Cardiovascular

CARDIOVASCULAR Heart infections A.

b.

Pericarditis 1. Definition and related terms a. in pericarditis, an infection (from a bacterium, a fungus, Systemic Lupus Erythematosus (SLE), etc.) inflames the pericardium. there may or may not be pericardial effusion or constrictive pericarditis.

c.

dressler's Syndrome, also called postmyocardial infarction syndrome, is a combination of pericarditis, pericardial effusion and constrictive pericarditis. It occurs several weeks to months after a myocardial infarction. Etiology unclear.

2.

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

3.

Findings a. sharp chest pain often relieved by leaning forward b. pericardial friction rub

c. d.

e. f. g.

4.

dyspnea fever, sweating, chills dysrhythmias pulsus paradoxus

client cannot lie flat without pain or dyspnea Management a. antibiotics to treat underlying infection b. corticosteroids: usually reserved for clients with pericarditis due to SLE, or clients who do not respond to NSAID c. NSAIDS/Asprin for pain and inflammation d. oxygen: to prevent tissue hypoxia e. surgical I. emergency pericardiocentesis if cardiac tamponade develops

II.

5.

for recurrent constrictive pericarditis, partial pericardiectomy (pericardial window) or total pericardiectomy Nursing interventions a. manage pain and anxiety

b. c. d. e.

f. client and family teaching - teach the cardio five Diagnostic studies a. EKG changes, arrythmias b. echocardiography to determine pericardial efusion or cardiac tamponade c. history and physical exam Myocarditis 2. Definition - an inflammatory condition of the myocardium caused by a. viral infection b. bacterial infection c. fungal infection d. serum sickness e. rheumatic fever f. chemical agent g. as a complication of a collagen disease, i.e. SLE 3. Epidemiology a. may be acute or chronic and may occur at any age. 6.

B.

the cardio-care six maintain a pericardiocentesis set at the bedside in case of cardiac tamponade. assess respiratory, cardiovascular, and renal status often. observe for findings of infiltration or inflammation at the venipuncture site, a possible complication of long-term IV administration. Rotate the IV sites often.

4.

5.

6.

7.

b. usually an acute virus and self-limited, but it may lead to acute heart failure. Findings a. depends on the type of infection, degree of myocardial damage, capacity of myocardium to recover, and host resistance b. may be minor or unnoticed: fatigue and dyspnea, palpitations, occasional precordial discomfort manifested as a mild chest soreness and persistent fever c. recent upper-respiratory infection with fever, viral pharyngitis, or tonsillitis d. cardiac enlargement e. f.

abnormal heart sounds:

a. b.

the cardio-care six

possibly findings of congestive heart failure such as pulsus alternans, dyspnea, and crackles g. tachycardia disproportionate to the degree of fever Diagnostic studies a. EKG for changes and arrythmias b. labs I. increases ESR II. increases myocardial enzymes such as: I. AST II. CK III. LDH c. endomyocardial biopsy (EMB) d. myocardial imaging Management a. antibiotics to treat underlying infection b. corticosteroids to decrease inflammation c. analgesics for pain d. oxygen to prevent tissue hypoxia Nursing interventions

c.

d. e. f. g.

C.

murmur, S3 or S4 or friction rub

with modified bedrest and less help with ADLs

assess for edema; weigh daily; record intake and output assess cardiovascular status frequently observe for findings of left-sided heart failure (dyspnea, hypotension and tachycardia) check often for changes in cardiac rhythm or conduction; auscultate heart sounds evaluate arterial blood gas levels as needed to ensure adequate oxygenation client and family teaching I. physical activity may be slowly increased to sitting in chair, walking in room, then outdoors. II. avoid pregnancy, alcohol, and competitive sports. III. immunize against infections. IV. teach client about anti-infective drugs. Stress importance of taking drugs as ordered. V. teach clients taking digitalis at home to: I. check pulse for one full minute before taking the dose, and withhold the drug if heart rate falls below 60 beats/minute. II. observe for findings of digitalis toxicity (anorexia, nausea, vomiting, blurred vision, cardiac arrhythmias) and for factors that may increase toxicity, such as electrolyte imbalance and hypoxia. VI. teach client to report rapidly beating heart.

Endocarditis 2. Definition and related terms a. an infection of the endocardium, heart valves, or cardiac prosthesis resulting from bacterial or fungal invasion. b. endocarditis can be classified as I. native valve endocarditis II. endocarditis in I.V. drug users

3.

4.

III. prosthetic valve endocarditis Epidemiology a. with proper treatment about 70% of clients recover. b. the prognosis is worse when endocarditis damages valves severely or involves a prosthetic valve. c. infective endocarditis occurs in 50 to 60% of clients with previous valvular disorders. d. systemic lupus erythematosus (SLE) often leads to nonbacterial endocarditis. e. 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. Findings of endocarditis

a. b. c.

d. e. f. g.

h. i. j. k. l. m. n.

cardiac murmurs in 85 to 90% of clients fever especially, a murmur that changes suddenly, or a new murmur that develops in the presence of a fever pericardial friction rub anorexia malaise clubbing of fingers neurologic sequelae of embolus petechiae of the skin (especially on the chest) splinter hemorrhage under the nails infarction of spleen: pain in the upper left quadrant, 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

o.

5.

6.

peripheral vascular occlusion: numbness and tingling in an arm, leg, finger, or toe, or signs of impending peripheral gangrene Management - clients at risk for prosthetic valves a. prophylaxis - to prevent endocarditis; i.e. MVP, cardiac lesions b. antibiotics - to treat underlying infection c. antipyretics - to control fever d. anticoagulants - to prevent embolization e. oxygen - to prevent tissue hypoxia f. surgical - possible valve replacement Nursing interventions

a.

the cardio-care six observe for findings of infiltration or inflammation at venipuncture site; rotate sites often. c. client and family teaching I. explain all procedures in a simple and culturally sensitive manner. II. involve the client and family in scheduling the daily routine activities. Allow client and family to participate in care. III. teach client relaxation techniques (meditation, visualization, or guided imagery) to cope with stress, pain, or insomnia. IV. explain endocarditis and the need for long-term therapy. V. explain the need for prophylactic antibiotics before dental work and other invasive procedures. VI. teach client to report fever, tachycardia, dyspnea and shortness of breath. Diagnostic studies a. health history b. lab data I. CBC b.

7.

D.

