Management of cardiovascular system

1
Management of cardiovascular system

• Miss M. N. PRIYADARSHANIE
• BSc in Nursing

2
Anatomy of the Heart
3
I-Assessment

• 1- Health history and clinical manifestation
• Cardiac Symptoms
• - Chest discomfort.
• - Shortness of breath
• - Edema and weight gain.
• - Palpitation (dysarrythmias).
• - Fatigue.
• - Dizziness and syncope.

4
I-Assessment

• 2- Nutrition and metabolism
• Diets that are restricted in sodium, fat,
  cholesterol, and calories.
• 3- Activity and Exercise
• If symptoms develop during exercise, what
  are nature of exercise.

5
I-Assessment

• 4- Physical examination
• a- General appearance
• - The nurse observes the patients level
  of consciousness, and thought process as an
  indication of the hearts ability to propel oxygen
  to the brain.
• b- Inspection of skin
• Pallor, cyanosis, Temp, reduce
  skin turgor, wounds.
• c- Blood Pressure
• d- Arterial pulses
• Pulse rate, rhythm, and volume.

6
II- Cardiac Auscultation

• Heart Sounds
• The normal heart sounds, S1, S2, are produced
  primarily by the closing of the heart values.
• a- S1 Closure of mitral and tricuspid valves.
• b- S2 Closure of aortic and pulmonic valves.
• C- Murmurs Are created by the turbulent flow of
  blood, the causes turbulence may be a critically
  narrowed valve or regurgitation of valves.

7
III- Diagnostic Evaluation

• 1- Laboratory Tests
• e.g Cardiac enzyme , blood chemistry
  (urea, creatinine, serum electrolyte, coagulation
  studies, lipid profile.)
• 2- Chest x-ray
• 3- Cardiac stress test To detect the
  ischemia, by increasing the metabolic demands for
  oxygen.
• 4- Echocardiograph
• Is non invasive ultrasound test used to
  examine the size, shape and motion of cardiac
  structures.
• 5- Cardiac Catheterization
• Is an invasive diagnostic procedure in
  which radiopaque.

8
III- Diagnostic Evaluation

• 6-Electro cardiography. (ECG)
• Normal Components of the EKG Waveform

9
Normal Components of the EKG Waveform

• P wave
• Indicates atrial depolarization, or contraction
  of the atrium.
• Normal duration is not longer than 0.11 seconds
  (less than 3 small squares)
• QRS complex
• Indicates ventricular depolarization, or
  contraction of the ventricles.
• Normally not longer than .10 seconds in duration
• T wave
• Indicates ventricular repolarization
• ST segment
• Indicates early ventricular repolarization
• PR interval
• Indicates AV conduction time
• Duration time is 0.12 to 0.20 seconds

10
Management of Patient with Coronary Vascular
Disease

• Coronary Artery Disease
• The most prevalent type of cardiovascular
  disease is coronary artery disease (CAD).
• Coronary Atherosclerosis
• Is an abnormal accumulation of lipid , or
  fatty substances and fibrous tissue in the vessel
  wall.
• Atheroma Begins as fatty streaks, lipids that
  are deposite on the intima of the arterial wall.

11
Management of Patient with Coronary Vascular
Disease

• Risk factors for (CAD)
• Non modifiable risk factors
• Family history.
• Increasing age.
• Gender.
• Race.
• Modifiable risk factors
• High blood cholesterol.
  Obesity.
• Smoking.
  Stress.
• Hypertension.
• Diabetes mellitus.

12
Management of Patient with Coronary Vascular
Disease

• Angina Pectoris
• Is a clinical syndrome usually characterized
  by episodes or paroxysm of pain or pressure in
  the anterior chest, the cause is usually
  insufficient coronary blood flow.
• - Factors those are associated with a typical
  angina pain
• Physical exertion.
• Exposure to cold.
• Eating a heavy meal.
• Stress or any emotion- provoking
  situation.

