Cardio Nursing- Course Audit 2[1]

transcript

Cardiovascular Cardiovascular SystemSystem

By:By:

Ms. Irene M. MagbanuaMs. Irene M. Magbanua

FOUR STAGES OF LIFEFOUR STAGES OF LIFE

CARDIOVASCULAR SYSTEMCARDIOVASCULAR SYSTEM

IMPORTANT FUNCTION:IMPORTANT FUNCTION:

- provide oxygen in every - provide oxygen in every tissue in the body which tissue in the body which is essential in performing is essential in performing its functionits function

CONSISTS of:CONSISTS of: HEARTHEART BLOOD VESSELBLOOD VESSEL BLOODBLOOD

HEARTHEART Hollow, muscularHollow, muscular 4-chambered 4-chambered Located in middle of thoracic cavity Located in middle of thoracic cavity

between lungs in space called between lungs in space called mediastinummediastinum ( ( The space between the The space between the lungs, which includes the heart, lungs, which includes the heart, pericardium, aorta and vena cava)pericardium, aorta and vena cava)

“ “Inverted cone”Inverted cone”

The Cardiovascular SystemThe Cardiovascular System

HEARTHEART

Normal Anatomy: MicroscopicNormal Anatomy: Microscopic Consists of Three layers- epicardium, Consists of Three layers- epicardium,

myocardium and endocardiummyocardium and endocardium

The The epicardiumepicardium covers the outer surface covers the outer surface of the heartof the heart

The The myocardiummyocardium is the middle muscular is the middle muscular layer of the heartlayer of the heart

The The endocardiumendocardium lines the chambers and lines the chambers and the valvesthe valves

The layer that covers the heart is the The layer that covers the heart is the PERICARDIUMPERICARDIUM

There are two parts- There are two parts- parietal and visceral parietal and visceral pericardiumpericardium

The space between the two pericardial The space between the two pericardial layers is the layers is the pericardial spacepericardial space

PERICARDIAL EFFUSIONPERICARDIAL EFFUSION

Normal Anatomy: GrossNormal Anatomy: Gross The heart is located in the LEFT side of The heart is located in the LEFT side of

the mediastinumthe mediastinum

The heart chambers are guarded by The heart chambers are guarded by valvesvalves

The Atrio-ventricular valves-The Atrio-ventricular valves-

The Semilunar valves-The Semilunar valves-

BLOOD VESSELSBLOOD VESSELS

Great vessels: Great vessels: large large veins and arteries veins and arteries leading directly to leading directly to and away from and away from heartheart SUPERIOR VENA CAVA AND SUPERIOR VENA CAVA AND

INFERIOR VENA CAVAINFERIOR VENA CAVA PULMONARY ARTERYPULMONARY ARTERY PULMONARY VEINPULMONARY VEIN AORTAAORTA

LAUGH BREAKLAUGH BREAK

BOY: Isang babaeng siopao nga!BOY: Isang babaeng siopao nga!

LEA: Babaeng siopao?LEA: Babaeng siopao?

BOY: Oo, yung may saping papel, may BOY: Oo, yung may saping papel, may napkin!napkin!

LEA: Ah ganun ba? Mayrun kaming siopao LEA: Ah ganun ba? Mayrun kaming siopao na badingna bading

BOY: Bading na siopao?BOY: Bading na siopao?

LEA: May sapin din, pero may itlog sa loob!LEA: May sapin din, pero may itlog sa loob!

AMO: Day, gamitin mo sa pader itong AMO: Day, gamitin mo sa pader itong chalk pamatay ng ipis.chalk pamatay ng ipis.MAID: Yis ati!MAID: Yis ati!NEXT DAYNEXT DAY... nagulat ang amo, nakasulat sa pader:... nagulat ang amo, nakasulat sa pader:EPES MAMATAY KAYUNG LAHAT! EPES MAMATAY KAYUNG LAHAT! SYET! PAKYO!SYET! PAKYO!

PASYENTE: Dok bakit pag tuwing PASYENTE: Dok bakit pag tuwing umiinm ako ng alak sumasakit ang tyan umiinm ako ng alak sumasakit ang tyan ko? Pero pag libre, di naman?ko? Pero pag libre, di naman?

DKTOR: Normal yan, manipis kasi atay DKTOR: Normal yan, manipis kasi atay mo. Tapos makapal mukha mo!mo. Tapos makapal mukha mo!

BUS HINOLDAP!BUS HINOLDAP!Holdaper: Re-reypin ko lahat ng babae Holdaper: Re-reypin ko lahat ng babae dito!dito!

Prosti: Ako na lang po, maawa kayo sa Prosti: Ako na lang po, maawa kayo sa iba..iba..

Lola: Sinabi na ngang LAHAT eh! Lola: Sinabi na ngang LAHAT eh! Sasagot pa!Sasagot pa!

CORONARY ARTERIESCORONARY ARTERIES

The Blood supply of The Blood supply of the heart comes the heart comes from the Coronary from the Coronary arteriesarteries

1.1. Right coronary Right coronary artery artery

2.2. Left coronary Left coronary arteryartery

CardiophysiologyCardiophysiology

Conduction systemConduction system Cardiac (heart) soundsCardiac (heart) sounds Heart rate and Blood pressureHeart rate and Blood pressure Cardiac cycleCardiac cycle

CHARACTERISTICS OF THE CHARACTERISTICS OF THE CARDIAC MUSCLECARDIAC MUSCLE

Inherent abilities of cardiac muscle cells: Inherent abilities of cardiac muscle cells: AutomaticityAutomaticity Conductivity Conductivity ExcitabilityExcitability RefractorinessRefractoriness

The CONDUCTING SYSTEM OF THE The CONDUCTING SYSTEM OF THE HEARTHEART

Consists of theConsists of the 1. 1. SA node- SA node- the pacemakerthe pacemaker 2. 2. AV node-AV node- slowest conduction slowest conduction 3. 3. Bundle of His – Bundle of His – branches into the branches into the

Right and the Left bundle branchRight and the Left bundle branch 4. 4. Purkinje fibers-Purkinje fibers- fastest conduction fastest conduction

HONEYMOON:HONEYMOON:

Wife: Hon wag mo ako bibiglain ha? Wife: Hon wag mo ako bibiglain ha? I'm still a virginI'm still a virginHusband: You mean ako ang una?Husband: You mean ako ang una?Wife: Yes, do it na please!Wife: Yes, do it na please!Husband: I did it na, kanina pa!!Husband: I did it na, kanina pa!!Wife: Ah ganon ba? Aray pala, shit!!! Wife: Ah ganon ba? Aray pala, shit!!!

Heart rateHeart rate Normal range is 60-100 beats per minuteNormal range is 60-100 beats per minute Tachycardia is greater than 100 bpmTachycardia is greater than 100 bpm Bradycardia is less than 60 bpmBradycardia is less than 60 bpm Sympathetic system INCREASES HRSympathetic system INCREASES HR Parasympathetic system (Vagus) Parasympathetic system (Vagus)

DECREASES HRDECREASES HR

The Heart: PhysiologyThe Heart: Physiology

The amount of blood the heart pumps The amount of blood the heart pumps out in each beat is called the out in each beat is called the STROKE STROKE VOLUMEVOLUME

When this volume is multiplied by the When this volume is multiplied by the number of heart beat in a minute (heart number of heart beat in a minute (heart rate), it becomes the rate), it becomes the CARDIAC CARDIAC OUTPUTOUTPUT

When the Cardiac Output is multiplied When the Cardiac Output is multiplied by the Total Peripheral Resistance, it by the Total Peripheral Resistance, it becomes the becomes the BLOOD PRESSURE BLOOD PRESSURE

Blood pressure is: Blood pressure is: Cardiac output X peripheral Cardiac output X peripheral

resistanceresistance

Cardiac Output RegulationCardiac Output Regulation

The heart pumps approximately The heart pumps approximately 5 L of 5 L of blood every minuteblood every minute

The heart rate increases with exercise; The heart rate increases with exercise; therefore cardiac output increasestherefore cardiac output increases

The cardiac output will vary according to The cardiac output will vary according to the amount of venous return.the amount of venous return.

Blood pressureBlood pressure Control is neural (central and Control is neural (central and

peripheral) and hormonalperipheral) and hormonal Baroreceptors in the carotid and aortaBaroreceptors in the carotid and aorta Hormones- ADH, Adrenergic Hormones- ADH, Adrenergic

hormones, Aldosterone and ANFhormones, Aldosterone and ANF

Blood pressureBlood pressure Hormones-Hormones- ADH, Adrenergic hormones, ADH, Adrenergic hormones,

Aldosterone and ANFAldosterone and ANF ADHADH increases water retention increases water retention Aldosterone Aldosterone increases sodium retention increases sodium retention

and water retention secondarilyand water retention secondarily Epinephrine and NE Epinephrine and NE increase HR and BPincrease HR and BP ANF=ANF= causes sodium excretion causes sodium excretion

Bakla at Macho nagkasabay sa CR...Bakla at Macho nagkasabay sa CR... Bakla: Ang laki naman nyan sayo...Bakla: Ang laki naman nyan sayo... Macho: Wala na tong silbi kasi iniwan Macho: Wala na tong silbi kasi iniwan

na ako ng GF ko... puputulin ko nana ako ng GF ko... puputulin ko nalang at ipapakain ko sa aso!lang at ipapakain ko sa aso!

Bakla: aw! aw! aw!Bakla: aw! aw! aw!