II. blood cultures III. ESR c. CXR - to detect CHF d. EKG - transesophageal echocardiogram to detect vegetation and abscess on valves Rheumatic heart disease (rheumatic endocarditis) 2. Definition and related terms a. rheumatic heart disease is damage to the heart by one or more episodes of rheumatic fever. Pathogen is a group A streptococci. b. rheumatic endocarditis is 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. 3. Epidemiology a. worldwide, 15 to 20 million new cases of rheumatic fever are reported each year. b. rheumatic fever follows a group A streptococcal infection. We could prevent it by finding and treating streptococcal pharyngitis. c. where malnutrition and crowded living are common, rheumatic fever is commonest in children between ages 5 and 15. d. rheumatic fever strikes most often during cool, damp weather. In the U.S., it is most common in the northern states. e. it is unknown how and why group A streptococcal infections cause the lesions called Aschoff bodies. f. damage depends on site of infection: most often the mitral valve in females and the aortic valve in males. g. 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. 4. Findings a. streptococcal pharyngitis I. sudden sore throat II. throat reddened with exudate III. swollen, tender lymph nodes at angle of jaw IV. headache and fever to 104 degrees Fahrenheit b. polyarthritis manifested by warm and swollen joints c. carditis

d. e.

f. g.

chorea erythema marginatum (wavy, thin red-line rash on trunk and extremities) subcutaneous nodules fever to 104 degrees Fahrenheit

h.

5.

6.

heart murmurs pericardial friction rub and pericardial rub i. no lab test confirms rheumatic fever, but some support the diagnosis. Management a. give antibiotics steadily to maintain level in blood. b. provide analgesics - for pain/inflammation c. oxygen to prevent tissue hypoxia. d. surgical - commissurotomy, valvuloplasty, prosthetic heart valve Nursing interventions

a. b. c. d.

the cardio-care six help the client with chorea to grasp objects; prevent falls. encourage family and friends to spend time with client and fight boredom during the long, tedious convalescence. client and family teaching I. explain all tests and treatments II. nutrition III. hygienic practices IV. to resume ADLs slowly and schedule rest periods V. to report penicillin reaction: rash, fever, chills

VI.

7.

to report findings of streptococcal infection I. sudden sore throat II. diffuse throat redness and oropharyngeal exudate III. swollen and tender cervical lymph glands IV. pain on swallowing V. temperature of 101 to 104 degree Fahrenheit VI. headache VII. nausea keep client away from people with respiratory infections explain necessity of long-term antibiotics arrange for a visiting nurse if necessary help the family and client cope with temporary chorea

VII. VIII. IX. X. Diagnostic studies a. antistreptolysin 0 titer - increased b. ESR - increased c. throat culture - positive for streptococci d. WBC count - increased e. RBC parameters - normocytic, normochromic anemia f. C-reactive protein - positive for streptococci

III. Valve Disorders A.

Mitral stenosis 1. Definition - mitral valve thickens and gets narrower, blocking blood flow from the left atrium to left ventricle.

b.

physiology (illustration ) i. function of the heart is the transport of oxygen, carbon dioxide, nutrients and waste products

ii.

cardiac cycle consists of: (illustration ) • systole - the phase of contraction during which the chambers eject blood • diastole - the phase of relaxation during which the chambers fill with blood. When heart pumps, myocardial layer contracts and relaxes.

iii.

blood flow: (illustration 1 illustration 2 ) • deoxygenated blood enters the right atrium through the superior and inferior vena cava • enters the right ventricle via the tricuspid valve • travels through the pulmonic valve to pulmonary arteries and lungs • oxygenated blood returns from lungs through the pulmonary veins into left atrium and enters the left ventricle via bicuspid (mitral) valve. • from the left ventricle, through the aortic valve through the aorta to the systemic circulation the heart itself is supplied with blood by the left and right

iv. v.

coronary arteries (illustration ) the vascular system is a continuous network of blood vessels. • the arterial system consists of arteries, arterioles and capillaries and delivers oxygenated blood to tissues • oxygen, nutrients and metabolic waste are exchanged at the microscopic level • the venous system, veins and venules, returns the blood to the heart (illustration

)

2.

Epidemiology a. b.

3.

4.

5.

Findings a. mild - no findings b. moderate to severe i. dyspnea on exertion ii. paroxysmal nocturnal dyspnea iii. orthopnea iv. weakness, fatigue, and palpitations c. peripheral and facial cyanosis in severe cases d. jugular vein distention e. with severe pulmonary hypertension or tricuspid stenosis - ascites

f. g. h. i.

edema

a.

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

hepatomegaly diastolic thrill at the cardiac apex

when client lies on left side, loud S1 or opening snap and a diastolic murmur at the apex j. crackles in lungs Management a. antiarrhythmics if needed b. if medication fails, atrial fibrillation is treated with cardioversion. c. low-sodium diet - to prevent fluid retention d. oxygen if needed - to prevent hypoxia e. surgery - mitral commissurotomy or valvotomy Nursing interventions b. c.

d. e.

B.

of clients with mitral stenosis, 2/3 are female most cases of mitral stenosis are caused by rheumatic fever

monitor the cardio seven

client and family i. explain the need for long-term antibiotic therapy and the need for additional antibiotics before dental care. ii. report early findings of heart failure such as dyspnea or a hacking, nonproductive cough. 6. Diagnostic studies/findings a. history and physical exam b. EKG- for changes of left atrial enlargement and right ventricle enlargement c. echocardiogram - for restricted movement of the mitral valves and diastolic turbulance Mitral insufficiency (or regurgitation) 3. Definition and related terms a. a damaged mitral valve allows blood from the left ventricle to flow back into the left atrium during systole. b. to handle the backflow, the atrium enlarges. So does the left ventricle, in part to make up for its lower output of blood. 4. Epidemiology a. follows birth defects such as transposition of the great arteries. b. in older clients, the mitral annulus may have become calcified. c. cause unknown; may be linked to a degenerative process. d. occurs in 5 to 10% of adults.

5.

6.

7.

Findings a. client may be asymptomatic b. orthopnea, dyspnea, fatigue, weakness, weight loss c. chest pain and palpitations d. jugular vein distention e. peripheral edema Management a. low-sodium diet - to prevent fluid retention b. oxygen as needed - to prevent tissue hypoxia c. antibiotics - to treat infection d. prophylactic antibiotics - to prevent infection e. surgery - mitral valvuloplasty or valve replacement Nursing interventions

a. b.

the cardio-care six

monitor the cardio seven monitor for left-sided heart failure, pulmonary edema, adverse reactions to drug therapy, and cardiac dysrhythmias especially atrial and ventricular fibrillation d. if client has surgery, monitor postoperatively for hypotension, arrhythmias and thrombus formation e. client and family teaching i. diet restrictions and drugs ii. explain tests and treatments iii. prepare client for long-term antibiotic and follow-up care. iv. stress the need for prophylactic antibiotics during dental care. v. teach client and family to report findings of heart failure: dyspnea and hacking, nonproductive cough. 8. Diagnostic findings a. EKG for arrythmias and changes of left atrial enlargement b. echocardiogram - to visualize regurgitant jets and flail chordae/leaflets c. cardiac cath shows regurgitation of blood from left ventricle to left atrium Tricuspid stenosis 3. Definition: narrowing of the tricuspid valve between right atrium and right ventricle 4. Epidemiology a. relatively uncommon b. usually associated with lesions of other valves c. caused by rheumatic fever 5. Findings a. dyspnea, fatigue, weakness, syncope b. peripheral edema c. jaundice with severe peripheral edema and ascites can mean that tricuspid stenosis has led to right ventricular failure d. may appear malnourished e. distended jugular vein 6. Management: surgery - valvulotomy or valve replacement; valvuloplasty 7. Nursing interventions c.

