Cardio Part One

CARDIOVASCULAR NCLEX REVIEW PART ONE 1- ANATOMY AND PHYSIOLOGY

Epidemiology 

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worldwide, millions of new cases of rheumatic fever are reported each year rheumatic fever follows a group A streptococcal infection prevention is simply to find and treat streptococcal pharyngitis with malnutrition and crowded living, rheumatic fever is most common in children between the ages of five and 15 rheumatic fever strikes most often during cool, damp weather. In the U.S., it is most common in the northern states no one knows how and why group A streptococcal infections cause the lesions called Aschoff bodies damage depends on site of infection: most often the mitral valve in females and the aortic valve in males malfunction of these valves leads to severe pericarditis, and sometimes pericardial effusion and fatal heart failure. Of those who survive this complication, about 20% die within ten years

Anatomy and Physiology Anatomy 1-Layers 

Pericardium: fibrous sac that encloses the heart

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Epicardium: covers exterior surface of heart muscle

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Myocardium: muscular portion of the heart

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Endocardium: lines cardiac chambers and covers surface of heart valves

Anatomy Continue 2-Chambers of heart ( illustration) 

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Right atrium: collecting chamber for incoming systemic venous system Right ventricle: propels blood into pulmonary system Left atrium: collects blood from pulmonary venous system Left ventricle: largest thick-walled muscle that acts as a highpressure pump which propels blood into the systemic arterial system

Anatomy Continue 3- Heart valves: membranous openings that allow one way blood flow  Atrioventricular valves: prevent backflow from ventricles to atria during systole  Tricuspid - valve between right atrium and right ventricle  Mitral - valve between left atrium and left ventricle  Semilunar valves prevent backflow from aorta and pulmonary arteries into ventricles during diastole  Pulmonic - valve between the right ventricle and pulmonary artery  Aortic - valve between left ventricle and aorta

Anatomy Continue 4- Blood supply to heart  Arteries - coronary  Right supplies right ventricle and the back part of the left ventricle  Left supplies mostly left ventricle and septum  Veins  Coronary sinus - wide venous channel that drains five coronary veins into the right atrium  Thebesian - the smallest coronary veins drain some venous blood directly into the right atrium and ventricle and the left ventricle

Anatomy Continue

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Veins 

Coronary sinus - wide venous channel that drains five coronary veins into the right atrium

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The besian - the smallest coronary veins drain some venous blood directly into the right atrium and ventricle and the left ventricle

Anatomy Continue 5- Conduction system 

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SA (Sinoatrial) node -referred to as the pacemaker of the heart, and located in the right atrium Junctional tissue - often referred to as the atrioventricular node (AV node) Bundle branch Purkinje system - the electrical system located in the septum and into cardiac tissues

Physiology

 Physiology 1-Function of the heart is the transport of oxygen, carbon dioxide, nutrients and waste products

Physiology Continue

2- Cardiac cycle consists of: 

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Systole - The phase of contraction during which the chambers eject blood Diastole - The phase of relaxation during which the chambers fill with blood When the heart pumps, myocardial layers contract and relax The atria and ventricles work in an asynchronous manner

Physiology Continue 3- Blood flow: 

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Deoxygenated blood enters the right atrium through the superior and inferior venae cavae This blood enters the right ventricle through the tricuspid valve Then the blood travels through the pulmonic valve to the pulmonary arteries and into the lungs Oxygenated blood returns from lungs through the pulmonary veins into the left atrium The blood then enters the left ventricle through the bicuspid (mitral) valve Finally, the blood, from the left ventricle, goes through the aortic valve into the aorta and

Physiology Continue:

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The heart itself is supplied with blood by the left and right coronary arteries, which are found at the base of the aorta above the aortic valves

Physiology Continue

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The vascular system is a continuous network of blood vessels  The arterial system consists of arteries, arterioles and capillaries and delivers oxygenated blood and nutrients to tissues  Oxygen, carbon dioxide, nutrients, and metabolic waste are exchanged at the capillary level  The venous system, veins and venules, returns the blood with carbon dioxide and metabolic wastes to the heart

Epidemiology 

Epidemiology 

May be acute or chronic

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May occur at any age

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Pericarditis may occur in up to 15% of persons with a transmural infarction.

