Cardiovascular Conditions

Coronary Artery Diseases

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 Non Modifiable Risk Factors

Age

Gender
Family History

Modifiable Risk Factors

Smoking Obesity

Stress
Elevated cholesterol Hypertension
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Angina Pectoris

 Pain in the chest from coronary insufficiency, in the absence of myocardial infarction

 Types: Stable
Predictable pattern 4 Es
Relieved by rest

Unstable ("pre-infarction", "crescendo", "acute coronary insufficiency")

Attacks accelerate in frequency intensity and duration Relieved by NTG

Leads to MI

Prinzmetal's ("variant")
is primarily attributable to vasospasm

Typical Anginal Pain Provocative- Pain is caused by activity/relieved by rest / NTG Quality - heavy crushing dull Region - Over sternum, epigastric area, jaw, back shoulder Severity -mild to severe Timing -usually related to activity/stress lasts 1-5 mins

 Other signs and symptoms:

Pain Pallor Diaphoresis Faintness Palpitations

Collaborative Management
Nitroglycerin (drug of choice)

Anticipate postural hypotension

Take maximum of 3 doses at 5 min interval SL route has burning or stinging sensation

has onset of 1-2 min, duration of 30 min

Sips of H2O improves absorption Avoid alcohol Advise client to carry 3 tabs Store in a cool, dry, dark place; replace stock q 6 months Observe for side effects Nitropatch applied OD in AM, rotating sites Evaluate effectiveness

 B-adrenergic blocking agents propanolol, metoprolol, etc Ca-channel blocker verapamil, nifedipine, diltiazem Platelet-aggregating inhibitors ASA, dypiridamole, ticlopidine Anticoagulants heparin Na, Warfarin Na (Coumadin), dicumarol

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 Surgeries
Percutaneous Transluminal Coronary Angioplasty (PTCA)
Compresses the plaque by using balloon tipped catheter under fluoroscopic guidance. Ideal in single vessel coronary artery disease Intravascular Stenting - done to prevent restenosis after PTCA

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 Coronary Artery Bypass Graft (CABG)

Reduce angina and improve activity tolerance Recommended for severe or multivessel involvement Main purpose is myocardial revascularization Common source of graft are saphenous vein and internal mammary artery

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Nursing Interventions
Administer, as ordered:
Oxygen Nitroglycerine

Rest Diet
Low fat, low Na, low cholesterol diet Avoid saturated fats Read food labels

Activity restriction within patients limitation

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Myocardial Infarction

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 ischemic myocardial cell necrosis Caused by coronary artery obstruction due to:
progressive development of atherosclerosis coronary artery spasm Embolism

Occlusion leads to anaerobic glycolysis

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Manifestations
Provocative
Quality Region Severity

Timing

-No relation to activity -No relief from rest / NTG -Heavy crushing dull -Over sternum, epigastric area, jaw, back, shoulder -Mild to severe often includes feeling of doom, nausea and vomiting , diaphoresis -Lasts more >15mins
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 Other signs and symptoms:

Dsypnea Changes in heart rate Nausea and vomiting Increased WBC and ESR

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Diagnostic Studies
Enzymes: Troponin elevates in 30 minutes CPK-MB elevates in 2 to 4 hours AST peaks in 24 to 36 hours LDH peaks in 48 to 72 hours.

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ECG changes:
ST elevation = myocardial injury ST depression = ischemia T wave inversion = myocardial ischemia large Q waves = necrosis

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"O BATMAN!": O - xygen B - eta blocker A anti-thrombotics (ASA etc.) T - hrombolytics (streptokinase etc) M - orphine A CE inhibitors N - itroglycerin
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Collaborative Management

Nursing Interventions
Administer, as ordered: Morphine sulfate Oxygen IVF to run KVO CBR Monitor: vital signs every 1 to 2 hours. cardiac rhythm for dsyrhythmias signs of congestive heart failure

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Congestive Heart Failure

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 Is the inability of the heart to maintain an adequate output of blood from one or more ventricles results to an inadequate supply of blood to the vital parts of the body

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TYPES OF CHF
LEFT-SIDED CHF
usually pulmonary by nature

RIGHT SIDED CHF

affects the periphery in general

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PATHWAY OF BLOOD OXYGENATION IN THE HEART