C.

a. b. c. d. e. f.

the cardio-care six monitor the cardio seven monitor for findings of heart failure, pulmonary edema, and adverse reactions to the drug therapy post valve surgery, monitor client for hypotension, arrhythmias and thrombus formation when client sits, elevate legs - to prevent dependent edema client and family teaching

i. ii.

8.

teach the cardio five

client must comply with long-term antibiotic and follow up care iii. emphasize the need for prophylactic antibiotics during dental care Diagnostic findings a. EKG - for arrythmias b. echocardiogram - right ventricular dilation

and paradoxic septal motion

D.

Tricuspid insufficiency (regurgitation) 1. Definition - tricuspid valve lets blood leak from the right ventricle back into the right atrium 2. Epidemiology a. results from dilation of the right ventricle and tricuspid valve ring b. most common in late stages of heart failure from rheumatic or congenital heart disease 3. Findings a. dyspnea, fatigue, weakness and syncope b. peripheral edema may cause discomfort 4. Management: surgical - valve replacement 5. Nursing interventions

a. b. c. d. e. f.

the cardio-care six monitor for cardio seven monitor for findings of heart failure, pulmonary edema, and adverse reactions to the drug therapy post-op monitor client for hypotension, arrhythmias and thrombus formation when sitting, client should raise legs - to prevent dependent edema client and family teaching

i. ii. iii. E.

Pulmonic stenosis 1. Definition - obstructed right ventricular outflow resulting in right ventricular hypertrophy 2. Epidemiology a. usually congenital, often with other birth defects such as tetralogy of Fallot b. rare among the elderly c. may result from rheumatic fever 3. Findings a. dyspnea, fatigue, chest pain and syncope b. peripheral edema may cause discomfort 4. Management: surgical - replace the valve via balloon and cardiac catheter 5. Nursing interventions a. same as tricuspid stenosis and tricuspid insufficiency b. monitor for findings of heart failure, pulmonary edema, and adverse reactions to to the drug therapy c. post-op: monitor client for hypotension, dysrhythmias and thrombus formation

d.

monitor the cardio seven client and family teaching - same as tricuspid stenosis and tricuspid insufficiency. Pulmonic insufficiency (regurgitation) 1. Definition - pulmonary valve fails to close, so that blood flows back into the right ventricle 2. Epidemiology a. a birth defect, or a result of pulmonary hypertension b. rarely, result of prolonged use of a pressure-monitoring catheter in the pulmonary artery 3. Findings a. dyspnea, fatigue, chest pain and syncope b. peripheral edema may cause discomfort c. if advanced: jaundice with ascites and peripheral edema d. possible malnourished appearance 4. Management a. diuretics - to mobilize edematous fluid to reduce pulmonary venous pressure e.

F.

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

b. c. d.

5.

sodium-restricted diet - to control underlying heart disease anticoagulants - to prevent blood clots digitalis - to increase the force or strength of cardiac contractions (inotropic action) e. surgery for severe cases: valvulotomy or valve replacement Nursing interventions

a. b. c. d. e. f. g.

the cardio-care six monitor the cardio seven monitor for findings of heart failure, pulmonary edema, and adverse reactions to drug therapy post-op: monitor client for hypotension, arrhythmias and thrombus formation provide rest periods when client sits, raise legs client and family teaching: (same as tricuspid stenosis, tricuspid insufficiency, and pulmonic stenosis)

i. ii. G.

the cardio five client's dentist must give client prophylactic antibiotics to prevent infection instruct client to raise legs when sitting to prevent dependent edema

iii. Aortic stenosis 1. Definition - aortic valve narrows. left ventricle must work harder, so needs more oxygen, and may suffer ischemia and heart failure. 2. Epidemiology a. most significant valvular lesion seen among elderly people. It usually leads to left-sided heart failure b. incidence increases with age c. occurs in 1% of the population d. about 80% of these people are male e. 20% of them die suddenly, around age 60 3. Findings a. classic triad: dyspnea, syncope, angina (see Assessing Clients with b.

c. d.

4.

5.

Cardiovascular Disorders fatigue palpitations

)

left-sided heart failure may bring on orthopnea, paroxysmal nocturnal dyspnea, and peripheral edema Management a. nitroglycerin to relieve chest pain b. low-sodium diet - to prevent fluid retention c. diuretics - to mobilize edematous fluid and to reduce pulmonary venous pressure d. digitalis - to increase the force or strength of cardiac contractions (inotropic action) e. oxygen - to prevent hypoxia f. surgery - percutaneous balloon valvuloplasty, then valve replacement Nursing interventions

a. b. c. d. e. f.

the cardio-care six monitor the cardio seven monitor for findings of heart failure, pulmonary edema, and adverse reactions to the drug therapy post-op: monitor client for hypotension, arrhythmias and clots when client sits, raise legs to prevent dependent edema client and family teaching: (same as tricuspid stenosis, tricuspid insufficiency, pulmonic stenosis and pulmonic insufficiency)

i. ii.

the cardio five client's dentist must administer prophylactic antibiotics

H.

iii. client should raise legs when sitting Aortic insufficiency (regurgitation) 1. Definition a. blood flows back into the left ventricle during diastole overloading the ventricle and causing it to hypertrophy. b. extra blood also overloads the left atrium and, eventually, the pulmonary system. 2. Epidemiology a. by itself, most common among males b. with mitral valve disease, more common among females c. may accompany Marfan's syndrome, ankylosing spondylitis, syphilis, essential hypertension or a defect of the ventricular septum 3. Findings a. uncomfortable awareness of heartbeat b. palpitations along with a pounding head

c. d. e.

dyspnea with exertion paroxysmal nocturnal dyspnea, with diaphoresis, orthopnea and cough

fatigue and syncope with exertion or emotion anginal chest pain unrelieved by sublingual nitroglycerin heartbeat that seems to jar the client's entire body client's nailbeds appear to be pulsating if nail tip is pressed, the root will flush and then pale (Quincke's sign) j. if left ventricle fails, client may show ankle edema and ascites k. pulsus biferiens Management a. digitalis - increases the heart's contractility (inotropic action) b. diuretics - to mobilize edematous fluids and to reduce pulmonary venous pressure c. sodium-restricted diet - to prevent fluid retention d. anticoagulant agents - to prevent blood clots e. surgical - valve replacement. however, aortic insufficiency often damages the ventricle before it is detected. Nursing interventions f. g. h. i.

