The Cardiovascular System

1
The Cardiovascular System

• NRS 108-ECC
• Majuvy L. Sulse RN, MSN, CCRN
• Lola Oyedele RN, MSN, CTN

2
ANATOMICAL POSITION OF THE HEART
From Monahan, F. Neighbors, M. (1998).
Medical-surgical nursing Foundations for
clinical practice, ed 2 Philadelphia W.B.
Saunders.
3
Structure and Functions of the Heart

• Hollow muscular organ encased by pericardium
• 3 layers- epicardium, myocardium, endocardium
• 4 chambers divided by septum
• Consists of valves AV valves Semilunar valves
• Functions-
• Circulatory- R L circulation Coronary
• Conduction- automaticity, excitability,
  conductivity
• SA node-internodal pathways-AV node-Bundle of
  His-RBBB, LBBB-Purkinje fibers-terminal branches
• Cardiac cycle-systole (contraction) diastole
  (relaxation/filling)
• Cardiac output-HR, SV, Preload, Afterload
  Contractility

4
HEART SOUNDS

• The first heart sound (S1) is heard as the AV
  valves close
• The second heart sound (S2) is heard when the
  semilunar valves close

5
HEART SOUNDS

• A fourth heart sound (S4) may be heard on atrial
  systole if resistance to ventricular filling is
  present this is an abnormal finding and the
  causes include cardiac hypertrophy, disease, or
  injury to the ventricular wall
• A third heart sound (S3) may be heard if
  ventricular wall compliance is decreased and
  structures in the ventricular wall vibrate this
  can occur in conditions such as congestive heart
  failure or valvular regurgitation however, an S3
  heart sound may be normal in individuals younger
  than 30 years of age

6
Normal Deviations associated with aging

• Chest wall
• Senile kyphosis
• Heart
• Increased incidence of CAD due to atherosclerosis
• Hypertrophy- higher collagen scarring, elastin
  decreased
• Decreased CO, increased afterload
• Valvular rigidity- valve incompetence murmur
• Decreased control of sympathetic nervous system (
  B adrenergic)- decreased response to stress
• Blood vessels
• Arterial stiffening- loss of elastin, thickened
  intima of arteries

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Cardiac Assessment

• Physical Examination
• General appearance
• Vital signs
• Inspection
• Auscultation- heart lungs
• Palpation
• Percussion

8
Cardiac Assessment

• Past health history
• Risk factors
• Medications
• Health perception, concept, management pattern
• Lifestyle-nutrition, activity, exercise, sleep
  pattern, sexuality
• Role relationship pattern
• Coping stress pattern
• Cultural values

9
Diagnostic Studies

• CBC
• RBC, Hgb, Hct, Sed rate
• Chemistry/Electrolytes
• Na. K, Ca, Magnesium
• Lipid profile
• Triglycerides, HDL-LDL
• Cardiac enzymes
• CPK, LDH, Troponin
• Coagulation studies
• PT, PTT, INR

10
CBC

• The red blood cell (RBC) count decreases in
  rheumatic heart disease and infective
  endocarditis and increases in conditions
  characterized by inadequate tissue oxygenation
• The white blood cell (WBC) count increases in
  infectious and inflammatory diseases of the heart
  and following myocardial infarction (MI) because
  large numbers of WBCs are needed to dispose of
  the necrotic tissue resulting from the infarction
• An elevated hematocrit can result from vascular
  volume depletion
• A decrease in hematocrit and hemoglobin can
  indicate anemia

11
Electrolytes

• SODIUM
• decreased with the use of diuretic, in heart
  failure- indicating water excess
• POTASSIUM
• Hypokalemia causes increased cardiac electrical
  instability, ventricular dysrhythmias, and
  increased risk of digitalis toxicity
• EKG would show flattening and inversion of the T
  wave, the appearance of a U wave, and sagging of
  the ST segment
• Hyperkalemia causes asystole and ventricular
  dysrhythmias
• A low magnesium level can cause ventricular
  tachycardia and fibrillation
• A high magnesium level can cause muscle weakness,
  hypotension, bradycardia, and a prolonged PR
  interval and wide QRS complex

12
Electrolytes

• Hypocalcemia can cause ventricular dysrhythmias,
  prolonged QT interval, and cardiac arrest
• Hypercalcemia can cause a shortened QT interval,
  AV block, tachycardia or bradycardia, digitalis
  hypersensitivity, and cardiac arrest
• Phosphorus levels should be interpreted with
  calcium levels because the kidneys retain or
  excrete one electrolyte in an inverse
  relationship with the other
• The BUN is elevated in heart disorders that
  adversely affect renal circulation, such as heart
  failure and cardiogenic shock
• An acute cardiac episode can elevate the blood
  glucose