13
Angina Types

• Stable Angina
• Most common and predictable occurs with
  predictable amount of activity or stress
• Occurs when work of heart is increased by
  physical exertion, exposure to cold, stress
• Relieved by rest and nitrates

14
Angina Types

• Unstable Angina
• Occurs with increasing frequency, severity,
  duration
• Pain is unpredictable and occurs with rest, low
  activity, stress
• At risk for myocardial infarction
• Silent Angina
• Asymptomatic ischemia, thought to very common
  with CHD
• May occur with activity or mental stress

15
Angina Pectoris

• Clinical Manifestation
• Chest pain. (Retrosternal pain).
• Weakness or numbness in the arms.
• Shortness of breath.
• Pallor, diaphoresis, dizziness or
• light headedness.
• Nausea, Vomiting.
• Anxiety.

16
Medical Management

• 1-Pharmacologic Therapy
• a-Nitroglycerine To decrease workload of the
  heart, and
• coronary artery vasodilation.
• b- Beta-adrenergic blocking agents Such as
  propranolol (Inderal),and atenolol(tenormine).To
  decrease heart rate,
• blood pressure and myocardium
  contractility.
• c- Calcium channel blocking agents Such as
  nipedipia, verpamil, and diltiazem.To decrease
  heart rate, decrease workload of heart, and
  increase coronary artery perfusion.
• d-Antiplatlates and anticoagulant medication.
• Aspirin prevent platelets aggregation.
• Heparin prevents the formation of new blood
  clots.
• e-Oxygen administration.

17
Medical Management

• 2- Invasive intervention and surgical management
• a- Percautanouse transluminal coronary
  angioplasty (PTCA).
• b- Coronary artery stent.
• c- Coronary artery bypass graft. (CABG).

18
Myocardial Infarction

• Definition Is a death of heart tissue caused by
  prolonging ischemia.
• - Necrosis of myocardial cells life-threatening
  event
• Loss of functional myocardium affects hearts
  ability to maintain effective cardiac output
• AMI and other ischemic heart diseases cause
  majority of deaths
• Majority of AMI deaths occur during initial
  period post symptoms 60 within first hour, 40
  prior to hospitalization

19
Myocardial Infarction

• Clinical Manifestation
• Sudden chest pain.
• Sweating.
• Nausea and vomiting.
• Cool, pale.
• Anxiety
• Diagnostic procedure
• ECG.
• Echocardiogram.
• Laboratory test. eg. Cardiac enzyme
• (CPK, Troponin.)

20
Medical Management

• The goal of medical management is to minimize
  myocardial damage, preserve myocardial function
  and prevent complication.
• a- Emergent PTCA or stent.
• b- Pharmacological therapy.e.g
  thrombolytics the purpose is to dissolve and
  lyses the thrombus in coronary artery.
  (Reperfusion)
• e.g. TPA (Tissue plasminogen activate),
  Streptokinase.
• c- Analgesic.
• d- Oxygen administration.

21

• Medical Management of Angina
• Opiate analgesics to reduced pain
• Vasodilators (GTN)
• Beta adrenergic blockers to reduced the work load
  of the heart, decreased myocardial oxygen demand
• Calcium channel blocker to dilate coronary
  arteries
• Antiplatelet agents to inhibit platelet
  aggregation

22

• Medical Management of MI
• Antiplatelet agents (Aspirin)
• Nitrates
• Beta blockers (Atenolol)
• Calcium channel blockers( Nifedepin )
• Heparin
• Thrombolytics ( Streptokinase )
• Morphine sulphate
• Oxygen
• Cholesterol lowering agents

23

• Prevention further attacks through self care
• Inhibit activity to precipitate angina
• Due medications
• Daily exercise
• No smoking
• Weight reduction
• Brief rest period

24

• Assessment
• Objective Data Related to MI and Angina
• Elevated BP or Decreased BP
• Elevated HR or Decreased HR
• Increased respiratory rate
• Diaphoresis
• Shortness of Breath
• ECG changes
• Decreased UOP

25

• Subjective Data Related to MI and Angina
• Pt complains of chest pain Or pain radiate to arm
• Pt complains of nausea, vomiting
• Pt complains of discomfort

26
Nursing Management

• Nursing Assessment
• Nursing Diagnosis
• Plan/Goal
• Interventions
• Evaluations
• Nursing Diagnosis
• Ineffective tissue perfusion
• Decreased cardiac output
• Acute pain
• Anxiety
• Activity intolerance

27
Myocardial Infarction

• Nursing intervention
• Relieving chest pain.
• Improving respiratory function.
• Promoting adequate tissue perfusion.
• Reducing anxiety.
• Managing and monitoring potential
  
• complication.