4.

5.

a.

same as all other valve disorders - the cardio-care six elevate head unless pulmonary problems have begun.

b. c. d.

monitor the cardio seven

e.

except don't need to

monitor for signs of heart failure, pulmonary edema, and drug reactions. post-op: monitor client for hypotension, arrhythmias and clots. client and family teaching

i. ii. iii.

same as all other valve disorders - the cardio five emphasize the need for prophylactic antibiotics during dental care instruct client to raise legs when sitting

. Failures of the Heart Muscle A.

Myocardial infarction (MI) 1. Definition - insufficient oxygen supply kills (causes necrosis of) myocardial tissue. MI may be sudden or gradual. total event takes 3 to 6 hours. 2. Epidemiology a. almost equal for men and women b. client history of smoking, obesity, high cholesterol/low density lipoprotein diet, physical/emotional stress c. a common killer in North America and Western Europe d. mortality about 25%. Of the sudden deaths from MI, more than half happen within an hour e. of those who survive the initial MI and recover, up to 10% die within the first year

3.

4.

Findings a. persistent, crushing substernal chest pain b. pain that may radiate to the left arm, jaw, neck and shoulder blades, with a feeling of impending doom c. pain may persist for 12 hours or more d. some clients report no pain, or call it mild indigestion e. fatigue, nausea, vomiting and shortness of breath f. sudden death g. within the first hour after an anterior MI, about 25% of clients experience tachycardia or hypertension. h. up to 50% of clients with an inferior MI experience the opposite: bradycardia or hypotension. i. women may experience fatigue, achiness, flu-like symptoms Management a. cardiac monitoring for arrythmias b. oxygen - to prevent tissue hypoxia c. bed rest - to decrease the workload of the heart d. pharmacologic agents - to stabilize client e. stool softeners - to decrease the workload of the heart caused by straining, which can cause vagal stimulation producing bradycardia and arrythmias f. narcotic analgesics - to reduce pain, anxiety and fear and decrease the workload of the heart g. beta-blocking agents - to slow heart rate h. sedatives - to decrease anxiety and fear and to decrease the workload of the heart i. antiarrhythmic - to prevent arrythmias which are the most common complications after an MI j. thrombolytic agents - to dissolve the thrombus in the coronary artery and reperfuse the myocardium k. nitrates - to decrease pain and decrease preload and afterload while increasing the myocardial oxygen supply l. anticoagulants - to prevent blood clots m. Swan-Ganz catheter to monitor pressure in pulmonary artery (measure functioning of left ventricle) n. intra-aortic balloon counterpulsation may be used for cardiogenic shock

o.

5.

6.

cardiac catheterization may be performed for PTCA p. surgery - coronary atherectomy or graft of a coronary artery bypass Diagnostic studies a. history and physical b. EKG - monitor for changes, arrythmias c. serum cardiac markers (CK - MB) - rises 4-6 degrees after acute MI; Returns to normal in three to four days. Troponin - rises quickly but remains elevated for two weeks Nursing interventions

a.

the cardio-care six plus monitor the following to prevent heart failure, infections and complications I. temperature II. daily weight III. intake and output IV. respiratory rate V. breath sounds VI. blood pressure VII. serum enzyme levels

VIII. IX. b.

c.

EKG readings

heart sounds, especially S3 and S4 assess pain and give analgesics as ordered. Record the severity, location, type, and duration of pain. do not give IM injections, or CK will be falsely elevated.

d.

e. f. g.

watch for crackles, cough, tachypnea, and edema which may predict left ventricle is failing. use antiembolism stockings to prevent venostasis and thrombophlebitis. assistance with range-of-motion exercises client and family teaching

I. II. III. IV. V. VI.

VII. B.

the cardio five explain the ICU or Coronary Care Unit, routine and machinery ask dietitian to speak with the client and family to reinforce teaching encourage client to join the cardiac rehab exercise program counsel gradual resumption of sexual activity; taking nitroglycerin before sex may prevent chest pain advise the client to report typical or atypical chest pain describe postmyocardial infarction syndrome; have client report it to physician stress that client must modify high-risk behaviors

VIII. Congestive heart failure 1. Definition/etiology a. heart fails to pump enough blood to support the body's functions b. types of CHF depend on which part of the heart fails: the left half that pumps to the body, or the right half that pumps to the lungs. c. etiology

I. II. III. IV. V. VI. VII.

2.

coronary artery disease (illustration

)

myocarditis cardiomyopathy infiltrative disorders: amyloidosis, tumors, sarcoidosis collagen-Vascular disease: systemic lupus scleroderma dysrhythmias that reduce cardiac filling time

erythematosus,

disorders that increase cardiac workload: hypertension, valve disease, anemia, hyperthyroidism VIII. cardiac tamponade Findings of Left CHF and Right CHF

3.

4.

Management a. objective: to restore balance between myocardial oxygen supply and demand b. treatments include oxygen, digitalis, vasodilators, nitrates antihypertensives, cardiac glycosides, diuretics, intra-aortic balloon counterpulsation, ventricular assist pumping, etc. Nursing interventions

a.

the cardio care six administer medications as ordered administer oxygen as ordered - to prevent tissue hypoxia monitor hemodynamic indicators e. monitor for findings of hyponatremia, hypokalemia f. restrict fluids and assess for findings of fluid retention g. client and family teaching i. medications and side effects ii. how to conserve energy and thus oxygen iii. teach client to report • weight gain of more than two pounds in 24 hours (equals 1 liter) • dyspnea • decreased exercise tolerance iv. importance of sodium-restricted diet 5. Diagnostic findings - the primary goal is to determine the underlying cause of the heart failure a. history and physical exam b. CXR - to determine heart size and pleural effusions c. EKG for changes, arrythmias d. echocardiogram to measure valvular abnormalities e. nuclear imaging - to determine myocardial contractility, myocardial perfusion, and acute cell injury f. hemodynamic monitoring of arterial blood pressure, pulmonary artery pressure, pulmonary artery wedge pressure and cardiac output Cardiac tamponade b. c. d.

B.

3.

Definition/etiology a. fluid quickly fills pericardial sac and limits cardiac output; cardiac tamponade is a medical emergency etiology i. acute pericarditis ii. post-op after cardiac surgery iii. pericardial effusions iv. chest trauma v. myocardial rupture vi. aortic dissection vii. anticoagulant therapy Findings: classic triad of findings a. hypotension with b. muffled heart sounds with c. high jugular venous pressure (increased CVP) Diagnosis (above) Management a. pericardiocentesis: needle aspiration of pericardial sac Nursing interventions a. bed rest with elevated head of bed b. prepare client for pericardiocentesis c. provide emotional support b.

4.

5. 6. 7.

V. Disorders of the Circulatory System:

A.

