Cardio.pdf

Assessment of Cardiovascular Function

A look at cardiac anatomy…..

Major Function:

The heart pumps blood to the tissues supplying them with oxygen and other nutrients.

Between the layers

Heart Chambers Right Atrium (RA) Left Atrium (LA) Right Ventricle (RV) Left Ventricle (LV) --- PMI

Inside the heart

Systole Contraction/Depolarization 1. Isovolumetric contraction phase 2. Ejection phase Diastole Relaxation/Repolarization 1. Isovolumetric relaxation phase 2. Filling phase

Heart Valves Atrioventricular valves Mitral valve (bicuspid valve) Tricuspid valve Semilunar Valve Aortic Valve Pulmonic Valve

ONE-WAY VALVE

Coronary Arteries 1. Left Coronary Artery a. Left Main Coronary Artery i. Left anterior descending artery ii. Left circumflex artery 2. Right Coronary Artery i. Posterior descending artery

Perfused during DIASTOLE!

Coronary Veins Venous blood from these veins returns to the heart primarily through the CORONARY SINUS Located posteriorly in the right atrium

Transmission of electrical impulses Generation and transmission of electrical impulses depend on these cell characteristics: • Automaticity • Excitability • Conductivity • Contractility

Electrical Conduction System of the Heart 1. Sinoatrial node 2. Atrioventricular node 3. Common bundle of his 4. Left and Right bundle of his 5. Purkinje fibers

Nerve supply to the heart •The heart is supplied by the two branches of the autonomic nervous system—the •sympathetic, or adrenergic, and •parasympathetic, or cholinergic.

STROKE VOLUME •Amount of blood ejected from one of the ventricles per heartbeat •Average resting SV is about 60 to 130 mL CARDIAC OUTPUT •Refers to the total amount of blood ejected by one of the ventricles in liters per minute. •Normal resting adult – 4 to 6 liters/minute

Therefore:

Effect of Heart Rate on Cardiac Output •Heart rate is affected by the central nervous system and baroreceptors *baroreceptors are specialized nerve cells located in the aortic arch and in both right and left internal carotid artery (at the point of bifurcation from the common carotid arteries) •sensitive to changes in BP

Note: • The percentage of the end-diastolic volume that is ejected with each stroke is called the ejection

fraction. • The ejection fraction can be used as an index of myocardial contractility: the ejection fraction decreases if contractility is depressed.

Gender considerations •Structural differences between the hearts of men and women have significant implications. • Woman’s heart tends to be smaller than man. • Coronary arteries are narrower in diameter.

*cardiac catheterization *angioplasty

Gender considerations • Women typically develop CAD 10 years later than men. • Estrogen (cardioprotective effects) Increase in HDL Decrease in LDL Dilation of the blood vessels, which enhance blood flow to the heart. *hormone replacement therapy

Risk Factors for Heart Disease Nonmodifiable risk factors include the following: •Positive family history for premature coronary artery disease •Increasing age •Gender (men and postmenopausal women) •Race (higher incidence in African Americans than in Caucasians)

Risk Factors for Heart Disease Modifiable risk factors include the following: • Hyperlipidemia • Hypertension • Cigarette smoking • Elevated blood glucose level • Obesity

• Physical inactivity • Type A personality characteristics, particularly hostility • Use of oral contraceptives

Blood Pressure •Systemic arterial BP is the pressure exerted on the walls of the arteries during ventricular systole and diastole. *invasive arterial monitoring systems *noninvasively by a sphygmomanometer and stethoscope

Blood Pressure

PULSE PRESSURE • difference between the systolic and the diastolic pressures • It is a reflection of stroke volume, ejection velocity, and systemic vascular resistance. • normally is 30 to 40 mm Hg • indicates how well the patient maintains cardiac output

Blood Pressure POSTURAL BLOOD PRESSURE CHANGES Gravitational redistribution of approximately 300 to 800 mL into the lower extremities and GI system immediately upon standing. Postural (orthostatic) hypotension occurs when the BP drops significantly after the patient assumes an upright posture. It is usually accompanied by dizziness, lightheadedness, or syncope.

