior surface ofthe heart?

13

A. Left atrium

B. Right atrium

C. Right auricle

D. Left ventricle

E. Right ventricle

Round & Round: CirculationRound & Round: Circulation

Fire Away!Fire Away!

[Cardiac conduction system][Cardiac conduction system]

Cardiac CycleCardiac Cycle

MAP =MAP =

Venous

Preload Contractility 1/Afterload

HR x SV

CO x TPRCO x TPR

Water intake (GI)Water output

(renal)

=

Venous

return

Venous

tone

Total blood

volume

MAPMAP SBP + 2(DBP)SBP + 2(DBP)33==

== 70 70 –– 105 mm Hg105 mm Hg

== ICPICP + + CPPCPP== ICPICP + + CPPCPP10 10 –– 20 mm Hg [ICP]20 mm Hg [ICP]

70 70 –– 80 mm Hg [CPP]80 mm Hg [CPP]

Intra Cranial PressureIntra Cranial Pressure

Cerebral Perfusion PressureCerebral Perfusion Pressure

Diagnostic Assessment Diagnostic Assessment

19

Diagnostic Assessment Diagnostic Assessment

DIAGNOSTIC ASSESSMENT

� Chest x-ray

� Fluoroscopy

� Cardiac Enzymes

� LDH - elevated in 48 hrs

� SGOT

20

� SGOT

� CPK – elevated 4-24 hrs

� CPK-MM [skeletal muscles]

� CPK-BB [brain]

� CPK-MB [myocardium, cardio-specific]

� Electrocardiography [ECG] – electrical activity

� Echocardiography [Ultrasound cardiography]

CARDIAC ENZYMES

Enzymes ONSET PEAKRETURN TO

NORMAL

CK 3-6 h 24 h 72-96 h

CPK-MB 4-6 24 72

LDH1st day

[24 h]3rd-4th day

Gradually

subsides

LDH1; LDH2 4 h 48 h

AST [SGOT] 2nd-4th day

DIAGNOSTIC ASSESSMENT

� Stress test (treadmill)

� Transesophageal echocardiography [TEE]

� Angiocardiography

� Positron Emission Tomography [PET]

22

� Positron Emission Tomography [PET]

� Coronary Arteriography

� Cardiac catheterization

� Hemodynamic monitoring

ELECTROCARDIOGRAPHYELECTROCARDIOGRAPHY

Rhythm Regular

Rate 60 – 100 bpm

P wave

Upright and rounded

Amplitude: < 0.25 mV

Duration: 0.06 – 0.11 sec

ST segment

Isoelectric (0 – 0.1 mV)

T wave

Upright and rounded

Amplitude:

< 0.5 mV in leads I – III

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Duration: 0.06 – 0.11 sec

Consistent in size and shape

Exists for every QRS complex

PR interval 0.12 – 0.20 sec

QRS complex 0.06 – 0.10

< 0.5 mV in leads I – III

< 0.1 mV in leads V1 – V6

QT interval 0.36 – 0.44 sec

Others: No ectopic or abberantly conducted impulses.

ELECTROCARDIOGRAPHYELECTROCARDIOGRAPHY

24

ECHOCARDIOGRAPHYECHOCARDIOGRAPHY

Coronary Arteriography

Introduction of radiopaque

catheter into brachial or

femoral artery [arteriotomy w/

percutaneous puncture] to

ascending aorta to coronary

artery for fluoroscopy

25

artery for fluoroscopy

� Nursing Intervention

� NPO

� Vital signs

� Check for bleeding at

puncture site

� Check color of extremity

and pulses

Cardiac Catheterization

� Measures O2 conc., saturation,

tension & pressure of heart

chambers

� Detects shunts, heart output &

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� Detects shunts, heart output &

pulmonary outflow

� Right CC: antecubital v → VC

→ R A&V → Pulm a.

� Left CC: brachia/femoral a →aorta → R V

Cardiac Catheterization

� Nursing Interventions

� Before: NPO, allergic hx, mark distal pulse, instruct

pt thudding sensations in chest & strong desire to

cough and transient heat

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cough and transient heat

� After: VS, peripheral pulses, site, chest pain, bed rest for 12-24hrs;

Femoral site – bleeding, inflammation, tenderness,

apply sandbag & ice on site, HOB >30°, avoid flexing femoral region

Hemodynamic MonitoringAssessment of circulatory status

� Central Venous Pressure [CVP] (N= 5-12 cms H2O)

� Catheter into external jugular vein → antecubital

or femoral v. → vena cava

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� Provides information on blood volume & adequacy

of venous return

� Reveals right atrial pressure

� Route for drawing blood samples, administration of

fluids or meds and pacing

CVP

29

Hemodynamic Monitoring (CVP)

Nursing Interventions

� Pt. in supine. Changes in position, coughing or

straining during reading may result to inaccuracies of

readings

� Zero point of manometer should be at a level with the

30

� Zero point of manometer should be at a level with the

pt’s R atrium (midaxillary line)

� To measure CVP: turn stopcock so that IV solution

flows into manometer filling to about 20-25cm level,

then turn stopcock to let flow the solution in the

manometer into pt.

� Observe the fall in the height of column of fluid in

manometer. Read where it stops.

