CARDIOLOGY NURSING Insertion of a catheter into the heart and surrounding vessels Determines the structure and

performance of the heart valves and surrounding vessels. Used to diagnose CAD, assess
HEART’S NORMAL ANATOMY coronary atery patency and determine extent of atherosclerosis
The heart is located in the LEFT side of the mediastinum Consists of Three layers - Pretest: Ensure Consent, assess for allergy to seafood and iodine, NPO, document
epicardium, myocardium and endocardium.The epicardium covers the outer surface of weight and height, baseline VS, blood tests and document the peripheral pulses. Fast for
the heart The myocardium is the middle muscular layer of the heart The endocardium 8-12 hours, teachings, medications to allay anxiety
lines the chambers and the valves.The layer that covers the heart is the PERICARDIUM Intra-test: inform patient of a fluttery feeling as the catheter passes through the heart;
There are two parts - parietal and visceral pericardium The space between the two inform the patient that a feeling of warmth and metallic taste may occur when dye is
pericardial layers is the pericardial space administered
The heart also has four chambers - two atria and two ventricles The Left atrium and the Post-test: Monitor VS and cardiac rhythm Monitor peripheral pulses, color and warmth
right atrium The left ventricle and the right ventricle.The heart chambers are guarded by and sensation of the extremity distal to insertion site Maintain sandbag to the insertion
valves The atrio-ventricular valves - tricuspid and bicuspid The semi-lunar valves - site if required to maintain pressure Monitor for bleeding and hematoma formation.
pulmonic and aortic valves.The Blood supply of the heart comes from the Coronary Maintain strict bed rest for 6-12 hours Client may turn from side to side but bed should
arteries 1. Right coronary artery supplies the RIGHT atrium and RIGHT ventricle, not be elevated more than 30 degrees and legs always straight Encourage fluid intake to
inferior portion of the LEFT ventricle, the POSTERIOR septal wall and the two nodes - flush out the dye Immobilize the arm if the antecubital vein is used Monitor for dye
AV (90%) and SA node (55%). Left coronary artery- branches into the LAD and the allergy
circumflex branch The LAD supplies blood to the anterior wall of the LEFT ventricle, the
anterior septum and the Apex of the left ventricle The CIRCUMFLEX branch supplies CVP
the left atrium and the posterior LEFT ventricle The CVP is the pressure within the SVC Reflects the pressure under which blood is
The CONDUCTING SYSTEM OF THE HEART Consists of the 1. SA node- the returned to the SVC and right atrium. Normal CVP is 0 to 8 mmHg/ 4-10 cm H2O
pacemaker 2. AV node- slowest conduction 3. Bundle of His – branches into the Right Elevated CVP indicates increase in blood volume, excessive IVF or heart/renal failure
and the Left bundle branch 4. Purkinje fibers- fastest conduction Low CVP may indicated hypovolemia, hemorrhage and severe vasodilatation
The Heart sounds 1. S1- due to closure of the AV valves 2. S2- due to the closure of the Measuring CVP 1. Position the client supine with bed elevated at 45 degrees 2. Position
semi-lunar valves 3. S3- due to increased ventricular filling 4. S4- due to forceful atrial the zero point of the CVP line at the level of the right atrium. Usually this is at the MAL,
contraction.Heart rate Normal range is 60-100 beats per minute Tachycardia is greater 4th ICS 3. Instruct the client to be relaxed and avoid coughing and straining.
than 100 bpm Bradycardia is less than 60 bpm Sympathetic system INCREASES HR
Parasympathetic system (Vagus) DECREASES HR.Blood pressure Cardiac output X ASSESSMENT ASSESSMENT
peripheral resistance Control is neural (central and peripheral) and hormonal 1. Health History Obtain description of present illness and the chief complaint Chest
Baroreceptors in the carotid and aorta Hormones- ADH, aldosterone, epinephrine can pain, SOB, Edema, etc. Assess risk factors
increase BP; ANF can decrease BP.The vascular system consists of the arteries, veins and 2. Physical examination Vital signs- BP, PP, MAP Inspection of the skin Inspection of the
capillaries The arteries are vessels that carry blood away from the heart to the periphery thorax Palpation of the PMI, pulses Auscultation of the heart sounds
The veins are the vessels that carry blood to the heart The capillaries are lined with 3. Laboratory and diagnostic studies CBC cardiac catheterization Lipid profile
squamos cells, they connect the veins and arteries. The lymphatic system also is part of arteriography Cardiac enzymes and proteins CXR CVP EEG Holter monitoring Exercise
the vascular system and the function of this system is to collect the extravasated fluid ECG
from the tissues and returns it to the blood
CARDIAC IMPLEMENTATION
Cardiac Assessment 1.Assess the cardio-pulmonary status VS, BP, Cardiac assessment
Laboratory Test Rationale 1. To assist in diagnosing MI 2. To identify abnormalities 3. To 2. Enhance cardiac output Establish IV line to administer fluids
assess inflammation 3. Promote gas exchange Administer O2 Position client in SEMI-Fowler’s Encourage
4. To determine baseline value 5. To monitor serum level of medications 6. To assess the coughing and deep breathing exercises
effects of medications 4. Increase client activity tolerance Balance rest and activity periods Assist in daily
activities
CARDIAC Proteins and enzymes 5. Promote client comfort Assess the client’s description of pain and chest discomfort
CK- MB ( creatine kinase) Administer medication as prescribed
Elevates in MI within 4 hours, peaks in 18 hours and then declines till 3 days 6. Promote adequate sleep
Normal value is 0-7 U/L 7. Prevent infection Monitor skin integrity of lower extremities Assess skin site for
edema, redness and warmth Monitor for fever Change position frequently
Lactic Dehydrogenase (LDH) 8. Minimize patient anxiety Encourage verbalization of feelings, fears and concerns
Elevates in MI in 24 hours, peaks in 48-72 hours Answer client questions. Provide information about procedures and medications
Normally LDH1 is greater than LDH2
MI- LDH2 greater than LDH1 (flipped LDH pattern) CARDIAC DISEASES
Normal value is 70-200 IU/L Coronary Artery Disease
Myocardial Infarction
Myoglobin Congestive Heart Failure
Rises within 1-3 hours Infective Endocarditis
Peaks in 4-12 hours Cardiac Tamponade
Returns to normal in a day Cardiogenic Shock
Not used alone
Muscular and RENAL disease can have elevated myoglobin VASCULAR DISEASES
Hypertension
LABORATORY PROCEDURES Buerger’s disease
Troponin I and T Varicose veins
Troponin I is usually utilized for MI Elevates within 3-4 hours, peaks in 4-24 hours and Deep vein thrombosis
persists for 7 days to 3 weeks! Normal value for Troponin I is less than 0.6 Aneurysm
ng/mL.REMEMBER to AVOID IM injections before obtaining blood sample! Early and
late diagnosis can be made! CAD
CAD results from the focal narrowing of the large and medium-sized coronary arteries
SERUM LIPIDS- Lipid profile measures the serum cholesterol, triglycerides and due to deposition of atheromatous plaque in the vessel wall
lipoprotein levels Cholesterol= 200 mg/dL Triglycerides- 40- 150 mg/dL. LDH- 130
mg/dL HDL- 30-70- mg/dL NPO post midnight (usually 12 hours) RISK FACTORS 1. Age above 45/55 and Sex- Males and post-menopausal females 2.
Family History 3. Hypertension 4. DM 5. Smoking 6. Obesity 7. Sedentary lifestyle 8.
ELECTROCARDIOGRAM (ECG) A non-invasive procedure that evaluates the electrical Hyperlipedimia
activity of the heart Electrodes and wires are attached to the patient Most important MODIFIABLE factors: Smoking Hypertension Diabetes Cholesterol
abnormalities
Holter Monitoring. A non-invasive test in which the client wears a Holter monitor and an
ECG tracing recorded continuously over a period of 24 hours. Instruct the client to Pathophysiology
resume normal activities and maintain a diary of activities and any symptoms that may Fatty streak formation in the vascular intima T-cells and monocytes ingest lipids in
develop the area of deposition atheroma narrowing of the arterial lumen reduced
coronary blood flow myocardial ischemia
ECHOCARDIOGRAM Non-invasive test that studies the structural and functional There is decreased perfusion of myocardial tissue and inadequate myocardial oxygen
changes of the heart with the use of ultrasound No special preparation is needed supply If 50% of the left coronary arterial lumen is reduced or 75% of the other coronary
artery, this becomes significant Potential for Thrombosis and embolism
S Stress Test- A non-invasive test that studies the heart during activity and detects and
evaluates CAD Exercise test, pharmacologic test and emotional test.Treadmill testing is Angina Pectoris