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CAUSES
Coronary Artery Disease Faulty Heart Valves Cardiomyopathy Congenital Heart Defects Heart Arrythmias Kidney Failure Hypertension (or related increase in BV)

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SIGNS AND SYMPTOMS

Fatigue and weakness
DOE

Persistent wheezing or cough with white or pink blood-tinged phlegm Pronounced neck veins
Peripheral edema
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 Ascites

Rapid weight gain (fluid retention)

Anorexia, N/V

Lightheadedness, dizzy spells or fainting spells Difficulty concentrating or decreased alertness

Irregular or rapid heartbeat
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Diagnostic Procedures
Chest X-ray ECG Echocardiogram Coronary Catheterization Blood Test

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MANAGEMENT
Digitalis Therapy The major therapy for CHF (+) inotropic, (-) chronotropic effects, (-)dromotropic effects

Nsg. Implication: check for HR below 60 and above 120

Monitor serum potassium (Normal 3.5-5.5 mEq/L) Examples: Lanoxin (Digoxin), Crystodigin (Digitoxin), Lanatoside (Cedilanid C), Deslanoside (Cedilanid D)

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Beware of Digitalis Toxicity!!!

G.I. Manifestations: Anorexia, N & V

Bradycardia
Dysrythmias (most dangerous) Yellow / green visions; halos around the light (elderly) In males: gynecomastia, decreased libido and impotence

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DIURETIC THERAPY
To decrease cardiac workload by reducing circulating BV Nsg. Implications: Assess for s/sx of hypokalemia when giving thiazides and loop diuretics Give potassium supplements Best given early AM or early PM

If thiazides are ineffective, a potassium sparing diuretic may be given.

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 1.

Examples of Diuretics: Thiazides

Chlorthiazide (Diuril)
Hyrochlorthiazide (Esixdrix Hyrdodiuril) Furosemide (Lasix) Bumetamide (Burmex) Spironolactone (Aldactone) Triamterene (Dyrenium)

2.

Loop Diuretics

3.

Potassim-sparing

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VASODILATORS
Decreases resistance to ventricular emptying, thereby decreasing afterload. Most commonly used as follows: 1. Nitroprusside (Nipride) 2. Hydralazine (Apresoline) 3. Nifedipine (a Calcium-channel blocker with vasodilator effect) 4. Captopril (an antihypertensive agent with vasodilator effect)
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Teaching Plan Diet:

Sodium-restricted Limit fats and cholesterol Limit alcohol and fluids

Stop smoking

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 Priority NDx Decreased cardiac output Fluid volume excess Activity intolerance

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NURSING MANAGEMENT
Provide oxygenation Promote rest and activity Decrease anxiety Facilitate fluid balance Provide skin care Promote nutrition Promote elimination Facilitate learning

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VASCULAR CONDITIONS
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Hypertension

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 Persistent elevation of the arterial blood pressure CO x TPR

May be:
systolic

diastolic
both pressures A sustained pressure = hypertension:
systolic = 140 mmHg diastolic = 90 mmHg

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Types
Primary / Essential / Idiopathic

unknown etiology
Predisposing factors Heredity

Age
Stress Secondary / Non-essential Secondary to other diseases Alcoholism Prolonged use of oral contraceptives

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 Hypertensive crisis sudden elevation in blood pressure life threatening Isolated systolic hypertension an elevation in systole only (>140 mmHg) affects elderly persons

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Alcohol Stress

P ills Obesity

DM

Cigarette Smoking

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 Diet and weight reduction

Restricted sodium
Low cholesterol

Collaborative Management

Lifestyle changes
alcohol moderation exercise regimen cessation of smoking

Antihypertensive drug therapy

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Nursing Interventions
Record baseline BP in 3 positions (lying, sitting, standing) and in both arms Continuously assess BP and report any erratic change Administer antihypertensive agents as ordered
monitor closely and assess for S/E

Monitor I & O

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 Client teaching and discharge planning:

risk factors dietary instructions compliance of antihypertensive medications routine follow up physician

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 Report symptoms of complications:

Visual disturbances Decreased urine output Chest pains Weakness or paresthesia

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Aneurysm

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 Outpouching of blood vessel wall Types:

fusiform - involving all three layers of the vessel wall Saccular one side only

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Etiology and Incidence

Commonly affected: Aorta Men, 50-70 May be caused by:

Arteriosclerosis
Syphilis

Hypertension
Infection Trauma to the BV
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Manifestations
Often asymptomatic Deep, diffuse chest pain Hoarseness Dysphagia