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Findings 

Sharp chest pain often relieved by sitting upright and leaning forward

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Pericardial friction rub

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Dyspnea

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Fever, sweating, chills

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Dysrhythmias and EKG changes

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Pulsus paradoxus

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Client cannot lie flat without severe pain or dyspnea

DATA COLLECTION FOR CLIENTS WITH CARDIOVASCULAR DISORDERS

Diagnostics

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Diagnostics  History and physical exam  Serum  increased  white blood cells  sedimentation rate  positive  blood cultures if infection  Antinuclar antibody (ANA) if due to connctive tissue disease  EKG changes on 12-lead  Echocardiography: to determine pericardial effusion or cardiac tamponade

Medical Management

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Medical Management  Antibiotics: to treat underlying infection  Corticosteroids: if no response to NSAID or if effusion  Anti inflammatory/analgesics: NSAID, ASA  Avoid anticoagulants because they may increase the possibility of cardiac tamponade from bleeding risk  Oxygen: to prevent tissue hypoxia  Surgical  Emergency pericardiocentesis if cardiac tamponade develops  For recurrent constrictive pericarditis, partial pericardiectomy (pericardial window) or total pericardiectomy

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Nursing interventions  Manage pain and anxiety  Semi-Fowler's or high-Fowler's position  Mild analgesics to keep pain at 0 to 2; on a scale of 1 to 10  Medications to treat cause

The Cardio-Care Six The Cardio-Care Six THE CARDIO-CARE SIX: A,B,C,D,E,F 

ADL: Help the client with activities of daily living and how to schedule activities that minimize cardiac stress.

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Bed rest

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Commode at bedside (it is less stressful to the heart than using a bedpan)

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Diversions: offer diversions that don't stress the heart (e.g., no hand-held electronic games).

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Elevate head of bed or sit client up to a position of comfort.

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Feelings: plan time for the client to express his concerns.

Client and Family Teaching - Teach the Cardio Five 

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Maintain a pericardiocentesis set at the bedside in case of cardiac tamponade Assess respiratory, cardiovascular, and renal status q 1 to 2 hours in acute phase Observe for pericarditis complications  dysrhythmias  cardiac tamponade  heart failure Observe for signs of infiltration or inflammation at the venipuncture site, a possible complication of long-term IV administration. Rotate the IV sites often.

TEACH THE CARDIO FIVE: TDDDS 

Tests and treatments: discuss them in simple, culturally sensitive ways.

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Drugs, their side effects, how long client will take them, and their expected effects.

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Diet: balanced nutrition and restrictions (such as low sodium).

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Disease, its management, when and what signs to report promptly: the 'watch-for s'.

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Smoker? Stress benefits of stopping smoking, minimization of other stimulants - caffeine, chocolate, nonprescription drugs, herb cautions

 

Myocarditis 

Myocarditis 

Definition - An inflammatory condition of the myocardium

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Epidemiology / Etiology  May be acute or chronic and may occur at any age.  Usually an acute virus and self-limited, but it may lead to acute heart failure.  Etiologies:  Viral infection  Bacterial infection  Fungal infection  Serum sickness  Rheumatic fever  Chemical agent 

As a complication of a collagen disease, i.e. SLE

Myocarditis 

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Findings Depends on the type of infection, degree of myocardial damage, capacity of myocardium to recover, and host resistance May be minor or unnoticed: fatigue and dyspnea, palpitations, occasional precordial discomfort manifested as a mild chest soreness and persistent fever Recent upper-respiratory infection with fever, viral pharyngitis, or tonsillitis Cardiac enlargement Abnormal heart sounds Possibly signs of heart failure such as pulsus alternans, dyspnea and crackles Tachycardia disproportionate to the degree of fever

Myocarditis

Myocarditis Nursing intervention 

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the cardio-care six with modified bedrest and less help with ADLs THE CARDIO-CARE SIX: A,B,C,D,E,F ADL: Help the client with activities of daily living and how to schedule activities that minimize cardiac stress. Bed rest Commode at bedside (it is less stressful to the heart than using a bedpan) Diversions: offer diversions that don't stress the heart (e.g., no hand-held electronic games). Elevate head of bed or sit client up to a position of comfort. Feelings: plan time for the client to express his concerns.  assess for edema ; weigh daily; record intake and output (figure)