Hypertension (illustration ) 1. Definitions a. hypertension - systolic blood pressure of 140 mm Hg or greater, diastolic blood pressure of 90 mm Hg or greater, or taking antihypertensive medication b. chronic hypertension of pregnancy - high blood pressure already present before week 20 of gestation c. accelerated hypertension - a hypertensive crisis: blood pressure rises very rapidly, threatening the brain

2.

Etiology and epidemiology

a. b.

c. d.

essential hypertension: cause unknown. possible factors include: i. family history- immediate family: mother, father, siser, brother ii. race- African American, Hispanic, Native American, more susceptible iii. stress iv. obesity- 20% more than ideal weight v. a diet high in sodium or saturated fat vi. use of tobacco vii. use of hormonal contraceptives viii. sedentary life-style ix. aging besides hypertension, most individuals have other risk factors for cardiovascular disease (CVD). secondary hypertension may result from i. renovascular disease ii. renal parenchymal disease iii. cushing's syndrome

iv. v. vi.

diabetes mellitus dysfunction of the thyroid, pituitary, or parathyroid coarctation of the aorta

vii. viii. 3.

4.

Findings a. b. c. d. e. f.

may be asymptomatic findings reflect the effect of hypertension on organ systems occipital headache, blurred vision, dizziness dizziness, palpitations, weakness, fatigue, and impotence nosebleeds bloody urine g. chest pain and dyspnea, if heart is involved Diagnosis a. based on the average of two or more blood pressure readings, two minutes apart, at each of two or more visits after an initial screening visit b. classification of adult hypertension

c.

5.

6.

pregnancy neurologic disorders

hypertension is classified according to its cause: i. primary or essential hypertension (about 90% of clients) ii. secondary hypertension (results from another disease; about 5% to 10% of clients) iii. accelerated hypertension - a hypertensive crisis

Management a. pharmacological i. initial therapy - for uncomplicated hypertension, it is recommended to start with a diuretic or Beta-adrenergic blocking agent ii. oxygen PRN in acute crisis iii. angiotensin-converting enzyme (ACE) inhibitors are used to treat left-sided heart failure and preferred if client is diabetic iv. antilipemics b. goals of treatment i. BP <130/85 mm Hg ii. control dyslipidemia, obesity, inactivity iii. control diabetes mellitus, if indicated Nursing interventions: reinforce client and family teaching regarding:

a. b. c.

d. e. f. g.

B.

client to use self-monitoring blood pressure cuff client to record readings at least twice weekly in a journal or calendar for review by care provider during visits client to set up routine for taking antihypertensive medications the need to warn against high-sodium antacids, and cold or sinus remedies with vasoconstrictors such as antihistamines diet low in sodium, cholesterol and saturated fat when client is to report extremely high blood pressure readings lifestyle modifications i. optimize body weight ii. drink alcohol based on current guidelines iii. moderate dietary sodium (two gm sodium diet) iv. exercise: regular moderately intense aerobic activity v. avoid tobacco products vi. manage stress triggers and responses to triggers

Coronary artery disease (illustration ) 5. Definition - fatty deposits in coronary arteries (atheroma or plaque) narrow the artery (by 75% or more) and cut flow of blood and oxygen to the heart muscle. 6. Epidemiology and etiology a. CAD is epidemic in the western world. b. more than 30% of men age 60 or older show signs of CAD on autopsy. c. most common cause: Atherosclerosis d. risk factors: i. over 40 white male ii. family history of CAD iii. high blood pressure

iv. v.

vi. vii.

7. 8.

high cholesterol smokers are twice as likely to have a myocardial infarction and four times as likely to die suddenly. The risk drops sharply within one year after smoking ceases. obesity (waist predominance); [added weight increases the risk of diabetes, hypertension and high cholesterol] sedentary life style

Findings: angina Management a. pharmacology i. nitrates such as nitroglycerin, isosorbide dinitrate (Isordil), or betaadrenergic neuron-blocking agents ii. oxygen - to prevent hypoxia iii. diuretics and beta-adrenergic blocking agents iv. aspirin - decreases platelet aggregation v. antilipemics - to decrease circulating lipids b. diet: reduce calories, salts, fats, cholesterol c. cardiac catheterization

i.

d.

after cardiac catheterization and percutaneous transluminal coronary angioplasty (PTCA), maintain heparinization; observe for bleeding systemically at the site, and keep the affected leg straight and immobile for six to 12 hours. ii. check for distal pulses. iii. to counter the diuretic effect of the dye, increase IV fluids and make sure client drinks plenty of fluids. iv. assess potassium level- observe for dysrhythmias v. observe findings of hypotension, bradycardia, diaphoresis, dizziness; give atropine and lay the client flat. rotational ablation i. after rotational ablation, monitor the client for chest pain, hypotension, coronary artery spasm and bleeding from the catheter site.

ii.

e.

provide heparin and antibiotic therapy for 24 to 48 hours or as ordered. laser coronary angioplasty

f.

9.

C.

Shock 5. 6.

surgical treatment - coronary artery bypass graft (CABG Nursing interventions a. help client with ADL (activities of daily living) b. partial bed rest c. reassure client d. assist with turning, deep breathing and coughing exercises e. relieve chest pain by oxygen and medication as ordered f. during angina attacks, monitor bp, heart rate, pain, meds, symptoms; get electrocardiogram g. keep nitroglycerin available for immediate use h. client and family teaching i. risks I. teach the risk factors for CAD (coronary artery disease) II. encourage client to lose excess weight; review low-fat, low-cholesterol diet III. teach smoking cessation IV. teach side effects of drugs for CAD V. stress - teach stress reduction techniques ii. avoid I. activities known to cause angina II. physical activities for two hours after meals III. very cold and very hot weather IV. alcohol and caffeine drinks V. diet pills, nasal decongestants, or any remedy that can raise heart rate or blood pressure iii. use I. nitroglycerin tablets; carry at all times II. if necessary nitroglycerin patch iv. report I. angina II. angina >15 minutes, go to clinic or hospital Definition - body cells need more oxygen than blood is supplying. cells and then organs fail. shock has many different causes. It is a medical emergency. Five types of shock: a. cardiogenic b. septic c. neurogenic d. anaphylactic e. hypovolemic

types of shock classified according to etiology: CHANS Cardiogenic - ventricle loses pumping power and cardiac output becomes inadequate Hypovolemic - excessive blood loss Anaphylactic - severe allergic reaction inappropriately dilates the veins to pool blood Neurogenic - sympathetic NS inappropriately dilates the veins to pool blood Septic shock - systemic infection causes excessive capillary permeability with excess intravascular volume loss 3.