13
Cardiac Enzymes

• CK-MB (CREATINE KINASE, MYOCARDIAL MUSCLE)
• An elevation in value indicates myocardial damage
• An elevation occurs within 4 to 6 hours and peaks
  18 to 24 hours following an acute ischemic attack
• Normal value in conventional units is 0 to 7 U/L
• LACTIC DEHYDROGENASE (LDH)
• Elevations in LDH occur 24 hours following
  myocardial infarction and peak in 48 to 72 hours
• When the serum concentration of LDH1 is higher
  than LDH2, the pattern is indicated as flipped
  signifying myocardial necrosis
• Normal value in conventional units is 70 to 200
  IU/L

14
Troponins

• Composed of three proteins cardiac troponin,
  troponin I, and troponin T
• Troponin I especially has a high affinity for
  myocardial injury it rises within 3 hours and
  persists for up to 7 days
• Normal values are quite low, with troponin T
  normally ranging from 0.0 to 0.2 ng/ml, and
  troponin I being less than 0.6 ng/ml thus any
  rise can indicate myocardial cell damage
• MYOGLOBIN LEVEL - an oxygen-binding protein found
  in cardiac and skeletal muscle
• Level rises within 1 hour after cell death, peaks
  in 4 to 6 hours, and returns to normal within 24
  to 36 hours (and in some clients, even faster)

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Diagnostic Studies

• X-ray/Fluoroscopy
• EKG
• Holter monitoring
• Stress test
• TEE
• EPS
• Thallium imaging
• Muga scan-Multiple gated acquisition image
• Echo
• Angiography/ Cardiac catheterization

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Chest X-ray

• DESCRIPTION
• Done to determine the size, silhouette, and
  position of the heart
• Specific pathological changes are difficult to
  determine via x-ray, but anatomical changes can
  be seen
• IMPLEMENTATION
• Prepare the client for x-ray film, explaining the
  purpose and procedure
• Remove jewelry

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ECG/EKG

• DESCRIPTION
• A common noninvasive diagnostic test that
  evaluates the hearts function by recording
  electrical activity
• IMPLEMENTATION
• Determine the clients ability to lie still and
  advise the client to lie still, breathe normally,
  and refrain from talking during the test
• Reassure the client that an electrical shock will
  not occur
• Document any cardiac medications the client is
  taking

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HOLTER MONITORING

• DESCRIPTION
• A noninvasive test in which the client wears a
  Holter monitor and an ECG tracing is recorded
  continuously over a period of 24 hours or more
• It identifies dysrhythmias if they occur and
  evaluates the effectiveness of antidysrhythmics
  or pacemaker therapy
• IMPLEMENTATION
• Instruct the client to resume normal daily
  activities and maintain a diary documenting
  activities and any symptoms that may develop

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ECHOCARDIOGRAM

• DESCRIPTION
• A noninvasive procedure based on the principles
  of ultrasound
• It evaluates structural and functional changes in
  the heart
• IMPLEMENTATION
• Determine the clients ability to lie still and
  advise the client to lie still, breathe normally,
  and refrain from talking during the test

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ECHOCARDIOGRAMPLACEMENT OF LEADS AND TRANSDUCER
21
Stress Test

• DESCRIPTION
• A noninvasive test that studies the heart during
  activity and detects and evaluates coronary
  artery disease
• Treadmill testing is the most commonly used mode
  of stress testing
• Stress testing may be used in conjunction with
  myocardial radionuclide testing, at which point
  the procedure becomes invasive because a
  radionuclide must be injected
• A consent form is required if a radionuclide is
  injected

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EXERCISE TESTING (STRESS TEST)
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Angiography

• DESCRIPTION
• Combines x-ray techniques and a computerized
  subtraction technique with fluoroscopy for
  visualization of the cardiovascular system
• A contrast medium (dye) is injected
• PREPROCEDURE
• Assess the client for allergy to contrast medium
  (dye), iodine, or seafood
• Obtain consent
• POSTPROCEDURE
• Monitor vital signs (VS)
• Assess injection site for bleeding or discomfort

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NUCLEAR CARDIOLOGY

• DESCRIPTION
• The use of radionuclide techniques and scanning
  in cardiovascular assessment
• The most common tests include technetium
  pyrophosphate scanning, thallium imaging, and
  multigated cardiac blood pool imaging (MUGA)
• PREPROCEDURE
• Obtain consent
• Inform the client that a small amount of
  radioisotope will be injected, and that the
  radiation exposure and risks are minimal
• POSTPROCEDURE
• Assess vital signs (VS)
• Assess injection site for bleeding or discomfort
• Inform the client that fatigue may be experienced
  

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Transesophageal Echocardiogram (TEE)

• Views internal structures of the heart and major
  vessels by inserting a thin flexible tube with a
  special tip down the throat.
• Tip of the probe sends out sound waves
  (ultrasound) that echo within the chest wall
  cavity. These echoes are picked up create
  picture of the heart that is displayed on the
  video monitor.
• Allows the cardiologist to evaluate any
  congenital defects, heart valve disease or if an
  artificial valve is functioning properly,
  presence of clots within the heart
• A liquid anesthetic is given to the patient to
  gargle. This will numb his throat tongue make
  the probe easier to swallow
• IV line for sedative to be given
• VS monitored including pulse oxymetry
• NPO not to smoke for at least 6 hours prior to
  test

