Cardiovascular Part Two
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CARDIOVASCULAR NCLEX REVIEW PART TWO 2- CARDIOVASCULAR DISORDERS
Insufficiency (or regurgitation), incompetence
Definition and related terms a damaged mitral valve allows blood from the left ventricle to flow back into the left atrium during ventricular systole to handle the backflow, the atrium enlarges. So does the left ventricle, in part to make up for its lower output of blood
Epidemiology / etiology follows birth defects such as transposition of the great arteries in older clients, the mitral annulus may have become calcified cause unknown; may be linked to a degenerative process occurs in 5-10% of adults Marfan's Syndrome papillary muscle dysfunction or rupture trauma mitral valve prolapse, also called Barlow's Syndrome or floppy mitral valve syndrome
Insufficiency (or regurgitation), incompetence
Findings client may be asymptomatic orthopnea, dyspnea, fatigue, weakness, weight loss chest pain and palpitations findings of RVHF jugular vein distention peripheral edema hepatomegaly
Diagnostics EKG for dysrhythmias and changes of left atrial enlargement echocardiogram - to visualize regurgitant jets and flail chordae / leaflets cardiac catheterization - shows regurgitation of blood from left ventricle to left atrium and increased pressures chest x-ray - shows cardiomegaly, pulmonary congestion
Insufficiency (or regurgitation), incompetence
Management low-sodium diet - to control underlying heart disease oxygen as needed - to prevent tissue hypoxia antibiotics - to treat infection prophylactic antibiotics - to prevent infection surgery - mitral valvuloplasty or valve replacement
Nursing interventions 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
Continue Nursing Intervention
if client has surgery, monitor postoperatively for hypotension, arrhythmias and thrombus formation reinforce client and family teaching regarding: diet restrictions and drugs explanation of tests and treatments long-term antibiotic and follow-up care the need for prophylactic antibiotics during routine dental care as cleaning, or for any invasive procedure need to report findings of heart failure: dyspnea and hacking, nonproductive cough
Tricuspid stenosis
Definition: narrowing of the blood flow through the tricuspid valve between the right atrium and right ventricle
Epidemiology relatively uncommon usually associated with lesions of other valves caused by rheumatic fever, IV drug abuses
Findings dyspnea, fatigue, weakness, syncope peripheral edema jaundice with severe peripheral edema and ascites can mean that tricuspid stenosis has led to right ventricular failure may appear malnourished distended jugular veins
Diagnostics EKG - for dysrhythmias echocardiogram - right ventricular dilation and paradoxic septal motion
Management: surgery - valvulotomy or valve replacement;
Tricuspid stenosis
Nursing interventions the Cardio-Care Six monitor the Cardio Seven monitor for findings of right heart failure and adverse reactions to the drug therapy post valve surgery, monitor client for hypotension, dysrhythmias and thrombus formation when client sits, elevate legs - to prevent dependent edema reinforce client and family teaching regarding: the Cardio Five client must comply with long-term antibiotic and follow up care the need for prophylactic antibiotics during dental care or other invasive procedures
Tricuspid insufficiency (regurgitation)
Definition - tricuspid valve lets blood leak from the right ventricle back into the right atrium during ventricular systole
Epidemiology results from dilation of the right ventricle and tricuspid valve ring most common in late stages of heart failure from rheumatic, congenital heart disease, pulmonary fibrosis
Findings dyspnea, fatigue, weakness and syncope peripheral edema may cause discomfort
Diagnostics - echocardiogram for abnormal valve movement
Management: surgical - valve replacement
Nursing interventions
Nursing interventions the Cardio-Care Six monitor for Cardio Seven monitor for signs of heart failure and adverse reactions to the drug therapy post-op: monitor client for hypotension, dysrhythmias and thrombus formation when sitting, client should raise legs - to prevent dependent edema reinforce client and family teaching regarding: the Cardio Five the need for prophylactic antibiotics during dental care or other invasive procedures the need to raise legs when sitting - to prevent dependent edema
Pulmonic stenosis
Definition - obstructed right ventricular outflow during ventricular systole resulting in right ventricular hypertrophy
Epidemiology usually congenital, often with other birth defects such as tetralogy of Fallot rare among the elderly may result from rheumatic fever, pulmonary hypertension, or fibrosis
Findings dyspnea, fatigue, chest pain and syncope peripheral edema may cause discomfort, impaired skin integrity