the most commonly used stress test. Used to determine CAD, Chest pain causes, drug Chest pain resulting from coronary atherosclerosis or myocardial ischemia
effects and dysrhythmias in exercise
Pre-test: consent may be required, adequate rest , eat a light meal or fast for 4 hours and Clinical Syndromes Three Common Types of ANGINA
avoid smoking, alcohol and caffeine 1. STABLE ANGINA The typical angina that occurs during exertion, relieved by rest and
Post-test: instruct client to notify the physician if any chest pain, dizziness or shortness drugs and the severity does not change
of breath . Instruct client to avoid taking a hot shower for 10-12 hours after the test 2. Unstable angina Occurs unpredictably during exertion and emotion, severity increases
with time and pain may not be relieved by rest and drug
Pharmacological stress test .Use of dipyridamole Maximally dilates coronary artery Side- 3. Variant angina Prinzmetal angina, results from coronary artery VASOSPASMS, may
effect: flushing of face occur at rest
Pre-test: 4 hours fasting, avoid alcohol, caffeine
Post test: report symptoms of chest pain ASSESSMENT FINDINGS 1. Chest pain- ANGINA The most characteristic symptom
PAIN is described as mild to severe retrosternal pain, squeezing, tightness or burning
CARDIAC catheterization sensation Radiates to the jaw and left arm
 HYPERTROPHIC CARDIOMYOPATHY Associated factors: 1. Genetic 2. Idiopathic
1. Chest pain- ANGINA Precipitated by Exercise, Eating heavy meals, Emotions like
excitement and anxiety and Extremes of temperature Relieved by REST and Pathophysiology Increased size of myocardium reduced ventricular volume
Nitroglycerin increased resistance to ventricular filling diastolic dysfunction
2. Diaphoresis 3. Nausea and vomiting 4. Cold clammy skin 5. Sense of apprehension
and doom 6. Dizziness and syncope RESTRICTIVE CARDIOMYOPATHY Associated factors 1. Infiltrative diseases like
AMYLOIDOSIS 2. Idiopathic
LABORATORY FINDINGS 1. ECG may show normal tracing if patient is pain-free.
Ischemic changes may show ST depression and T wave inversion 2. Cardiac Slide 112: RESTRICTIVE CARDIOMYOPATHY Pathophysiology Rigid ventricular
catheterization Provides the MOST DEFINITIVE source of diagnosis by showing the wall impaired stretch and diastolic filling decreased output Diastolic dysfunction
presence of the atherosclerotic lesions
Assessment findings 1. PND 2. Orthopnea 3. Edema 4. Chest pain 5. Palpitations 6.
NURSING MANAGEMENT 1. Administer prescribed medications Nitrates- to dilate the dizziness 7. Syncope with exertion
coronary arteries Aspirin- to prevent thrombus formation Beta-blockers- to reduce BP and
HR Calcium-channel blockers- to dilate coronary artery and reduce vasospasm Laboratory Findings 1. CXR- may reveal cardiomegaly 2. ECHOCARDIOGRAM 3.
2. Teach the patient management of anginal attacks Advise patient to stop all activities ECG 4. Myocardial Biopsy
Put one nitroglycerin tablet under the tongue Wait for 5 minutes If not relieved, take
another tablet and wait for 5 minutes Another tablet can be taken (third tablet) If Medical Management 1. Surgery 2. pacemaker insertion 3. Pharmacological drugs for
unrelieved after THREE tablets seek medical attention symptom relief
3. Obtain a 12-lead ECG
4. Promote myocardial perfusion Instruct patient to maintain bed rest Administer O2 @ 3 Nursing Management 1.Improve cardiac output Adequate rest Oxygen therapy Low
lpm Advise to avoid valsalva maneuvers Provide laxatives or high fiber diet to lessen sodium diet
constipation Encourage to avoid increased physical activities 2. Increase patient tolerance Schedule activities with rest periods in between
5. Assist in possible treatment modalities PTCA- percutaneous transluminal coronary 3. Reduce patient anxiety Support Offer information about transplantations Support
angioplasty To compress the plaque against the vessel wall, increasing the arterial lumen family in anticipatory grieving
CABG- coronary artery bypass graft To improve the blood flow to the myocardial tissue
6. Provide information to family members to minimize anxiety and promote family Infective endocarditis
cooperation Infection of the heart valves and the endothelial surface of the heart Can be acute or
7. Assist client to identify risk factors that can be modified chronic
8. Refer patient to proper agencies
Etiologic factors 1. Bacteria- Organism depends on several factors 2. Fungi
Myocardial infarction
Death of myocardial tissue in regions of the heart with abrupt interruption of coronary Risk factors 1. Prosthetic valves 2. Congenital malformation 3. Cardiomyopathy 4. IV
blood supply drug users 5. Valvular dysfunctions
ETIOLOGY and Risk factors 1. CAD 2. Coronary vasospasm 3. Coronary artery
occlusion by embolus and thrombus 4. Conditions that decrease perfusion- hemorrhage, Pathophysiology
shock Direct invasion of microbes microbes adhere to damaged valve surface and
proliferate damage attracts platelets causing clot formation erosion of valvular
Risk factors leaflets and vegetation can embolize
1. Hypercholesterolemia 2. Smoking 3. Hypertension 4. Obesity 5. Stress 6. Sedentary
lifestyle Assessment findings 1. Intermittent HIGH fever 2. anorexia, weight loss 3. cough, back
pain and joint pain 4. splinter hemorrhages under nails 5. Osler’s nodes- painful nodules
PATHOPHYSIOLOGY Interrupted coronary blood flow myocardial ischemia on fingerpads 6. Roth’s spots- pale hemorrhages in the retina
anaerobic myocardial metabolism for several hours myocardial death depressed 7. Heart murmurs 8. Heart failure
cardiac function triggers autonomic nervous system response further imbalance
of myocardial O2 demand and supply Prevention
Antibiotic prophylaxis if patient is undergoing procedures like dental extractions,
ASSESSMENT findings 1. CHEST PAIN Chest pain is described as severe, persistent, bronchoscopy, surgery, etc.
crushing substernal discomfort Radiates to the neck, arm, jaw and back
1. CHEST PAIN Occurs without cause, primarily early morning NOT relieved by rest or LABORATORY EXAM Blood Cultures to determine the exact organism
nitroglycerin Lasts 30 minutes or longer
2. Dyspnea 3. Diaphoresis 4. cold clammy skin 5. N/V 6. restlessness, sense of doom 7. Nursing management
tachycardia or bradycardia 8. hypotension 9. S3 and dysrhythmias 1. regular monitoring of temperature, heart sounds 2. manage infection 3. long-term
antibiotic therapy
Laboratory findings
1. ECG- the ST segment is ELEVATED. T wave inversion, presence of Q wave 2. Medical management 1. Pharmacotherapy IV antibiotic for 2-6 weeks Antifungal agents
Myocardial enzymes- elevated CK- MB, LDH and Troponin levels 3. CBC- may show are given – amphotericin B
elevated WBC count 4. Test after the acute stage- Exercise tolerance test, thallium scans, 2. Surgery Valvular replacement
cardiac catheterization
CHF
Nursing Interventions A syndrome of congestion of both pulmonary and systemic circulation caused by
1. Provide Oxygen at 2 lpm, Semi-fowler’s 2. Administer medications Morphine to inadequate cardiac function and inadequate cardiac output to meet the metabolic demands
relieve pain nitrates, thrombolytics, aspirin and anticoagulants Stool softener and of tissues.Inability of the heart to pump sufficiently The heart is unable to maintain
hypolipidemics 3. Minimize patient anxiety Provide information as to procedures and adequate circulation to meet the metabolic needs of the body Classified according to the
drug therapy 4. Provide adequate rest periods 5. Minimize metabolic demands Provide major ventricular dysfunction- Left or Right
soft diet Provide a low-sodium, low cholesterol and low fat diet 6. Minimize anxiety
Reassure client and provide information as needed 7. Assist in treatment modalities such Etiology of CHF 1. CAD 2. Valvular heart diseases 3. Hypertension 4. MI 5.
as PTCA and CABG 8. Monitor for complications of MI- especially dysrhythmias, since Cardiomyopathy 6. Lung diseases 7. Post-partum 8. Pericarditis and cardiac tamponade
ventricular tachycardia can happen in the first few hours after MI 9. Provide client
teaching PATHOPHYSIOLOGY LEFT Ventricular pump failure back up of blood into the
pulmonary veins increased pulmonary capillary pressure pulmonary congestion
Medical Management decreased cardiac output decreased perfusion to the brain, kidney and other
1. ANALGESIC The choice is MORPHINE It reduces pain and anxiety Relaxes tissues oliguria, dizziness
bronchioles to enhance oxygenation
2. ACE Prevents formation of angiotensin II Limits the area of infarction CHF PATHOPHYSIOLOGY RIGHT ventricular failure blood pooling in the venous
3. Thrombolytics Streptokinase, Alteplase Dissolve clots in the coronary artery allowing circulation increased hydrostatic pressure peripheral edema blood pooling
blood to flow venous congestion in the kidney, liver and GIT