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Electrophysiology Study (EPS)

• A catheter is inserted into a vein/artery in the
  groin to allow measurements of the electrical
  activity pathways usually abnormally fast or
  slow heart rhythms.
• May lead to further treatment as pacemaker, AICD,
  or Ablation

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CARDIAC CATHETERIZATION
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Cardiac Catheterization

• DESCRIPTION
• Involves insertion of a catheter into the heart
  and surrounding vessels
• Obtains information about the structure and
  performance of the heart valves and circulatory
  system
• PREPROCEDURE
• Document baseline vital signs, and note the
  quality and presence of peripheral pulses for
  postprocedure comparison
• Inform the client that a local anesthetic will be
  administered prior to catheter insertion
• Inform the client that he or she may feel
  fatigued because of the need to lie still and
  quiet on a relatively hard table for up to 2
  hours

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Cardiac Cath

• POSTPROCEDURE
• Monitor VS and cardiac rhythm for dysrhythmias at
  least every 30 minutes for 2 hours initially
• Assess for chest pain, and if dysrhythmias or
  chest pain occur, notify the physician
• Monitor peripheral pulses and the color, warmth,
  and sensation of the extremity distal to
  insertion site at least every 30 minutes for 2
  hours initially
• Notify the physician if the client complains of
  numbness and tingling the extremity becomes
  cool, pale or cyanotic or loss of the peripheral
  pulses occurs
• Monitor the pressure dressing for bleeding or
  hematoma formation
• Apply a sandbag to the insertion site to provide
  additional pressure if required
• Monitor for bleeding and if bleeding occurs,
  apply pressure immediately and notify the
  physician

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Cardiac Cath

• POSTPROCEDURE
• Monitor for hematoma, and if a hematoma develops,
  notify the physician
• Keep extremity extended for 4 to 6 hours, keeping
  the leg straight to prevent arterial occlusion
• Maintain strict bed rest for 6 to 12 hours,
  however the client may turn from side to side do
  not elevate the head of the bed more than 15
  degrees
• If the antecubital vessel was used, immobilize
  the arm using an armboard
• Encourage fluids if not contraindicated to
  promote renal excretion of the dye
• Monitor for nausea, vomiting, rash, or other
  signs of hypersensitivity to the dye

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Hemodynamic Studies

• CVP
• Swan-ganz catheter
• Right atrial pressure (RAP)
• Right ventricular pressure (RVP)
• Pulmonary artery pressure (PAP)
• Pulmonary capillary wedge pressure (PCWP)
• Cardiac output/ cardiac index

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Hemodynamic Studies

• DESCRIPTION
• The CVP is the pressure within the superior vena
  cava and reflects the pressure under which blood
  is returned to the superior vena cava and right
  atrium
• CVP is measured with a central venous line in the
  superior vena cava or by a balloon flotation
  catheter in the pulmonary artery
• Normal CVP pressure is 5 to 10 mmHg
• An elevated CVP measurement indicates an increase
  in blood volume due to sodium and water
  retention, excessive IV fluids, alterations in
  fluid balance, or renal failure
• A decreased CVP measurement indicates a decrease
  in circulating blood volume, and may be due to
  hemorrhage or severe vasodilation with pooling of
  blood in the extremities that limits venous
  return, and fluid imbalances

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MEASURING CENTRAL VENOUS PRESSURE
34
Inflammatory Heart Diseases

• Rheumatic Heart disease
• Myocarditis
• Pericarditis
• Cardiomyopathy

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Rheumatic Heart Disease

• Inflammatory disease of the heart involving all
  layers
• Chronic condition characterized by scarring
  deformity of the heart valves
• Sequela to B hemolytic strep infection
• Socio-economic conditions, familial factors
  altered immune response also predisposes
  rheumatic fever
• Targets joints (polyarthritis), heart (Carditis),
  skin ( Erythema marginatum CNS( Sydenhams
  chorea)
• Aschoff bodies- nodules from reaction to
  inflammation- scarring of myocardium
• Attach to valves, attracts platelets fibrin
• Causes valvular disorders, cardiomegaly heart
  failure

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Rheumatic Heart Disease

• Diagnostic studies
• Throat cultures
• ASO titer (antistreptolysin O)
• CRP-Creactive protein
• ESR WBC
• Echo-valvular insufficiency thickening
• Management
• Bed rest
• Drug therapy-
• Antibiotics to fight infection as prophylaxis
  prior to invasive procedure
• Salicylates cortecosteroids to control fever
  joint manifestations

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Pericarditis

• DESCRIPTION
• An acute or chronic inflammation of the
  pericardium
• Chronic pericarditis, a chronic inflammatory
  thickening of the pericardium, constricts the
  heart causing compression
• The pericardial sac becomes inflamed
• Can result in loss of pericardial elasticity or
  an accumulation of fluid within the sac
• Heart failure or cardiac tamponade may result