Diagnostics - echocardiogram for abnormal valve or blood movement
Management: surgical - replace the valve via balloon and cardiac
Nursing interventions
Nursing interventions Same as tricuspid stenosis and tricuspid insufficiency monitor for signs of heart failure, pulmonary edema, and adverse reactions to the drug therapy post-op: monitor client for hypotension, dysrhythmias and thrombus formation
monitor the Cardio Seven reinforce client and family teaching - same as tricuspid stenosis and tricuspid insufficiency
Pulmonic insufficiency (regurgitation)
Definition - pulmonary valve fails to close, so that blood flows back into the right ventricle during ventricular diastole Epidemiology a birth defect, or a result of pulmonary hypertension rarely, result of prolonged use of a pressure-monitoring catheter in the pulmonary artery Findings dyspnea, fatigue, chest pain and syncope peripheral edema may cause discomfort if advanced: jaundice with ascites and peripheral edema possible malnourished appearance Diagnostics - echocardiogram for abnormal blood or valve movement Management diuretics - to mobilize edematous fluid to reduce pulmonary venous pressure sodium-restricted diet - to control underlying heart disease anticoagulants - to prevent blood clots digitalis - to increase the force or strength of cardiac contractions
Pulmonic insufficiency (regurgitation)
Nursing interventions
the Cardio-Care Six monitor the Cardio Seven monitor for findings of heart failure and adverse reactions to drug therapy post-op: monitor client for hypotension, dysrhythmias and thrombus formation provide frequent rest periods reinforce client and family teaching: (same as tricuspid stenosis, tricuspid insufficiency, and pulmonic stenosis)
Aortic stenosis
Definition - aortic valve stiffens to narrow opening. left ventricle must work harder, so needs more oxygen, and may suffer ischemia and heart failure Epidemiology Most significant valvular lesion seen among elderly people. It usually leads to left-sided heart failure, left ventricular hypertrophy, and cardiomyopathy incidence increases with age occurs in 1% of the population about 80% of these people are male 20% of them die suddenly, around age of 60 years Findings classic triad: dyspnea, syncope, angina (see Clients with Cardiovascular Disorders ) fatigue palpitations left-sided heart failure may bring on orthopnea, paroxysmal nocturnal dyspnea, and peripheral edema Diagnostics: echocardiogram for abnormal blood flow movement
Aortic stenosis
Management nitroglycerin - to relieve chest pain low-sodium diet - to control underlying heart disease diuretics - to mobilize fluid and to reduce pulmonary venous pressure digitalis - to increase the force or strength of cardiac contractions oxygen - to prevent hypoxia surgery - percutaneous balloon valvuloplasty, then valve replacement
Nursing interventions 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, dysrhythmias and clots reinforce client and family teaching: (same as tricuspid stenosis, tricuspid insufficiency, pulmonic stenosis and pulmonic insufficiency)
Aortic insufficiency (regurgitation)
Definition blood flows back into the left ventricle during ventricular diastole overloading the ventricle and causing it to hypertrophy extra blood also overloads the left atrium and, eventually, the pulmonary system Epidemiology by itself, most common among males with mitral valve disease, more common among females may accompany Marfan's syndrome, ankylosing spondylitis, syphilis, essential hypertension or a defect of the ventricular septum Findings uncomfortable awareness of heartbeat palpitations along with a pounding head 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 may appear to be pulsating when fingertip is pressed (Quincke's sign)
Aortic insufficiency (regurgitation)
Diagnostics: chest x-ray echocardiogram cardiac catherization Management digitalis - increases the heart's contractility diuretics - to mobilize edematous fluids and to reduce pulmonary venous pressure sodium-restricted diet - to control underlying heart disease anticoagulant agents - to prevent blood clots ACE inhibitors decrease cardiac workload and assist to increase oxygenation surgical - valve replacement (however, aortic insufficiency often damages the ventricle before it is detected)
Aortic insufficiency (regurgitation)
Nursing interventions
same as all other valve disorders - The Cardio-Care Six except don't need to elevate head unless pulmonary problems have begun monitor the Cardio Seven monitor for signs of heart failure, pulmonary edema, and drug reactions post-op: monitor client for hypotension, arrhythmias and clots reinforce client and family teaching regarding: same as all other valve disorders - The Cardio Five
Failures of the Heart Muscle Myocardial infarction (MI)
Definition - insufficient oxygen supply kills (causes necrosis of) myocardial tissue. Process of infarction may take from one to six hours.