NURSING INTERVENTIONS AFTER ACUTE EPISODE
1. Maintain bed rest for the first 3 days 2. Provide passive ROM exercises 3. Progress
with dangling of the feet at side of bed 4. Proceed with sitting out of bed, on the chair for
30 minutes TID 5. Proceed with ambulation in the room toilet hallway
TID.Cardiac rehabilitation To extend and improve quality of life Physical conditioning
Patients who are able to walk 3-4 mph are usually ready to resume sexual activities
CARDIOMYOPATHIES
Heart muscle disease associated with cardiac dysfunction
1. Dilated Cardiomyopathy 2. Hypertrophic Cardiomyopathy 3. Restrictive
cardiomyopathy
LEFT SIDED CHF ASSESSMENT FINDINGS 1. Dyspnea on exertion 2. PND 3.
Orthopnea 4. Pulmonary crackles/rales 5. cough with Pinkish, frothy sputum 6.
Tachycardia 7. Cool extremities 8. Cyanosis 9. decreased peripheral pulses 10. Fatigue
11. Oliguria 12. signs of cerebral anoxia
RIGHT SIDED CHF ASSESSMENT FINDINGS 1. Peripheral dependent, pitting edema
2. Weight gain 3. Distended neck vein 4. hepatomegaly 5. Ascites 6. Body weakness 7.
Anorexia, nausea 8. Pulsus alternans
Slide 147: CHF LABORATORY FINDINGS 1. CXR may reveal cardiomegaly 2. ECG
may identify Cardiac hypertrophy 3. Echocardiogram may show hypokinetic heart