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PERICARDITIS

• ASSESSMENT
• Precordial pain in the anterior chest that
  radiates to the left side of the neck, shoulder,
  or back
• Pain that is aggravated by breathing
  (particularly inspiration), coughing, and
  swallowing
• Pain is worse when in the supine position and may
  be relieved by leaning forward
• Pericardial friction rub (scratchy, high-pitched
  sound) heard on auscultation, produced by the
  rubbing of the inflamed pericardial
  layers-hallmark finding
• Fever and chills
• Fatigue and malaise
• Elevated WBC count
• ECG changes- key diagnostic clues
• Signs of right-sided heart failure in clients
  with chronic constrictive pericarditis

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Pericarditis

• IMPLEMENTATION
• Assess the nature of the pain anxiety
• Position the client side-lying, high-Fowlers, or
  upright and leaning forward
• Administer analgesics, (nonsteroidal
  antiinflammatory drugs (NSAIDs), or
  corticosteroids for pain as prescribed
• Avoid the administration of aspirin and
  anticoagulants because they increase the risk of
  tamponade
• Auscultate for a pericardial friction rub
• Evaluate the blood culture report
• Administer antibiotics for bacterial infection as
  prescribed
• Administer diuretics and digoxin (Lanoxin) as
  prescribed to the client with chronic
  constrictive pericarditis
• Assist with pericardiocentesis if prescribed

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Pericardiocentesis
41
Myocarditis

• DESCRIPTION
• An acute or chronic inflammation of the
  myocardium due to pericarditis, systemic
  infection, or allergic response
• ASSESSMENT
• Fever
• Pericardial friction rub
• A gallop rhythm
• A murmur that sounds like fluid passing an
  obstruction
• Pulsus alterans
• Signs of heart failure
• Fatigue
• Dyspnea, tachycardia, chest pain

42
Myocarditis

• IMPLEMENTATION
• Assist the client to a position of comfort as
  sitting up and leaning forward
• Administer analgesics, salicylates, NSAIDs as
  prescribed, to reduce fever and pain
• Administer oxygen as prescribed
• Provide adequate rest periods
• Limit activities to avoid overexertion and to
  decrease the workload of the heart
• Administer digoxin (Lanoxin) as prescribed and
  monitor for signs of digoxin toxicity
• Administer antidysrhythmics as prescribed
• Administer antibiotics as prescribed to treat the
  causative organism
• Monitor for complications, which can include
  thrombus, heart failure, or cardiomyopathy

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ENDOCARDITIS

• DESCRIPTION
• An inflammation of the inner lining of the heart
  and valves
• Occurs primarily in clients who are IV drug
  abusers, have had valve replacements, or have
  mitral valve prolapse or other structural defects
  
• Ports of entry for the infecting organism include
  the oral cavity (especially if the client had a
  dental procedure in the previous 3 to 6 months),
  cutaneous invasion, infections, or by invasive
  procedures or surgery

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BACTERIAL INFECTIVE ENDOCARDITIS
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Endocarditis

• ASSESSMENT
• Fever- 90 of patients
• Anorexia
• Weight loss
• Fatigue
• Cardiac murmurs noted in 80 of cases
• Heart failure
• Embolic complications from vegetation fragments
  traveling through the circulation
• Petechiae
• Splinter hemorrhages in the nail beds
• Oslers nodes (reddish tender lesions) on the
  pads of the fingers, hands, and toes
• Janeways lesions (nontender hemorrhagic lesions)
  on the fingers, toes, nose, or earlobes
• Roth spots- hemmorhaging retinal lesions
• Splenomegaly
• Clubbing of the fingers

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OSLERS NODES
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JANEWAY LESION
48
CLUBBING
49
ENDOCARDITIS

• IMPLEMENTATION
• Provide adequate rest balanced with activity to
  prevent thrombus formation
• Monitor cardiovascular status
• Monitor for signs of heart failure
• Monitor for pulmonary emboli as evidenced by
  pleuritic chest pain, dyspnea, and cough
• Assess skin, mucous membranes, and conjunctiva
  for petechiae
• Assess nail beds for splinter hemorrhages
• Assess for Oslers nodes on the pads of the
  fingers, hands, and toes
• Assess for Janeways lesions on the fingers,
  toes, nose, or earlobes

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Endocarditis

• CLIENT EDUCATION
• Signs and symptoms of complications and to notify
  the physician if they occur
• Importance of good oral hygiene
• Brush teeth twice daily with a soft toothbrush
  followed by oral rinses
• Avoid irrigation devices, electric toothbrushes,
  and flossing, because these activities can cause
  the gums to bleed, allowing bacteria to enter the
  mucous membranes and bloodstream
• Inform the client of the importance of
  prophylactic antibiotics prior to any invasive
  procedure and the importance of informing all
  health care professionals of his or her disease