Epidemiology / etiology client history of smoking, obesity, high cholesterol/low density lipoprotein diet, physical/emotional stress may be cocaine induced factors affecting mortality: age number of occluded vessels previous history of MI presence of cardiogenic shock females have twice the mortality of males; may be related to the fact that they tend to be older and have more significant risk factors
Myocardial infarction (MI)
Myocardial infarction (MI)
Diagnostics
history and physical
EKG - monitor for changes in the 12 lead, dysrhythmias
serum markers - elevated
isoenzymes - CK-MB, LDH, LDH2
muscle proteins - troponin, myoglobin
Management
cardiac monitoring for dysrhythmias
supplemental oxygen - to prevent tissue hypoxia
bed rest - to decrease the workload of the heart, often with bathroom privileges
stool softeners - to decrease the workload of the heart caused by straining, which can cause vagal stimulation producing bradycardia and dysrythmias
narcotic analgesics - to reduce pain, anxiety, fear, and decrease the workload of the heart
Continue Managment : antidysrhythmic - to prevent dysrythmias, which are the most common complications after an MI thrombolytic agents - to dissolve the thrombus in the coronary artery and reperfuse the myocardium - usually given first nitrates - to decrease pain and decrease preload and afterload while increasing the myocardial oxygen supply anticoagulants - to prevent blood clots Swan-Ganz catheter to monitor pressure in pulmonary artery (measure functioning of left ventricle) intra-aortic balloon counterpulsation may be used for cardiogenic shock cardiac catheterization may be performed for PTCA or stent insertion
Myocardial infarction (MI) Nursing interventions the Cardio-Care Six plus monitor the following to identify early heart failure, infections and complications temperature daily weight intake and output respiratory rate breath sounds blood pressure EKG readings EKG MEASURES ELECTRICAL ACTIVITY OF HEART Electrocardiogram = (ECG) = (EKG) Do not confuse with Echocardiogram (Echo) An EKG is a graphic recording of the electrical currents of the heart. It may be a one-lead, which is used for continuous monitoring, or a 12-lead, which is used for diagnostic purposes. The EKG records two basic events depolarization and repolarization as a series of waves:
Nursing interventions
monitor pain management and give analgesics as needed, and record the severity, location, type, duration of pain, and effectiveness of medications monitor for cough, tachypnea, and crackles, which may predict left ventricle is failing as ordered apply antiembolism stockings and intermittent pneumatic compression devices to prevent venostasis and thrombophlebitis assist with range-of-motion exercises reinforce client and family teaching regarding: the Cardio Five the ICU or Coronary Care Unit, the associated routines and machinery, and communication methods to client and family encourage client to join the cardiac rehab exercise program, if ordered reinforce education for the gradual resumption of sexual activity taking nitroglycerin before sex may prevent chest pain advise the client when to report typical or atypical chest pain to care provider reinforce information about postmyocardial infarction syndrome; and to report it to care provider stress that client must modify risky life-style behaviors assist with dietary consultation as indicated
Heart failure
Findings: earliest to latest
Diagnostics - the primary goal is to determine the underlying cause of the heart failure history and physical exam CXR - to determine heart size and pleural effusions EKG for changes and dysrhythmias echocardiogram to measure valvular abnormalities nuclear imaging - to determine myocardial contractility, myocardial perfusion, and acute cell injury hemodynamic monitoring of arterial blood pressure, pulmonary artery pressure, pulmonary artery wedge pressure and cardiac output
Management goal is to restore balance between the myocardial oxygen supply and the demand treatments include oxygen, digitalis, vasodilators, nitrates, antihypertensives, cardiac glycosides, diuretics, intra-aortic balloon counterpulsation, ventricular assist pumping, etc.
Heart failure
Cardiac tamponade
Definition /etiology
Fluid quickly fills pericardial sac and minimizes cardiac output. Cardiac tamponade is a medical emergency. PRINCIPLES OF CARDIOPULMONARY RESUSCITATION (CPR) ADVANCED CARDIAC LIFE SUPPORT
Early access
Early CPR
Early defibrillation
Early advanced cardiac life support
Give drugs after defibrillation (in the adult)
For drug delivery, antecubital veins are first choice because central-line placement would interrupt CPR
Endotracheal tube placement
Intraosseous route for drugs is alternative (in children)
Cardiac tamponade
Etiology acute pericarditis post-op after cardiac surgery pericardial effusions chest trauma myocardial rupture aortic dissection anticoagulant therapy malignancy Findings: classic triad of symptoms hypotension with muffled heart sounds with high jugular venous pressure: increased CVP, increased jugular vein distention if no hypovolemia Diagnostics chest x-ray echocardiogram computerized tomogram of chest Management pericardiocentesis: needle aspiration of pericardial sac
Cardiac tamponade
Nursing interventions
bed rest with elevated head of bed 35 to 45 degrees prepare client for pericardiocentesis provide emotional support prepare for surgery if pericardiocentesis is ineffective monitor for complications of procedure pneumothorax dysrhythmias hypotension
Disorders of the Circulatory System Hypertension EIGHT FACTORS THAT AFFECT ARTERIAL BLOOD PRESSURES
Cardiac output
Resistance in peripheral vessels (arterioles)
Arterial elasticity: Elastic vessels let blood flow at lower pressures; rigid, sclerotic vessels require higher pressures.