ASSOCIATED FACTORS 1. Heavy alcohol intake 2. Pregnancy 3. Viral infection 4.
Idiopathic
PATHOPHYSIOLOGY Diminished contractile proteins poor contraction
decreased blood ejection increased blood remaining in the ventricle ventricular
stretching and dilatation. SYSTOLIC DYSFUNCTION
LABORATORY FINDINGS 4. ABG and Pulse oximetry may show decreased O2
saturation 5. PCWP is increased in LEFT sided CHF and CVP is increased in RIGHT
sided CHF
NURSING INTERVENTIONS 1. Assess patient's cardio- pulmonary status 2. Assess
VS, CVP and PCWP. Weigh patient daily to monitor fluid retention 3. Administer
medications- usually cardiac glycosides are given- DIGOXIN or DIGITOXIN, Diuretics,
vasodilators and hypolipidemics are prescribed 4. Provide a LOW sodium diet. Limit
fluid intake as necessary 5. Provide adequate rest periods to prevent fatigue6. Position on
semi-fowler’s to fowler’s for adequate chest expansion 7. Prevent complications of
immobility
CHF NURSING INTERVENTION AFTER THE ACUTE STAGE 1. Provide
opportunities for verbalization of feelings 2. Instruct the patient about the medication
regimen- digitalis, vasodilators and diuretics 3. Instruct to avoid OTC drugs, Stimulants,
smoking and alcohol 4. Provide a LOW fat and LOW sodium diet 5. Provide potassium
supplements 6. Instruct about fluid restriction 7. Provide adequate rest periods and
schedule activities 8. Monitor daily weight and report signs of fluid retention
RISK FACTORS • Atherosclerosis • Infection= syphilis • Connective tissue disorder •
Genetic disorder= Marfan’s Syndrome
PATHOPHYSIOLOGY Damage to the intima and media weakness outpouching
Dissecting aneurysm tear in the intima and media with dissection of blood through
the layers
ASSESSMENT • Asymptomatic • Pulsatile sensation on the abdomen • Palpable bruit
LABORATORY: • CT scan • Ultrasound • X-ray • Aortography