Findings: progression of shock

a.

initial stage: i. decreased cardiac output and perfusion ii. cellular function interrupted iii. anaerobic metabolism increases iv. no clinical symptoms at this stage compensatory stage: neural, chemical, and hormonal mechanisms act to restore perfusion. i. neural compensation: pressoreceptors in aorta activate sympathetic nervous system (NS), which contracts blood vessels so that skin cools; sympathetic NS stimulates heart, so tachycardia sets in; it cuts blood flow to kidneys and gastrointestinal system, and dilates pupils. ii. Hormonal compensation: decreased blood flow to kidneys releases angiotensin, which constricts vessels and increases BP; Angiotensin stimulates the secretion of aldosterone. Aldosterone makes kidneys retain sodium, which increases serum osmolality, which in turn stimulates antidiuretic hormone; ADH causes water retention. • increased sodium and water retention results in increased BP, decreased urine volume and increased urine specific gravity. • anterior pituitary is stimulated to secrete Adrenocorticotropic hormone , and ACTH acts on adrenal cortex to increase secretion of glucocorticoids, which increase serum glucose.

b.

iii. iv.

2.

chemical compensation: decreased pulmonary blood flow causes hypoxemia; hypoxemia is sensed by chemoreceptors that increase rate and depth of respirations, which results in respiratory alkalosis findings of compensatory stage of shock • altered L.O.C. • tachypnea • anxiety, restlessness • skin cool and clammy • diaphoresis • thirst • pupils dilated • tachycardia • weak peripheral pulses • decreased bowel sounds • decreased urine output • concentrated urine

progressive stage of shock - compensatory mechanisms can no longer maintain perfusion. iii. severe hypoperfusion iv. massive cell death v. organs begin to fail vi. findings of progressive stage of shock • consciousness - L.O.C. severely depressed • lungs -hypoventilation, moist crackles • cardiovascular - decreased BP: systolic below 90 mm mg, narrowing pulse pressure, tachycardia, irregular pulse, peripheral pulses weak, thready • elimination - urine volume below 20 cc/hour, urine osmolality dilute, absent bowel sounds

3.

refractory stage: shock irreversible: death from multi-system organ failure is evident iii. findings of refractory stage of shock • cardiac failure • respiratory failure • renal shutdown • liver dysfunction • loss of consciousness

ii. iii.

diagnostics management - objective: to correct underlying cause and prevent progression • cardiogenic shock o pharmacologic treatments







 o

positive inotropic agents: increase myocardial contractility and improve systolic ejection: dobutamine (Dobutrex), amrinone lactate (Inocor) vasodilators: improve heart's pumping action by reducing its workload: nitroglycerin (Corobid), nitroprusside sodium (Nipride), (Usually limited to clients with failing ventricular function) vasopressors: increase peripheral vascular resistance and elevate blood pressure: norepinephrine (Levophed), dopamine hydrochloride (Intropin) oxygen therapy

surgical treatments



intra-aortic balloon counterpulsation

  • •

• •

left and right ventricular assist pumping heart transplant

hypovolemic shock: rapid fluid replacement therapy to replace lost volume anaphylactic shock: o epinephrine (adrenalin) o antihistamines o aminophylline (truphylline) neurogenic: depends on causative agent septic: antibiotic therapy

THE CARDIO-CARE SIX: A,B,C,D,E,F

1. 2. 3. 4. 5. 6.

ADL: Help the client with activities of daily living. Bed rest Commode at bedside (it stresses the heart less than using a bedpan does). Diversions: offer diversions that don't stress the heart. Elevate head of bed, or sit client up. Feelings: Let clients express concern; reassure when activity will resume.

iv.

nursing interventions for shock: the cardio-care six except • do not elevate or lower head: maintain complete bed rest in flat position or with legs slightly raised to increase venous return • do not move client; no commode • keep client warm • administer parenteral therapy, drugs, and O2 as ordered • monitor mean hemodynamic indicators as ordered • blood plasma expanders or packed cells

VI. Dysrhythmias and Lesser Vascular Disorders A.

Dysrhythmias 1. Definition: disturbance in heart rate or rhythm 2. Types of dysrhythmia a. supraventricular: sinus, atrial, and junctional i. sinus tachycardia

ii. iii. iv.

v. vi. vii.

b.

sinus bradycardia sinus arrhythmia premature atrial complexes atrial tachycardia atrial flutter

atrial fibrillation viii. premature junctional complex ix. junctional tachycardia ventricular

i. ii. iii. iv. v.

c.

premature ventricular contraction ventricular tachycardia ventricular fibrillation asystole

atrioventricular block: vi. first degree A-V block (no treatment) vii. second degree A-V block (no treatment) viii. third degree A-V block Nursing interventions i. supraventricular dysrhythmias A. asymptomatic - no nursing interventions indicated B. symptomatic

A.

administer medications as ordered provide emotional support teach client A. medications and side effects B. to wear dysrhythmia identification jewelry ventricular dysrhythmias A. administer medications as ordered B. C.

ii.

B. C. D. E.

F. G.

monitor monitor hemodynamic indicators as ordered administer oxygen as ordered provide a restful environment prepare the client for cardioversion

initiate cardiopulmonary resuscitation as indicated provide emotional support teach client A. medications and side effects B. importance of dysrhythmia identification jewelry atrio-ventricular (AV) conduction disturbances A. asymptomatic: no nursing interventions indicated B. symptomatic A. administer medications as ordered H. I.

iii.

B. C. D. E. 3.

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

Aneurysms a. Definition, four types, two locations i. dilation of an artery due to a weakness in the arterial wall ii. four types of aneurysms A. saccular: outpouching of one wall in a circumscribed area B. fusiform: involves complete circumference of artery C. dissecting: accumulation of blood separating the layers of the arterial wall D. pseudoaneurysm: tear of the full thickness of the arterial wall, leading to a collection of blood contained in the connective tissue iii. two locations: abdominal aorta and thoracic aorta A. location one: abdominal aortic aneurysm A. findings of abdominal aortic aneurysm A. usually asymptomatic B. vague abdominal or back pain C. tenderness on palpation D. hypotension E. diminished pulses in lower extremities F. commonest site: just below renal arteries and above iliac arteries B. treatment - surgical repair

C.

nursing interventions

A.

care of the client undergoing surgery after surgery, watch for back pain, a sign of retroperitoneal hemorrhage C. monitor perfusion D. provide comfort measures E. provide emotional support F. teach client - to avoid prolonged sitting and lifting of heavy objects location two: thoracic aortic aneurysm A. findings of thoracic aortic aneurysm A. may be asymptomatic B. vague chest pain C. dyspnea D. distended neck veins B. management - surgical repair C. nursing interventions A. care of the client undergoing surgery B.

iv.