Hemodynamic Monitoring

Swan-Ganz Pressure (N=5-12 cms H2O)

� Catheter into external jugular vein/subclavian →superior vena cava → R atrium → tricuspid valve → R

vent → pulm a. → pulm capillary [pulm capillary

wedge pressure]

31

wedge pressure]

� Interpretations of Pressure Readings:

Pulmonary Artery Pressure [PAP]: 10-20 mmHg;

- increased in pts w/ chronic pulmonary disease & CHF

Pulmonary Capillary Wedge Pressure: 4-12 mmHg

- indicative of pressure in the L cardiac chambers

Swan-Ganz Procedure

32

PAWP CATHETER

The PRESSUREPRESSURE Guidelines

ressure monitor

ise slowly to � orthostatic hypotension

ating must be considered

tay on medications

PP

RR

EE

SS

33

tay on medications

topping or skipping is discouraged

ndesirable responses

emind to exercise & to stop alcohol

liminate smoking; educate

SS

SS

UU

RR

EE

� Laboratory test of a blood sample

� Analysis of major electrolytes, cholesterol,

triglycerides, uric acid, bicarbonate,

creatinine, BUN, bilirubin, CK, LD, LD

Blood chemistryBlood chemistry

34

creatinine, BUN, bilirubin, CK, LD, LD

isoenzymes, troponin I, trop T, AST, ALT

� Note any drugs that may alter results

� Restrict exercise

� Withhold IM injections, food & fluids

� Assess site for bleeding

FBS 70 – 110 mg/dL

RBS < 200

BUN 8 – 20

Crea 0.5 – 2.0

CHONs

Total 6.4 – 8.3 g/dL

Na+ 135 – 145 mEq/L

K+ 3.5 – 5.5

Cl- 98 – 106

Mg+ 1.3 – 2.1

CO2 20 – 30

HCO3- 20 – 30

Ca2+ 4.5 – 5

Blood chemistryBlood chemistry

35

Total 6.4 – 8.3 g/dL

Albu 3.5 – 5.0

Globu 2.5 – 3.5

A/G 1.5:1 – 2.5:1

Bilirubin

Total 0.2 – 1.0 mg/dL

Direct < 0.3

Indirect < 0.8

Ca 4.5 – 5

9 – 11 mg/dL

PO4- 2.5 – 4.5

AST/SGOT 5 – 40 U/mL

ALT/SGPT 5 – 35

Osmolality 280 – 300 mOsm/kg

COAGULATION STUDIESCOAGULATION STUDIES

BT 1 – 9 min

CT 5 – 15

PT 11 – 12.5 sec

PTT 60 – 70

APTT 30 – 40

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APTT 30 – 40

TT 8 – 12

CRT 50 % in 2 hrs

Fibrinogen 200 – 400 mg/dL

Plasminogen 2.5 – 4.5 mmol/mL

LIPID PANELLIPID PANEL

Choles < 200 mg/dL

HDLs

M > 45

F >55

37

F >55

LDLs 60 – 180

VLDLs 25 – 50

TGs

M 40 – 160

F 35 – 135

CARDIAC ENZYMES

AST/SGOT 5 – 40 U/mL

CPK

M 12 – 70

F 10 – 55

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CPK-MB 0 %

LDH 45 – 90 U/L

Myoglobin < 85 ng/mL

Troponin I < 0.03

Troponin T < 0.2

CRP < 0.8 mg/dL

HEMATOLOGY

RBCs

M 4.7 - 6.1 x106/mm3

F 4.2 - 5.4

WBCs 5,000 – 10,000N 55 – 70 %L 20 – 40M 2 – 8E 1 – 4B 0.5 – 1

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Hgb M 14 – 18 g/dL

F 12 – 16

Hct M 42 – 52 %

F 37 – 47

B 0.5 – 1

Platelets

150,000 – 400,000/mm3

ABG analysisABG analysis

� Test of arterial blood for oxygenation, ventilation, and acid-base status

� Before the procedure:� Document temperature

� Note patient’s need

40

� Note patient’s need

� Perform Allen’s test

� Avoid a limb with a shunt

� After the procedure:� Check site for bleeding

� Maintain pressure dressing

� Check peripheral pulses of the affected limb

ABGs

pH 7.35 – 7.45

PCO2 35 – 45 mmHg

PO2 80 – 100

41

PO2 80 – 100

HCO3- 21 – 28 mEq/L

AG 8 – 16

SPO2 95 – 100 %

BE 0 – 2

AcidAcid--Base DisturbancesBase Disturbances

Disturbance pH pCO2 [HCO3-] Compensation

(mEq/L) (mmHg)

Respiratory acidosis < 7.35 ↑ N ↑ HCO3-

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↑ ↑ 3

Respiratory alkalosis > 7.45 ↓ N ↓ HCO3-

Metabolic acidosis < 7.35 N ↓ ↓ pCO2

Hypervent

Metabolic alkalosis > 7.45 N ↑ ↑ pCO2

Hypovent

Pharmacology Pharmacology

43

Pharmacology Pharmacology

Nitroglycerin

MOA:

Relaxes vascular

smooth system, ↓

myocardial demand

Interventions:

Monitor BP & AP

Have client sit or lie

down (first time)

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myocardial demand

for O2, ↓ LV preload

by dilating veins, thus

indeirectly ↓

afterload

down (first time)

NO defibrillation over

area of nitro patch

Assist during ambulation

Nitroglycerin

Health Teachings

Oral: Take on an empty stomach, with a glass of water.