CARDIOGENIC SHOCK Medical Management: • Anti-hypertensives • Synthetic graft

Heart fails to pump adequately resulting to a decreased cardiac output and decreased
tissue perfusion ETIOLOGY 1. Massive MI 2. Severe CHF 3. Cardiomyopathy 4.
Cardiac trauma 5. Cardiac tamponade
ASSESSMENT FINDINGS 1. HYPOTENSION 2. oliguria (less than 30 ml/hour) 3.
tachycardia 4. narrow pulse pressure 5. weak peripheral pulses 6. cold clammy skin 7.
changes in sensorium/LOC 8. pulmonary congestion
LABORATORY FINDINGS Increased CVP Normal is 4-10 cmH2O
Nursing Management: • Administer medications • Emphasize the need to avoid increased
abdominal pressure • No deep abdominal palpation • Remind patient the need for serial
ultrasound to detect diameter changes
PERIPHERAL ARTERIAL OCCLUSIVE DISEASE
Refers to arterial insufficiency of the extremities usually secondary to peripheral
atherosclerosis. Usually found in males age 50 and above The legs are most often
affected

NURSING INTERVENTIONS 1. Place patient in a modified Trendelenburg (shock ) Risk factors for Peripheral Arterial occlusive disease
position 2. Administer IVF, vasopressors and inotropics such as DOPAMINE and Non-Modifiable 1. Age 2. gender 3. family predisposition
DOBUTAMINE 3. Administer O2 Modifiable 1. Smoking 2. HPN 3. Obesity 4. Sedentary lifestyle 5. DM 6. Stress
4. Morphine is administered to decreased pulmonary congestion and to relieve pain 5.
Assist in intubation, mechanical ventilation, PTCA, CABG, insertion of Swan-Ganz cath ASSESSMENT FINDINGS 1. INTERMITTENT CLAUDICATION- the hallmark of
and IABP 6. Monitor urinary output, BP and pulses 7. cautiously administer diuretics and PAOD This is PAIN described as aching, cramping or fatiguing discomfort consistently
nitrates reproduced with the same degree of exercise or activity
1. INTERMITTENT CLAUDICATION- This pain is RELIEVED by REST This
CARDIAC TAMPONADE commonly affects the muscle group below the arterial occlusion 2. Progressive pain on
A condition where the heart is unable to pump blood due to accumulation of fluid in the the extremity as the disease advances 3. Sensation of cold and numbness of the
pericardial sac (pericardial effusion).This condition restricts ventricular filling resulting extremities 4. Skin is pale when elevated and cyanotic/ruddy when placed on a dependent
to decreased cardiac output Acute tamponade may happen when there is a sudden position 5. Muscle atrophy, leg ulceration and gangrene
accumulation of more than 50 ml fluid in the pericardial sac
Diagnostic Findings 1. Unequal pulses between the extremities 2. Duplex
Causative factors 1. Cardiac trauma 2. Complication of Myocardial infarction 3. ultrasonography 3. Doppler flow studies
Pericarditis 4. Cancer metastasis
PAOD
ASSESSMENT FINDINGS 1. BECK’s Triad- Jugular vein distention, hypotension and Medical Management 1. Drug therapy Pentoxyfylline (Trental) reduces blood viscosity
distant/muffled heart sound 2. Pulsus paradoxus 3. Increased CVP 4. decreased cardiac and improves supply of O2 blood to muscles Cilostazol (Pletaal) inhibits platelet
output 5. Syncope 6. anxiety 7. dyspnea 8. Percussion- Flatness across the anterior chest aggregation and increases vasodilatation 2. Surgery- Bypass graft and anastomoses

Laboratory FINDINGS 1. Echocardiogram 2. Chest X-ray Nursing Interventions

1. Maintain Circulation to the extremity Evaluate regularly peripheral pulses,
NURSING INTERVENTIONS 1. Assist in PERICARDIOCENTESIS 2. Administer IVF temperature, sensation, motor function and capillary refill time Administer post-operative
3. Monitor ECG, urine output and BP 4. Monitor for recurrence of tamponade care to patient who underwent surgery
2. Monitor and manage complications Note for bleeding, hematoma, decreased urine
Pericardiocentesis Patient is monitored by ECG Maintain emergency equipments Elevate output Elevate the legs to diminish edema Encourage exercise of the extremity while on
head of bed 45-60 degrees Monitor for complications- coronary artery rupture, bed Teach patient to avoid leg-crossing
dysrhythmias, pleural laceration and myocardial trauma 3. Promote Home management Encourage lifestyle changes Instruct to AVOID smoking
Instruct to avoid leg crossing
HYPERTENSION
A systolic BP greater than 140 mmHg and a diastolic pressure greater than 90 mmHg BUERGER’S DISEASE
over a sustained period, based on two or more BP measurements.Types of Hypertension Thromboangiitis obliterans A disease characterized by recurring inflammation of the
1. Primary or ESSENTIAL Most common type 2. Secondary Due to other conditions like medium and small arteries and veins of the lower extremities Occurs in MEN ages 20-35
Pheochromocytoma, renovascular hypertension, Cushing’s, Conn’s , SIADH RISK FACTOR: SMOKING!