The Heart: PhysiologyThe Heart: Physiology

The The PRELOADPRELOAD is the degree of is the degree of stretching of the heart muscle stretching of the heart muscle when it is filled-up with bloodwhen it is filled-up with blood

The The AFTERLOADAFTERLOAD is the resistance is the resistance to which the heart must pump to to which the heart must pump to eject the bloodeject the blood

Anatomy & PhysiologyAnatomy & PhysiologyTerminologyChronotropic

effect

Dromotropic effect

Inotropic effect

Refers to a change in heart rate A positive chronotropic effect refers to an

increase in heart rate A negative chronotropic effect refers to a

decrease in heart rate Refers to a change in the speed of conduction

through the AV junction A positive dromotropic effect results in an

increase in AV conduction velocity A negative dromotropic effect results in a

decrease in AV conduction velocity Refers to a change in myocardial contractility A postive inotropic effect results in an

increase in myocardial contractility A negative inotropic effect results in a

decrease in myocardial contractility

PATIENT: Nurse bakit TAE ko may PATIENT: Nurse bakit TAE ko may kasamang plema?kasamang plema?

NURSE: Ok lang yan! Mas delikado kung NURSE: Ok lang yan! Mas delikado kung pag singa mo may kasamang TAE!pag singa mo may kasamang TAE!

Factors regulating Stroke Factors regulating Stroke VolumeVolume

1. Degree of stretch of the cardiac muscle 1. Degree of stretch of the cardiac muscle before contraction before contraction (Starling’s Law); (Starling’s Law); determined by the volume of blood in the determined by the volume of blood in the ventricle at the end of diastole or diastolic ventricle at the end of diastole or diastolic filling.filling.

2. 2. Contactility: Contactility: ability of the myocardium ability of the myocardium to contract; contractility is increased by to contract; contractility is increased by circulating catecholamines and circulating catecholamines and medications like digitalismedications like digitalis

3. 3. Preload :Preload : the filling of the ventricles at the filling of the ventricles at the end of diastole. The more the the end of diastole. The more the ventricles fill, the more the cardiac ventricles fill, the more the cardiac muscles are stretched, and the greater the muscles are stretched, and the greater the force of the contraction during systole force of the contraction during systole (Starling’s Law). If there is a decrease in (Starling’s Law). If there is a decrease in contractility and in cardiac output.contractility and in cardiac output.

4. 4. AfterloadAfterload: the pressure in the aorta that : the pressure in the aorta that the ventricles must overcome to pump the ventricles must overcome to pump blood into the systemic circulation.blood into the systemic circulation.

A decrease in the afterload causes a A decrease in the afterload causes a decrease in the workload of the ventricles; decrease in the workload of the ventricles; this in turn will assist to increase the stroke this in turn will assist to increase the stroke volume and the cardiac outputvolume and the cardiac output

Factors that increase Factors that increase myocardial oxygen demandsmyocardial oxygen demands

Increased heart rateIncreased heart rate Increased force of contractionsIncreased force of contractions Increased afterloadIncreased afterload

Cardiac compensatory Cardiac compensatory mechanismsmechanisms

When the normal compensatory When the normal compensatory mechanisms cannot maintain cardiac mechanisms cannot maintain cardiac output to meet body needs, the client is output to meet body needs, the client is in a state of in a state of cardiac cardiac decompensation.decompensation.

SUKO SA MISTER:SUKO SA MISTER:

Misis 1: Suko na ako sa mister ko, lagi na Misis 1: Suko na ako sa mister ko, lagi na lang ako binubugbog bago lang ako binubugbog bago niroromansa. ..niroromansa. ..

Misis 2: Mas grabe yung mister ko. Misis 2: Mas grabe yung mister ko. Binubugbog ako tapos si Inday angBinubugbog ako tapos si Inday angniroromansa.niroromansa.

The The vascular system vascular system consists of the consists of the arteries, veins and capillariesarteries, veins and capillaries

The The arteriesarteries are vessels that carry blood are vessels that carry blood away from the heart to the peripheryaway from the heart to the periphery

The The veinsveins are the vessels that carry blood are the vessels that carry blood to the heartto the heart

The The capillariescapillaries are lined with squamous are lined with squamous cells, they connect the veins and arteriescells, they connect the veins and arteries

The The lymphatic system lymphatic system also is part of the also is part of the vascular system and the function of this vascular system and the function of this system is to collect the extravasated fluid system is to collect the extravasated fluid from the tissues and returns it to the bloodfrom the tissues and returns it to the blood

Differences Between Blood Vessel Differences Between Blood Vessel TypesTypes

26Slide 11.26

Walls of arteries are the thickest

Lumens of veins are larger

Skeletal muscle “milks” blood in veins toward the heart

Walls of capillaries are only one cell layer thick to allow for exchanges between blood and tissue

Movement of Blood Through Movement of Blood Through VesselsVessels

27Slide 11.27

Most arterial blood is pumped by the heart

Veins use the milking action of muscles to help move blood

Figure 11.9

Tutpik!Tutpik!

Kustomer: Ano ba naman itong tutpik Kustomer: Ano ba naman itong tutpik nyo, iisa na nga lang, ang dali pang nyo, iisa na nga lang, ang dali pang mabali!mabali!

Waiter (inis): Alam nyo, sir, ang dami Waiter (inis): Alam nyo, sir, ang dami nang gumamit nyan, pero kayo lang nang gumamit nyan, pero kayo lang nakabali!nakabali!

Major Arteries of Systemic CirculationMajor Arteries of Systemic Circulation

30Slide 11.30

Figure 11.11

Blood Supply to:Blood Supply to:

Bone – Haversian canal and Volkmann’s canalBone – Haversian canal and Volkmann’s canal Blood Vessel – vasa vasorumBlood Vessel – vasa vasorum Heart – coronary arteriesHeart – coronary arteries Brain – common carotid artery – external and Brain – common carotid artery – external and

internal carotid artery, internal carotid artery, anterior, middle and posterior cerebral artery anterior, middle and posterior cerebral artery (Circle of Willis)(Circle of Willis)

Upper Extremities – basillic – cephalic – brachial Upper Extremities – basillic – cephalic – brachial – radial and ulnar– radial and ulnar

Lower Extremities –iliac – femoral popliteal – Lower Extremities –iliac – femoral popliteal – saphenous – tibialsaphenous – tibial

Blood Supply to:Blood Supply to:

Eyes – choroids (between sclera and retina) Eyes – choroids (between sclera and retina) cornea gets 02 from the atmospherecornea gets 02 from the atmosphere

Kidneys – renal artery – interlobar artery – Kidneys – renal artery – interlobar artery – arcuate artery – interlobular artery – afferent arcuate artery – interlobular artery – afferent arteriole – glomerulus – efferent arteriole - vasa arteriole – glomerulus – efferent arteriole - vasa recta – back to the heartrecta – back to the heart

Liver – celiac artery – hepatic artery and hepatic Liver – celiac artery – hepatic artery and hepatic portal vein (food laden) - liver sinusoids (mixed portal vein (food laden) - liver sinusoids (mixed blood) – hepatic cells extract 02, nutrients and blood) – hepatic cells extract 02, nutrients and detoxify toxic substances.detoxify toxic substances.

Organs of the GIT – celiac trunkOrgans of the GIT – celiac trunk Lungs – bronchial arteries Lungs – bronchial arteries

Major Veins of Systemic CirculationMajor Veins of Systemic Circulation

31Slide 11.31

Figure 11.12

Arterial Supply of the BrainArterial Supply of the Brain

32Slide 11.32

Figure 11.13

Hepatic Portal CirculationHepatic Portal Circulation

33Slide 11.33

Figure 11.14

Circulation to the FetusCirculation to the Fetus

34Slide 11.34

DALAWANG MADRE NIREREYP:DALAWANG MADRE NIREREYP:

MADRE 1: Jusko! Patawarin nyo po MADRE 1: Jusko! Patawarin nyo po sya, di po nya alam ang ginagawa sya, di po nya alam ang ginagawa nya!nya!

MADRE 2: Sister yung akin MADRE 2: Sister yung akin marunong!!!! Whooooo! Yeeaahhh!!! marunong!!!! Whooooo! Yeeaahhh!!!

Blood PressureBlood Pressure

Measure of force exerted by blood against Measure of force exerted by blood against the wallthe wall

Blood moves through vessels because of Blood moves through vessels because of blood pressureblood pressure

Measured by listening for Korotkoff sounds Measured by listening for Korotkoff sounds produced by turbulent flow in arteries as produced by turbulent flow in arteries as pressure released from blood pressure pressure released from blood pressure cuffcuff

Blood Pressure: Effects of FactorsBlood Pressure: Effects of Factors

39bSlide 11.39b

Temperature

Heat has a vasodilation effect

Cold has a vasoconstricting effect

Chemicals

Various substances can cause increases or decreases

Factors Determining Blood PressureFactors Determining Blood Pressure

40Slide 11.40

Figure 11.19

PulsePulse

35Slide 11.35

Pulse – pressure wave of blood

Monitored at “pressure points” where pulse is easily palpated

Figure 11.16

Pulse PressurePulse Pressure Difference between Difference between

systolic and diastolic systolic and diastolic pressurespressures

Increases when Increases when stroke volume stroke volume increases or vascular increases or vascular compliance compliance decreasesdecreases

Pulse pressure can Pulse pressure can be used to take a be used to take a pulse to determine pulse to determine heart rate and heart rate and rhythmicityrhythmicity

Variations in Blood PressureVariations in Blood Pressure

41Slide 11.41

Human normal range is variable Normal

140–110 mm Hg systolic 80–75 mm Hg diastolic

Hypotension Low systolic (below 110 mm HG) Often associated with illness

Hypertension High systolic (above 140 mm HG) Can be dangerous if it is chronic

Effects of Aging on the Effects of Aging on the HeartHeart

Gradual changes in heart function, minor Gradual changes in heart function, minor under resting condition, more significant under resting condition, more significant during exerciseduring exercise

Hypertrophy of left ventricleHypertrophy of left ventricle Maximum heart rate decreasesMaximum heart rate decreases Increased tendency for valves to function Increased tendency for valves to function

abnormally and arrhythmias to occurabnormally and arrhythmias to occur Increased oxygen consumption required Increased oxygen consumption required

to pump same amount of bloodto pump same amount of blood

Cardiac Cardiac AssessmentAssessment

Cardiac History Interview Focused assessment

CARDIAC ASSESSMENTCARDIAC ASSESSMENT

Health HistoryHealth HistoryObtain description of Obtain description of

present illness and the chief present illness and the chief complaintcomplaint

Chest pain, DOB, Edema, Chest pain, DOB, Edema, etc.etc.