SL

45

SL

�Take at first sign of anginal pain

�Take every 5 mins to a maximum of 3 doses

�If NO relief, seek MD

�Stinging or biting sensation reflects potency

�Protect from light, moisture and heat

Transderm patch: OD in AM; Rotate sites

Lidocaine

MOA: decreases cardiac excitability, cardiac conduction is delayed in the atrium or ventricle

Undesirable effects:� ↓ or ↑ HR

Drug interactions:

�↑ effects with Phenytoin, Procainamide,

46

� ↓ or ↑ HR

� ↓ BP

� Confusion� Drowsiness (1st sign of

toxicity)

� Dizziness� Nausea, vomiting

� Seizures (severe toxicity)

� Cardiac arrest

Procainamide, Propranolol, quinidine,

�↑ risk of toxicity with ß-adrenergic blockers, cimetidine

Lidocaine

Interventions

�Give I.V.

�Monitor serum levels: 1.5-5 mcg/ml

�Monitor EKG, BP, PR

47

�Monitor EKG, BP, PR

�Monitor I & O

�Do not mix syringes with cefazolin and amphotericin B

�Have Dopamine available for circulatory collapse

�Assist and provide safety

ACE Inhibitors

MOA: suppress the RAAS; blocks the conversion of angiotensin I to angiotensin II

Interactions:� Probenecid: ↓ elimination

�NSAIDs: hypotensive effect

�Other anti-HTN: ↑hypotensive effects

Hyperkalemia

48

Undesirable effects:

�Gastric irritation

�Headache

�Dizziness

�↑ HR

�Angioedema

�Hyperkalemia

�Hyperkalemia

Interventions:� Assess for renal function

�Do not give with food

�Do not take potassium-rich foods

ACE Inhibitors

S VR/PVR decreased

Treatment for MI

Release of aldosterone is low

C ough; contraindicated in renal artery stenosis

Hypotension;

49

is low

Occult diabetic nephropathy

LVD after MI is low

Hypotension; hyperlipidemia

F ood has less taste; WOF hypotension

Angiotensin II receptor blockers (ARBs)

MOA: blocks angiotensin II from binding with angiotensin receptors; lowering BP

Administer without regard

to meals

Renal function tests –

review

50

BP

Information:�Same with ACE inhibitors

review

B locks vasoconstriction

effect of RAAS

S alt substitution or

potassium supplements is

not allowed

Alpha adrenergic blockers

MOA: blocks alpha1

adrenergic receptors resulting in vasodilation of arteries and veins; decreases PVR; relaxes smooth muscles of bladder and prostate

S yncope; sexual dysfunction

I ncreased drowsiness; orthostatic hypotension,

51

smooth muscles of bladder and prostate

Undesirable effects:� Same as other anti-HTN

meds

� WOF: 1st dose syncope

� 2-3 H post initial dose

orthostatic hypotension, HR

Need to be recumbent for 3-4 H after initial dose

Beta adrenergic blockers

MOA: blocks ß1 (heart) or ß2 (lungs) receptors to prevent the release of catecholamines; decreases contractility, renin release and sympathetic output

Bradycardia

Lipidemia/libido �

brOnchospasm

CHF; conduction abnormalities

52

sympathetic output

Caution: �COPD�CHF� Sinus bradycardia� Heart block� DM

abnormalities

Konstriction, peripheral vascular

Exhaustion; emotional depression

Reduces glucose

Calcium channel blockers

MOA: blocks Ca2+ influx into the cells causing decreased contractility, decreased PVR and low BP

Interventions:

� Elevate extremity affected

53

low BP

Undesirable effects:� Hypotension

� Headache

� Dizziness

� Peripheral edema

� Constipation

affected

� Increased dietary fiber; increase OFI

� Take with meals or milk

Central alpha2 agonist

MOA: decreases release of adrenergic hormones from the brain resulting in a

C ontrols release of adrenergic hormones

A dverse effects: low BP, hepatotoxicity, hemolytic anemia

T ransient drowsiness

54

hormones from the brain resulting in a decrease PVR, hence BP

T ransient drowsiness

A rterial pressure is lowered

P aradoxical HTN with

propranolol

R ecord baseline VS

E valuate weight and liver function

S lowly taper the doses

Vasodilators

MOA: direct

relaxation of

vascular smooth

muscles,

decreases

D ilates vascular muscles

I ncreases renal and cerebral flow

L upus-like reaction (fever, facial rash, muscle and joint ache, splenomegaly)

55

decreases

afterload

joint ache, splenomegaly)

A ssess for peripheral edema

T ake with food

O ther SE: headache, dizziness, anorexia, tachycardia, hypotension

R eview BP

DD iet high in K+ for all except aldactone

II ntake and output daily

UU ndesirable effects: F&E imbalance

RR eview HR, BP

EE lderly with caution

56

EE lderly with caution

TT ake with or after meals in AM

II ncreased risk of orthostatic hypotension; move slowly

CCancel alcohol

DigitalisDD ig therapeutic level: 0.5 – 2ng/ml

II ncreases myocardial contractility

GGastrointestinal or CNS signs

First signs of toxicity: � Adult: ANV

� Older child: upset stomach

� Elderly: vertigo, headache,

Nursing responsibilities

� Check for drug level

� Check K+, Mg+, Ca2+

� Eat rich sources of K+

� Low Na+ diet

57

� Elderly: vertigo, headache, depression, muscle weakness, drowsiness & confusion

Other signs:� Bradycardia

� ECG changes (heart block)

� Photophobia

� Yellow-green halos around visual images

� Flashes of light

� Low Na diet

� Check apical pulse

� Do not give with antacids (1

t0 2 H apart)

� Caution with use of CCB

and BB

� Monitor I & O; WOF signs of

CHF

Cholestyramine (Questran);

Colestipol (Colestid)

Bile acid sequestrant

LDL IS ↓ 15-30%

I

58

INCREASE FLUID & FIBER

PT MONITORING (BLEEDING)

INCREASE GI DISTRESS: CONSTIPATION, NV

DECREASES ABSORTION OF MANY MEDS

Clofibrate (Atromid-S)

Gemfibrozil (Lopid)

Anti-triglyceredemia

LIVER OR RENAL DISEASE [WARNING!!!]