PATHOPHYSIOLOGY Multi-factorial etiology BP= CO (SV X HR) x TPR Any PATHOPHYSIOLOGY

increase in the above parameters will increase BP 1. Increased sympathetic activity 2. Cause is UNKNOWN Probably an Autoimmune disease Inflammation of the arteries
Increased absorption of Sodium, and water in the kidney thrombus formation occlusion of the vessels
3. Increased activity of the RAAS 4. Increased vasoconstriction of the peripheral vessels
5. insulin resistance ASSESSMENT FINDINGS 1. Leg PAIN Foot cramps in the arch (instep claudication)
after exercise Relieved by rest Aggravated by smoking, emotional disturbance and cold
ASSESSMENT FINDINGS 1. Headache 2. Visual changes 3. chest pain 4. dizziness 5. chilling 2. Digital rest pain not changed by activity or rest
N/V 3. Intense RUBOR (reddish-blue discoloration), progresses to CYANOSIS as disease
advances 4. Paresthesia
Risk factors for Cardiovascular Problems in Hypertensive patients Major Risk factors 1. Diagnostic Studies 1. Duplex ultrasonography 2. Contrast angiography
Smoking 2. Hyperlipidemia 3. DM 4. Age older than 60 5. Gender- Male and post
menopausal W 6. Family History Nursing Interventions
DIAGNOSTIC STUDIES 1. Health history and PE 2. Routine laboratory- urinalysis, 1. Assist in the medical and surgical management Bypass graft amputation 2. Strongly
ECG, lipid profile, BUN, serum creatinine , FBS 3. Other lab- CXR, creatinine clearance, advise to AVOID smoking 3. Manage complications appropriately
24-huour urine protein Post-operative care: after amputation Elevate stump for the FIRST 24 HOURS to
minimize edema and promote venous return Place patient on PRONE position after 24
MEDICAL MANAGEMENT 1. Lifestyle modification 2. Drug therapy 3. Diet therapy hours Assess skin for bleeding and hematoma Wrap the extremity with elastic bandage
Drug therapy Diuretics Beta blockers Calcium channel blockers ACE inhibitors A2
Receptor blockers Vasodilators Medical Management
1. Drug therapy Pentoxyfylline (Trental) reduces blood viscosity and improves supply of
NURSING INTERVENTIONS 1. Provide health teaching to patient Teach about the O2 blood to muscles Cilostazol (Pletaal) inhibits platelet aggregation and increases
disease process Elaborate on lifestyle changes Assist in meal planning to lose weight vasodilatation 2. Surgery- Bypass graft and anastomoses
1. Provide health teaching to the patient Provide list of LOW fat , LOW sodium diet of
less than 2-3 grams of Na/day Limit alcohol intake to 30 ml/day Regular aerobic exercise
Advise to completely Stop smoking
2. Provide information about anti- hypertensive drugs Instruct proper compliance and not RAYNAUD’S DISEASE
abrupt cessation of drugs even if pt becomes asymptomatic/ improved condition Instruct A form of intermittent arteriolar VASOCONSTRICTION that results in coldness, pain
to avoid over-the-counter drugs that may interfere with the current medication and pallor of the fingertips or toes Cause : UNKNOWN Most commonly affects
3.. Promote Home care management Instruct regular monitoring of BP Involve family WOMEN, 16- 40 years old
members in care Instruct regular follow-up 4. Manage hypertensive emergency and
urgency properly ASSESSMENT FINDINGS 1. Raynaud’s phenomenon A localized episode of
vasoconstriction of the small arteries of the hands and feet that causes color and
Vascular Diseases temperature changes. W-B-R Pallor- due to vasoconstriction, then Blue- due to pooling of
Deoxygenated blood Red- due to exaggerated reflow/hyperemia 2. tingling sensation 3.
ANEURYSM Burning pain on the hands and feet
Dilation involving an artery formed at a weak point in the vessel wall
ANEURYSM Saccular= when one side of the vessel is affected Fusiform= when the Medical management Drug therapy with the use of CALCIUM channel blockers To
entire segment becomes dilated prevent vasospasms
 Nursing Interventions 1. instruct patient to avoid situations that may be stressful 2. Pathophysiology Toxins cause a direct bone marrow depression acellualr bone
instruct to avoid exposure to cold and remain indoors when the climate is cold 3. instruct marrow decreased production of blood elements
to avoid all kinds of nicotine 4. instruct about safety. Careful handling of sharp objects
ASSESSMENT FINDINGS 1. fatigue 2. pallor 3. dyspnea 4. bruising
: Venous diseases 5. splenomegaly 6. retinal hemorrhages

VARICOSE VEINS LABORATORY FINDINGS 1. CBC- decreased blood cell numbers 2. Bone
THESE are dilated veins usually in the lower extremities marrow aspiration confirms the anemia- hypoplastic or acellular marrow replaced by fats

Predisposing Factors Pregnancy Medical Management 1. Bone marrow transplantation 2. Immunosupressant

Prolonged standing or sitting Constipation (for hemorrhoids) Incompetent venous valves drugs 3. Rarely, steroids 4. Blood transfusion

Pathophysiology Factors venous stasis increased hydrostatic pressure Nursing management 1. Assess for signs of bleeding and infection 2. Instruct to
edema avoid exposure to offending agents