Postural (orthostatic) hypotension Example:

Lying down, BP 120/70, heart rate 70 Sitting, BP 100/55, heart rate 90 Standing, BP 98/52, heart rate 94

Palpation of arterial pulse

Arterial pulses *pulse deficit = a difference between the apical rate and radial rate NURSING ALERT • Do not palpate temporal or carotid arteries simultaneously, because it is possible to decrease the blood flow to the brain.

Jugular Venous Pulsations • An estimate of right-sided heart function can be made by observing the pulsations of the jugular veins of the neck, which reflects the central venous pressure (CVP) • CVP is the pressure in the right atrium and right ventricle at the end of the diastole. • Visible just above the clavicle, adjacent to the sternocleidomastoid muscles.

Heart Inspection and Palpation •The heart is examined indirectly by inspection, palpation, percussion, and auscultation of the chest wall. •A systematic approach is the cornerstone of a thorough assessment.

Heart Inspection and Palpation • Examination of the chest wall is performed in the following six areas: Aortic area Pulmonic area Erb’s point Right ventricular or tricuspid area Left ventricular or apical area/mitral Epigastric area

Heart Inspection and Palpation APICAL IMPULSE •A broad and forceful apical impulse is known as a left ventricular heave or lift. Thrill •Abnormal, turbulent blood flow within the heart may be palpated with the palm of the hand as a purring sensation. •associated with a loud murmur.

Normal heart sounds • The normal heart sounds:

S1 and S2 are produced primarily by the closing of the heart valves. S3, S4 gallops—diastole (resistance during ventricular filling) *gallop sounds are very low frequency sounds and are heard with the BELL of the stethoscope. opening snaps, systolic clicks and murmurs. SUMMATION GALLOP

Murmurs are created by turbulent flow of blood in the heart.

Friction Rub is a harsh, grating sound that can be heard in both systole and diastole. •Caused by the abrasion of the inflamed pericardial surfaces from pericarditis •Use diaphragm of the stethoscope

Cardiac biomarker analysis •Creatine kinase (CK) and its isoenzyme CK-MB are the most specific enzymes analyzed in acute MI, and they are the first enzyme levels to rise.

Cardiac biomarker analysis •Lactic dehydrogenase and its isoenzymes also are analysed in patients who have delayed seeking medical attention, because these blood levels rise and peak in 2 to 3 days, much later than CK levels

Cardiac biomarker analysis • Myoglobin an early marker of MI, is a heme protein with a small molecular weight. This allows it to be rapidly released from damaged myocardial tissue and accounts for its early rise, within 1 to 3 hours after the onset of an acute MI. Myoglobin peaks in 4 to 12 hours and returns to normal in 24 hours.

Cardiac biomarker analysis • Troponin I a contractile protein found only in cardiac muscle. elevated serum troponin I concentrations can be detected within 3 to 4 hours; they peak in 4 to 24 hours and remain elevated for 1 to 3 weeks.

Blood chemistry, Hematology, and Coagulation Studies

•Lipid profile •HDL •LDL •Triglycerides

•Brain (B-Type Natriuretic Peptide)

•C-Reactive Protein

Diagnostic Exams

•Chest X-ray and Fluoroscopy •ECG •Hardwire Monitor •Holter •Cardiac Stress Test •Echocardiography

•TEE •MPI •CT scan •Cardiac Catheterization

Management of Patients with Dysrhythmias and Conduction Problems

Dysrhythmias •are disorders of the formation or conduction (or both) of electrical impulse within the heart •These disorders can cause disturbances of the heart rate, the heart rhythm, or both. •diagnosed by analyzing the electrocardiographic waveform.

Influences on HR and contractility • Stimulation of the sympathetic system: increases heart rate (positive chronotropy), Increases conduction through the AV node (positive dromotropy), Increases the force of myocardial contraction (positive inotropy). Sympathetic stimulation also constricts peripheral blood vessels, therefore increasing blood pressure.

Influences on HR and contractility • Parasympathetic stimulation: reduces the heart rate (negative chronotropy), reduces AV conduction (negative dromotropy), reduces the force of atrial myocardial contraction (negative inotropy) The decreased sympathetic stimulation results in dilation of arteries, thereby lowering blood pressure.