Assess risk factorsAssess risk factors

CARDIAC ASSESSMENTCARDIAC ASSESSMENT

Physical examination Physical examination Vital signs- BP, PP, Vital signs- BP, PP, Inspection of the skinInspection of the skin Inspection of the thoraxInspection of the thorax Palpation of the PMI, pulsesPalpation of the PMI, pulses Auscultation of the heart soundsAuscultation of the heart sounds

Fig. 13.23Fig. 13.23

WHY NURSING?WHY NURSING?

Do you know why I took up nursing? It Do you know why I took up nursing? It was in 4was in 4thth year high school that I saw a year high school that I saw a vision of a great woman bearing a light vision of a great woman bearing a light in her right hand wearing a long gown in her right hand wearing a long gown and a headress calling me to serve and a headress calling me to serve her……. her…….

STATUE OF LIBERTYSTATUE OF LIBERTY

CARDIAC ASSESSMENTCARDIAC ASSESSMENTLaboratory and diagnostic studiesLaboratory and diagnostic studies CBC CBC Cardiac catheterizationCardiac catheterization Lipid profileLipid profile ArteriographyArteriography Cardiac enzymes and proteinsCardiac enzymes and proteins CXRCXR CVPCVP ECGECG Holter monitoringHolter monitoring Exercise ECGExercise ECG

Laboratory Test RationaleLaboratory Test Rationale 1. To assist in diagnosing MI1. To assist in diagnosing MI 2. To identify abnormalities2. To identify abnormalities 3. To assess inflammation3. To assess inflammation

Laboratory Test RationaleLaboratory Test Rationale 4. To determine baseline value4. To determine baseline value 5. To monitor serum level of 5. To monitor serum level of

medicationsmedications 6. To assess the effects of 6. To assess the effects of

medicationsmedications

LABORATORY PROCEDURES LABORATORY PROCEDURES

CARDIAC Proteins and enzymesCARDIAC Proteins and enzymesCK- MB ( creatine kinase)CK- MB ( creatine kinase)

Elevates in MI Elevates in MI within 4 within 4 hours, peaks in 18 hours hours, peaks in 18 hours and then declines till 3 and then declines till 3 daysdays

CARDIAC Proteins and enzymesCARDIAC Proteins and enzymes

CK- MB ( creatine kinase)CK- MB ( creatine kinase)Normal value is 0-7 U/LNormal value is 0-7 U/L

CARDIAC Proteins and enzymesCARDIAC Proteins and enzymesLactic Dehydrogenase (LDH)Lactic Dehydrogenase (LDH)

Elevates in MI in 24 hours, Elevates in MI in 24 hours, peaks in 48-72 hourspeaks in 48-72 hours

CARDIAC Proteins and enzymesCARDIAC Proteins and enzymesLactic Dehydrogenase (LDH)Lactic Dehydrogenase (LDH)

Normal value is 70-200 IU/LNormal value is 70-200 IU/L

MyoglobinMyoglobinRises within 1-3 hoursRises within 1-3 hoursPeaks in 4-12 hoursPeaks in 4-12 hoursReturns to normal in a dayReturns to normal in a day

LABORATORY PROCEDURESLABORATORY PROCEDURES

Troponin I and TTroponin I and T Troponin I is usually utilized for Troponin I is usually utilized for

MIMI Elevates within 3-4 hours, peaks Elevates within 3-4 hours, peaks

in 4-24 hours and persists for 7 in 4-24 hours and persists for 7 days to 3 weeks!days to 3 weeks!

Normal value for Troponin I is Normal value for Troponin I is less than 0.6 ng/mLless than 0.6 ng/mL

Troponin I and TTroponin I and T REMEMBER to AVOID IM REMEMBER to AVOID IM

injections before obtaining injections before obtaining blood sample!blood sample!

Early and late diagnosis can be Early and late diagnosis can be made!made!

MyoglobinMyoglobinNot seen alone in cardiac Not seen alone in cardiac

problemsproblemsMuscular and RENAL disease Muscular and RENAL disease

can have elevated myoglobincan have elevated myoglobin

SERUM LIPIDSSERUM LIPIDSLipid profile measures the Lipid profile measures the

serum cholesterol, serum cholesterol, triglycerides and lipoprotein triglycerides and lipoprotein levelslevels

Cholesterol= <200 mg/dLCholesterol= <200 mg/dLTriglycerides- 40- 150 mg/dLTriglycerides- 40- 150 mg/dL

SERUM LIPIDSSERUM LIPIDSLDL- 130 mg/dLLDL- 130 mg/dLHDL- 30-70- mg/dLHDL- 30-70- mg/dLNPO post midnight NPO post midnight

(usually 12 hours)(usually 12 hours)

AFTER THE WEDDING:AFTER THE WEDDING:

Husband: Sinungaling ka, sabi mo Husband: Sinungaling ka, sabi mo virgin ka! Bakit kagabi maluwag na!virgin ka! Bakit kagabi maluwag na!

Wife: Ulol ka! Dahil lasing ka, Wife: Ulol ka! Dahil lasing ka, katabi mo kagabi si mama! katabi mo kagabi si mama!

ELECTROCARDIOGRAM ELECTROCARDIOGRAM (ECG)(ECG)

A non-invasive procedure A non-invasive procedure that evaluates the electrical that evaluates the electrical activity of the heartactivity of the heart

Electrodes and wires are Electrodes and wires are attached to the patient attached to the patient

ELECTROCARDIOGRAM ELECTROCARDIOGRAM (ECG)(ECG)

Tell the patient that there is Tell the patient that there is no risk of electrocutionno risk of electrocution

Avoid muscular Avoid muscular contraction/movement contraction/movement

Holter MonitoringHolter MonitoringA non-invasive test in which A non-invasive test in which

the client wears a Holter the client wears a Holter monitor and an ECG tracing monitor and an ECG tracing recorded continuously over recorded continuously over a period of 24 hoursa period of 24 hours

The Cardiovascular SystemThe Cardiovascular SystemLABORATORY PROCEDURESLABORATORY PROCEDURES

Holter MonitoringHolter Monitoring Instruct the client to resume Instruct the client to resume

normal activities and normal activities and maintain a diary of activities maintain a diary of activities and any symptoms that may and any symptoms that may developdevelop

ECHOCARDIOGRAMECHOCARDIOGRAMNon-invasive test that studies Non-invasive test that studies

the structural and functional the structural and functional changes of the heart with the changes of the heart with the use of ultrasounduse of ultrasound

No special preparation is No special preparation is neededneeded

Stress TestStress TestA non-invasive test that A non-invasive test that

studies the heart during studies the heart during activity and detects and activity and detects and evaluates CADevaluates CAD

Exercise test, pharmacologic Exercise test, pharmacologic test and emotional testtest and emotional test

Stress TestStress TestTreadmill testing is the most Treadmill testing is the most

commonly used stress testcommonly used stress testUsed to determine CAD, Used to determine CAD,

Chest pain causes, drug Chest pain causes, drug effects and dysrhythmias in effects and dysrhythmias in exerciseexercise

Stress TestStress TestPre-test:Pre-test: consent may be consent may be

required, adequate rest, eat required, adequate rest, eat a light meal or fast for 4 a light meal or fast for 4 hours and avoid smoking, hours and avoid smoking, alcohol and caffeinealcohol and caffeine

Post-test:Post-test: instruct client to instruct client to notify the physician if any notify the physician if any chest pain, dizziness or chest pain, dizziness or shortness of breath shortness of breath

Instruct client to avoid taking Instruct client to avoid taking a hot shower for 10-12 hours a hot shower for 10-12 hours after the testafter the test

Pharmacological stress testPharmacological stress testUse of Use of dipyridamoledipyridamoleMaximally dilates coronary Maximally dilates coronary

arteryarterySide-effect: flushing of faceSide-effect: flushing of face

Pharmacological stress Pharmacological stress testtest

Pre-test:Pre-test: 4 hours fasting, 4 hours fasting, avoid alcohol, caffeineavoid alcohol, caffeine

Post test:Post test: report symptoms report symptoms of chest painof chest pain

LABORATORY PROCEDURESLABORATORY PROCEDURESCARDIAC catheterizationCARDIAC catheterization Insertion of a catheter into Insertion of a catheter into

the heart and surrounding the heart and surrounding vesselsvessels

Determines the structure and Determines the structure and performance of the heart performance of the heart valves and surrounding valves and surrounding vesselsvessels

CARDIAC catheterizationCARDIAC catheterizationUsed to diagnose CAD, Used to diagnose CAD,

assess coronary artery assess coronary artery patency and determine patency and determine extent of atherosclerosisextent of atherosclerosis