28

• What are the Nursing measures should be taken ?
• Administration of oxygen
• Determination of Vital sign
• 12 Lead ECG
• Assess baseline labs ABGs, electrolytes,
  BUN/Creatinine, cardiac profile
• Prompt pain relief 1st with nitrate followed by
  narcotic analgesics
• Comfortable positioning of client
• Document and report chest pain, noting
  precipitating factors
• Encourage restful atmosphere

29

• Case scenarios
• 01. A client is currently admitted to an acute
  care facility for the inability to compensate for
  cardiac insufficiency. She is experiencing a
  variety of acute clinical manifestations related
  to her inability to oxygen adequately from a
  decreased myocardial perfusion. Her BP
  88/52Hgmm, PR 112Bt/mint, RR28brt/mint, Spo2
  94.She is complaining of chest pain and nausea.

30
Nursing Assessment

• Subjective Data
• Complaining of chest pain
• Complaining of nausea
• Objective Data
• Her BP 88/52Hgmm
• PR 112Bt/mint
• RR28brt/mint
• Spo2 94

31
Nursing Diagnosis

• Ineffective cardiac tissue perfusion secondary to
  coronary artery disease as evidenced by pt is
  complaining of chest pain
• Nursing Goal
• Patient will maintain effective cardiac perfusion

32
Nursing Interventions and Rationale

• Assess the patients condition well to identify
  baseline data of the pt
• Keep patient on bed or chair in rest
• to decreased cardiac work load
• Position changing to facilitate breathing
• Check skin temperature and peripheral pulses
  frequently ,to determine adequate tissue
  perfusion
• Administer oxygen as prescribed to facilitate
  breathing

33

• Give vasodilator as prescribed to reduced
  myocardial demand
• Give pain relief medications and relaxation
  therapy
• ECG to identify changes
• Blood sample collecting to identify the condition
  correctly
• Vital checking

34
Nursing Evaluation

• Patient maintained effective cardiac perfusion
  with effective HR ,BP and good saturation
• Case scenarios
• 02. A 65-year-old woman with type 2 diabetes
  presents to the emergency department she is
  short of breath and complaining of neck and
  shoulder pain. Her blood pressure is 155/90,and
  her heart rate is 125.She is sweating also.
  Prepare a nursing care plan based on the
  scenario.

35
Cardiac Failure Congestive heart failure (
CHF)

• Referred to as a cardiac failure, is
  the inability of the heart to pump sufficient
  blood to meet the needs of the tissue for oxygen
  and nutrient.
• - The term congestive heart failure
• when referring to Lt- sided and right-sided
  heart failure.
• - Cardiac failure commonly occurs with disorders
  of cardiac muscle that result in decrease
  contractile properties of the heart, lead to
  decrease myocardial contractility include.
• Myocardial dysfunction (especially from coronary
  atherosclerosis), arterial hypertension, and
  valvular dysfunction.

36
Left Sided Cardiac failure

• Pulmonary congestion occurs when the left
  ventricle cannot pump the blood out of the
  chamber. This increase pressure in the left
  ventricle and decrease the blood flow from the
  left atrium. The pressure in the left atrium
  increase, which decrease the blood flow coming
  from the pulmonary vessels. The result increase
  in pressure in the pulmonary circulation forces
  fluid into the pulmonary tissue and alveoli.
• Sings Symptoms
• Dyspnea on exertion. Pulmonary
  Crackles.
• Orthopnea.
  Restlessness and anxiety.
• Cough.
  Tachycardia.

37
Right sided heart failure

• The right side of the heart cannot eject blood,
  and thus can not accommodate all the blood that
  normally returns to it from the venous
  circulation.
• Sings Symptoms
• Edema of the lower extremities.
• Wight gain.
• Hepatomegally (enlargement of the liver).
• Distended neck vein.
• Ascites (an accumulation of fluid in the
  peritoneal cavity).
• Anorexia and nausea.
• Nocturia.
• Weakness.
• Pitting edema.