DETERMINING VENTRICULAR HEART RATE FROM THE ELECTROCARDIOGRAM Sequence method

DETERMINING VENTRICULAR HEART RATE FROM THE ELECTROCARDIOGRAM 1500 method

HR= 1500/small boxes

DETERMINING VENTRICULAR HEART RATE FROM THE ELECTROCARDIOGRAM 300 method HR= 300/big boxes

DETERMINING VENTRICULAR HEART RATE FROM THE ELECTROCARDIOGRAM • Six-second ECG strip

V1 V2 V3 V4 V5 V6 RA LA RL LL

Fourth intercostal space at the right sternal border Fourth intercostal space at the left sternal border Halfway between leads V2 and V4 Fifth intercostal space in the midclavicular line Left anterior axillary line on the same horizontal plane as V4 Left midaxillary line on the same horizontal plane as V4 and V5 Right arm (inner wrist) Left arm (inner wrist) Right leg (inner ankle) Left leg (inner ankle)

Sinus Arrhythmia

ATRIAL DYSRHYTHMIAS: Premature Atrial Complex (PAC) • PAC is a single ECG complex that occurs when an electrical impulse starts in the atrium before the next normal impulse of the sinus node.

ATRIAL DYSRHYTHMIAS: Premature Atrial Complex

Atrial Flutter •P wave: Saw-toothed shape. These waves are referred to as F waves.

Atrial Flutter

Atrial Fibrillation (a-fib) • Atrial fibrillation causes a rapid, disorganized, and uncoordinated twitching of atrial musculature.

Atrial Fibrillation (a-fib)

Atrioventricular Nodal Reentry Tachycardia

Remember! Don’t perform carotid sinus massage on older patients.

Ventricular Tachycardia

Ventricular Fibrillation • Ventricular fibrillation is a rapid but disorganized ventricular rhythm that causes ineffective quivering of the ventricles. There is no atrial activity seen on the ECG.

Ventricular Fibrillation

Ventricular asystole • flatline

CONDUCTION ABNORMALITIES •First-Degree Atrioventricular Block •Second Degree AV block Type I •Second Degree AV block Type 2

CONDUCTION ABNORMALITIES

Second-Degree Atrioventricular Block, Type I. (Wenckebach)

Second-Degree Atrioventricular Block, Type II. Mobitz II

Third-Degree Atrioventricular Block (Complete Heart Block)

Adjunctive modalities and management Remember: Acute dysrhythmias may be treated with medications or with external therapy. CARDIOVERSION AND DEFIBRILLATION

CARDIOVERSION

•Defibrillation---- an emergency treatment, •Cardioversion, usually a planned procedure. •Electrical current may be delivered through paddles or conductor pads.

PACEMAKER THERAPY • A pacemaker is an electronic device that provides electrical stimuli to the heart muscle.

Management of Patients with Coronary Vascular Disorders

Coronary Artery Disease (CAD) •Most prevalent type of cardiovascular disease in adults •results from the narrowing of the coronary arteries over time due to atherosclerosis (coronary atherosclerosis)

•The primary effect of CAD is the loss of oxygen and nutrients to myocardial tissue because of diminished coronary blood flow.

•Angina pectoris •ischemia •infarction

Diagnostic studies •Electrocardiography •Cardiac catheterization •Blood lipid levels

Surgical procedures 1. PTCA 2. Laser angioplasty 3. Atherectomy 4. Vascular stent 5. Coronary artery bypass grafting

Medications 1. Nitrates to dilate the coronary arteries and decrease preload and afterload 2. Calcium channel blockers to dilate coronary arteries and reduce vasospasm 3. Cholesterol-lowering medications to reduce the development of atherosclerotic plaques 4. b-Blockers to reduce the BP in individuals who are hypertensive

Types of angina • Stable angina • predictable and consistent pain that occurs on exertion and is relieved by rest • Unstable angina (also called preinfarction angina or crescendo angina) • symptoms occur more frequently and last longer than stable angina. • The threshold for pain is lower, and pain may occur at rest.