LABORATORY PROCEDURESLABORATORY PROCEDURESPretest:Pretest: Ensure Consent, Ensure Consent,

assess for allergy to assess for allergy to seafood and iodine, NPO, seafood and iodine, NPO, document weight and document weight and height, baseline VS, blood height, baseline VS, blood tests and tests and document the document the peripheral pulsesperipheral pulses

Pretest:Pretest: Fast for 8-12 Fast for 8-12 hours, teachings, hours, teachings, medications to allay medications to allay anxietyanxiety

Intra-test:Intra-test: inform patient of a inform patient of a fluttery feeling as the catheter fluttery feeling as the catheter passes through the heartpasses through the heart;;

- inform the patient that a - inform the patient that a feeling of warmth and metallic feeling of warmth and metallic taste may occur when dye is taste may occur when dye is administeredadministered

Post-test: Post-test: Monitor VS and cardiac rhythmMonitor VS and cardiac rhythm Monitor peripheral pulses, color and Monitor peripheral pulses, color and

warmth and sensation of the extremity warmth and sensation of the extremity distal to insertion site distal to insertion site

Maintain sandbag to the insertion site Maintain sandbag to the insertion site if required to maintain pressureif required to maintain pressure

Monitor for bleeding and hematoma Monitor for bleeding and hematoma formationformation

LABORATORY PROCEDURESLABORATORY PROCEDURES Maintain strict bed rest for 6-12 hoursMaintain strict bed rest for 6-12 hours Client may turn from side to side but Client may turn from side to side but

bed should not be elevated more than bed should not be elevated more than 30 degrees and legs always straight30 degrees and legs always straight

Encourage fluid intake to flush out the Encourage fluid intake to flush out the dyedye

Immobilize the arm if the antecubital Immobilize the arm if the antecubital vein is usedvein is used

Monitor for dye allergyMonitor for dye allergy

CVPCVPThe CVP is the pressure The CVP is the pressure

within the SVCwithin the SVCReflects the pressure under Reflects the pressure under

which blood is returned to which blood is returned to the SVC and right atriumthe SVC and right atrium

CVPCVP Normal CVP Normal CVP is is 0 to 8 mmHg/0 to 8 mmHg/ 4-4-

10 cm H2O10 cm H2O

CVPCVP Elevated CVP indicates Elevated CVP indicates

increase in blood volume, increase in blood volume, excessive IVF or heart/renal excessive IVF or heart/renal failurefailure

CVPCVP Low CVP may indicate Low CVP may indicate

hypovolemia, hemorrhage hypovolemia, hemorrhage and severe vasodilatationand severe vasodilatation

Measuring CVPMeasuring CVP 1. Position the client supine with 1. Position the client supine with

bed elevated at bed elevated at 45 degrees (CBQ)45 degrees (CBQ) 2. Position the zero point of the CVP 2. Position the zero point of the CVP

line at the level of the right atrium. line at the level of the right atrium. Usually this is at the Usually this is at the MAL, 4MAL, 4thth ICS ICS

3. Instruct the client to be relaxed 3. Instruct the client to be relaxed and avoid coughing and straining.and avoid coughing and straining.

CARDIAC IMPLEMENTATIONCARDIAC IMPLEMENTATION

1. 1. Assess the cardio-pulmonary Assess the cardio-pulmonary statusstatus

VS, BP, Cardiac assessment VS, BP, Cardiac assessment

2. 2. Enhance cardiac outputEnhance cardiac output Establish IV line to administer Establish IV line to administer

fluidsfluids

3. 3. Promote gas exchangePromote gas exchangeAdminister O2Administer O2Position client in Position client in SEMI-Fowler’sSEMI-Fowler’sEncourage coughing and deep Encourage coughing and deep

breathing exercisesbreathing exercises

4. 4. Increase client activity toleranceIncrease client activity toleranceBalance rest and activity periodsBalance rest and activity periodsAssist in daily activitiesAssist in daily activitiesProvide strict bed rest if indicatedProvide strict bed rest if indicatedSoft foodsSoft foodsAssistance in self-careAssistance in self-care

5. 5. Promote client comfortPromote client comfortAssess the client’s description of Assess the client’s description of

pain and chest discomfortpain and chest discomfortAdminister medication as Administer medication as

prescribedprescribedMorphine for MIMorphine for MINitroglycerine for AnginaNitroglycerine for AnginaDiuretics to relieve congestion (CHF)Diuretics to relieve congestion (CHF)

6. 6. Promote adequate sleepPromote adequate sleep7. 7. Prevent infectionPrevent infection

Monitor skin integrity of lower Monitor skin integrity of lower extremitiesextremities

Assess skin site for edema, Assess skin site for edema, redness and warmthredness and warmth

Monitor for feverMonitor for fever Change position frequentlyChange position frequently

8. 8. Minimize patient anxietyMinimize patient anxietyEncourage verbalization of Encourage verbalization of

feelings, fears and concernsfeelings, fears and concernsAnswer client questions. Answer client questions.

Provide information about Provide information about procedures and medicationsprocedures and medications

Activity Intolerance

Monitor TPR and BPSpace activities in the dayPermit rest periods before activityLimit activity 1 hour before mealsTeach energy conservation measures like bed rest

Edema Instruct patient to avoid constricting garmentsInstruct to elevate edematous areasInstruct patient to avoid dependent positionsTeach patient to prepare low sodium mealsApply anti-embolic stockings

Pain Instruct patient to stop activity when pain occursAdminister nitroglycerine for anginaPace activities within patient’s limitsInstruct patient to avoid cold temperatures and smokingInstruct to report unrelieved pain immediately

CARDIAC DISEASESCARDIAC DISEASES

Coronary Artery DiseaseCoronary Artery DiseaseMyocardial InfarctionMyocardial InfarctionCongestive Heart FailureCongestive Heart Failure Infective EndocarditisInfective EndocarditisCardiac TamponadeCardiac TamponadeCardiogenic ShockCardiogenic Shock

VASCULAR DISEASESVASCULAR DISEASES

HypertensionHypertensionBuerger’s diseaseBuerger’s diseaseAneurysmAneurysmVaricose veinsVaricose veinsDeep vein thrombosisDeep vein thrombosis

CADCADCORONARY ARTERY DSECORONARY ARTERY DSE

results from the focal results from the focal narrowing of the large and narrowing of the large and medium-sized coronary medium-sized coronary arteries due to deposition of arteries due to deposition of atheromatous plaque in the atheromatous plaque in the vessel wallvessel wall

CADCADRISK FACTORSRISK FACTORS 1. Age above 45/55 and Sex- Males and 1. Age above 45/55 and Sex- Males and

post-menopausal femalespost-menopausal females 2. Family History2. Family History 3. Hypertension3. Hypertension 4. DM4. DM 5. Smoking5. Smoking 6. Obesity6. Obesity 7. Sedentary lifestyle7. Sedentary lifestyle 8. Hyperlipedimia8. Hyperlipedimia

CADCADRISK FACTORSRISK FACTORS

Most important MODIFIABLE Most important MODIFIABLE factors:factors:

SmokingSmoking HypertensionHypertension DiabetesDiabetes Cholesterol abnormalitiesCholesterol abnormalities

CAD: CAD: PathophysiologyPathophysiologyFatty streak formation in the vascular intimaFatty streak formation in the vascular intima

T-cells and monocytes ingest lipids in the area of T-cells and monocytes ingest lipids in the area of depositiondeposition

AtheromaAtheroma

narrowing of the arterial lumen narrowing of the arterial lumen

reduced coronary blood flowreduced coronary blood flow

myocardial ischemiamyocardial ischemia

CADCAD

PathophysiologyPathophysiology There is decreased perfusion of There is decreased perfusion of

myocardial tissue and inadequate myocardial tissue and inadequate myocardial oxygen supplymyocardial oxygen supply

If 50% of the left coronary arterial If 50% of the left coronary arterial lumen is reduced or 75% of the lumen is reduced or 75% of the other coronary artery, this other coronary artery, this becomes significantbecomes significant

CADCAD

PathophysiologyPathophysiology Potential for Thrombosis and Potential for Thrombosis and

embolismembolism

Angina PectorisAngina Pectoris

Chest pain resulting from Chest pain resulting from coronary atherosclerosis coronary atherosclerosis or myocardial ischemiaor myocardial ischemia

Angina Pectoris: Clinical SyndromesAngina Pectoris: Clinical Syndromes

THREE COMMON TYPES OF ANGINATHREE COMMON TYPES OF ANGINA

11. STABLE ANGINA. STABLE ANGINAThe typical angina that The typical angina that occurs during exertion, occurs during exertion, relieved by rest and drugs relieved by rest and drugs and the and the severity does not severity does not changechange

Angina Pectoris: Clinical SyndromesAngina Pectoris: Clinical Syndromes

Three Common Types of ANGINAThree Common Types of ANGINA

2. 2. Unstable anginaUnstable anginaOccurs unpredictably Occurs unpredictably during exertion and during exertion and emotion, emotion, severity increases severity increases with timewith time and pain may not and pain may not be relieved by rest and drugbe relieved by rest and drug

Angina Pectoris: Clinical Angina Pectoris: Clinical SyndromesSyndromes

Three Common Types of ANGINAThree Common Types of ANGINA

3. 3. Variant anginaVariant anginaPrinzmetal anginaPrinzmetal angina, results , results from coronary artery from coronary artery VASOSPASMS, VASOSPASMS, may occur may occur at restat rest