Assessment findings Megaloblastic Anemias

Tortuous superficial veins on the legs Leg pain and Heaviness Dependent edema Anemias characterized by abnormally large RBC secondary to impaired DNA
synthesis due to deficiency of Folic acid and/or vitamin B12
Laboratory findings Venography Duplex scan pletysmography
Slide 263: Megaloblastic Anemias Folic Acid deficiency Causative factors 1.
Medical management Alcoholism 2. Mal-absorption 3. Diet deficient in uncooked vegetables
Pharmacological therapy Leg vein stripping Anti-embolic stockings Pathophysiology of Folic acid deficiency Decreased folic acid impaired
DNA synthesis in the bone marrow impaired RBC development, impaired nuclear
Nursing management 1. Advise patient to elevate the legs 2. Caution patient to avoid maturation but CYTOplasmic maturation continues large size
prolonged standing or sitting
3. Provide high-fiber foods to prevent constipation 4. Teach simple exercise to promote Megaloblastic Anemias Vitamin B12 deficiency Causative factors 1. Strict
venous return 5. Caution patient to avoid knee-length stockings and constrictive clothings vegetarian diet 2. Gastrointestinal malabsorption 3. Crohn's disease 4.
6. Apply anti-embolic stockings as directed 7. Avoid massage on the affected area gastrectomy

DVT- Deep Vein Thrombosis Megaloblastic Anemias Vitamin B12 deficiency Pernicious Anemia Due to the
Inflammation of the deep veins of the lower extremities and the pelvic veins The absence of intrinsic factor secreted by the parietal cells Intrinsic factor binds with
inflammation results to formation of blood clots in the area Vit. B12 to promote absorption

Predisposing factors Prolonged immobility Varicosities Traumatic procedures Assessment findings 1. weakness 2. fatigue 3. listless 4.
neurologic manifestations are present only in Vit. B12 deficiency
Complication PULMONARY thromboembolism Assessment findings Pernicious Anemia – Beefy, red, swollen tongue – Mild
diarrhea – Extreme pallor – Paresthesias in the extremities
Assessment findings Leg tenderness
Leg pain and edema Positive HOMAN’s SIGN Laboratory findings 1. Peripheral blood smear- shows giant RBCs, WBCs with giant
hypersegmented nuclei 2. Very high MCV 3. Schilling’s test 4. Intrinsic
Laboratory findings Venography Duplex scan factor antibody test
Medical management Antiplatelets Anticoagulants Vein stripping and grafting Anti-
embolic stockings Medical Management 1. Vitamin supplementation – Folic acid 1 mg daily 2.
Diet supplementation – Vegetarians should have vitamin intake 3. Lifetime monthly
Nursing management 1. Provide measures to avoid prolonged immobility Repositioning injection of IM Vit B12
Q2 Provide passive ROM Early ambulation
2. Provide skin care to prevent the complication of leg ulcers 3. Provide anti-embolic Nursing Management 1. Monitor patient 2. Provide assistance in ambulation
stockings 4. Administer anticoagulants as prescribed 5. Monitor for signs of pulmonary 3. Oral care for tongue sore 4. Explain the need for lifetime IM injection of vit
embolism B12

Blood disorders Hemolytic Anemia: Sickle Cell

Anemia Nutritional anemia Hemolytic anemia Aplastic anemia Sickle cell
anemia
A condition in which the hemoglobin concentration is lower than normal. Three broad
categories 1. Loss of RBC- occurs with bleeding 2. Decreased RBC production
3. Increased RBC destruction
Hypoproliferative Anemia Iron Deficiency Anemia –Results when the dietary intake
of iron is inadequate to produce hemoglobin
Etiologic Factors –1. Bleeding- the most common cause –2. Mal-absorption –3.
Malnutrition –4. Alcoholism
Pathophysiology –The body stores of iron decrease, leading to depletion of hemoglobin tachycardia, murmurs and cardiomegaly
synthesis
–The oxygen carrying capacity of hemoglobin is reduced tissue hypoxia
Assessment Findings
1. Pallor of the skin and mucous membrane 2. Weakness and fatigue 3.
General malaise 4. Pica
5. Brittle nails 6. Smooth and sore tongue 7. Angular cheilosis
Laboratory findings
1. CBC- Low levels of Hct, Hgb and RBC count 2. low serum iron, low ferritin
3. Bone marrow aspiration- MOST definitive
Medical management 1. Hematinics 2. Blood transfusion
Nursing Management
1. Provide iron rich-foods – Organ meats (liver) – Beans – Leafy green vegetables – temperature that may cause vasoconstriction 4. Monitor and prevent potential
Raisins and molasses
2. Administer iron Oral preparations tablets- Fe fumarate, sulfate and gluconate
Advise to take iron ONE hour before meals Take it with vitamin C Continue
taking it for several months
2. Administer iron Oral preparations- liquid It stains teeth Drink it with a
straw Stool may turn blackish- dark in color Advise to eat high-fiber diet to
counteract constipation
2. Administer iron IM preparation Administer DEEP IM using the Z- track
method Avoid vigorous rubbing Can cause local pain and staining
APLASTIC ANEMIA
Acondition characterized by decreased number of RBC as well as WBC and platelets
Asevere chronic incurable hemolytic anemia that results from heritance of the sickle
hemoglobin gene.
Causative factor –Genetic inheritance of the sickle gene- HbS gene
Slide 274: Hemolytic Anemia: Sickle Cell Pathophysiology Decreased O2, Cold,
Vasoconstriction can precipitate sickling process Factors cause defective
hemoglobin to acquire a rigid, crystal-like C-shaped configuration Sickled RBCs will
adhere to endothelium pile up and plug the vessels ischemia results pain,
swelling and fever
Assessment Findings 1. jaundice 2. enlarged skull and facial bones 3.
Primary sites of thrombotic occlusion: spleen, lungs and CNS Chest pain,
dyspnea
1. Sickle cell crises – Results from tissue hypoxia and necrosis 2. Acute chest
syndrome – Manifested by a rapidly falling hemoglobin level, tachycardia, fever and
chest infiltrates in the CXR
Medical Management 1. Bone marrow transplant 2. Hydroxyurea –Increases the
HbF 3. Long term RBC trnasfusion
Nursing Management 1. manage the pain –Support and elevate acutely inflamed joint
–Relaxation techniques –analgesics 2. Prevent and manage infection –Monitor status
of patient –Initiate prompt antibiotic therapy
3. Promote coping skills –Provide accurate information –Allow patient to verbalize
her concerns about medication, prognosis and future pregnancy 4. Monitor and
prevent potential complications –Provide always adequate hydration –Avoid cold,
complications –Leg ulcer Aseptic technique 4. Monitor and prevent potential
complications –Priapism Sudden painful erection Instruct patient to empty
bladder, then take a warm bath
Polycythemia
Refers to an INCREASE volume of RBCs The hematocrit is ELEVATED to more
than 55% Clasified as Primary or Secondary
POLYCYTHEMIA VERA –Primary Polycythemia –A proliferative disorder in
which the myeloid stem cells become uncontrolled
POLYCYTHEMIA VERA Causative factor –unknown