51
Cardiomyopathty

• Categories
• Congestive-Dilated
• Hypertrophic
• Restrictive
• Risk factors
• Cardiotonic agents-cocaine, alcohol
• HTN
• CAD
• Valvular disorder
• Pregnancy

52
Cardiomyopathy

• Diagnostics-History and PE, Echo, CXR, ECG,
  Cardiac Cath, Nuclear imaging studies
• Nursing diagnosis interventions
• Decreased cardiac output R/T alterations in
  structure function
• Activity intolerance
• Provide rest
• On going monitoring
• Diet drug therapy
• Therapy
• Palliative
• Curative- Digitalis, diuretics, anticoagulants,
  antiarrythmics, Betablockers, inotropes, ace
  inhibitors
• Cardiac transplant

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VALVULAR HEART DISEASE

• DESCRIPTION
• Occurs when the heart valves cannot fully open
  (stenosis) or close completely (insufficiency or
  regurgitation)
• Prevents efficient blood flow through the heart

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TYPES OF VALVULAR HEART DISEASE

• MITRAL, TRICUSPID, AORTIC, PULMONIC
• STENOSIS- Valvular tissue thickens and narrows
  the valve opening, impedes blood flow from one
  chamber to another
• INSUFFICIENCY/REGURGITATION- Valve is incompetent
  and prevents complete valve closure, BLOOD FLOWS
  BACK TO CHAMBER
• VALVE PROLAPSE-Valve leaflets protrude into the
  left atrium during systole

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Mitral Valve Disease

• Mitral valve stenosis
• Obstruction to blood flow causing Increased
  pressure to eject blood low CO
• L atrial hypertrophy, pulmonary congestion R
  ventricular hypertrophy
• Manifestations
• Diastolic murmur-best heard at apex with bell
• Dyspnea, orthopnea R/T pulmonary congestion
  reduced lung compliance
• Management
• Diuretics, digitalis, anticoagulation

56
Mitral Valve Regurgitation

• Incomplete closure of valve- CO
• L atrial hypertrophy, pulmonary congestion, R
  ventricular hypertrophy
• Manifestations fatigue, weakness,dyspnea
• Complications-Atrial fibrillation emboli
• Management- diuretics, digitalis,
  beta-blockers,anticoagulation
• Mitral valve prolapse regurgitation

57
Aortic Valve Disease

• Aortic stenosis
• Maybe congenital or acquired (secondary to RH)
• Narrowed outlet CO pressure L ventricles
• Pulmonary HTN from increased LV pressure LA
  filling pressures
• Preload is important to open valve-No NTG
• Manifestations
• Systolic crescendo-decrescendo murmur ending
  before S2
• Chest pain on exertion
• Dyspnea from pulmonary edema
• Complications
• Dysrhythmias

58

• Aortic Regurgitation-backflow-LV-hypertrophy-incre
  ase ventricular force-high SBP
• Manifestations-
• Acute-abrupt onset of dyspnea, chest pain-shock
• Chronic-
• Corrigans pulse- abrupt distension during systole
  quick collapse on diastole
• Austin Flint murmur- low frequency diastolic
  rumble

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EFFECTS OF AORTIC REGURGITATION
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Tricuspid Pulmonic Valve Disease

• R side of heart
• Stenosis regurgitation pathology
• Manifestations are R/T R venticular dysfunction/
  R sided heart failure
• Management related to R sided failure

61
VALVULAR HEART DISEASE REPAIR PROCEDURES

• BALLOON VALVULOPLASTY
• An invasive, nonsurgical procedure
• The passage of a balloon catheter from the
  femoral vein through the atrial septum to the
  mitral valve, or through the femoral artery to
  the aortic valve
• The balloon is inflated to enlarge the orifice
• Institute precautions for arterial puncture if
  appropriate
• Monitor for bleeding from the catheter insertion
  site
• Monitor for signs of systemic emboli
• Monitor for signs of a regurgitant valve by
  monitoring cardiac rhythm, heart sounds, and
  cardiac output

62
Valvular Repair Procedures

• MITRAL ANNULOPLASTY
• Tightening and suturing the malfunctioning valve
  annulus to eliminate or markedly reduce
  regurgitation
• COMMISSUROTOMY/VALVOTOMY
• Accomplished with cardiopulmonary bypass during
  open heart surgery
• The valve is visualized, thrombi are removed from
  the atria, fused leaflets are incised and calcium
  is debrided from the leaflets, thus widening the
  orifice
• MECHANICAL PROSTHETIC VALVES
• Prosthetic valves are very durable but can fail
• Thromboembolism is a problem following the valve
  replacement and lifetime anticoagulant therapy is
  required
• BIOPROSTHETIC VALVES
• Biological grafts are xenografts (valves from
  other species), porcine valves (pig), bovine
  valves (cow), or homografts (human cadavers)
• There is little risk of clot formation
  therefore, long-term anticoagulation is not
  indicated