ASSESSMENT FINDINGSASSESSMENT FINDINGS1. 1. Chest pain- ANGINAChest pain- ANGINA The most characteristic symptomThe most characteristic symptom PAIN is described as mild to PAIN is described as mild to

severe retrosternal pain, severe retrosternal pain, squeezingsqueezing, tightness or burning , tightness or burning sensationsensation

Radiates to the jawRadiates to the jaw and left arm and left arm

ASSESSMENT FINDINGSASSESSMENT FINDINGS

1. 1. Chest pain- ANGINAChest pain- ANGINA Precipitated by Precipitated by EExercise, xercise, EEating ating

heavy meals, heavy meals, EEmotions like motions like excitement and anxiety and excitement and anxiety and EExtremes of temperaturextremes of temperature

Relieved by REST and NitroglycerinRelieved by REST and Nitroglycerin

ASSESSMENT FINDINGSASSESSMENT FINDINGS 2. Diaphoresis2. Diaphoresis 3. Nausea and vomiting3. Nausea and vomiting 4. Cold clammy skin4. Cold clammy skin 5. Sense of apprehension and 5. Sense of apprehension and

doomdoom 6. Dizziness and syncope6. Dizziness and syncope

LABORATORY FINDINGSLABORATORY FINDINGS1.1. ECG ECG may show normal tracing if may show normal tracing if

patient is pain-free. patient is pain-free. - Ischemic changes may show ST - Ischemic changes may show ST

depression and T wave inversiondepression and T wave inversion

LABORATORY FINDINGSLABORATORY FINDINGS

2. 2. Cardiac catheterizationCardiac catheterization Provides the MOST DEFINITIVE Provides the MOST DEFINITIVE

source of diagnosis by showing the source of diagnosis by showing the presence of the atherosclerotic presence of the atherosclerotic lesionslesions

NURSING DIAGNOSES:NURSING DIAGNOSES: Decreased cardiac outputDecreased cardiac output Impaired gas exchangeImpaired gas exchange Activity intoleranceActivity intolerance AnxietyAnxiety

NURSING MANAGEMENTNURSING MANAGEMENT1. Administer prescribed medications1. Administer prescribed medications NitratesNitrates- to dilate the venous vessels - to dilate the venous vessels

decreasing venous return and to some decreasing venous return and to some extent dilate the coronary arteriesextent dilate the coronary arteries

AspirinAspirin- to prevent thrombus formation- to prevent thrombus formation Beta-blockersBeta-blockers- to reduce BP and HR- to reduce BP and HR Calcium-channel blockersCalcium-channel blockers- to dilate - to dilate

coronary artery and reduce vasospasmcoronary artery and reduce vasospasm

2. 2. Teach the patient management of anginal Teach the patient management of anginal attacksattacks

Advise patient to stop all activities Advise patient to stop all activities Put one nitroglycerin tablet under the tonguePut one nitroglycerin tablet under the tongue Wait for 5 minutesWait for 5 minutes If not relieved, take another tablet and wait for If not relieved, take another tablet and wait for

5 minutes5 minutes Another tablet can be taken (third tablet)Another tablet can be taken (third tablet) If unrelieved after THREE tabletsIf unrelieved after THREE tablets seek seek

medical attentionmedical attention

3. 3. Obtain a 12-Obtain a 12-lead ECGlead ECG

4. 4. Promote myocardial perfusionPromote myocardial perfusion Instruct patient to maintain bed restInstruct patient to maintain bed rest Administer O2 @ 3 lpmAdminister O2 @ 3 lpm Advise to Advise to avoid valsalva maneuversavoid valsalva maneuvers Provide laxatives or high fiber diet Provide laxatives or high fiber diet

to lessen constipationto lessen constipation Encourage to avoid increased Encourage to avoid increased

physical activitiesphysical activities

Angina PectorisAngina Pectoris5. 5. Assist in possible treatment modalitiesAssist in possible treatment modalities PTCA-PTCA- percutaneous transluminal percutaneous transluminal

coronary angioplastycoronary angioplasty To compress the plaque against the To compress the plaque against the

vessel wall, increasing the arterial vessel wall, increasing the arterial lumenlumen

CABG-CABG- coronary artery bypass graft coronary artery bypass graft To improve the blood flow to the To improve the blood flow to the

myocardial tissuemyocardial tissue

6. Provide information to family 6. Provide information to family members to minimize anxiety members to minimize anxiety and promote family cooperationand promote family cooperation

7. Assist client to identify risk 7. Assist client to identify risk factors that can be modifiedfactors that can be modified

8. Refer patient to proper 8. Refer patient to proper agenciesagencies

Myocardial infarctionMyocardial infarction

Death of myocardial Death of myocardial tissue in regions of the tissue in regions of the heart with heart with abrupt abrupt interruptioninterruption of coronary of coronary blood supply blood supply

ETIOLOGY and Risk factorsETIOLOGY and Risk factors 1. CAD1. CAD 2. Coronary vasospasm2. Coronary vasospasm 3. Coronary artery occlusion by 3. Coronary artery occlusion by

embolus and thrombusembolus and thrombus 4. Conditions that decrease 4. Conditions that decrease

perfusion- hemorrhage, shockperfusion- hemorrhage, shock

Risk factorsRisk factors 1. Hypercholesterolemia1. Hypercholesterolemia 2. Smoking2. Smoking 3. Hypertension3. Hypertension 4. Obesity4. Obesity 5. Stress5. Stress 6. Sedentary lifestyle6. Sedentary lifestyle

PATHOPHYSIOLOGYPATHOPHYSIOLOGY Interrupted coronary blood flowInterrupted coronary blood flow

myocardial ischemia myocardial ischemia anaerobic anaerobic myocardial metabolism for several myocardial metabolism for several hourshours myocardial deathmyocardial death depressed cardiac function depressed cardiac function triggers autonomic nervous system triggers autonomic nervous system response response further imbalance of further imbalance of myocardial O2 demand and supplymyocardial O2 demand and supply

ASSESSMENT findingsASSESSMENT findings1. CHEST PAIN1. CHEST PAIN Chest pain is described as Chest pain is described as

severe, persistent, severe, persistent, crushingcrushing substernal discomfortsubsternal discomfort

Radiates to the neck, arm, jaw Radiates to the neck, arm, jaw and backand back

ASSESSMENT findingsASSESSMENT findings

1. CHEST PAIN1. CHEST PAIN Occurs without cause, primarily Occurs without cause, primarily

early morningearly morning NOTNOT relieved by rest or relieved by rest or

nitroglycerinnitroglycerin Lasts 30 minutes or longerLasts 30 minutes or longer

Assessment findingsAssessment findings 2. Dyspnea2. Dyspnea 3. Diaphoresis3. Diaphoresis 4. Cold clammy skin4. Cold clammy skin 5. N/V5. N/V 6. restlessness, sense of doom6. restlessness, sense of doom 7. tachycardia or bradycardia7. tachycardia or bradycardia 8. hypotension8. hypotension 9. S3 and dysrhythmias9. S3 and dysrhythmias

Laboratory findingsLaboratory findings 1. ECG- the ST segment is 1. ECG- the ST segment is

ELEVATED, T wave inversion, ELEVATED, T wave inversion, presence of Q wavepresence of Q wave

2. Myocardial enzymes- 2. Myocardial enzymes- elevated elevated CK-MB, LDH and Troponin levelsCK-MB, LDH and Troponin levels

Laboratory findingsLaboratory findings 3. CBC- may show elevated 3. CBC- may show elevated

WBC count WBC count 4. Test after the acute stage- 4. Test after the acute stage-

Exercise tolerance test, Exercise tolerance test, thallium scans, cardiac thallium scans, cardiac catheterizationcatheterization

PainPainDecreased cardiac outputDecreased cardiac outputImpaired gas exchangeImpaired gas exchangeActivity intoleranceActivity intoleranceAltered tissue perfusionAltered tissue perfusionConstipationConstipation

Myocardial infarctionMyocardial infarctionNursing InterventionsNursing Interventions

1. Provide Oxygen at 2 lpm, Semi-1. Provide Oxygen at 2 lpm, Semi-fowler’sfowler’s

2. Administer medications2. Administer medications Morphine to relieve painMorphine to relieve pain Nitrates, thrombolytics, aspirin Nitrates, thrombolytics, aspirin

and anticoagulantsand anticoagulants Stool softener and hypolipidemicsStool softener and hypolipidemics

Nursing InterventionsNursing Interventions3. Minimize patient anxiety3. Minimize patient anxiety

Provide information as to Provide information as to procedures and drug therapyprocedures and drug therapy

Allow verbalization of feelingsAllow verbalization of feelings Morphine can be administeredMorphine can be administered

4. Provide adequate rest periods4. Provide adequate rest periods Bed rest during acute stageBed rest during acute stage

5. Minimize metabolic demands5. Minimize metabolic demands Provide soft dietProvide soft diet Provide a low-sodium, low Provide a low-sodium, low

cholesterol and low fat dietcholesterol and low fat diet

6. Assist in treatment modalities 6. Assist in treatment modalities such as PTCA and CABGsuch as PTCA and CABG

7. Monitor for complications of MI- 7. Monitor for complications of MI- especially dysrhythmias, since especially dysrhythmias, since ventricular tachycardia can happen ventricular tachycardia can happen in the first few hours after MIin the first few hours after MI

8. Provide client teaching8. Provide client teaching

Medical ManagementMedical Management 1. 1. ANALGESICANALGESIC

The choice is The choice is MORPHINEMORPHINE It reduces pain and anxietyIt reduces pain and anxiety Relaxes bronchioles to enhance Relaxes bronchioles to enhance

oxygenationoxygenation

Medical ManagementMedical Management 2. 2. ACE inhibitorsACE inhibitors

Prevents formation of Prevents formation of angiotensin IIangiotensin II

Limits the area of infarctionLimits the area of infarction

Medical ManagementMedical Management 3. 3. Thrombolytic therapyThrombolytic therapy