B. b.

C.

care of the client undergoing cardiac surgery

Etiology - atherosclerosis

Arterial occlusive disease 1. Definition: insufficient blood may be acute or chronic. 2. Acute arterial occlusive disease a. etiology

i. ii. b.

the

arteries;

usually

embolism, thrombosis, and trauma (illustration 1

in

legs.

illustration 2

) femoral artery most often affected

paresthesia in affected limb

if untreated, gangrene management

i. ii.

pharmacology anticoagulants surgical treatment • embolectomy

• • •

3.

in

findings i. pain in affected limb ii. cyanosis in affected limb

iii. iv.

c.

supply

bypass of affected artery (illustration ) amputation of limb percutaneous transluminal coronary angioplasty Chronic arterial occlusive disease a. etiology i. arteriosclerosis obliterans, aneurysms, hypercoagulability states, tobacco use ii. slow, progressive arteriosclerotic changes give collateral circulation a chance to form iii. collateral circulation cannot give tissues enough oxygen; result is hypoperfusion iv. hypoperfusion leads to ischemia v. usually affects legs b. findings

i. ii. iii.

iv. c.

intermittent claudication indicates mild to moderate obstruction pain at rest indicates severe obstruction affected limb will show • edema • paresthesia • weak or absent pulses • skin: waxy, hairless, cool, pale, cyanotic in men, impotence

management i. pharmacologic

• • • •

ii.

anticoagulants - to prevent blood clots vasodilators antiplatelet drugs - to prevent platelet aggregation pentoxifylline (Trental): increases blood flow by thinning blood surgical treatment • endarterectomy

• • • • •

5.

femoral-popliteal bypass (illustration ) sympathectomy amputation of affected limb for gangrene laser coronary angioplasty (LTA) peripheral angioplasty Both acute and chronic arterial occlusive disease c.nursing interventions i. administer medications as ordered ii. monitor peripheral pulses and blanch test iii. provide comfort measures iv. help client develop an exercise program

v. vi. vii.

care of the client undergoing surgery provide foot care teach client • to change positions frequently • to avoid crossing legs • to avoid any constrictive clothing on legs • to avoid trauma to lower extremities • foot care • to place legs in dependent position to increase blood flow

CARE OF CLIENTS TAKING ORAL ANTICOAGULANTS

1. 2. 3. 4. 5. 6. 7. 8.

Medicate same time every day Wear medical identification jewelry: wearer takes anticoagulants Use a soft toothbrush Do not use a straight razor; use an electric razor Avoid alcohol Report any signs of bleeding, red or black bowel movements, headaches, rashes, red or pinktinged urine, sputum Avoid trauma Monitor levels of the anticoagulant in the blood

CARE OF THE CLIENT UNDERGOING CARDIAC SURGERY WITH CARDIOPULMONARY BYPASS

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19.

Monitor hemodynamics for lower cardiac output or excess fluid Measure fluid intake and output Monitor specific gravity of urine Monitor ECG (EKG) rate and rhythm Monitor peripheral perfusion Monitor neurological status Administer IV fluids as ordered Administer oxygen as ordered Care of the client on a ventilator Administer medications as ordered Provide comfort measures Limit fluid intake as ordered Weigh client daily Monitor for signs of cardiac tamponade Administer blood and blood products as ordered Provide emotional support Observe incision sites for signs of infection Care of the client with chest tubes Monitor arterial blood gases as ordered 1. Raynaud's phenomenon (arteriopastic disease) 1. Definition: disorder of small cutaneous arteries causing vasospasm. usually affects the fingers bilaterally. 2. Etiology 1. unknown 2. frequently occurs in women 3. may be triggered by stress, cold

3. 4.

5.

Findings Management 1. pharmacologic agents 2. antihypertensive agents: reserpine (Serpasil) 3. alpha-adrenergic blocking agents: phenoxybenzamine (Dibenzyline), tolazoline (Piscoline) 4. vasodilators 5. surgery 1. sympathectomy in advanced stages

2. amputation of fingers showing gangrene Nursing interventions 1. administer medications as ordered 2. care of the client undergoing surgery 3. teach client 1. to manage stress 2. to stop smoking, avoid caffeine 3. to avoid temperature extremes 4. protection from cold 5. medications and their side effects

SIGNS OF ARTERIAL INSUFFICIENCY IN THE EXTREMITIES 1. 2. 3. 4.

Pale color on elevation, dusky red color when lowered Cool to touch Decreased or absent peripheral pulses Little or no edema

5. 6. 7. 8. 9.

Thin, shiny skin and decreased growth of hair Thickened nails Pain unrelieved by rest and/or activity Chronic pain may be either steady or intermittent Claudication pain as tight feeling, burning, fatigue, ache or cramping 1. Thromboangiitis obliterans (Buerger's disease) 1. Definition: blocking of the medium and small arteries, usually in the legs and feet. 2. Etiology 1. affects men more than women 2. 25 to 40 age group who smoke 3. the disease only occurs in smokers

3.

Findings

1. 2. 3. 4.

5.

intermittent claudication numbness and tingling of toes weak or absent peripheral pulses ischemic ulcerations may occur can lead to gangrene

SIGNS OF ARTERIAL INSUFFICIENCY IN THE EXTREMITIES 1. 2. 3. 4. 5. 6. 7. 8. 9.

Pale color on elevation, dusky red color when lowered Cool to touch Decreased or absent peripheral pulses Little or no edema Thin, shiny skin and decreased growth of hair Thickened nails Pain unrelieved by rest and/or activity Chronic pain may be either steady or intermittent Claudication pain as tight feeling, burning, fatigue, ache or cramping 1. Management 1. smoking cessation 2. other treatment, see arterial occlusive disease 3. analgesics 4. surgery in late stages, amputation 2. Nursing interventions 1. assist client with smoking cessation 2. see nursing interventions for arterial occlusive disease: 1. administer medications as ordered 2. monitor peripheral pulses and blanch test 3. provide comfort measures 4. help client to develop an exercise program 5. care of the client undergoing surgery 6. provide foot care 7. teach client how stopping smoking can relieve symptoms

2.

Varicose veins (illustration ) 1. Definition: dilation of superficial veins of the legs and feet. 2. Etiology 1. usually found in greater saphenous vein (leg) 2. incompetent valves (incompetence, vavular) in the superficial veins 3. increased pressure in veins causing them to distend 4. risk factors: standing for long periods, pregnancy

3.

4.