63
Porcine Aortic valve
Mechanical Valves
Valve replacement procedures
64
CLIENT INSTRUCTIONS FOLLOWING VALVE REPLACEMENT

• Adequate rest is important and fatigue is usual
• Need for anticoagulant therapy if a mechanical
  prosthetic valve was inserted
• Hazards related to anticoagulant therapy and to
  notify the physician if bleeding or excessive
  bruising occurs
• Importance of good oral hygiene to reduce the
  risk of infective endocarditis
• Heavy lifting (greater than 10 pounds) is to be
  avoided and to exercise caution when in an
  automobile to prevent injury to the sternal
  incision
• If a prosthetic valve was inserted, a soft,
  audible clicking sound may be heard
• Importance of prophylactic antibiotics prior to
  any invasive procedure and the importance of
  informing all health care professionals of the
  valvular disease history
• Obtain and wear a Medic Alert bracelet

65
Coronary Artery Disease

• Pathology-focal deposits of cholesterol lipids
  within the intimal wall of the artery-causes
  decrease in lumen size--decreased blood flow
  (ischemia to tissues major organs- may lead to
  emboli formation

66
CAD

• Causes decreased perfusion of myocardial tissue
  and inadequate myocardial oxygen supply
• Leads to hypertension, angina, dysrhythmias,
  myocardial infarction, heart failure, and death
• Collateral circulation, more than one artery
  supplying a muscle with blood, is normally
  present in the coronary arteries, especially in
  older persons
• The development of collateral circulation takes
  time and develops when chronic ischemia occurs to
  meet the metabolic demands therefore, an
  occlusion of a coronary artery in a younger
  individual is more likely to be lethal than in an
  older individual
• Symptoms occur when the coronary artery is
  occluded to the point that inadequate blood
  supply to the muscle occurs, causing ischemia
• Coronary artery narrowing is significant if the
  lumen diameter of the left main artery is reduced
  at least 50, or if any major branch is reduced
  at least 75
• The goal of treatment is to alter the
  atherosclerotic progression

67
Coronary Artery Disease

• Risk factors-
• Modifiable-smoking, obesity, stress, physical
  immobility, hyperlipidemia, DM, type-A
  personality
• Non-modifiable- age, gender, ethnicity, genetic
  inheritance
• Clinical manifestations- asymptomatic until acute
  decrease in blood flow to heart develops
• Diagnostic studies-
• Cholesterol, lipid profile, EKG, coronary
  arteriogram, CT scan
• Medical management
• Treat cause control modifiable risk factors
• Restore blood supply
• Drug therapy
• Complications
• Angina, MI, stroke

68
SURGICAL PROCEDURES

• PTCA to compress the plaque against the walls of
  the artery and dilate the vessel
• Laser angioplasty to vaporize the plaque
• Atherectomy to remove the plaque from the artery
• Vascular stent to prevent the artery from closing
  and to prevent restenosis
• Coronary artery bypass graft to improve blood
  flow to the myocardial tissue that is at risk for
  ischemia or infarction due to the occluded artery
  

69
Myocardial Infarction (MI)

• Injury to myocardium from sudden restriction of
  blood flow to the heart.
• Etiology/ Pathophysiology
• Main cause is CAD-build up of atherosclerotic
  plaque in coronary arteries restricting blood
  flow to the heart.
• Risk factors age, gender, family history,
  diabetes ethnicity
• Smoking, obesity, stress, elevated cholesterol
  HTN
• Coronary aretry blood flow is blocked-thrombus
  formation or persistent vasospasm-deprivation of
  oxygen-persistent ischemia may rapidly lead to
  tissue death.
• Angina pectoris- chest pain from restricted blood
  flow

70
ANGINA

• DESCRIPTION
• Chest pain resulting from myocardial ischemia
  caused by inadequate myocardial blood and oxygen
  supply
• Caused by an imbalance between oxygen supply and
  demand
• Causes include obstruction of coronary blood flow
  due to atherosclerosis, coronary artery spasm,
  and conditions increasing myocardial oxygen
  consumption

71
Angina

• STABLE ANGINA
• Also called exertional angina
• Occurs with exertion or emotional stress, and is
  relieved with rest or nitroglycerin
• It usually has a stable pattern of onset,
  duration, severity, and relieving factors
• UNSTABLE ANGINA
• Also called preinfarction angina
• Occurs with an unpredictable degree of exertion
  or emotion and increases in occurrence, duration,
  and severity over time
• Pain may not be relieved with nitroglycerin

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Angina

• VARIANT ANGINA
• Also called Prinzmetals or vasospastic angina
• Results from coronary artery spasm and is similar
  to classic angina but lasts longer
• May occur at rest
• Attacks may be associated with ST segment
  elevation noted on the ECG
• INTRACTABLE ANGINA
• A chronic, incapacitating angina that is
  unresponsive to interventions
• POSTINFARCTION ANGINA
• Occurs after an MI, when residual ischemia may
  cause episodes of angina