INCREASE EFFECT OF: WARFARIN & SULFONYLUREAS

59

I

VLDL; LDL; CHOLESTEROL & TRIGLYCERIDES CHECK

ENCOURAGE DIET LOW IN FAT, CHOLESTEROL, SUGARS

RESTRICT ALCOHOL

ThrombolyticsThrombolytics[Streptokinase (Stretase), Urokinase (Abbokinase)]

Action: binds with plasminogen causing conversion to

plasmin, which dissolves blood clots

Indication: thrombosis

CBC, Hb, HCT

LOOK FOR

DYSRHYTHMIAS

OBSERVE BLEEDING

TIMELY VS

60

Undesirable effects: headache, nausea, rash, fever,

bleeding, hemorrhage, allergic reaction, hypotension

Health teachings:

� Increased risk for bleeding with other anti-

coagulants and NSAIDS

� Initiate bleeding protocol measures

HEPARIN

PTT 1.5-2.5 x control

Protamine sulfate

IV or SQ

ASPIRIN

TIA, CVA, MI

WOF bleeding

Take with water.

ANTICOAGULANTSANTICOAGULANTS

61

IV or SQ

Keep from

bleeding

COUMADIN

PTT 1.5-2.5 x control

Vitamin K

GAS & ROPE

Chamomile, gingko, ginseng, garlic, ginger

HEPARINHEPARIN COUMADINCOUMADIN ASAASA

ACTION

Combines with

antithrombin III to retard

thrombin activity; blocks

F Xa & IIa

Interferes with the

hepatic synthesis of

Vit K; F VII, IX, X

Platelet

aggregation

inhibitor; inhibits

thromboxane A2, a

vasoconsctrictor &

inducer of platelet

aggregation

INDICATION ThrombosisSlows extension of a

blood clot

Reduces risk of

death from MI

UNDESIRABLE Hematuria, bleeding AND, rash bleeding, GI discomforts,

62

UNDESIRABLE EFFECTS

Hematuria, bleeding

gums, frank

hemorrhage

AND, rash bleeding,

hematuria,

thrombocytopenia

GI discomforts,

bleeding, dizziness,

tinnitus

CONSIDERATIONS

PTT: 1.5-2.5Xcontrol; will

return to baseline 1-2 H

Antidote: Protamine SO4

Use electric razors, soft

bristle toothbrush, 5-min

pressure

GAS: effect

ROPE: �� effect

risk of bleeding:

chamomile, garlic,

ginko and ginseng

PT: 1.5-2.5xcontrol

Avoid Vit K-rich

foods

Take with full glass

of water.

Cardiovascular DisordersCardiovascular Disorders

63

Cardiovascular DisordersCardiovascular Disorders

OXYGENATION (Cardiovascular)

CORONARY ARTERY DISEASE or Coronary Ischemic HD

Myocardial impairment due to imbalance

between coronary blood flow myocardial O2

demand

64

demand

Manifested as:

Ischemia [Angina Pectoris] – reversible

Infarction – irreversible

Ischemia – reversible if myocardial blood

flow is ↑ or the need for the demand is ↓may progress to infarction


Angina Pectoris

Chest pain associated w/ transient myocardial

ischemia

Causes:

66

Causes:

Atherosclerosis – most common

Vasospasm

Aortic stenosis

Kinds:

Stable [Effort] AP

Unstable [Preinfarction] AP

ASSESSMENT OF PAIN

PProvoking / Precipitating / PalliativeQQuality

RRegion / Radiation

67

RRegion / RadiationSSeverityTTiming


Angina Pectoris

Signs & Symptoms:Substernal or precordial pain radiating to L shoulder lasting for 3-5 mins, relieved by restHeaviness, tightness, squeezing precipitated by exertion, emotion and exposure to cold

68

exertion, emotion and exposure to coldVS may be normal

Diagnostic Tests:Nitroglycerine test – relieves painBlood chemistry - ↑ cholesterolStress test, abnormal ECG – inverted T-wavesCardiac enzymes – NCoronary arteriography – plaque accumulation


Angina Pectoris

Nursing Intervention↑ O2 to the myocardium & relief of acute attacksAdminister meds as ordered.