Streptokinase, AlteplaseStreptokinase, Alteplase Dissolve clots in the coronary Dissolve clots in the coronary

artery allowing blood to flowartery allowing blood to flow

NURSING INTERVENTIONS AFTER ACUTE NURSING INTERVENTIONS AFTER ACUTE EPISODEEPISODE

1. Maintain bed rest for the first 3 1. Maintain bed rest for the first 3 daysdays

2. Provide passive ROM exercises2. Provide passive ROM exercises 3. Progress with dangling of the feet 3. Progress with dangling of the feet

at side of bedat side of bed

NURSING INTERVENTIONS AFTER NURSING INTERVENTIONS AFTER ACUTE EPISODEACUTE EPISODE

4. Proceed with sitting out of bed, 4. Proceed with sitting out of bed, on the chair for 30 minutes TIDon the chair for 30 minutes TID

5. Proceed with ambulation in the 5. Proceed with ambulation in the roomroom toilet toilet hallway TID hallway TID

NURSING INTERVENTIONS AFTER NURSING INTERVENTIONS AFTER ACUTE EPISODEACUTE EPISODE

Cardiac rehabilitationCardiac rehabilitation To extend and improve quality of lifeTo extend and improve quality of life Physical conditioningPhysical conditioning Patients who are able to walk 3-4 mph Patients who are able to walk 3-4 mph

are usually ready to resume sexual are usually ready to resume sexual activitiesactivities

CARDIOMYOPATHIESCARDIOMYOPATHIES

Heart muscle disease Heart muscle disease associated with cardiac associated with cardiac dysfunctiondysfunction

1. Dilated Cardiomyopathy1. Dilated Cardiomyopathy2. Hypertrophic 2. Hypertrophic

CardiomyopathyCardiomyopathy3. Restrictive cardiomyopathy3. Restrictive cardiomyopathy

DILATED CARDIOMYOPATHYDILATED CARDIOMYOPATHY

ASSOCIATED FACTORSASSOCIATED FACTORS 1. Heavy alcohol intake1. Heavy alcohol intake 2. Pregnancy2. Pregnancy 3. Viral infection3. Viral infection 4. Idiopathic4. Idiopathic

DILATED CARDIOMYOPATHYDILATED CARDIOMYOPATHYPATHOPHYSIOLOGYPATHOPHYSIOLOGY Diminished contractile proteinsDiminished contractile proteins

poor contractionpoor contraction decreased decreased blood ejectionblood ejection increased blood increased blood remaining in the ventricleremaining in the ventricle ventricular stretching and ventricular stretching and dilatation. dilatation.

SYSTOLIC DYSFUNCTIONSYSTOLIC DYSFUNCTION

HYPERTROPHIC HYPERTROPHIC CARDIOMYOPATHYCARDIOMYOPATHY

Associated factors:Associated factors:1. Genetic1. Genetic2. Idiopathic2. Idiopathic

HYPERTROPHIC HYPERTROPHIC CARDIOMYOPATHYCARDIOMYOPATHY

PathophysiologyPathophysiology Increased size of Increased size of

myocardiummyocardium reduced reduced ventricular volumeventricular volume increased increased resistance to ventricular resistance to ventricular fillingfilling diastolic dysfunctiondiastolic dysfunction

RESTRICTIVE RESTRICTIVE CARDIOMYOPATHYCARDIOMYOPATHY

PathophysiologyPathophysiologyRigid ventricular wallRigid ventricular wall

impaired stretch and diastolic impaired stretch and diastolic fillingfilling decreased output decreased output

Diastolic dysfunctionDiastolic dysfunction

Assessment findingsAssessment findings 1. PND1. PND 2. Orthopnea2. Orthopnea 3. Edema3. Edema 4. Chest pain4. Chest pain 5. Palpitations5. Palpitations 6. dizziness6. dizziness 7. Syncope with exertion7. Syncope with exertion

Laboratory FindingsLaboratory Findings 1. CXR- may reveal 1. CXR- may reveal

cardiomegalycardiomegaly 2. ECHOCARDIOGRAM2. ECHOCARDIOGRAM 3. ECG3. ECG 4. 4. Myocardial BiopsyMyocardial Biopsy

Medical ManagementMedical Management 1. Surgery= heart transplant1. Surgery= heart transplant 2. pacemaker insertion2. pacemaker insertion 3. Pharmacological drugs for 3. Pharmacological drugs for

symptom reliefsymptom relief

Nursing ManagementNursing Management

1. Improve cardiac output1. Improve cardiac output Adequate restAdequate rest Oxygen therapyOxygen therapy Low sodium dietLow sodium diet

Nursing ManagementNursing Management

2. Increase patient tolerance2. Increase patient tolerance Schedule activities with rest Schedule activities with rest

periods in betweenperiods in between

Nursing ManagementNursing Management3. Reduce patient anxiety3. Reduce patient anxiety Support patientSupport patient Offer information about Offer information about

transplantationstransplantations Support family in anticipatory Support family in anticipatory

grievinggrieving

Infective endocarditisInfective endocarditis

Infection of the heart Infection of the heart valves and the endothelial valves and the endothelial surface of the heartsurface of the heart

Can be acute, sub-acute Can be acute, sub-acute or chronicor chronic

Etiologic factorsEtiologic factors1. Bacteria- Organism 1. Bacteria- Organism

depends on several factorsdepends on several factors2. Fungi2. Fungi

Infective EndocarditisInfective Endocarditis

Risk factorsRisk factors 1. Prosthetic valves1. Prosthetic valves 2. Congenital malformation2. Congenital malformation 3. Cardiomyopathy3. Cardiomyopathy 4. IV drug users4. IV drug users 5. Valvular dysfunctions5. Valvular dysfunctions

Infective endocarditisInfective endocarditisPathophysiologyPathophysiology

Direct invasion of microbesDirect invasion of microbes

microbes adhere to damaged valve surface microbes adhere to damaged valve surface and proliferateand proliferate

damage attracts platelets causing clot damage attracts platelets causing clot formationformation

erosion of valvular leaflets and the clot and erosion of valvular leaflets and the clot and vegetation can embolizevegetation can embolize

Assessment findingsAssessment findings 1. Intermittent high grade fever1. Intermittent high grade fever 2. anorexia, weight loss2. anorexia, weight loss 3. cough, back pain and joint 3. cough, back pain and joint

painpain 4. splinter hemorrhages under 4. splinter hemorrhages under

nailsnails

Assessment findingsAssessment findings5. Osler’s nodes- painful 5. Osler’s nodes- painful

nodules on fingerpadsnodules on fingerpads6. Roth’s spots- pale 6. Roth’s spots- pale

hemorrhages in the retinahemorrhages in the retina

Assessment findingsAssessment findings7. Heart murmurs7. Heart murmurs8. Heart failure= usually 8. Heart failure= usually

acute heart failureacute heart failure

PreventionPreventionAntibiotic prophylaxis if Antibiotic prophylaxis if

patient is undergoing patient is undergoing procedures like dental procedures like dental extractions, bronchoscopy, extractions, bronchoscopy, surgery, etc.surgery, etc.

PreventionPreventionAny invasive procedure that is Any invasive procedure that is

associated with transient associated with transient bacteremia may cause the bacteremia may cause the microrganism to lodge in the microrganism to lodge in the damaged, irregular valvesdamaged, irregular valves

LABORATORY EXAMLABORATORY EXAMBlood Cultures to determine Blood Cultures to determine

the exact organismthe exact organismUsually, 3 culture specimens Usually, 3 culture specimens

are obtained and antibiotic are obtained and antibiotic sensitivity done sensitivity done

Nursing managementNursing management 1. Regular monitoring of 1. Regular monitoring of

temperature, heart sounds temperature, heart sounds 2. Manage infection2. Manage infection 3. Long-term antibiotic therapy 3. Long-term antibiotic therapy

is given to ensure eradication is given to ensure eradication of bacteriaof bacteria

Medical managementMedical management

1. 1. PharmacotherapyPharmacotherapy IV antibiotic for 2-6 weeksIV antibiotic for 2-6 weeksAntifungal agents are given – Antifungal agents are given –

amphotericin Bamphotericin B

Medical managementMedical management

2. 2. SurgerySurgeryValvular replacementValvular replacement

CHFCHF

A syndrome of congestion of A syndrome of congestion of both pulmonary and systemic both pulmonary and systemic circulation caused by circulation caused by inadequate cardiac function inadequate cardiac function and inadequate cardiac and inadequate cardiac output to meet the metabolic output to meet the metabolic demands of tissuesdemands of tissues

CHFCHF

Inability of the heart to Inability of the heart to pump sufficientlypump sufficiently

The heart is unable to The heart is unable to maintain adequate maintain adequate circulation to meet the circulation to meet the metabolic needs of the metabolic needs of the bodybody

CHFCHF

This can happen acutely or This can happen acutely or chronically chronically

AcuteAcute in Myocardial infarction in Myocardial infarction

ChronicChronic cardiomyopathies cardiomyopathies

CHFCHF

Classified according to the Classified according to the major ventricular major ventricular dysfunction:dysfunction:

1.1. Left Ventricular failureLeft Ventricular failure2.2. Right ventricular failureRight ventricular failure

CHFCHFEtiology of CHFEtiology of CHF

1. CAD1. CAD2. Valvular heart diseases2. Valvular heart diseases3. Hypertension3. Hypertension4. MI4. MI5. Cardiomyopathy5. Cardiomyopathy6. Lung diseases6. Lung diseases7. Post-partum7. Post-partum8. Pericarditis and cardiac tamponade8. Pericarditis and cardiac tamponade