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MI-Coronary Circulation

• LAD-L ventricular muscle
• L circumflex-posterior wall of LV, SA node (39),
  AV node )(12), LV muscle
• RCA-R ventricle
• Inferior portion of L Ventricle, SA node (59),
  AV node (88)

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MI

• Inferior Wall-Lead ll, lll, AVF
• Lateral Wall-I, AVL, V5, V6
• Anterior Wall- V1-V4

ST elevation
T wave inversion
75
MI

• ASSESSMENT PAIN
• Can develop slowly or quickly
• Usually described as mild or moderate pain
• Substernal, crushing, squeezing pain
• May radiate to the shoulders, arms, jaw, neck,
  back
• Usually lasts less than 5 minutes however, can
  last up to 15 to 20 minutes
• Dyspnea
• Pallor
• Sweating
• Palpitations and tachycardia
• Dizziness and faintness
• Hypertension
• Digestive disturbances

76
Treatment of MI

• The goal of treatment is to provide relief of an
  acute attack, correct the imbalance between
  myocardial oxygen supply and demand, prevent the
  progression of the disease and further attacks to
  reduce the risk of MI
• Assess pain
• Provide bed rest
• Administer oxygen at 3 L via nasal cannula as
  prescribed
• Administer nitroglycerin as prescribed to dilate
  the coronary arteries, reduce the oxygen
  requirements of the myocardium, and relieve the
  chest pain
• Obtain a 12-lead ECG
• Assess hemodynamic status
• Provide continuous cardiac monitoring

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Treatment for MI

• MEDICATIONS
• Nitroglycerine
• Morphine Sulfate
• Anticoagulant or Antiplatelet or thrombolytic
  therapy may be prescribed to inhibit platelet
  aggregation and reduce the risk of developing an
  acute MI
• Betablockers post MI
• Antidysrhythmic drugs
• SURGICAL PROCEDURES
• Same procedures performed to treat CAD( PTCA,
  CABG)
• Client Education
• Cardiac rehabilitation
• Lifestyle change
• Medication regimen
• Bleeding precautions

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Diagnostics for MI

• ECG
• Normal during rest, with ST depression or
  elevation and/or T wave inversion during an
  episode of pain
• STRESS TEST
• Chest pain or changes in the ECG or vital signs
  during testing may indicate ischemia
• CARDIAC ENZYMES
• Normal findings in angina, elevated in MI
• CARDIAC CATHETERIZATION
• Provides a definitive diagnosis

79
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80
ARTERIAL AND VENOUS DISORDERS
81
HYPERTENSION

• DESCRIPTION
• Persistent elevation of the systolic blood
  pressure above 140 mmHg and the diastolic blood
  pressure above 90 mmHg
• Most significant predictor of developing coronary
  artery disease and a major risk factor for
  coronary, cerebral, renal, and peripheral
  vascular disease
• The disease is initially asymptomatic

82
HYPERTENSION

• DESCRIPTION
• The goals of treatment include to reduce the
  blood pressure and to prevent or lessen the
  extent of organ damage
• Nonpharmacological approaches, such as lifestyle
  changes, may be initially prescribed and if the
  BP cannot be decreased after a reasonable time
  period (1 to 3 months), then the client may
  require pharmacological treatment

83
HYPERTENSION ORGAN INVOLVEMENT

• EYES
• Visual changes
• BRAIN
• Cerebrovascular accident (CVA)
• CARDIOVASCULAR SYSTEM
• Congestive heart failure (CHF), hypertensive
  crisis
• KIDNEYS
• Renal failure

84
HYPERTENSIVE RETINOPATHY
From Michelson JB, Friedlaender MH (1996) The eye
in clinical medicine. London Times Mirror
International Publishers.
85
HYPERTROPHY OF THE LEFT VENTRICLE IN HYPERTENSION
From Cotran RS, Kumar V, Collins T Robbins
pathologic basis of disease, ed. 6, Philadelphia,
1999, W.B. Saunders.
86
HYPERTENSION

• TYPES
• Primary or essential
• Secondary

87
PRIMARY OR ESSENTIAL HYPERTENSION

• DESCRIPTION
• No known etiology
• RISK FACTORS
• Aging
• Family history
• Black race with higher prevalence in males
• Obesity
• Smoking
• Stress

88
SECONDARY HYPERTENSION

• DESCRIPTION
• Occurs as a result of other disorders or
  conditions
• Treatment depends on the cause and the organs
  involved
• PRECIPITATING CONDITIONS
• Cardiovascular disorders
• Renal disorders
• Endocrine system disorders
• Pregnancy
• Medications

89
HYPERTENSION

• ASSESSMENT
• May be asymptomatic
• Headache
• Visual disturbances
• Dizziness
• Chest pain
• Tinnitus
• Flushed face
• Epistaxis