Viscosity
Too many red blood cells (RBCs) or plasma proteins increases pressure
Lower viscosity, from anemia or lack of RBCs, decreases pressure
Age: newborns have low blood pressure, which increases with age
Weight: the higher the weight, the higher the blood pressure
Exercise: faster heart rates mean higher systolic blood pressure
Autonomic Nervous System: The sympathetic nervous system speeds the heart rate; the parasympathetic
Hypertension
Definitions hypertension - systolic blood pressure of 140 mm Hg or greater, diastolic blood pressure of 90 mm Hg or greater, on at least three separate occasions pregnancy induced hypertension (PIH) - high blood pressure present before week 20 of gestation accelerated hypertension - a hypertensive crisis: blood pressure rises very rapidly threat of immediate vascular necrosis and end-organ damage, particularly to the heart, kidneys, retina and brain blood pressure is usually greater than 180/120 mm Hg or a mean arterial pressure of more than 150 mm Hg
Hypertension Etiology and epidemiology HOW THE BODY CONTROLS BLOOD PRESSURE Arterial blood pressure (BP): increases with increase in: cardiac output , peripheral resistance or blood volume.
Intrinsic control: hour by hour, chemoreceptors control blood flow according to the tissues' use of oxygen and the amount of carbon dioxide in the brain.
Extrinsic control: overrides intrinsic control when necessary.
For rapid, short-term adjustments, the body monitors blood pressure via stretch receptors (baroreceptors) in the walls of the carotid sinus and the aortic arch .
Control of blood pressure begins in vasomotor centers in medulla oblongata, through the autonomic nervous system, the kidneys, and hormones such as epinephrine and angiotensin.
If arterial pressure increases above normal, the body lowers BP by decreasing heart rate (mediated by acetylcholine , the neurotransmitter of the parasympathetic nervous system.)
If arterial pressure falls, BP is raised by increasing cardiac output (mediated by epinephrine, the neurotransmitter of the sympathetic nervous system)
Slow, long-term control of blood pressure is achieved through:
excretion of sodium and water by the kidney
by the activity of the renin-angiotensin system
by the atrial natriuretic factor - a hormone released from the right atrium in response to increased atrial stretch
and antidiuretic hormone ( ADH )
Hypertension
Hypertension
Diagnostics
based on the average of three or more blood pressure readings, two minutes apart, at each of three or more visits after an initial screening visit classification of adult hypertension hypertension is classified according to its cause: primary or essential hypertension (about 90% of clients) secondary hypertension (results from another disease; about 5% to 10% of clients) PIH - associated with pregnancy accelerated hypertension - a hypertensive crisis
Hypertension
Management
pharmacological initial therapy - for uncomplicated hypertension, it is recommended to start with a diuretic or Beta-adrenergic blocking agent oxygen prn in acute crisis angiotensin-converting enzyme (ACE) inhibitors are used to treat left-sided heart failure and preferred if client is diabetic antilipemics other: weight loss, regular exercise, limit sodium intake goals of treatment blood pressure < 140/90 mm Hg, or after cardiac surgery blood pressure < 120 / 80 control dyslipidemia, obesity, inactivity control diabetes mellitus, if indicated
Hypertension
Nursing interventions: reinforce client and family teaching regarding:
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
optimize body weight
drink alcohol based on current guidelines
moderate dietary sodium (2-gm sodium diet)
exercise: regular moderately intense aerobic activity
avoid tobacco products
manage stress triggers and responses to triggers
Coronary artery disease
Coronary artery disease (CAD)
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.
Coronary artery disease
Epidemiology and etiology CAD is epidemic in the western world more than 30% of men age 60 or older show signs of CAD on autopsy most common cause: atherosclerosis risk factors: gender: over 40 white male ; women after menopause family history of CAD uncontrolled high blood pressure high cholesterol , triglycerides smokers are twice as likely to have a myocardial infarction and four times as likely to die suddenly - this risk drops sharply within one year after smoking ceases obesity (waist predominance); [added weight increases the risk of diabetes, hypertension and high cholesterol] physical inactivity stressed lifestyle
Findings: Angina TYPES OF ANGINA
Angina, especially after physical exertion, is the classic finding of coronary artery disease.
Angina appears commonly with nausea, vomiting, fainting, sweating, and cool extremities
Angina may follow excitement, a large meal, or exposure to extreme cold or heat.
Types of angina
Nocturnal angina - occurs during sleep to wake client
Angina predictable and relieved by nitroglycerine: stable angina.
More frequent and lasting angina: unstable angina.