Types of angina • Variant angina (also called Prinzmetal’s angina): • pain at rest with reversible ST-segment elevation; thought to be caused by coronary artery vasospasm

Clinical Manifestations

Pharmacologic therapy Nitroglycerin (NTG) •Nitrates are the standard treatment for angina pectoris. •Potent vasodilator

NTG might be given in several routes: •Sublingual or spray •Oral capsule •Topical agent, and •IV

Guidelines 1. Instruct the patient to make sure the mouth is moist, the tongue is still, and saliva is not swallowed until the nitroglycerin tablet dissolves. If the pain is severe, the patient can crush the tablet between the teeth to hasten sublingual absorption.

Guidelines 2. Advise the patient to carry the medication at all times as a precaution. However, because nitroglycerin is very unstable, it should be carried securely in its original container (eg, capped dark glass bottle); tablets should never be removed and stored in metal or plastic pillboxes.

Guidelines 3. Explain that nitroglycerin is volatile and is inactivated by heat, moisture, air, light, and time. Instruct the patient to renew the nitroglycerin supply every 6 months.

Guidelines 4. Inform the patient that the medication should be taken in anticipation of any activity that may produce pain. Because nitroglycerin increases tolerance for exercise and stress when taken prophylactically (ie, before anginaproducing activity, such as exercise, stairclimbing, or sexual intercourse), it is best taken before pain develops.

Guidelines 5. Recommend that the patient note how long it takes for the nitroglycerin to relieve the discomfort. Advise the patient that if pain persists after taking three sublingual tablets at 5-minute intervals, emergency medical services should be called.

Guidelines 6. Discuss possible side effects of nitroglycerin, including flushing, throbbing headache, hypotension, and tachycardia.

Guidelines Most physicians prescribe application of topical nitroglycerin paste three or four times daily or every 6 hours (excluding the midnight dose), and application of the nitroglycerin patch every morning and removed at 10 PM. This dosing regimen allows for a 6- to 8-hour nitratefree period to prevent the body’s development of tolerance.

Other medications •Beta Adrenergic Blocking Agents •Calcium Channel Blocking Agents •Aspirin •Heparin •Oxygen Therapy

ACUTE CORONARY SYNDROME (ACS) an emergent situation characterized by an acute onset of myocardial ischemia that results in myocardial death if definitive interventions do not occur promptly.

ACUTE CORONARY SYNDROME (ACS) The spectrum of ACS includes:

•Unstable angina •NSTEMI •STEMI

Myocardial infarction (MI)

occurs when myocardial tissue is abruptly and severely deprived of oxygen Ischemia can lead to necrosis of myocardial tissue if blood flow is not restored. Infarction does not occur instantly but evolves over several hours.

Assessment 1. Pain

Levine Sign

Assessment 1. Pain 2. Nausea and vomiting 3. Diaphoresis 4. Dyspnea 5. Dysrhythmias 6. Feelings of fear and anxiety 7. Pallor, cyanosis, coolness of extremities

Risk factors 1. Atherosclerosis 2. Coronary artery disease 3. Elevated cholesterol levels 4. Smoking 5. Hypertension

6. Obesity 7. Physical inactivity 8. Impaired glucose tolerance 9. Stress

Diagnostic studies •Cardiac biomarkers •ECG •Echocardiography •Cardiac Stress testing •Cardiac catheterization

Begin routine medical interventions:

MONA • Supplemental oxygen • Nitroglycerine • Morphine • Aspirin 162-325 mg

• Beta blocker • ACE inhibitor • Anticoagulation therapy

Management of Patients with Structural, Infectious, and Inflammatory Cardiac Disorders

VALVULAR HEART DISORDERS

Valvular Heart Disease •Valvular heart disease can affect any of the valves in the heart. •Diseased valves may have an altered structure, which changes the blood flow. •Disorders of the endocardium, the innermost lining of the heart and valves, damage heart valves.

Valvular Heart Disease Valvular heart diseases include: • Mitral stenosis. • • • •

Mitral regurgitation. Mitral valve prolapse. Aortic stenosis. Aortic regurgitation.