90
HYPERTENSION

• IMPLEMENTATION GOALS
• To reduce the blood pressure
• To prevent or lessen the extent of organ damage

91
HYPERTENSION

• IMPLEMENTATION
• Question the client regarding the signs and
  symptoms indicative of hypertension
• Obtain the blood pressure (BP) two or more times
  on both arms with the client supine and standing
  compare the BP with prior documentation
• Determine family history of hypertension
• Identify current medication therapy
• Obtain weight
• Evaluate dietary patterns and sodium intake

92
HYPERTENSION

• IMPLEMENTATION
• Assess for visual changes or retinal damage
• Assess for cardiovascular changes, such as
  distended neck veins, increased heart rate,
  dysrhythmias
• Evaluate chest x-ray for heart enlargement
• Assess neurological system
• Evaluate renal function
• Evaluate results of diagnostic and laboratory
  studies

93
HYPERTENSION

• NONPHARMACOLOGICAL
• Weight reduction, if necessary, or maintenance of
  ideal weight
• Dietary sodium restriction to 2 g daily as
  prescribed
• Moderate intake of alcohol and caffeine-containing
  products
• Initiation of a regular exercise program

94
HYPERTENSION

• NONPHARMACOLOGICAL
• Avoidance of smoking
• Relaxation techniques and biofeedback therapy
• Elimination of unnecessary medications that may
  contribute to the hypertension

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HYPERTENSION STEPPED CARE APPROACH

• DESCRIPTION
• If a pharmacological approach to treating
  hypertension is required, a single medication is
  prescribed and monitored for its effectiveness
• Medications are added to the treatment regimen
  until the BP is controlled
• Refer to the module entitled Cardiovascular
  Medications, for information regarding
  medications to treat hypertension

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HYPERTENSION STEPPED CARE APPROACH

• STEP 1
• A single medication is prescribed, which may be a
  diuretic, beta blocker, calcium channel blocker,
  or angiotensin-converting enzyme (ACE) inhibitor
• STEP 2
• Step 1 therapy is evaluated after 1 to 3 months
• If the response is not adequate, compliance is
  evaluated
• The medication may be increased or a new
  medication is prescribed, or a second medication
  is added to the treatment plan

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HYPERTENSION STEPPED CARE APPROACH

• STEP 3
• Compliance is evaluated
• Further evaluation of Step 2
• If a therapeutic response is not adequate, a
  second medication is substituted or a third
  medication is added to the treatment plan
• STEP 4
• Compliance is evaluated
• Careful assessment of factors limiting the
  antihypertensive response is done
• A third or fourth medication may be added to the
  treatment plan

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HYPERTENSION CLIENT EDUCATION

• Importance of compliance with the treatment plan
• The disease process, explaining that symptoms
  usually do not develop until organs have suffered
  damage
• Planning a regular exercise program, avoiding
  heavy weight lifting and isometric exercises
• Importance of beginning the exercise program
  gradually
• Express feelings about daily stress
• Identify ways to reduce stress

99
HYPERTENSION CLIENT EDUCATION

• Relaxation techniques
• Incorporate relaxation techniques into the daily
  living pattern
• Technique for monitoring blood pressure
• Maintain a diary of blood pressure readings
• Importance of lifelong medication and the need
  for follow-up treatment
• Dietary restriction, which may include sodium,
  fat, calories, and cholesterol

100
HYPERTENSION CLIENT EDUCATION

• How to shop and prepare low-sodium meals
• List of products that contain sodium
• Read labels of products to determine sodium
  content focusing on substance listed as sodium,
  NaCl, and MSG
• Bake, roast, or boil foods, avoid salt in
  preparation of foods, and avoid using salt at the
  table
• Fresh foods are best to consume and to avoid
  canned foods

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HYPERTENSION CLIENT EDUCATION

• The action, side effects, and scheduling of
  medications
• If uncomfortable side effects occur, to contact
  the physician and not to stop the medication
• Avoid over-the-counter medication
• Importance of follow-up care

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HYPERTENSIVE CRISIS

• DESCRIPTION
• Any clinical condition requiring immediate
  reduction in blood pressure
• An acute and life-threatening condition
• The accelerated hypertension requires emergency
  treatment, since target organ damage (brain,
  heart, kidneys, retina of the eye) can occur
  quickly
• Death can be caused by stroke, renal failure, or
  cardiac disease

103
HYPERTENSIVE CRISIS

• ASSESSMENT
• A diastolic pressure above 120 mmHg
• Headache
• Drowsiness
• Confusion
• Changes in neurological status
• Tachycardia and tachypnea
• Dyspnea
• Cyanosis
• Seizures

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HYPERTENSIVE CRISIS

• IMPLEMENTATION
• Maintain a patent airway
• Administer IV antihypertensive medications as
  prescribed
• Monitor vital signs assessing BP every 5 minutes
• Assess for hypotension during the administration
  of antihypertensives
• Place the client in a supine position if
  hypotension occurs