38
Heart Failure Diagnostics

• Electrolytes.
• UA, BUN, creatinine
• LFTs
• ABGs
• ECG
• Echocardiography

39
Hemodynamic Monitoring

• Intra-arterial pressure (art line A line)
• Direct and continuous monitoring of systolic,
• diastolic, mean arterial pressure arterial
  blood
• sampling
• Central venous pressure (CVP)
• Measures blood volume/venous return reflects
• right heart filling pressures
• Pulmonary artery pressure (PA Swan-Ganz
• catheter)
• Evaluate left ventricular and overall cardiac
• function

40
Medical Management

• The basic objectives in treating patients with
  congestive heart failure are the following
• Reducing the workload on the heart.
• Increasing the force and efficiency of
  myocardial contraction.
• Pharmacological Therapy
• a-ACE (Angiotinsin converted enzyme)
  inhibitors
• ACE inhibitors promote vasodilation and
  diuresis by decreasing after load and preload,
  they decrease the work load of the heart.

41

• b-Diuretic Therapy.
• c-Digitalis. The most commonly prescribed forms
  of digitalis for patients with CHF are digoxin
  (lanoxine) and digotoxin.
• - The medication increases the force of
  myocardial
• contraction and slows conduction through
  the AVnode.
• d- Dobutamine (dobutrex)
• It stimulates the beta1-adrenergic receptor,
  and its major action to increase cardiac
  contractility.
• e- Other Medication. e.g Anticoagulant,
  Beta-adrenergic blockers (propranolol, atenolol)

42
Infectious Disease of the Heart

• Rheumatic Endocarditis
• - It is results directly from rheumatic fever
  caused by group A Streptococcal infection.
• - The disease affects all bony joint,
  producing polyarthritis the heart is also a
  target organ and is where the most serious damage
  occurs.
• - Rheumatic endocarditis are not infectious in
  origin rather they represent reaction occurring
  in response to hemolytic streptococci, Leukocytes
  accumulate in the affected tissue and forms
  nodules, which are replaced by scars, and
  preventing them from closing completely.
• - The most common site of valvular
  regurgitation is the mitral valve.

43
Rheumatic Endocarditic

• Prevention and Treatment
• - Early and adequate treatment of streptococcal
  infections.
• - Long term antibiotic therapy is the
  treatment of choice.
• - Penicillin administered parentally remains
  the medication of choice.

44
Infectious Disease of the Heart

• II- Myocarditis
• Is an inflammation process involving the
  myocardium.
• - Myocarditis can cause heart dilatation,
  thrombi on the heart wall.
• Medical Management
• - Antibiotic Therapy (penicillin).
• - Same used for congestive heart failure.
• III- Pericarditis
• Refers to an inflammation of the
  pericardium, the membrane sac enveloping the
  heart.
• Clinical Manifestation
• - Sever pain may be felt beneath the
  clavicle and in the neck and left scapular
  region. Pericardial pain is aggravated by
  breathing.
• Medical Management
• - Antibiotic therapy.
• - Analgesic and NSAID. e.g
  indomethacin(indocin).

45
Cardiomyopathies

• Is a heart muscle disease associated with cardiac
  dysfunction.
• Dilated cardiomyopathy (dilation of the
  ventricles)
• Hypertrophic cardiomyopathy (increase in size and
  mass of heart muscle)
• Restrictive cardiomyopathy (diastolic dysfunction
  caused by rigid ventricular walls)

46

• Nursing Assessment Cardiomyopathy
• Obtain vital signs every 15 minutes during acute
  phase.
• Assess the patient for changes in neurological
  function hourly and as clinically indicated.
• Assess for skin warmth, color, and capillary
  refill time.
• Assess for chest discomfort because myocardial
  ischemia may result from poor perfusion.
• Assess heart and lung sounds to evaluate the
  degree in heart failure

47

• Nursing Goal
• Patient alert and oriented
• Skin warm and dry
• Pulses strong and equal bilaterally
• Absence of life-threatening dysrythmias
• Urine output 30 ml/hr
• CVP 2 to 6 mm Hg
• Capillary refill lt 3 sec
• BP 90 to 120 mm Hg
• HR 60 to 100 beats/min

48

• NURSING DIAGNOSES Impaired gas exchange
  Decreased cardiac output
• Activity intolerance
• NURSING INTERVENTION Place patient in a
  semi-Fowlers position for comfort, which eases
  respiratory effort. Record intake and output of
  fluids. Monitor vital signs to assess for
  increased respiratory rate, arrythmias. Monitor
  electrocardiogram to look for changes from
  previous tracing.