CAUSATIVE FACTORS 1. Environmental toxins- pesticides, benzene 2. POLYCYTHEMIA VERA Pathophysiology –The stem cells grow uncontrollably
Certain drugs- Chemotherapeutic agents, chloramphenicol, phenothiazines, Sulfonamides –The bone marrow becomes HYPERcellular and all the blood cells are increased in
3. Heavy metals 4. Radiation number
–The spleen resumes its function of hematopoiesis and enlarges –Blood becomes thick
and viscous causing sluggish circulation
–Overtime, the bone marrow becomes fibrotic

Assessment findings –1. Skin is ruddy –2. Splenomegaly –3. headache –4. dizziness,
blurred vision –5. Angina, dyspnea and thrombophlebitis
Laboratory findings –1. CBC- shows elevated RBC mass –2. Normal oxygen saturation –
3 Elevated WBC and Platelets

Complications –1. Increased risk for thrombophlebitis, CVA and MI –2. Bleeding due to
dysfunctional blood cells

Medical Management –1. To reduce the high blood cell mass- PHLEBOTOMY –2.
Allopurinol –3. Dipyridamole –4. Chemotherapy to suppress bone marrow

Polycythemia Nursing Management – 1. Primary role of the nurse is EDUCATOR –

2. Regularly asses for the development of complications – 3. Assist in weekly
phlebotomy – 4. Advise to avoid alcohol and aspirin – 5. Advise tepid sponge bath or
cool water to manage pruritus

Leukemia
Malignant disorders of blood forming cells characterized by UNCONTROLLED
proliferation of WHITE BLOOD CELLS in the bone marrow- replacing marrow
elements . The WBC can also proliferate in the liver, spleen and lymph nodes.
Theleukemias are named after the specific lines of blood cells afffected primarily –
Myeloid – Lymphoid – Monocytic The leukemias are named also according to the
maturation of cells ACUTE – The cells are primarily immature CHRONIC –
The cells are primarily mature or diferentiated ACUTE myelocytic leukemia
ACUTE lymphocytic leukemia CHRONIC myelocytic leukemia CHRONIC
lymphocytic leukemia

ETIOLOGIC FACTORS – UNKNOWM – Probably exposure to radiation – Chemical

agents – Infectious agents – Genetic

PATHOPHYSIOLOGY of ACUTE Leukemia Uncontrolled proliferation of immature

cells suppresses bone marrow function severe anemia, thrombocytopenia and
granulocytopenia

PATHOPHYSIOLOGY of CHRONIC Leukemia Uncontrolled proliferation of

DIFFERENTIATED cells slow suppression of bone marrow function milder
symptoms

Slide 304: Leukemia ASSESSMENT FINDINGS ACUTE LEUKEMIA – Pallor

– Fatigue – Dyspnea – Hemorrhages – Organomegaly – Headache – vomiting

ASSESSMENT FINDINGS CHRONIC LEUKEMIA – Less severe symptoms –

organomegaly

LABORATORY FINDINGS Peripheral WBC count varies widely Bone marrow

aspiration biopsy reveals a large percentage of immature cells- BLASTS
Erythrocytes and platelets are decreased
Medical Management 2. Chemotherapy 3. Bone marrow transplantation

Nursing Management 1. Manage AND prevent infection – Monitor temperature –

Assess for signs of infection – Be alert if the neutrophil count drops below 1,000
cells/mm3
2. Maintain skin integrity 3. Provide pain relief 4. Provide information as to therapy-
chemo and bone marrow transplantation