Dyspnea
Pallor Rupture = hemorrhage

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Diagnostic Test
Aortography - exact location X-rays
chest film abnormal widening of aorta abdominal film - calcification within walls of aneurysm

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Collaborative Management
Hypertension control Surgery
resection of the aneurysm and replacement with a Teflon/Dacron graft

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Nursing Interventions
Prepare for surgery and implement postop care Watch out for signs of shock Advise client to prevent increased IAP

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Raynauds Disease Raynauds Phenomenon

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 Characterized by intermittent arteriospasm with resultant ischemia in the extremities

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Etiology and Incidence

Commonly affects digits of the hands Women, 18 and 40 Risk factor: Chemical pollutants Cold environment Cigarette smoking Emotional stress

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 Raynauds disease Unknown cause

Hereditary
2 years history Raynauds phenomenon

secondary to other disorders:

Occlusive arterial diseases Connective tissue diseases

Primary pulmonary hypertension

Hypothyroidism Neurologic diseases

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Manifestations
Pain (secondary to ischemia) Paresthesia Coldness Tingling in one or more digits Intermittent color changes (pallor, cyanosis) Small ulcerations Gangrene tips of digits

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Nursing Interventions
Client teaching
importance of stopping smoking need to maintain warmth Protection of the hands (gloves)

Administer vasodilators as ordered

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Thromboangitiis Obliterans
(Buergers Disease)

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 Characterized by inflammatory changes in both arteries and veins resulting in destruction of small and medium vessels Usually affects the lower extremities

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Etiology and Incidence

Exact cause: Unknown Men ages 25-40 Cigarette smoking (> 20 sticks/day)

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Manifestations
Intermittent claudication Sensitivity to cold (skin may at first be white, changing to blue then red) Pulselessness Ulceration and gangrene (advanced)

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 Drugs:

Collaborative Management

Vasodilators - improve arterial circulation

Analgesics - relieve ischemic pain Anticoagulants - prevent thrombus formation Lipid reducing drug: cholestyramine, colestipol HCl, lovastatin (Mevacor), atorvastatin

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 Surgery
bypass grafting balloon catheter dilation amputation (if necessary)

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Nursing Interventions
Health teachings
stop smoking Maintaining warmth

Administer medications, as ordered. Prepare for surgery, if indicated.

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Venous Thrombosis
(Thrombophlebitis)

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 Refers to inflammation of a vein Precipitated by a thrombus formation Commonly occurs in the veins of the extremities: Saphenous Femoral Popliteal

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Types
Deep vein thrombosis (DVT)
A stationary clot in deeper veins of the legs

Superficial thrombophlebitis
inflammation of a vein closer to the surface accompanied by formation of a stationary clot within the vein

Phlebitis
inflammation of one or more veins without resultant clot formation.
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Risk factors: Obesity CHF Immobility MI Pregnancy

Oral contraceptives
Trauma Sepsis Cigarette smoking Dehydration Severe anemias Complication of surgery

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Manifestations
Pain in the affected extremity

Superficial vein
Tenderness Redness Induration along course of the vein

Deep vein
Swelling
Venous distension of limb (+) Homans sign
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 DVT and phlebitis may result in pulmonary embolism (when clot break off)
Sudden chest pain Dyspnea Decreased blood oxygen (Po2) Agitation Cyanosis Tachycardia

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Collaborative Management
Anticoagulants: Heparin blocks conversion of prothrombin to thrombin and reduces formation of thrombus Prolongs PTT Warfarin (coumadin) blocks prothrombin synthesis by interfering with vitamin K synthesis Prolongs PT

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Nursing Interventions
Deep Vein Thrombosis Assess respiratory and circulatory functions Admister medications, as prescribed: Anticoagulant therapy Thrombolytic therapy Avoid manipulation (eg, massage) Elevate the extremity Observe the extremity for edema

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Superficial thrombophlebitis Apply warm compresses over the affected site. Elevate the extremity. Administer anti-inflammatory agents, as prescribed.

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Superficial thrombophlebitis Apply warm compresses over the affected site. Elevate the extremity. Administer anti-inflammatory agents, as prescribed.