REVIEW OF VALVES

Cardiomyopathies There are three types of cardiomyopathy: • Restrictive: ventricles are stiff and cannot fill properly. • Hypertrophic: walls of the ventricles thicken and become stiff. • Dilated: ventricles enlarge but are not able to pump enough blood for the body’s needs. • Ischemic cardiomyopathy is a term frequently used to describe an enlarged heart caused by coronary artery disease, which is usually accompanied by heart failure

Infectious Diseases of the Heart •Among the most common infections of the heart are infective endocarditis, myocarditis, and pericarditis. •The ideal management is prevention.

Prevention primary prevention in high-risk patients: • Antibiotic prophylaxis: • Dental procedures • Tonsillectomy or adenoidectomy • Surgical procedures that involve intestinal or respiratory mucosa

Nursing Management

NURSING ALERT Patients with myocarditis are sensitive to digitalis. • They must be closely monitored for digitalis toxicity, which is evidenced by dysrhythmia, anorexia, nausea, vomiting, headache, and malaise and BLURRED OR DOUBLE VISION and GREENISH-YELLOW HALOS AROUND IMAGES.

Nursing Management • Assesses the patient’s temperature • continuous cardiac monitoring with personnel and equipment readily available to treat life-threatening dysrhythmias. • Elastic compression stockings and passive and active exercises should be used: • embolization from venous thrombosis and mural thrombi can occur.

MONITORING AND MANAGING POTENTIAL COMPLICATIONS

•Cardiac tamponade. • Pericardial effusion. • Infection.

MANAGEMENT OF PATIENTS WITH COMPLICATIONS FROM HEART DISEASE

Heart Failure (HF) •often referred to as congestive heart failure (CHF)

Heart Failure (HF) •A clinical syndrome resulting from structural or functional cardiac disorders that impair the ability of the ventricles to fill or eject blood. •is the inability of the heart to pump sufficient blood to meet the needs of the tissues for oxygen and nutrients.

CHRONIC HEART FAILURE Types of HF 1. diastolic heart failure 2. systolic heart failure

Heart Failure (HF) •Low EF is a hallmark of systolic HF •New York Heart Association (NYHA) classification of heart failure:

(NYHA) Classification of Heart Failure Classific ation

Signs and symptoms

I

No limitation of physical activity Ordinary activity does not cause undue fatigue; palpitation, or dyspnea

II

Slight limitation of physical activity Comfortable at rest, but no ordinary physical activity causes fatigue, palpitation, or dyspnea Marked limitation of physical activity Comfortable at rest, but less than ordinary activity causes fatigue, palpitation, or dyspnea. Unable to carry out any physical activity without discomfort Symptoms of cardiac insufficiency at rest If any physical activity is undertaken, discomfort is increased

III

IV

Classification of Heart Failure (HF) 1. Left-sided heart failure 2. Right-sided heart failure

Diagnostic Exam • Electrocardiography • Chest x-ray

•BNP level: increased • Echocardiogram

Treatments for HF Goal is to decrease workload on the heart. • Diuretics • ACE inhibitors: dilate blood vessels decreasing workload of heart. • Angiotensin II receptor blockers: can be used in place of ACE inhibitors. • Beta-blockers: slow the heart rate; prevent remodeling. • Vasodilators: cause blood vessels to dilate.

Treatments for HF • Positive inotropic drugs • Anticoagulants: prevent clot formation. • Opioids: relieve anxiety and decrease the workload on the heart especially in pulmonary hypertension. • Oxygen therapy: improves oxygenation. • Lifestyle modification: exercise; weight loss

Cardiogenic shock • called pump failure • Condition of diminished cardiac output that severely impairs tissue perfusion. • can happen because of a damaged muscle, poor ventricular filling, or poor outflow from the heart. • As cardiogenic shock progresses, the vital organs begin to lose perfusion until the heart is no longer able to perfuse itself!

THROMBOEMBOLISM • Causes (cardiac in origin)

Intracardiac thrombus atrial fibrillation Mural thrombi

Deep vein thrombosis (DVT)

PERICARDIAL EFFUSION AND CARDIAC TAMPONADE • Pericardial effusion refers to the accumulation of fluid in the pericardial sac.