Myocarditis 

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assess for edema ; weigh daily; record intake and output monitor cardiovascular status watch for signs of leftsided heart failure (dyspnea, hypotension and tachycardia) check often for changes in cardiac rhythm or conduction monitor arterial blood gas levels as needed to ensure adequate oxygenation

Myocarditis

Endocarditis 

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Definition and related terms  an infection of the endocardium, heart valves, or cardiac prosthesis resulting from bacterial or fungal invasion.  endocarditis can be classified as  native valve endocarditis  endocarditis in I.V. drug users  prosthetic valve endocarditis Epidemiology  with proper treatment about 70% of clients recover.  the prognosis is worse when endocarditis damages valves severely or involves a prosthetic valve  infective endocarditis occurs in 50 to 60% of clients with previous valvular disorders.  systemic lupus erythematosus (SLE) often leads to nonbacterial endocarditis.  in 12% to 35% of clients with subacute endocarditis, lesions produce clots that show the findings of splenic, renal, cerebral or pulmonary infarction, or peripheral vascular occlusion.

Endocarditis

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especially, a murmur that changes suddenly, or a new murmur that develops in the presence of a fever fever pericardial friction rub anorexia malaise clubbing of fingers petechiae of the skin, especially on the chest; conjunctiva, oral mucosa, abdomen splinter hemorrhage under the nails

Endocarditis

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neurologic sequelae of embolus   infarction of spleen: pain in the upper left quadrant of abdomen, radiating to the left shoulder, and abdominal rigidity infarction in kidney: hematuria, pyuria, flank pain, and decreased urine output infarction in brain: hemiparesis, aphasia, and other neurologic deficits infarction in lung: cough, pleuritic pain, pleural friction rub, dyspnea and hemoptysis peripheral vascular occlusion: numbness and tingling in an arm, leg, finger, or toe, or signs of impending peripheral gangrene

SIGNS OF VENOUS INSUFFICIENCY IN THE LOWER EXTREMITIES     

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Skin color reddish brown or cyanotic if extremity lowered Normal temperature Normal pulse Often marked edema, usually foot to calf Brown pigmentation around ankles  Diagnostics  health history  lab data  CBC - elevated WBC  blood cultures - positive for microbe  ESR - elevated  CXR - to detect heart failure or cardiomegaly  transesophageal echocardiogram to detect vegetation and abscesses on valves  EKG to detect dysrhythmias    Management - Clients at risk for prosthetic valves  prophylaxis - to prevent endocarditis; i.e. MVP, cardiac lesions  antibiotics - to treat underlying infection  antipyretics - to control fever  anticoagulants - to prevent embolization  oxygen - to prevent tissue hypoxia  surgical - possible valve replacement

Endocarditis Nursing interventions  the Cardio-Care Six  THE CARDIO-CARE SIX: A,B,C,D,E,F  ADL: Help the client with activities of daily living and how to schedule activities that minimize cardiac stress.  Bed rest  Commode at bedside (it is less stressful to the heart than using a bedpan)  Diversions: offer diversions that don't stress the heart (e.g., no hand-held electronic games).  Elevate head of bed or sit client up to a position of comfort.  Feelings: plan time for the client to express his

Endocarditis 

watch for signs of infiltration or inflammation at venipuncture site; rotate sites according to agency policy

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reinforce client and family teaching regarding:  explanation of all procedures in a simple and culturally sensitive manner  involvement of the client and family in scheduling the daily routine activities and allowing client and family to participate in care  relaxation techniques (meditation, visualization, or guided imagery) to cope with stress, pain, or insomnia  endocarditis and the need for long-term therapy  the need for prophylactic antibiotics before dental work and other invasive procedures  to report fever, tachycardia, dyspnea and sudden shortness of breath.

Rheumatic heart disease (rheumatic endocarditis) 

Definition and related terms 

rheumatic heart disease - damage to the heart by one or more episodes of rheumatic fever. Pathogen is a group A streptococci.

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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 thicken.