Short & long acting nitrates [NG]β-adrenergic agonists [Propranolol]

69

β-adrenergic agonists [Propranolol]Reducing demand for O2

Limit activities, moderate exerciseSedatives, tranquilizers, antidepressants

Helping client prevent future attacksDiet – low calorie, saturated fat5-6 small frequent feedingsDaily exercise; avoid cold environment, smoking


Myocardial Infarction

Life threatening condition caused by

occlusion of coronary artery or its branches

leading to death of myocardial cells

70

Causes:

Atherosclerosis

Thrombus

Embolus

Coronary artery spasm


71


72



Signs & Symptoms:Steady constrictive substernal chest pain, sever, not relieved by rest & NitroglycerineSymptoms of shock, increase in tempNausea & vomiting, diaphoresis, pallor

73

Nausea & vomiting, diaphoresis, pallorAnxiety and apprehension

Management:Provide rest – CBR, use bedside commodeRelieve pain – demerol or morphineO2 by mask, cannula or nasal catheterECG monitoringIVF to KVO



Management:

Diuretics

β-adrenergic agonistsAnti-arrhythmics [Procainamide, Lidocaine]

74

Anti-arrhythmics [Procainamide, Lidocaine]

Diet: no iced or very hot drinks, may

precipitate arrhythmias, no gas-forming foods

Mild laxatives, stool softeners

If due to thrombus: give

Thrombolytics [Streptokinase]

Follow up therapy w/ anticoagulant

Heparin, Coumadin, ASA, Dicumarol


CONGESTIVE HEART FAILURE (CHF)

Inability of the heart to pump blood from the

ventricles as quickly as it enters the atria leading

to congestion in the lungs & systemic circulation

75

to congestion in the lungs & systemic circulation

Causes:

inflow of blood → heart is greatly reduced

inflow of blood → heart is greatly increased

outflow of blood from the heart is obstructed

myocardial damage

increased metabolic state



Cardiac Compensatory Mechanisms:

Ventricular dilatation

Ventricular hypertrophy

76

Ventricular hypertrophy

Tachycardia

Forms of CHF:

Left ventricular failure

Right ventricular failure

Clinical ManifestationsClinical Manifestations

LeftLeft--sided HFsided HF RightRight--sided HFsided HF

Forward EffectsForward Effects

Weakness, fatigue,

mental confusion,

insomnia, anxiety, oliguria

� Volume to the lungs

78

insomnia, anxiety, oliguria

Backward EffectsBackward Effects

Breathlessness, cough,

orthopnea, crackles,

PCWP, frothy sputum

Ankle/pretibial edema,

ascites, hepatomegaly,

splenomegaly, anorexia,

JV distention, wt gain,

CVP

Congestive Heart Failure

79



Interventions:

Improve ventricular pump performance

Inotropic agents [Digitalis]

Administer O2 therapy

Reduce myocardial workload

81

Reduce myocardial workload

Preload:

Administer diuretics

Restrict fluid & Na intake

Upright position

Phlebotomy

Afterload:

Vasodilators

Reduce physical and emotional stress


ACUTE PULMONARY EDEMA

Complication of L-sided HF

Edema results from the heart’s inability to pump

adequately

82

adequately

Results in impaired oxygenation & hypoxia

Causes:

Heart failure

Atherosclerosis

Valvular disease



Assessment findings:

• Dyspnea

• Paroxysmal cough

• Blood-tinged frothy sputum

83

• Blood-tinged frothy sputum

• Orthopnea

• Restlessness

Diagnostic test findings:

CXR: interstitial edema

ABGs: respiratory alkalosis or acidosis

ECG: tachycardia, ventricular enlargementEMODYNAMICS: ↑ PAWP, CVP, ↓ CO



Medical management:

Low-sodium diet; limit fluids

O2 therapy

High-Fowler’s position

84

High-Fowler’s position

VS, I/O, ECG, & hemodynamics

Analgesics

Vasodilators

Cardiac inotropes & glycosides

Nitrates

Bronchodilators

Pulse oximetry



Nursing management:

Assess CV & respiratory status

Withhold food & fluid

Provide:

85

Provide:

Suctioning

Turning

Coughing

Deep breathing

Keep in High-Fowler’s

Allay anxiety

Note the color, amount & consistency of

sputum



Home instructions:

• Recognize the signs of fluid overload &

respiratory distress

Sleep with the head of the bed elevated

86

• Sleep with the head of the bed elevated

Complications:

Digitalis toxicity

Fluid overload

Pulmonary embolism

Hypokalemia

Hyernatremia


CARDIOGENIC SHOCK

Failure of the heart to pump adequately,

thereby educing the CO & compromising tissue

perfusion

87

Causes:

MI

Myocarditis

Advanced heart block

Heart failure

Metabolic abnormalities

Cardiac tamponade

Pulmonary embolus


CARDIOGENIC SHOCK


Hypotension

SBP <90 mm Hg

Oliguria:

88

Oliguria:

<30 mL/H

Cold, clammy, pale skin

Tachycardia

Restlessness

Diagnostic findings:

ABGs:metabolic acidosis, hypoxemia

ECG: MI (enlarge Q wave, ST elevation)

Injury � Myocardial

contractility HR� SV

� LV

emptying

� Coronary

artery perfusion

Myocardial Preload

LV dilation &

backup of blood

CARDIOGENIC SHOCK

89

Compensation

Decompensation

& death

� COMyocardial

hypoxia

�Myocardial

contractility

Preload

Pulmonary

congestion


CARDIOGENIC SHOCK

Management:

O2 therapy

Semi-Fowler’s position

90


Intra-aortic balloon pump

Diuretics

Vasodilators

Cardiac inotropes

Vasopressors

Adrenergic agents


CARDIOGENIC SHOCK

Nursing management:

Administer:

IVF, O , medications

91

IVF, O2, medications

Assess CV, respiratory status, & fluid balance

Monitor & record:

VS

I/O

Hemodynamics

LOC

Lab values


CARDIOGENIC SHOCK

Complications:

• Arrhythmias

Cardiac arrest

92

• Cardiac arrest

• Infection

Surgical interventions:

CABG

Heart transplantation


MITRAL STENOSIS

Narrowing of the mitral valve opening

Due to:

Rheumatic endocarditis

Congenital


• Fatigue

94

• Fatigue

• Dyspnea on exertion

• Peripheral edema

• Orthopnea


CXR: enlargement of the LA & RV; pulmonary

congestion

ECHOCARDIOGRAM: thickened mitral valve & LA

enlargement


MITRAL STENOSIS

Management:

Low-sodium diet; fluid restrictions


95


Cardiac glycosides

Nitrates

Diuretics

Anti-arrhythmics

Ani-coagulants

Antibiotics


MITRAL STENOSIS

Nursing management:

Administer:


96


Assess CV & respiratory response

Monitor & record:

VS

I/O

Hemodynamics

ECG readings

Lab values


MITRAL STENOSIS

Home care:� Signs & symptoms� Activity limitations� Infection control� Occult blood

Surgery:� Valve

replacement� Open mitral

commissurotomy

97

� Occult blood

Complications:ThrombosisEmbolismHFAtrial fibrillation

commissurotomy


MITRAL INSUFFICIENCY

Incomplete closure of the mitral valve

Due to:↑ LA pressure

Pulmonary HTN

LA hypertrophy

98

LA hypertrophy


• Fatigue


• Peripheral edema

• Angina pectoris

• Orthopnea




ECHOCARDIOGRAM: enlarged LA,

abnormal movement of the mitral valveCARDIAC CATH: ↑ LA pressure & ↑ LV pressure

99

Management:

Low-sodium diet; fluid restrictions


Cardiac glycosides

Nitrates

Diuretics

Anti-arrhythmics

Ani-coagulants



Nursing management:

Maintain on diet; limit OFI

Keep on semi-Fowler’s position

100

Keep on semi-Fowler’s position

Assess peripheral edema


AORTIC STENOSIS

Narrowing of the aortic valve

Lower CO leads to increased congestion

in the lungs causing RSHF

101

Causes:

Syphilis

Rheumatic fever

Atherosclerosis

Congenital malformations


AORTIC STENOSIS


• Angina pectoris

• Pulmonary HTN

• LSHF

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• LSHF

• Orthopnea


ECG: L bundle branch block, 10 heart block,

LV hypertrophy

ECHOCARDIOGRAM: thickened LV wall,

thickened aortic valve that moves

abnormally


AORTIC STENOSIS

Medical management:

• Low-sodium diet; fluid

restrictions

• Monitor lab studies

• Cardiac glycosides

Nursing management:

• Maintain on diet

• Limit OFI

• Assess CV & respi status

• Monitor & record:

103


• Nitrates

• Diuretics

• Anti-arrhythmics

• Percutaneous

transluminal

valvuloplasty

• Monitor & record:

VS , I/O,

Hemodynamics,

ECG readings, Lab

values


AORTIC STENOSIS

Complications:

• HF

• Pulmonary edema

104

• Pulmonary edema

Surgery:

Aortic valve replacement

Commissurotomy


AORTIC INSUFFICIENCY

Retrograde flow of blood from the aorta to the

LV

An incomplete closure of the aortic valve

105

An incomplete closure of the aortic valve

Causes:

Syphilis

Rheumatic fever

Infective endocarditis

Atherosclerosis

Congenital defect




• Signs of LSHF


106


• Dizziness

• Angina pectoris


CXR: enlarged LV, aortic valve calcification

ECHOCARDIOGRAM: LV enlargement,

abnormal valve movement



Medical management:

• Low-sodium diet; fluid

restrictions

• Antibiotics

Nursing management:

Maintain on diet; limit

OFI

Assess CV & respi status

107

• Antibiotics


• Nitrates

• Diuretics

• ACE inhibitors

• Anti-arrhythmics

• Percutaneous

transluminal

valvuloplasty

Assess CV & respi status

Monitor & record:

VS , I/O,

Hemodynamics,

ECG readings, Lab

values



Complications:

• HF

• Thrombosis

108

• Thrombosis

• Embolism

• Infection

Surgery:

Valvuloplasty

Valve replacement


ARTERIAL OCCLUSIVE

DISEASE

Obstruction or

narrowing of the

aorta’s lumen & its

major branches

Causes:

Atherosclerosis

Emboli

Thrombosis

Trauma or

fracture

109

major branches

Reduced perfusion

Obstruction:

endogenous or

exogenous

fracture

Risk factors:

Age

DM

Family history

Hyperlipidemia

HTN

Smoking


ARTERIAL OCCLUSIVE DISEASE


Femoral, popliteal or innominate arteries:↓ decreased distal pulses

Mottling & pallor

110

Mottling & pallor

Paralysis & paresthesia

Sudden & localized pain*

Internal & external carotid arteries:

stroke., TIA

Subclavian:

Subclavian steal syndrome

Vertebral & basilar:

TIA



Angiography findings:

The type (thrombus or embolus), location, &

degree of obstruction

Collateral circulation

111

Collateral circulation

Medications:

Antilipemics

Antiplatelets

Pentoxyfilline

Anticoagulants

Throbolytics



Nursing management:

Assess distal pulses, skin color, & temperature

Assess pain & give analgesics

112

Assess pain & give analgesics

Administer IV fluids, O2, & medications as Rx

Monitor for signs of stroke


ABDOMINAL AORTIC ANEURYSM

Dilation of or localized weakness in the medial

layer of an abdominal artery

Causes: Atherosclerosis, HTN, smoking

4 types:

Saccular – unilateral, pouch-like bulge

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1. Saccular – unilateral, pouch-like bulge

2. Fusiform – spindle-shaped bulge;

encompasses entire diameter of the vessel

3. Dissecting – hemorrhagic separation of the

medial layer of vessel wall; creates a false

lumen

4. False – pulsating hematoma; often mistaken

for an abdominal aneurysm


ABDOMINAL AORTIC ANEURYSM

114


PERIPHERAL VASCULAR DISEASEChronic inadequate blood flow in the lower

extremities

Types:

1. Arteriosclerosis obliterans – sclerosis of arterioles

resulting in thickening of the walls & occlusion

115

resulting in thickening of the walls & occlusion

2. Raynaud’s phenomenon – intermittent

vasoconstriction & ischemia of fingers & toes

accompanied by pallor & cyanosis

3. Buerger’s disease (thromboangiitis obliterans) –

inflammation of BV resulting in occlusion of the

vessel

Causes: Atherosclerosis, vasospasm, inflammation


PERIPHERAL VASCULAR DISEASE

Assessment findings:Intermittent claudicationPain at restTrophic changes: thickened nails, absence of hair, & taut skinDiminished or absent pulses in extremities (unilateral)

116

Diminished or absent pulses in extremities (unilateral)Temperature changes in extremitiesColor changes:

Rubor, cyanosis, pallorUlcerations in extremities

Diagnostic findings:ARTERIOGRAPHY: location of obstructionDOPPLER STUDIES: decreased blood flow & arterial pressure



117

Buerger’s disease

Raynaud’s phenomenon


PERIPHERAL VASCULAR

DISEASE

Management:

• Active ROM &

isometric

Nursing management:

Assess for:

Pulses

118

isometric

exercises

• Antiplatelet

agents

• Vasodilators

• Anticoagulants

• Antilipemics

Pulses

Color

Temperature

Complaints of

abnormal

sensations

Numbness

or tingling



Home care:Symptoms of ↓ peripheral circulation

Skin breakdown

119

Skin breakdown

Foot care

Avoid stress

Prolonged standing

Extremes of temperature

Constrictive clothing

Crossing legs at knee when seated



Complication:

• Gangrene

• Septicemia

• Pressure sores

120

• Pressure sores

• Acute vascular occlusion

Surgery:

Bypass grafting

Endarterectomy

Sympathectomy

Amputation

Embolectomy


THROMBOPHLEBITIS

Massing of RBCs in a fibrin network

Obstruction by enlarged thrombus

Results to inflammation of the venous wall causing

clots to form

Causes:

121

Causes:

Venous stasis

Varicose veins, pregnancy, HF, prolonged

bed rest

Hypercoagulability

Cancer, blood dyscrasias, oral contraceptives

Injury to venous wall

IV, fractures, antibiotics


THROMBOPHLEBITIS


SUPERFICIAL VEINS:

Red, warm skin

DEEP VEINS:

Major venous trunks:

Edema

122

Edema

(+) Homans sign

Tenderness

Cyanosis

Venous distention

SMALL VEINS:

Tenderness

Induration

Minimal to no distention


THROMBOPHLEBITIS


VENOGRAPHY/ PHLEBOGRAPHY : venous filling

defectsUTZ: ↓ blood flow

Management:

Activity limitation

123

Activity limitation

Antiembolism stockings

Anticoagulants

Nursing management:

Assess for Homans sign

Apply warm, moist compress

Measure & record circumference of thighs & calves

Keep patient I bed & elevate extremities


THROMBOPHLEBITIS

Complications:

• Pulmonary embolism

• Stroke

124

• Stroke

Surgical intervention:

Vena cava filter

Vein ligation & stripping

Thrombectomy




Asymptomatic

Lower abdominal pain, lower back pain

Abdominal mass to the left of the midline

Abdominal pulsations

125

Abdominal pulsations

Bruits


Apparent on CXR, abdominal UTZ,

aortography

Medications:

Analgesics

ß-blockers



Nursing management:

Check peripheral circulation

Observe for signs of shock:

Anxiety

126

Anxiety

Restlessness

Decreased pulse pressure

Increased thready pulse

Pale, cool, moist, clammy skin

Palpate abdomen for distention

Teach signs & symptoms of decreased

peripheral circulation



Complication:

Rupture of aneurysm

Hemorrhage

127

Hemorrhage

Renal insufficiency

Surgery:

Resection of aneurysm

Endovascular graft repair


CARDIOMYOPATHY

Disease of the heart’s muscle impacting the

structure & function of the ventricle

Heart failure develops later

Myocardium becomes flabby

128

Types:

1. Congestive (dilated) – chronic alcoholism

2. Hypertrophic – idiopathic hypertrophic

subaortic stenosis

Pressure overload hypertension or aortic

valve stenosis

Hypertrophic cardiomyopathy

3. Restrictive (obliterative) – amyloidosis, cancer


CARDIOMYOPATHY

Major manifestations:

• Dyspnea

• Dry cough

• Fatigue

129

• Fatigue

• Palpitations

• Weakness


ECG: LV hypertrophy

ECHOCARDIOGRAM: decreased myocardial

function

CXR: cardiomegaly


CARDIOMYOPATHY

Management:

• Low-sodium diet; fluid restrictions

• LV assist device

• Diuretics

ß-blockers

130

• ß-blockers

• Anticoagulants

• CCBs

• ACE inhibitors

Nursing management:

Keep in semi-Fowler’s position

Monitor ECG results

Administer O2 & medications


CARDIOMYOPATHY

Home care:

Signs & symptoms of HF

Weigh daily: Report increments of 3 lbs.