New York Heart AssociationNew York Heart Association

Class 1Class 1 Ordinary physical activity does Ordinary physical activity does

NOT cause chest pain and NOT cause chest pain and fatiguefatigue

No pulmonary congestionNo pulmonary congestion AsymptomaticAsymptomatic NO limitation of ADLsNO limitation of ADLs

Class 2Class 2 SLIGHT limitation of ADLsSLIGHT limitation of ADLs NO symptom at restNO symptom at rest Symptoms with INCREASED Symptoms with INCREASED

activityactivity Basilar crackles and S3Basilar crackles and S3

Class 3Class 3Markedly limitation on ADLsMarkedly limitation on ADLsComfortable at rest BUT Comfortable at rest BUT

symptoms present in symptoms present in LESS LESS than ordinary activitythan ordinary activity

Class 4Class 4SYMPTOMS are present at SYMPTOMS are present at

restrest

CHFCHFPATHOPHYSIOLOGYPATHOPHYSIOLOGY

LEFT Ventricular pump failureLEFT Ventricular pump failure

back up of blood into the pulmonary veinsback up of blood into the pulmonary veins

increased pulmonary capillary pressureincreased pulmonary capillary pressure

pulmonary congestion (edema)pulmonary congestion (edema)

Pulmonary manifestationsPulmonary manifestations

CHFCHF

PATHOPHYSIOLOGYPATHOPHYSIOLOGYLEFT ventricular failureLEFT ventricular failure

Decreased cardiac outputDecreased cardiac output

Decreased perfusion to the brain, kidney Decreased perfusion to the brain, kidney and other tissues and other tissues

Cerebral anoxia, fatigue, oliguria, Cerebral anoxia, fatigue, oliguria, dizzinessdizziness

CHFCHF

PATHOPHYSIOLOGYPATHOPHYSIOLOGYRIGHT ventricular failureRIGHT ventricular failure

blood pooling in the venous blood pooling in the venous circulation circulation

increased hydrostatic pressureincreased hydrostatic pressure

peripheral edemaperipheral edema

CHFCHF

PATHOPHYSIOLOGYPATHOPHYSIOLOGYRIGHT ventricular failureRIGHT ventricular failure

Venous blood poolingVenous blood pooling

venous congestion in the kidney, venous congestion in the kidney, liver and GITliver and GIT

LEFT SIDED CHFLEFT SIDED CHFASSESSMENT FINDINGSASSESSMENT FINDINGS

1. Dyspnea on exertion, activity 1. Dyspnea on exertion, activity intoleranceintolerance

2. PND2. PND 3. Orthopnea3. Orthopnea 4. Pulmonary crackles/rales4. Pulmonary crackles/rales 5. Cough with Pinkish, frothy 5. Cough with Pinkish, frothy

sputumsputum 6. Tachycardia6. Tachycardia

LEFT SIDED CHFLEFT SIDED CHFASSESSMENT FINDINGSASSESSMENT FINDINGS

7. Cool extremities7. Cool extremities8. Cyanosis8. Cyanosis9. decreased peripheral pulses9. decreased peripheral pulses10. Fatigue10. Fatigue11. Oliguria11. Oliguria12. signs of cerebral anoxia12. signs of cerebral anoxia

RIGHT SIDED CHFRIGHT SIDED CHFASSESSMENT FINDINGSASSESSMENT FINDINGS

1. Peripheral dependent, 1. Peripheral dependent, pitting edemapitting edema

2. Weight gain2. Weight gain3. Distended neck vein3. Distended neck vein4. hepatomegaly4. hepatomegaly5. Ascites5. Ascites

RIGHT SIDED CHFRIGHT SIDED CHFASSESSMENT FINDINGSASSESSMENT FINDINGS

6. Body weakness6. Body weakness 7. Anorexia, nausea7. Anorexia, nausea 8. Pulsus alternans8. Pulsus alternans 9. 9. NocturiaNocturia= urination at night at = urination at night at

frequent intervals as the blood frequent intervals as the blood moves from interstitial space to moves from interstitial space to the intravascular space and is the intravascular space and is excretedexcreted

CHFCHF

LABORATORY FINDINGSLABORATORY FINDINGS 1. CXR may reveal 1. CXR may reveal

cardiomegalycardiomegaly 2. ECG may identify Cardiac 2. ECG may identify Cardiac

hypertrophyhypertrophy 3. Echocardiogram may show 3. Echocardiogram may show

hypokinetic hearthypokinetic heart

CHFCHF

LABORATORY FINDINGSLABORATORY FINDINGS 4. ABG and Pulse oximetry may 4. ABG and Pulse oximetry may

show decreased O2 saturationshow decreased O2 saturation 5. PCWP is increased in LEFT 5. PCWP is increased in LEFT

sided CHF and CVP is sided CHF and CVP is increased in RIGHT sided CHFincreased in RIGHT sided CHF

CHFCHF

NURSING INTERVENTIONSNURSING INTERVENTIONS 1. Assess patient's cardio-1. Assess patient's cardio-

pulmonary statuspulmonary status 2. Assess VS, CVP and 2. Assess VS, CVP and

PCWP. Weigh patient daily to PCWP. Weigh patient daily to monitor fluid retentionmonitor fluid retention

CHFCHFNURSING INTERVENTIONSNURSING INTERVENTIONS 3. Administer medications- 3. Administer medications-

usually cardiac glycosides are usually cardiac glycosides are given- DIGOXIN or DIGITOXIN, given- DIGOXIN or DIGITOXIN, Diuretics, vasodilators and Diuretics, vasodilators and hypolipidemics are prescribedhypolipidemics are prescribed

CHFCHFCardiotonics Cardiotonics

Positive Positive inotropic inotropic agentsagents

To increase cardiac To increase cardiac contractilitycontractility

DiureticsDiuretics To decrease the To decrease the intravascular volume intravascular volume in the circulationin the circulation

Low Sodium Low Sodium DietDiet

To minimize water To minimize water retentionretention

HypolipidemicHypolipidemicss

To decrease the lipid To decrease the lipid levels of high risk levels of high risk patients patients

CHFCHFNURSING INTERVENTIONSNURSING INTERVENTIONS

Digoxin Health teachingDigoxin Health teaching Oral tablet usually once a dayOral tablet usually once a day Increases force of contractionIncreases force of contraction DECREASES heart rateDECREASES heart rate Assess: Apical pulse, ECG, Assess: Apical pulse, ECG,

hypokalemiahypokalemia

CHFCHFNURSING INTERVENTIONSNURSING INTERVENTIONS

Digoxin Health teachingDigoxin Health teaching Withhold the drug if apical Withhold the drug if apical

pulse is less than 60pulse is less than 60 Note for early signs of toxicity: Note for early signs of toxicity:

NAVDANAVDA Provide potassium Provide potassium

supplementssupplements

CHFCHF

NURSING INTERVENTIONSNURSING INTERVENTIONS 4. Provide a LOW sodium diet. 4. Provide a LOW sodium diet.

Limit fluid intake as necessaryLimit fluid intake as necessary 5. Provide adequate rest 5. Provide adequate rest

periods to prevent fatigueperiods to prevent fatigue

CHFCHF

NURSING INTERVENTIONSNURSING INTERVENTIONS 6. Position on semi-fowler’s to 6. Position on semi-fowler’s to

fowler’s for adequate chest fowler’s for adequate chest expansionexpansion

7. Prevent complications of 7. Prevent complications of immobilityimmobility

CHFCHF

NURSING INTERVENTION AFTER THE NURSING INTERVENTION AFTER THE ACUTE STAGEACUTE STAGE

1. Provide opportunities for 1. Provide opportunities for verbalization of feelingsverbalization of feelings

2. Instruct the patient about the 2. Instruct the patient about the medication regimen- digitalis, medication regimen- digitalis, vasodilators and diureticsvasodilators and diuretics

3. Instruct to avoid OTC drugs, 3. Instruct to avoid OTC drugs, Stimulants, smoking and alcoholStimulants, smoking and alcohol

CHFCHF

4. Provide a LOW fat and LOW 4. Provide a LOW fat and LOW sodium dietsodium diet

5. Provide potassium 5. Provide potassium supplementssupplements

6. Instruct about fluid restriction6. Instruct about fluid restriction

CHFCHF

7. Provide adequate rest periods 7. Provide adequate rest periods and schedule activitiesand schedule activities

8. Monitor daily weight and report 8. Monitor daily weight and report signs of fluid retentionsigns of fluid retention

CARDIOGENIC SHOCKCARDIOGENIC SHOCK

Heart fails to pump Heart fails to pump adequately resulting to a adequately resulting to a decreased cardiac output decreased cardiac output and decreased tissue and decreased tissue perfusionperfusion

ETIOLOGYETIOLOGY 1. Massive MI1. Massive MI 2. Severe CHF2. Severe CHF 3. Cardiomyopathy3. Cardiomyopathy 4. Cardiac trauma4. Cardiac trauma 5. Cardiac tamponade5. Cardiac tamponade

CARDIOGENIC SHOCKCARDIOGENIC SHOCKASSESSMENT FINDINGSASSESSMENT FINDINGS 1. HYPOTENSION1. HYPOTENSION 2. Oliguria (less than 30 ml/hour)2. Oliguria (less than 30 ml/hour) 3. Tachycardia3. Tachycardia 4. Narrow pulse pressure4. Narrow pulse pressure 5. weak peripheral pulses5. weak peripheral pulses 6. cold clammy skin6. cold clammy skin 7. changes in sensorium/LOC7. changes in sensorium/LOC 8. pulmonary congestion8. pulmonary congestion