Rheumatic heart disease (rheumatic endocarditis) 

Epidemiology       

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worldwide, millions of new cases of rheumatic fever are reported each year rheumatic fever follows a group A streptococcal infection - prevention is simply to find and treat streptococcal pharyngitis with malnutrition and crowded living, rheumatic fever is most common in children between the ages of five and 15 rheumatic fever strikes most often during cool, damp weather. In the U.S., it is most common in the northern states no one knows how and why group A streptococcal infections cause the lesions called Aschoff bodies damage depends on site of infection: most often the mitral valve in females and the aortic valve in males malfunction of these valves leads to severe pericarditis, and sometimes pericardial effusion and fatal heart failure. Of those who survive this complication, about 20% die within ten years

Rheumatic heart disease (rheumatic endocarditis) 

Findings 

streptococcal pharyngitis 

sudden sore throat

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throat reddened with exudate

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swollen, tender lymph nodes at angle of jaw

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headache

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fever to 104 degrees Fahrenheit

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polyarthritis manifested by warm and swollen joints

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carditis

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chorea

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erythema marginatum (wavy, thin red-line rash on trunk and extremities)

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subcutaneous nodules

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fever to 104 degrees Fahrenheit

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heart murmurs  pericardial friction rub and pericardial rub

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

Rheumatic heart disease (rheumatic endocarditis) 

Diagnostics  antistreptolysin 0 titer (ASO titer) - increased  ESR - increased  throat culture - positive for streptococci  WBC count - increased  RBC parameters - normocytic, normochromic anemia  C-reactive protein - positive for streptococci

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Management  give antibiotics on schedule to maintain blood levels  provide analgesics - for pain/inflammation PRN  oxygen to prevent tissue hypoxia  surgical - commissurotomy, valvuloplasty, prosthetic heart valve

Rheumatic heart disease (rheumatic endocarditis) 

Nursing Interventions  the cardio-care six  assist the client with chorea in grasping objects; prevent falls  encourage family and friends to spend time with client and fight boredom during the long, tedious convalescence  reinforce client and family teaching regarding:  explanation of all tests and treatments  nutritional needs  hygienic practices  resumption of ADLs slowly and scheduling rest periods  to report penicillin reactions: rash, fever, chills

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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 degree Fahrenheit  headache  nausea  the avoidance of crowds and people with respiratory infections  explanation of the necessity of long-term antibiotics  actions to cope with the temporary chorea

Valve Disorders 

Mitral stenosis  Definition - Mitral valve thickens, with result of narrowing passageway and blocking blood flow from the left atrium to the left ventricle during atrial systole  Epidemiology  of clients with mitral stenosis, two-thirds are female  most cases of mitral stenosis are caused by rheumatic fever  Findings  mild - no symptoms  moderate to severe  dyspnea on exertion  paroxysmal nocturnal dyspnea (PND)  orthopnea  weakness, fatigue,

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complications  peripheral and facial cyanosis in severe cases  jugular vein distention  with severe pulmonary hypertension or tricuspid stenosis - ascites  edema  hepatomegaly  diastolic thrill at the cardiac apex

Valve Disorders

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Diagnostics 

history and physical exam

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EKG - for changes of left atrial enlargement and right ventricle enlargement

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echocardiogram - for restricted movement of the mitral valves and diastolic turbulance

Management 

antidysrhythmics as indicated

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if medication fails, atrial fibrillation is treated with cardioversion.

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low-sodium diet - to control underlying heart disease

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oxygen if needed - to prevent hypoxia

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surgery - mitral commissurotomy or valvotomy

Valve Disorders 

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Nursing interventions  the Cardio-Care Six  watch closely for findings of heart failure, pulmonary edema and reactions to drug therapy  if client has had surgery, watch for hypotension, dysrhythmias, and thrombus formation  monitor The Cardio Seven  reinforce client and family teaching regarding: TEACH THE CARDIO FIVE: TDDDS Tests and treatments: discuss them in simple, culturally sensitive ways. Drugs, their side effects, how long client will take them, and their expected effects. Diet: balanced nutrition and restrictions (such as low sodium). Disease, its management, when and what signs to report promptly: the 'watchfor s '. Smoker? Stress benefits of stopping smoking, minimization of other stimulants - caffeine, chocolate, nonprescription drugs, herb cautions explaination of the need for long-term antibiotic therapy and the need for additional antibiotics before dental care or any invasive procedure the need to report early findings of heart failure such as dyspnea or a hacking, nonproductive cough