Effort-induced pain that occurs more and more often: crescendo angina
Severe angina at rest: Prinzmetal's angina - associated with coronary artery spasm
Angina
Diagnostics serum elevations homocysteine levels C-reactive protein LDH cholesterol triglycerides cardiac catherization
Management pharmacology nitrates such as nitroglycerin, isosorbide dinitrate (Isordil), or beta-adrenergic neuron-blocking agents oxygen - to prevent hypoxia diuretics and beta-adrenergic blocking agents antiplatelet agents: aspirin (8/mg daily), the most commonly used, reduces platelet aggregation Antilipemics - to decrease circulating lipids
Angina
Insufficiency (or regurgitation), incompetence
Definition and related terms a damaged mitral valve allows blood from the left ventricle to flow back into the left atrium during ventricular systole to handle the backflow, the atrium enlarges. So does the left ventricle, in part to make up for its lower output of blood
Epidemiology / etiology follows birth defects such as transposition of the great arteries in older clients, the mitral annulus may have become calcified cause unknown; may be linked to a degenerative process occurs in 5-10% of adults Marfan's Syndrome papillary muscle dysfunction or rupture trauma mitral valve prolapse, also called Barlow's Syndrome or floppy mitral valve syndrome
Insufficiency (or regurgitation), incompetence
Findings client may be asymptomatic orthopnea, dyspnea, fatigue, weakness, weight loss chest pain and palpitations findings of RVHF jugular vein distention peripheral edema hepatomegaly
Diagnostics EKG for dysrhythmias and changes of left atrial enlargement echocardiogram - to visualize regurgitant jets and flail chordae / leaflets cardiac catheterization - shows regurgitation of blood from left ventricle to left atrium and increased pressures chest x-ray - shows cardiomegaly, pulmonary congestion
Insufficiency (or regurgitation), incompetence
Management low-sodium diet - to control underlying heart disease oxygen as needed - to prevent tissue hypoxia antibiotics - to treat infection prophylactic antibiotics - to prevent infection surgery - mitral valvuloplasty or valve replacement
Nursing interventions 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
Continue Nursing Intervention
if client has surgery, monitor postoperatively for hypotension, arrhythmias and thrombus formation reinforce client and family teaching regarding: diet restrictions and drugs explanation of tests and treatments long-term antibiotic and follow-up care the need for prophylactic antibiotics during routine dental care as cleaning, or for any invasive procedure need to report findings of heart failure: dyspnea and hacking, nonproductive cough
Tricuspid stenosis
Definition: narrowing of the blood flow through the tricuspid valve between the right atrium and right ventricle
Epidemiology relatively uncommon usually associated with lesions of other valves caused by rheumatic fever, IV drug abuses
Findings dyspnea, fatigue, weakness, syncope peripheral edema jaundice with severe peripheral edema and ascites can mean that tricuspid stenosis has led to right ventricular failure may appear malnourished distended jugular veins
Diagnostics EKG - for dysrhythmias echocardiogram - right ventricular dilation and paradoxic septal motion
Management: surgery - valvulotomy or valve replacement;
Tricuspid stenosis
Nursing interventions the Cardio-Care Six monitor the Cardio Seven monitor for findings of right heart failure and adverse reactions to the drug therapy post valve surgery, monitor client for hypotension, dysrhythmias and thrombus formation when client sits, elevate legs - to prevent dependent edema reinforce client and family teaching regarding: the Cardio Five client must comply with long-term antibiotic and follow up care the need for prophylactic antibiotics during dental care or other invasive procedures
Tricuspid insufficiency (regurgitation)
Definition - tricuspid valve lets blood leak from the right ventricle back into the right atrium during ventricular systole
Epidemiology results from dilation of the right ventricle and tricuspid valve ring most common in late stages of heart failure from rheumatic, congenital heart disease, pulmonary fibrosis
Findings dyspnea, fatigue, weakness and syncope peripheral edema may cause discomfort
Diagnostics - echocardiogram for abnormal valve movement
Management: surgical - valve replacement
Nursing interventions
Nursing interventions the Cardio-Care Six monitor for Cardio Seven monitor for signs of heart failure and adverse reactions to the drug therapy post-op: monitor client for hypotension, dysrhythmias and thrombus formation when sitting, client should raise legs - to prevent dependent edema reinforce client and family teaching regarding: the Cardio Five the need for prophylactic antibiotics during dental care or other invasive procedures the need to raise legs when sitting - to prevent dependent edema
Pulmonic stenosis
Definition - obstructed right ventricular outflow during ventricular systole resulting in right ventricular hypertrophy