Management: Pericardiocentesis

Cardiac arrest The heart is unable to pump and circulate blood to the body’s organs and tissues

Pulseless Electrical Activity (PEA) •Occurs when electrical activity is present on the ECG but cardiac contractions are ineffective

ASSESSMENT AND MANAGEMENT OF PATIENTS WITH VASCULAR DISORDERS AND PROBLEMS OF PERIPHERAL CIRCULATION

Vascular System The vascular system consists of TWO interdependent systems. 1. right side of the heart pumps blood through the lungs to the pulmonary circulation 2. left side of the heart pumps blood to all other body tissues through the systemic circulation.

100,000 km of blood vessels

WALLS OF ARTERIES composed of three layers: 1. intima 2. media 3. adventitia (externa)

ANATOMY OF THE VASCULAR SYSTEM:

Lymphatic Vessels

• Peripheral lymphatic vessels join larger lymph vessels and pass through regional lymph nodes before entering the venous circulation. lymph nodes filter foreign particles. permeable to large molecules and provide the only means by which interstitial proteins can return to the venous system

ARTERIAL DISORDERS • Arterial disorders cause ischemia and tissue necrosis

Arteriosclerosis vs Atherosclerosis Arteriosclerosis • most common disease of the arteries

•hardening of the arteries

Atherosclerosis •Changes consist of the accumulation of lipids, calcium, blood components, carbohydrates, and fibrous tissue on the intimal layer of the artery

Arteriosclerosis vs Atherosclerosis

Treatments • Antiplatelets: thin the blood, prevent clot formation. • Lipid-lowering agents: lower cholesterol. • Antihypertensives: lower blood pressure. • Thrombolytics: dissolve blood clots. • Anticoagulants: thin the blood; prevent clot formation. • Exercise: to improve circulation and help with weight control

AORTIC ANEURYSM Aneurysm: a localized sac or dilation formed at a weak point in the wall of the aorta •The most common forms of aneurysms are saccular or fusiform. •A saccular aneurysm projects from one side of the vessel only.

Thoracic aortic aneurysm • occurs in the part of the aorta that passes through the chest (thorax). • It is an abnormal widening of the ascending, transverse, or descending part of the aorta

Causes • High blood pressure • Syphilis • Blunt injury to the chest • Atherosclerosis • Bacterial infections, usually at an atherosclerotic plaque • Rheumatic vasculitis • Coarctation of the aorta

Abdominal aortic aneurysm •bulge in the wall of the aorta is located in the part of the aorta that passes through the abdomen.

Causes •Atherosclerosis •Hypertension •Hereditary connective-tissue disorders (Marfan’s syndrome) •Blunt trauma •Infections (syphilis) •Thrombus formation

Signs and symptoms •Change in LOC •Pulsatile mass in periumbilical area •Systolic bruit over aorta •Lumbar pain that radiates to the flank and groin; severe, persistent abdominal and back pain •Weakness, sweating, tachycardia, hypotension

Test and treatments •Pain- usually a late clue. • Palpitation: pulsating mass in midline of abdomen; tenderness. • Auscultation: bruit. • Abdominal x-ray • Ultrasonography: shows size of aneurysm. •CT SCAN and MRI

Buerger’s disease (Thromboangiitis Obliterans) Buerger’s disease is an occlusive disease of the median and small arteries and veins. The distal upper and lower limbs are affected most commonly.

Clinical Manifestations • Intermittent claudication • Ischemic pain occurring in the digits while at rest • Aching pain that is more severe at night • Cool, numb, or tingling sensation • Diminished pulses in the distal extremities • Extremities that are cool and red in the dependent position • Development of ulcerations in the extremities

Interventions • Instruct the client to stop smoking. • Monitor pulses. • Instruct the client to avoid injury to the upper and lower extremities. • Administer vasodilators as prescribed. • Instruct the client regarding medication therapy.