49

• Explain to the patient fluids restriction may be
  necessary as heart failure isa concurrent
  disease with dilated cardiomyopathy. Record
  daily weight and call physician if weight
  increases 3 lbs (1.4 kg). No smoking or
  drinking alcohol. No straining during bowel
  movements. Increase exercise.
• Medical Management
• Heart transplantation
• Mechanical assistive devices

50
Hypertension

• It is a systolic blood pressure greater than 140
  mmHg and a diastolic pressure 90 mmHg based on
  average two or more readings
• Types
• Primary Hypertension (essential hypertension)
  high blood pressure of unidentified cause
• Secondary Hypertension high blood pressure from
  an identified cause

51
Identifiable causes of hypertension

• Sleep apnea
• Drug induced or related causes
• Chronic kidney disease
• Primary aldosteronism
• Vascular disease
• Thyroid disease

52
Clinical manifestation

• Often no signs and symptoms
• Late signs are retinal hemorrhages, arteriolar
  narrowing, papilledema
• Pathological changes include coronary artery
  disease, kidney damage, and cerebrovascular
  involvement

53
Lifestyle modification to manage Hypertension

• Weight reduction
• Dietary sodium reduction
• Physical activity
• Moderation of alcohol consumption

54
Medical Management

• Goal is to achieve BP 140/90 mm Hg. or lower
• Pharmacologic therapy includes diuretics,
  beta-blockers, or both

55

• Nursing Assessment
• B/P over 140/90
• dizziness
• fatigue and/or confusion
• palpitations
• epistaxis
• blurred vision
• bounding pulse
• S4 heart sound
• in the late stages
• peripheral edema
• hemorrhages
• papilledema of the eye due to hypertensive
  retinopathy
• possible formation of an abdominal aneurysm
• bruits over the abdominal aorta, femoral arteries
  and/or carotid arteries

56

• Nursing Diagnosis
• Deceased Cardiac Output,
• Ineffective Tissue Perfusion cerebral
• Disturbed Sensory Perception
• visual and Deficient Fluid Volume.

57

• 1.Margaret Spezia is a married, 49-year-old
  Italian lady. For the past 2 months Mrs. Spezia
  has had frequent morning headaches, and
  occasional dizziness and blurred vision. At her
  annual physical examination 1 month ago,her blood
  pressure was 168/104 and 156/94.She was
  instructed to reduce her fat and cholesterol
  intake, to avoid using salt at the table,and to
  start walking for 30 to 45minutes daily.
  Mrs.Spezia returns to the clinic for follow-up.

58

• Fatigue related to effects of hypertension and
  stresses of daily life
• Imbalanced nutrition More than body
  requirements related to excessive food intake
• Ineffective health maintenance related to
  inability to modify lifestyle
• Deficient knowledge related to effects of
  prescribed treatment

59

• Interventions
• Teach to take own blood pressure daily and record
  it, bringing the record to scheduled clinic
  visits.
• Teach name, dose, action, and side effects of
  her antihypertensive medication.
• Instruct to walk for 15 minutes each day this
  week, and to investigate swimming classes at the
  local pool.
• Discuss strategies for achieving a realistic
  weight loss goal.
• Refer for a dietary consultation for further
  teaching about fat and sodium restrictions.
• Discuss stress-reducing techniques, helping
  identify possible Choices.

60
Hypertensive Crises

• Hypertensive Emergency- BP must be lowered
  immediately to prevent damage to target organs.
  E.g. MI, ICH, Aortic aneurysm
• Hypertensive Urgency- BP must be lowered within a
  few hours.