Epidemiology usually congenital, often with other birth defects such as tetralogy of Fallot rare among the elderly may result from rheumatic fever, pulmonary hypertension, or fibrosis
Findings dyspnea, fatigue, chest pain and syncope peripheral edema may cause discomfort, impaired skin integrity
Diagnostics - echocardiogram for abnormal valve or blood movement
Management: surgical - replace the valve via balloon and cardiac
Nursing interventions
Nursing interventions Same as tricuspid stenosis and tricuspid insufficiency monitor for signs of heart failure, pulmonary edema, and adverse reactions to the drug therapy post-op: monitor client for hypotension, dysrhythmias and thrombus formation
monitor the Cardio Seven reinforce client and family teaching - same as tricuspid stenosis and tricuspid insufficiency
Pulmonic insufficiency (regurgitation)
Definition - pulmonary valve fails to close, so that blood flows back into the right ventricle during ventricular diastole Epidemiology a birth defect, or a result of pulmonary hypertension rarely, result of prolonged use of a pressure-monitoring catheter in the pulmonary artery Findings dyspnea, fatigue, chest pain and syncope peripheral edema may cause discomfort if advanced: jaundice with ascites and peripheral edema possible malnourished appearance Diagnostics - echocardiogram for abnormal blood or valve movement Management diuretics - to mobilize edematous fluid to reduce pulmonary venous pressure sodium-restricted diet - to control underlying heart disease anticoagulants - to prevent blood clots digitalis - to increase the force or strength of cardiac contractions
Pulmonic insufficiency (regurgitation)
Nursing interventions
the Cardio-Care Six monitor the Cardio Seven monitor for findings of heart failure and adverse reactions to drug therapy post-op: monitor client for hypotension, dysrhythmias and thrombus formation provide frequent rest periods reinforce client and family teaching: (same as tricuspid stenosis, tricuspid insufficiency, and pulmonic stenosis)
Aortic stenosis
Definition - aortic valve stiffens to narrow opening. left ventricle must work harder, so needs more oxygen, and may suffer ischemia and heart failure Epidemiology Most significant valvular lesion seen among elderly people. It usually leads to left-sided heart failure, left ventricular hypertrophy, and cardiomyopathy incidence increases with age occurs in 1% of the population about 80% of these people are male 20% of them die suddenly, around age of 60 years Findings classic triad: dyspnea, syncope, angina (see Clients with Cardiovascular Disorders ) fatigue palpitations left-sided heart failure may bring on orthopnea, paroxysmal nocturnal dyspnea, and peripheral edema Diagnostics: echocardiogram for abnormal blood flow movement
Aortic stenosis
Management nitroglycerin - to relieve chest pain low-sodium diet - to control underlying heart disease diuretics - to mobilize fluid and to reduce pulmonary venous pressure digitalis - to increase the force or strength of cardiac contractions oxygen - to prevent hypoxia surgery - percutaneous balloon valvuloplasty, then valve replacement
Nursing interventions 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, dysrhythmias and clots reinforce client and family teaching: (same as tricuspid stenosis, tricuspid insufficiency, pulmonic stenosis and pulmonic insufficiency)
Aortic insufficiency (regurgitation)
Definition blood flows back into the left ventricle during ventricular diastole overloading the ventricle and causing it to hypertrophy extra blood also overloads the left atrium and, eventually, the pulmonary system Epidemiology by itself, most common among males with mitral valve disease, more common among females may accompany Marfan's syndrome, ankylosing spondylitis, syphilis, essential hypertension or a defect of the ventricular septum Findings uncomfortable awareness of heartbeat palpitations along with a pounding head 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 may appear to be pulsating when fingertip is pressed (Quincke's sign)
Aortic insufficiency (regurgitation)
Diagnostics: chest x-ray echocardiogram cardiac catherization Management digitalis - increases the heart's contractility diuretics - to mobilize edematous fluids and to reduce pulmonary venous pressure sodium-restricted diet - to control underlying heart disease anticoagulant agents - to prevent blood clots ACE inhibitors decrease cardiac workload and assist to increase oxygenation surgical - valve replacement (however, aortic insufficiency often damages the ventricle before it is detected)
Aortic insufficiency (regurgitation)
Nursing interventions
same as all other valve disorders - The Cardio-Care Six except don't need to elevate head unless pulmonary problems have begun monitor the Cardio Seven monitor for signs of heart failure, pulmonary edema, and drug reactions post-op: monitor client for hypotension, arrhythmias and clots reinforce client and family teaching regarding: same as all other valve disorders - The Cardio Five
Failures of the Heart Muscle Myocardial infarction (MI)
Definition - insufficient oxygen supply kills (causes necrosis of) myocardial tissue. Process of infarction may take from one to six hours.