Demonstrate exercises to increase CO

Refrain from smoking & drinking alcohol

131

Refrain from smoking & drinking alcohol

Complications:

• Heart failure

• Arterial emboli

Surgery:

Ventricular myomectomy

Heart transplant


ENDOCARDITISEndocardial lining inflammation

Destruction of heart valve leaflets

Causes:

132

Causes:

ß-hemolytic strep infections

S. aureus, Candida, G(-)

Rheumatic heart disease

Dental procedures

Invasive monitoring

IV drug abuse


ENDOCARDITIS


• Elevated temperature

• Heart murmur


• BLOOD CULTURES: (+) microorganisms

133

• BLOOD CULTURES: (+) microorganisms

• ECHOCARDIOGRAPHY: valvular damage,

vegetations

Medical management:

Antibiotics

(+) inotropic agents

Antipyretics

Anticoagulants


ENDOCARDITIS

Nursing management:

• Administer medications

• Asses CV status

• Encourage rest periods

Home care:

Complications:

• Embolism

• HF

• Mycotic aneurysm

134

Home care:

• Avoid infections

• Monitor for infections

specially after dental or

gynecologic exam;

seek treatment

• Wear ID

Surgery:

Valve replacement


PERICARDITIS

Inflammation of the pericardium

May be: fibrinous or effusive

Causes:

Infection

135

Infection

Neoplasms

High dose radiation to the chest

Hypersensitivity or autoimmune disease

Hydralazine or procainamide

Postcardiac injury

Aortic aneurysm

Myxedema


PERICARDITIS


Pain characteristics:

Sharp, usually sudden over the sternum

Radiates to the neck, shoulders, back &

137

Radiates to the neck, shoulders, back &

arms

Increases with deep inspiration or when

lying down

Decreases when sitting up & leaning

forward


PERICARDITIS

Diagnostic findings:ECGElevated ST segmentsQRS segments may be diminished with pericardial effusionRhythm changes may occur:

138

Rhythm changes may occur:Atrial ectopic rhythms – atrial fibrillation & sinus arrhythmia

Echocardiography reveals the problem

Management:Bed as long as fever & pain persistNSAIDSCorticosteroidsAntibiotics


PERICARDITIS

Nursing management:

• Maintain CBR

• Place on upright position

• Monitor & record VS, I/O, & hemodynamics

• Assess pain & give analgesics as Rx

139

Complications:

• Pericardial effusion

• HF

• Chronic RSHF

• Cardiac tamponade

Surgery:

Pericardectomy

CONDUCTION ARRHYTHMIASDisruptions in the normal events

of the cardiac cycle

140

Sinus Tachycardia

HR > 100 beats/min originating from the SA node

(100-160bpm); regular rhythm

Causes

Fever, apprehension, physical activity, anemia,

CONDUCTION ARRHYTHMIAS

141

Fever, apprehension, physical activity, anemia,

hyperthyroidism, epinephrine, caffeine

Management

Correction of underlying cause

No stimulants

Drugs of choice: Propranolol [Inderal], Digoxin

Sinus Bradycardia

HR < 60 beats/min; regular rhythm

Causes

Excessive vagal/or ↓ sympathetic tone

MI, intracranial tumors, meningitis


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MI, intracranial tumors, meningitis

N variation of HR in well-trained athlete

Management

Not needed, unless CO is inadequate

Pharmacotherapy: Atropine, Isuprel

Pacemakers – pulse generator to control

potentially dangerous dysrhythmias

Premature Ventricular Contractions

HR varies according to number of PVCs

Irregular rhythm

Causes

Myocardial dse, CHD, hypoxia

Electrolyte imbalance [hypokalemia]


143

Electrolyte imbalance [hypokalemia]

Digitalis tx, stimulants

Management

IV push Lidocaine, then IV drip

Procainamide [Pronestyl]

Treatment of underlying cause

Atrial Fibrillation

Atrial rate: 35-600bpm

Vent. rate: 100-160 bpm; irregular

May be seen it pts with:

Rheumatic mitral stenosis, thyrotoxicosis,


144

Rheumatic mitral stenosis, thyrotoxicosis,

hypertensive disease, cardiomyopathy,

pericarditis and CHD

Management

Digitalis, Propranolol

Verapamil in conjunction w/ digitalis

Direct-current cardioversion

Ventricular Tachycardia

Run of 3 or more consecutive PVCs

Atrial rate: 60-100bpm

Vent. rate: 110-250bpm

Occasional ventricular irregularity


145

Occasional ventricular irregularity

Causes: Acute MI, CAD, intoxication, hypokalemia

Management

IV push Lidocaine, then IV drip

Procainamide via IV infusion

Propranolol [Inderal], Bretylium

Direct-current cardioversion

CARDIOVASCULAR CARDIOVASCULAR CARDIOVASCULAR CARDIOVASCULAR CARDIOVASCULAR CARDIOVASCULAR CARDIOVASCULAR CARDIOVASCULAR

DISORDERSDISORDERSDISORDERSDISORDERSDISORDERSDISORDERSDISORDERSDISORDERS

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Microsoft Power Point Cardiovascular Disorders Ebi

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