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 Health Teaching Avoid: Standing & sitting for long periods constrictive clothing Crossing legs at the knees Smoking Oral contraceptives Importance of adequate hydration Use of elastic stockings when ambulatory

Importance of: planned rest with elevation of feet weight reduction and exercise

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PERICARDITIS

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 Refers to inflammation of the pericardium. It may be acute, chronic, or constrictive:

a. Acute
fibrous exudate usually self-limiting.

b. Chronic
increase in inflammatory exudate that continues beyond an anticipated period of time

c. Constrictive
a. scar tissue that forms between the visceral and parietal layers of pericardium

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Manifestations
Acute Chest pain
worsens with deep breathing, coughing, swallowing, and changing position

Fever Malaise Flu like symptoms Chronic pericarditis Established by routine chest film.

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Constrictive pericarditis fibrous scarring and calcification (encases the heart) Pericardial effusion Complication:
Cardiac tamponade - compression that results from an excessive accumulation of fluid or blood in the pericardial space.
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Nursing Interventions
Prepare the patient for diagnostic procedures

Administer, ordered:
Antibiotic

Anti-inflammatory
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 Monitor vital signs frequently. Provide support and reassurance. Provide patient teaching covering:
Disease process Causative factors Preventive measures

Prepare the patient in severe cardiac tamponade for pericardiocentesis

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 INFECTIVE ENDOCARDITIS

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 Refers to inflammation or infection of the pericardium or the heart valves. Classifications:

Acute - affects persons with normal hearts. Subacute affects persons with damaged hearts.

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Etiology
Acute - hematogenous
Staphylococcus aureus B-hemolytic Streptococcus

Subacute
Streptococcus viridans non hemolytic and microaerophilic streptococci
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Manifestations
Valve with damage (due to colonization)

Microbes that are in the blood adhere to the area then proliferate.
Initial damage to the valves (also known as endothelium) exposes the basement membrane
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Attracts platelets; causes clot formation

Sloughing of disease, with erosion of valve leaflets or myocardial damage Congestive heart failure
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1. Other Manifestations:
Sudden fever Septicemia Valvular insufficiency Heart failure Stroke

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Overview of nursing interventions

1. Institute appropriate testing to identify the pathogen, as ordered. 1. Minimize the organisms effect:
antibiotic therapy, as prescribed, for 4 to 6 weeks. broad-spectrum antibiotic therapy, as ordered, while awaiting bacteriologic confirmation (eg, intravenous high-dose penicillin with gentamycin, streptomycin, or vancomycin).
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1. Provide supportive therapy to prevent and manage heart failure. 2. Prepare the patient for valve replacement surgery if medical intervention fails. 3. Prevent the disease by administering antibiotics prophylactically before the patient undergoes any procedure that may cause bacteremia.

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MYOCARDITIS
Focal or diffuse inflammation of the myocardium; may be viral (most common) or bacterial (rare).

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Etiology
Viral myocarditis may be caused by coxsackie virus. Bacterial myocarditis is associated with rheumatic fever and the diphtheria toxin. Other causes include hypersensitivity reactions, autoimmune responses, chemical and physical agents, and radiation therapy.
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Pathophysiologic processes and manifestations:

1. Myocarditis can be asymptomatic or can produce symptoms of heart failure. 2. Manifestations of viral myocarditis may include: a. Tachycardia b. Dyspnea c. Low grade fever d. Malaise e. History of upper respiratory infection

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1.In young adults, sudden death has occurred; in adults, viral myocarditis is likely to be benign and self-limiting.
1.Laboratory analysis reveals leukocytosis and elevated ALT, AST and LDH.

1.Manifestation of right and left heart failure can occur with advanced disease.
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Nursing Interventions
1. 1. Obtain viral antigen detection or serologic testing, as ordered, to aid in diagnosis. 2. 2. Prepare the patient for myocardial biopsy, which may also aid diagnosis. 3. 3. Administer appropriate antibiotics for bacterial myocarditis, as ordered. 4. 4. Institute measures to decrease cardiac workload, such as bed rest.

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1.

A. For the patient with heart failure: a. 1. Administer digitalis, diuretics, and oxygen therapy, as ordered. b. 2. Restrict sodium. c. 3. Encourage activities that improve oxygen supply and decrease oxygen demand. 2. B. Administer antiarrthymics, with caution, for dysrhythmias; administer anticoagulants for thromboembolic events, as prescribed. 3. C. Use immunosuppressive therapy, as prescribed, to resolve inflammation.
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