Epidemiology / etiology client history of smoking, obesity, high cholesterol/low density lipoprotein diet, physical/emotional stress may be cocaine induced factors affecting mortality: age number of occluded vessels previous history of MI presence of cardiogenic shock females have twice the mortality of males; may be related to the fact that they tend to be older and have more significant risk factors
Myocardial infarction (MI)
Myocardial infarction (MI)
Diagnostics
history and physical
EKG - monitor for changes in the 12 lead, dysrhythmias
serum markers - elevated
isoenzymes - CK-MB, LDH, LDH2
muscle proteins - troponin, myoglobin
Management
cardiac monitoring for dysrhythmias
supplemental oxygen - to prevent tissue hypoxia
bed rest - to decrease the workload of the heart, often with bathroom privileges
stool softeners - to decrease the workload of the heart caused by straining, which can cause vagal stimulation producing bradycardia and dysrythmias
narcotic analgesics - to reduce pain, anxiety, fear, and decrease the workload of the heart
Continue Managment : antidysrhythmic - to prevent dysrythmias, which are the most common complications after an MI thrombolytic agents - to dissolve the thrombus in the coronary artery and reperfuse the myocardium - usually given first nitrates - to decrease pain and decrease preload and afterload while increasing the myocardial oxygen supply anticoagulants - to prevent blood clots Swan-Ganz catheter to monitor pressure in pulmonary artery (measure functioning of left ventricle) intra-aortic balloon counterpulsation may be used for cardiogenic shock cardiac catheterization may be performed for PTCA or stent insertion
Myocardial infarction (MI) Nursing interventions the Cardio-Care Six plus monitor the following to identify early heart failure, infections and complications temperature daily weight intake and output respiratory rate breath sounds blood pressure EKG readings EKG MEASURES ELECTRICAL ACTIVITY OF HEART Electrocardiogram = (ECG) = (EKG) Do not confuse with Echocardiogram (Echo) An EKG is a graphic recording of the electrical currents of the heart. It may be a one-lead, which is used for continuous monitoring, or a 12-lead, which is used for diagnostic purposes. The EKG records two basic events depolarization and repolarization as a series of waves:
Nursing interventions
monitor pain management and give analgesics as needed, and record the severity, location, type, duration of pain, and effectiveness of medications monitor for cough, tachypnea, and crackles, which may predict left ventricle is failing as ordered apply antiembolism stockings and intermittent pneumatic compression devices to prevent venostasis and thrombophlebitis assist with range-of-motion exercises reinforce client and family teaching regarding: the Cardio Five the ICU or Coronary Care Unit, the associated routines and machinery, and communication methods to client and family encourage client to join the cardiac rehab exercise program, if ordered reinforce education for the gradual resumption of sexual activity taking nitroglycerin before sex may prevent chest pain advise the client when to report typical or atypical chest pain to care provider reinforce information about postmyocardial infarction syndrome; and to report it to care provider stress that client must modify risky life-style behaviors assist with dietary consultation as indicated
Heart failure
Findings: earliest to latest
Diagnostics - the primary goal is to determine the underlying cause of the heart failure history and physical exam CXR - to determine heart size and pleural effusions EKG for changes and dysrhythmias echocardiogram to measure valvular abnormalities nuclear imaging - to determine myocardial contractility, myocardial perfusion, and acute cell injury hemodynamic monitoring of arterial blood pressure, pulmonary artery pressure, pulmonary artery wedge pressure and cardiac output
Management goal is to restore balance between the myocardial oxygen supply and the demand treatments include oxygen, digitalis, vasodilators, nitrates, antihypertensives, cardiac glycosides, diuretics, intra-aortic balloon counterpulsation, ventricular assist pumping, etc.
Heart failure
Cardiac tamponade
Definition /etiology
Fluid quickly fills pericardial sac and minimizes cardiac output. Cardiac tamponade is a medical emergency. PRINCIPLES OF CARDIOPULMONARY RESUSCITATION (CPR) ADVANCED CARDIAC LIFE SUPPORT
Early access
Early CPR
Early defibrillation
Early advanced cardiac life support
Give drugs after defibrillation (in the adult)
For drug delivery, antecubital veins are first choice because central-line placement would interrupt CPR
Endotracheal tube placement
Intraosseous route for drugs is alternative (in children)
Cardiac tamponade
Etiology acute pericarditis post-op after cardiac surgery pericardial effusions chest trauma myocardial rupture aortic dissection anticoagulant therapy malignancy Findings: classic triad of symptoms hypotension with muffled heart sounds with high jugular venous pressure: increased CVP, increased jugular vein distention if no hypovolemia Diagnostics chest x-ray echocardiogram computerized tomogram of chest Management pericardiocentesis: needle aspiration of pericardial sac
Cardiac tamponade
Nursing interventions
bed rest with elevated head of bed 35 to 45 degrees prepare client for pericardiocentesis provide emotional support prepare for surgery if pericardiocentesis is ineffective monitor for complications of procedure pneumothorax dysrhythmias hypotension
Disorders of the Circulatory System Hypertension EIGHT FACTORS THAT AFFECT ARTERIAL BLOOD PRESSURES
Cardiac output
Resistance in peripheral vessels (arterioles)
Arterial elasticity: Elastic vessels let blood flow at lower pressures; rigid, sclerotic vessels require higher pressures.