Findings 1. pain after period of standing 2. foot and ankle swelling at end of day 3. distended leg veins Management 1. objective: to reduce pain and halt underlying condition 2. medical: sclerotherapy (injection of sclerosing agent that causes vein thrombosis)

3. surgical: vein ligation (Vein stripping) Nursing interventions 1. care of the client undergoing surgery 2. post-operative care includes 1. application of elastic stocking or bandages 2. elevation of leg 3. teach client 1. not to cross legs 2. to elevate legs as much as possible 3. to avoid prolonged sitting or standing Thrombophlebitis 1. Definition: A clot inflames the wall of a superficial blood vessel. 2. Etiology 1. trauma 2. intravenous catheters 3. prolonged immobility 4. IV drug use 3. Findings 1. redness 2. swelling 3. tenderness 4. warmth 4. Management 1. bed rest, with elastic stockings 2. elevation of affected extremity 3. anticoagulants - to prevent clot formation 4. analgesics - to control discomfort 5. Nursing interventions 1. keep leg elevated 2. monitor 1. for findings of pulmonary embolism (sudden pain, cyanosis, hemoptysis, shock) 2. vital signs, including peripheral pulses 3. for findings of vascular impairment (pallor, cyanosis, coolness) 3. administer analgesics as ordered 4. client teaching 1. avoid tight or constricting clothing 2. stop cigarette smoking 3. avoid maintaining one position for long periods Deep venous thrombosis 1. Definition: clotting in a deep vein 2. Etiology and risk 1. immobilization 2. sepsis 3. hematological disorders and clotting disorders 4. malignancies 5. congestive heart failure 5.

3.

4.

6.

myocardial infarction obesity pregnancy fractures 10. venipuncture 11. surgeries: orthopedic, neurologic, urologic and gynecologic 12. risk of pulmonary embolus 7. 8. 9.

3. 4.

Findings unilateral edema of extremity Management 1. objective: to eliminate the clot and prevent complications 2. bed rest 3. anticoagulant therapy - to prevent new clots 4. thrombolytic therapy - to dissolve thrombus

5.

compression stockings surgery - thrombectomy Nursing interventions 1. monitor for findings of pulmonary embolus 2. maintain bed rest

6.

5.

3.

administer medications as ordered teach client 1. medications and side effects 2. to avoid prolonged immobility 3. to maintain adequate fluid intake Deep venous thrombosis 1. Definition: clotting in a deep vein 2. Etiology and risk 1. immobilization 2. sepsis 3. hematological disorders and clotting disorders 4. malignancies 5. congestive heart failure 4.

5.

6.

myocardial infarction obesity pregnancy fractures 10. venipuncture 11. surgeries: orthopedic, neurologic, urologic and gynecologic 12. risk of pulmonary embolus 7. 8. 9.

3. 4.

5.

Findings unilateral edema of extremity Management 1. objective: to eliminate the clot and prevent complications 2. bed rest 3. anticoagulant therapy - to prevent new clots 4. thrombolytic therapy - to dissolve thrombus 5. compression stockings 6. surgery - thrombectomy Nursing interventions 1. monitor for findings of pulmonary embolus 2. maintain bed rest

3. 4.

6.

Venous stasis ulcers 1. Definition: chronic skin and subcutaneous ulcers usually found on legs, ankles or feet. 2. Etiology 1. chronic venous insufficiency 2. incompetent valves (vavular, incompetence) in perforating veins or deep veins cause venous stasis 3. pressure of blood pooling causes capillaries to leak 4. ulcer begins as small, inflamed, tender area 5. any trauma causes tissue to break or it may break spontaneously 6. site: pretibial and medial supramalleolar areas of ankle

3.

4.

administer medications as ordered teach client 1. medications and side effects 2. to avoid prolonged immobility 3. to maintain adequate fluid intake

Management

Findings 1. open skin lesion with irregular border 2. skin around ulcer usually brown and leathery 3. pain in affected area

1.

5.

• •

• • • • • • • • • • • •

objective: to correct venous hypertension and both prevent and correct ulceration 2. local wound care 3. antibiotics and analgesics as indicated 4. surgery 1. debridement 2. skin grafting 3. removal of veins with incompetent valves Nursing interventions 1. keep legs elevated, with feet above level of heart at all times 2. apply elastic bandages as ordered 3. cleanse and dress ulcer as ordered 4. administer drugs as ordered 5. teach client 1. to report any signs of inflammation immediately 2. to avoid trauma to affected limb 3. to provide skin care 4. to apply elastic bandages

Cardiovascular disease is the leading cause of death among Americans. Take blood pressures correctly  give client 5 minutes rest.  take blood pressure while client is lying, sitting, and standing.  ask client if he/she has recently smoked, drank a beverage containing caffeine or was emotionally upset. If so, repeat blood pressure in 30 minutes. Rarely, the heart may lie on the right side instead of the left, this is called Dextrocardia. Valves control the direction of the blood flow through the heart. Flow is unidirectional. When the atria contract, the atrioventricular valves swing open, allowing the blood to flow down into the ventricles. When the ventricles contract the valves snap shut preventing blood from flowing back up into the atria. Semilunar valves open allowing blood to eject during ventricular contraction. If the SA node fails to generate an impulse, the AV node takes over, generating a slower rate. If the AV node fails to generate an impulse, the Bundle of His takes over, generating an even slower rate. If the Bundle of His fails to generate an impulse, the Purkinje fibers take over and generate an even slower rate. Damaged areas of the heart may also stimulate contractions and produce arrhythmias. Rapid, short-term control of blood pressure is achieved by cardiac and vascular reflexes that are initiated by stretch receptors (baroreceptors) in the walls of the carotid sinus and the aortic arch. Many clients with angina or MIs benefit from involvement in a structured cardiac rehabilitation program to assist clients to increase their activity level in a monitored environment. Current research suggests that life style and personal habits are closely related to cardiac changes once attributed to aging. The elderly are less able to physically adapt to stressful physical and emotional conditions, because their hearts do three things less quickly: the myocardium contracts less easily, the left ventricle ejects blood less quickly, and the heart is slower to conduct the impulse for a heartbeat. Because different enzymes are released into the blood at varying periods after a myocardial infarction, it is important to evaluate enzyme levels in relation to the onset of the physical symptoms such as chest pain. Clients who are in postoperative recovery, on bed rest, obese, taking hormonal contraceptives or had knee or hip surgery should be monitored closely for thrombophlebitis. Adrenergic Adrenergic Afterload Angioplasty Angiotensin-converting Antiarrhythmic Arterial

neuron-blocking enzyme

(ACE) line

agents inhibitors

Atherectomy Auscultatory Automaticity Bounding Calcium Cardiac Cardiac Cholinergic Conductivity Coronary Depolarization Echocardiography Excitability Hyperlipidemia Preload Repolarization Streptokinase Stress Stroke Tamponade, Vasoconstrictors Vasodilators

• • • • • • • • • • • • • • • • • • •

gap pulse channel

blockers catheterization output

Artery

Alveolocapillary membrane Aortic Valve Bypass Cardiac cycle Chambers of the heart Circulation of blood through heart and major vessels Conduction system of the heart Coronary arteries (anterior and posterior) Normal and diseased coronary arteries Pericardicentesis Pericardium QRST Complex of Electrocardiogram/ECG Leads Raynaud's Phenomenon Structure of an artery Systemic arteries Systemic blood pressure Ventricular fibrillation Ventricular tachycardia Varicose Veins

Bypass

test volume cardiac