Raynaud’s disease Raynaud’s disease is vasospasm of the arterioles and arteries of the upper and lower extremities. Vasospasm causes constriction of the cutaneous vessels. Attacks are intermittent and occur with exposure to cold or stress. Affects primarily fingers, toes, ears, and cheeks

Clinical Manifestation •Blanching of the extremity, followed by cyanosis during vasoconstriction; Reddened tissue when the vasospasm is relieved •Numbness, tingling, swelling, and a cold temperature at the affected body part

Venous Disorders

Venous Thromboembolism • Deep vein thrombosis

• Pulmonary embolism

Pathophysiology •Virchow’s triad

Causes •Estrogen therapy, oral contraceptives •Hypercoagulability states •Pregnancy and childbirth •Orthopedic surgery

Causes •Obesity •Dehydration •Smoking •Prolonged immobility: postoperative clients, bed-ridden clients, persons who experience prolonged travel, and spinal cord injury clients

Clinical manifestations •Heat; erythema •Swelling •Pain

Diagnostic Tests • Doppler ultrasonography: confirms diagnosis by checking leg for clots.

Treatments • Prevention of pulmonary embolism. • Elevate the affected leg: prevents thrombus enlargement. • Anticoagulants: thin the blood. • Thrombolytics: dissolve the thrombus. • Filter (umbrella) placement: traps emboli before they can reach the lungs.

Varicose Veins • Varicose veins are abnormally enlarged superficial veins of the lower extremities. • They occur most often in the saphenous veins located on the insides of the lower extremities.

Causes •Familial predisposition •Congenital weakness of the vein •Obesity, pregnancy, abdominal tumors prolonged standing, major surgeries, prolonged bed rest. •Trauma

Clinical Manifestations • Edema • Cramping or pain in affected extremity • Heaviness in affected extremity • Itching, redness, rash • Phlebitis

Diagnostic Tests • Palpation: May feel the veins when they are not visible. • X-ray: assesses functioning of deep veins. • Ultrasonography: assesses functioning of deep veins.

Treatments • Elevating the legs • Elastic stockings (support hose): compress the veins and prevent them from stretching and hurting. • Surgical stripping: removes varicose veins. • Sclerotherapy (injection therapy) • Laser therapy: cuts or destroys tissue.

Assessment and Management of Patients With Hypertension

Hypertension • Hypertension is an abnormally high pressure in the arteries. • peripheral vasoconstriction. • Vasoconstriction decreases blood flow to end organs

Causes • Primary hypertension • Lifestyle: obesity, • Secondary hypertension sedentary lifestyle, stress, smoking, excessive • Pheochromocytoma alcohol consumption, • Hyperthyroidism increased salt intake • Hyperaldosteronism • Arteriosclerosis • Cushing’s syndrome • Renal disease

CLASSIFICATION OF BLOOD PRESSURE FOR ADULTS

Clinical Manifestations Primary HPN- no symptoms silent killer Secondary HPN Associated with the underlying cause HPN Emergency: Confusion, drowsiness, chest pain, breathlessness

Diagnostic Exam • Test for suspected underlying cause. • Blood pressure monitoring. • 24-hour blood pressure monitor: confirms consistent hypertension. • Serum BUN: elevated. • Serum creatinine: elevated. • Urinalysis: positive for blood cells and albumin.

Diagnostic Exam • Auscultation: check for abdominal bruit, irregular heart sounds. • Eye examination with ophthalmoscope: views arterioles of retina is an indication that other blood vessels in the body are damaged. • Electrocardiography:detects enlargement of the heart.

Treatments • Lifestyle modification • Diuretics: dilate blood vessels; help kidneys eliminate sodium and water. • Beta-blockers: decrease blood pressure; decrease chest pain. • ACE inhibitors: dilate arterioles and lower blood pressure.

Treatments • Angiotension II blockers: lower blood pressure. • Calcium-channel blockers: dilate arterioles and lower blood pressure. • Direct vasodilators: dilate blood vessels and lower blood pressure.

Hypertensive Crises • There are two hypertensive crises that require nursing intervention: 1. hypertensive emergency 2. hypertensive urgency 180/120 mmHg

HYPERTENSIVE EMERGENCY Hypertensive emergency • situation in which blood pressure must be lowered immediately (not necessarily to less than 140/90 mm Hg) to halt or prevent damage to the target organs.

HYPERTENSIVE URGENCY Hypertensive urgency • a situation in which blood pressure must be lowered within a few hours. • Blood pressure is elevated but there is no evidence of impending or progressive target organ damage. • Elevated BP associated with severe headache, nosebleeds or anxiety are classified as urgencies.

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