Viscosity
Too many red blood cells (RBCs) or plasma proteins increases pressure
Lower viscosity, from anemia or lack of RBCs, decreases pressure
Age: newborns have low blood pressure, which increases with age
Weight: the higher the weight, the higher the blood pressure
Exercise: faster heart rates mean higher systolic blood pressure
Autonomic Nervous System: The sympathetic nervous system speeds the heart rate; the parasympathetic
Hypertension
Definitions hypertension - systolic blood pressure of 140 mm Hg or greater, diastolic blood pressure of 90 mm Hg or greater, on at least three separate occasions pregnancy induced hypertension (PIH) - high blood pressure present before week 20 of gestation accelerated hypertension - a hypertensive crisis: blood pressure rises very rapidly threat of immediate vascular necrosis and end-organ damage, particularly to the heart, kidneys, retina and brain blood pressure is usually greater than 180/120 mm Hg or a mean arterial pressure of more than 150 mm Hg
Hypertension Etiology and epidemiology HOW THE BODY CONTROLS BLOOD PRESSURE Arterial blood pressure (BP): increases with increase in: cardiac output , peripheral resistance or blood volume.
Intrinsic control: hour by hour, chemoreceptors control blood flow according to the tissues' use of oxygen and the amount of carbon dioxide in the brain.
Extrinsic control: overrides intrinsic control when necessary.
For rapid, short-term adjustments, the body monitors blood pressure via stretch receptors (baroreceptors) in the walls of the carotid sinus and the aortic arch .
Control of blood pressure begins in vasomotor centers in medulla oblongata, through the autonomic nervous system, the kidneys, and hormones such as epinephrine and angiotensin.
If arterial pressure increases above normal, the body lowers BP by decreasing heart rate (mediated by acetylcholine , the neurotransmitter of the parasympathetic nervous system.)
If arterial pressure falls, BP is raised by increasing cardiac output (mediated by epinephrine, the neurotransmitter of the sympathetic nervous system)
Slow, long-term control of blood pressure is achieved through:
excretion of sodium and water by the kidney
by the activity of the renin-angiotensin system
by the atrial natriuretic factor - a hormone released from the right atrium in response to increased atrial stretch
and antidiuretic hormone ( ADH )
Hypertension
Hypertension
Diagnostics
based on the average of three or more blood pressure readings, two minutes apart, at each of three or more visits after an initial screening visit classification of adult hypertension hypertension is classified according to its cause: primary or essential hypertension (about 90% of clients) secondary hypertension (results from another disease; about 5% to 10% of clients) PIH - associated with pregnancy accelerated hypertension - a hypertensive crisis
Hypertension
Management
pharmacological initial therapy - for uncomplicated hypertension, it is recommended to start with a diuretic or Beta-adrenergic blocking agent oxygen prn in acute crisis angiotensin-converting enzyme (ACE) inhibitors are used to treat left-sided heart failure and preferred if client is diabetic antilipemics other: weight loss, regular exercise, limit sodium intake goals of treatment blood pressure < 140/90 mm Hg, or after cardiac surgery blood pressure < 120 / 80 control dyslipidemia, obesity, inactivity control diabetes mellitus, if indicated
Hypertension
Nursing interventions: reinforce client and family teaching regarding:
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
optimize body weight
drink alcohol based on current guidelines
moderate dietary sodium (2-gm sodium diet)
exercise: regular moderately intense aerobic activity
avoid tobacco products
manage stress triggers and responses to triggers
Coronary artery disease
Coronary artery disease (CAD)
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.
Coronary artery disease
Epidemiology and etiology CAD is epidemic in the western world more than 30% of men age 60 or older show signs of CAD on autopsy most common cause: atherosclerosis risk factors: gender: over 40 white male ; women after menopause family history of CAD uncontrolled high blood pressure high cholesterol , triglycerides smokers are twice as likely to have a myocardial infarction and four times as likely to die suddenly - this risk drops sharply within one year after smoking ceases obesity (waist predominance); [added weight increases the risk of diabetes, hypertension and high cholesterol] physical inactivity stressed lifestyle
Findings: Angina TYPES OF ANGINA
Angina, especially after physical exertion, is the classic finding of coronary artery disease.
Angina appears commonly with nausea, vomiting, fainting, sweating, and cool extremities
Angina may follow excitement, a large meal, or exposure to extreme cold or heat.
Types of angina
Nocturnal angina - occurs during sleep to wake client
Angina predictable and relieved by nitroglycerine: stable angina.
More frequent and lasting angina: unstable angina.
Effort-induced pain that occurs more and more often: crescendo angina
Severe angina at rest: Prinzmetal's angina - associated with coronary artery spasm
Angina
Diagnostics serum elevations homocysteine levels C-reactive protein LDH cholesterol triglycerides cardiac catherization
Management pharmacology nitrates such as nitroglycerin, isosorbide dinitrate (Isordil), or beta-adrenergic neuron-blocking agents oxygen - to prevent hypoxia diuretics and beta-adrenergic blocking agents antiplatelet agents: aspirin (8/mg daily), the most commonly used, reduces platelet aggregation Antilipemics - to decrease circulating lipids
Angina
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