LABORATORY FINDINGSLABORATORY FINDINGS Increased CVP due to pooling of Increased CVP due to pooling of

blood in the venous systemblood in the venous system Normal is 4-10 cmH2ONormal is 4-10 cmH2O

Metabolic acidosisMetabolic acidosis

NURSING INTERVENTIONSNURSING INTERVENTIONS 1. Place patient in a modified 1. Place patient in a modified

Trendelenburg (shock ) positionTrendelenburg (shock ) position

2. Administer IVF, vasopressors and 2. Administer IVF, vasopressors and inotropics such as DOPAMINE and inotropics such as DOPAMINE and DOBUTAMINEDOBUTAMINE

NURSING INTERVENTIONSNURSING INTERVENTIONS

3. Administer O23. Administer O2

4. Morphine is administered to 4. Morphine is administered to decreased pulmonary decreased pulmonary congestion and to relieve pain, congestion and to relieve pain, relieve anxietyrelieve anxiety

5. Assist in intubation, mechanical 5. Assist in intubation, mechanical ventilation, PTCA, CABG, insertion ventilation, PTCA, CABG, insertion of Swan-Ganz cath and IABPof Swan-Ganz cath and IABP

6. Monitor urinary output, BP and 6. Monitor urinary output, BP and pulsespulses

7. cautiously administer diuretics 7. cautiously administer diuretics and nitratesand nitrates

CARDIAC TAMPONADECARDIAC TAMPONADE

A condition where the heart A condition where the heart is unable to pump blood is unable to pump blood due to accumulation of fluid due to accumulation of fluid in the pericardial sac in the pericardial sac (pericardial effusion)(pericardial effusion)

Causative factorsCausative factors 1. Cardiac trauma1. Cardiac trauma 2. Complication of Myocardial 2. Complication of Myocardial

infarctioninfarction 3. Pericarditis3. Pericarditis 4. Cancer metastasis4. Cancer metastasis

This condition restricts This condition restricts ventricular filling resulting to ventricular filling resulting to decreased cardiac outputdecreased cardiac output

Acute tamponade may happen Acute tamponade may happen when there is a sudden when there is a sudden accumulation of more than 50 accumulation of more than 50 ml fluid in the pericardial sacml fluid in the pericardial sac

ASSESSMENT FINDINGSASSESSMENT FINDINGS 1. BECK’s Triad- Jugular vein 1. BECK’s Triad- Jugular vein

distention, hypotension and distention, hypotension and distant/muffled heart sounddistant/muffled heart sound

2. Pulsus paradoxus2. Pulsus paradoxus 3. Increased CVP3. Increased CVP 4. Decreased cardiac output4. Decreased cardiac output

ASSESSMENT FINDINGSASSESSMENT FINDINGS 5. Syncope5. Syncope 6. Anxiety6. Anxiety 7. Dyspnea 7. Dyspnea 8. Percussion- Flatness across 8. Percussion- Flatness across

the anterior chestthe anterior chest

Laboratory FINDINGSLaboratory FINDINGS1. Echocardiogram= shows 1. Echocardiogram= shows

accumulated fluid in the accumulated fluid in the pericardial sac pericardial sac

2. Chest X-ray2. Chest X-ray

NURSING INTERVENTIONSNURSING INTERVENTIONS 1. Assist in 1. Assist in

PERICARDIOCENTESISPERICARDIOCENTESIS 2. Administer IVF2. Administer IVF 3. Monitor ECG, urine output and 3. Monitor ECG, urine output and

BPBP 4. Monitor for recurrence of 4. Monitor for recurrence of

tamponadetamponade

PericardiocentesisPericardiocentesis

Patient is monitored by ECG Patient is monitored by ECG Maintain emergency equipmentsMaintain emergency equipments Elevate head of bed 45-60 degreesElevate head of bed 45-60 degrees Monitor for complications- Monitor for complications-

coronary artery rupture, coronary artery rupture, dysrhythmias, pleural laceration dysrhythmias, pleural laceration and myocardial traumaand myocardial trauma

General Measures to Improve General Measures to Improve Peripheral CirculationPeripheral Circulation

1. Implement Regular Physical Activity – 1. Implement Regular Physical Activity – to facilitate movement of venous bloodto facilitate movement of venous blood

2. Eliminate cigarette smoking- to 2. Eliminate cigarette smoking- to prevent vasoconstrictionprevent vasoconstriction

3. Control hyperlipidemia and cholesterol 3. Control hyperlipidemia and cholesterol levels- to prevent the progression of levels- to prevent the progression of atherosclerosisatherosclerosis

HYPERTENSIONHYPERTENSION

A systolic BP greater than A systolic BP greater than 140 mmHg and a diastolic 140 mmHg and a diastolic pressure greater than 90 pressure greater than 90 mmHg over a sustained mmHg over a sustained period, based on two or more period, based on two or more BP measurementsBP measurements..

HYPERTENSIONHYPERTENSIONTypes of HypertensionTypes of Hypertension

1. Primary or ESSENTIAL1. Primary or ESSENTIAL Most common typeMost common type

2. Secondary 2. Secondary Due to other conditions like Due to other conditions like

Pheochromocytoma, renovascular Pheochromocytoma, renovascular hypertension, Cushing’s, Conn’s , hypertension, Cushing’s, Conn’s , SIADHSIADH

PATHOPHYSIOLOGYPATHOPHYSIOLOGY Multi-factorial etiologyMulti-factorial etiology

BP= CO (SV X HR) x TPRBP= CO (SV X HR) x TPR

Any increase in the above Any increase in the above parameters will increase BPparameters will increase BP

HYPERTENSIONHYPERTENSIONRisk factors for Cardiovascular Problems in Risk factors for Cardiovascular Problems in

Hypertensive patientsHypertensive patientsMajor Risk factorsMajor Risk factors 1. Smoking1. Smoking 2. Hyperlipidemia2. Hyperlipidemia 3. DM3. DM 4. Age older than 60 4. Age older than 60 5. Gender- Male and post menopausal 5. Gender- Male and post menopausal

womenwomen 6. Family History6. Family History

PATHOPHYSIOLOGYPATHOPHYSIOLOGY

Any increase in the above Any increase in the above parameters will increase BPparameters will increase BP

1. Increased sympathetic activity1. Increased sympathetic activity 2. Increased absorption of Sodium, 2. Increased absorption of Sodium,

and water in the kidneyand water in the kidney

Any increase in the above parameters Any increase in the above parameters will increase BPwill increase BP

3. Increased activity of the RAAS3. Increased activity of the RAAS 4. Increased vasoconstriction of the 4. Increased vasoconstriction of the

peripheral vesselsperipheral vessels 5. Insulin resistance5. Insulin resistance

ASSESSMENT FINDINGSASSESSMENT FINDINGS 1. Headache1. Headache 2. Visual changes2. Visual changes 3. chest pain3. chest pain 4. dizziness4. dizziness 5. N/V5. N/V

DIAGNOSTIC STUDIESDIAGNOSTIC STUDIES 1. Health history and PE1. Health history and PE 2. Routine laboratory- urinalysis, 2. Routine laboratory- urinalysis,

ECG, lipid profile, BUN, serum ECG, lipid profile, BUN, serum creatinine , FBScreatinine , FBS

3. Other lab- CXR, creatinine 3. Other lab- CXR, creatinine clearance, 24-huour urine proteinclearance, 24-huour urine protein

MEDICAL MANAGEMENTMEDICAL MANAGEMENT1. Lifestyle modification1. Lifestyle modification2. Diet therapy2. Diet therapy3. Drug therapy3. Drug therapy

MEDICAL MANAGEMENTMEDICAL MANAGEMENTDrug therapyDrug therapy

DiureticsDiuretics Beta blockersBeta blockers Calcium channel blockersCalcium channel blockers ACE inhibitorsACE inhibitors A2 Receptor blockersA2 Receptor blockers VasodilatorsVasodilators

NURSING INTERVENTIONSNURSING INTERVENTIONS1. Provide health teaching to 1. Provide health teaching to

patientpatient Teach about the disease Teach about the disease

processprocess Elaborate on lifestyle changesElaborate on lifestyle changes Assist in meal planning to lose Assist in meal planning to lose

weightweight

NURSING INTERVENTIONSNURSING INTERVENTIONS1. Provide health teaching to the 1. Provide health teaching to the

patientpatient Provide list of LOW fat , Provide list of LOW fat , LOW LOW

sodium diet of less than 2-3 grams sodium diet of less than 2-3 grams of Na/dayof Na/day

Limit alcohol intake to Limit alcohol intake to 30 ml/day30 ml/day Regular aerobic exerciseRegular aerobic exercise Advise to completely stop smokingAdvise to completely stop smoking

Nursing InterventionsNursing Interventions2. Provide information about anti-2. Provide information about anti-

hypertensive drugshypertensive drugs Instruct proper compliance and not Instruct proper compliance and not

abrupt cessation of drugs even if pt abrupt cessation of drugs even if pt becomes asymptomatic/ improved becomes asymptomatic/ improved conditioncondition

Instruct to avoid over-the-counter Instruct to avoid over-the-counter drugs that may interfere with the drugs that may interfere with the current medicationcurrent medication

Nursing InterventionNursing Intervention

3. Promote Home care management3. Promote Home care management Instruct regular monitoring of BPInstruct regular monitoring of BP Involve family members in careInvolve family members in care Instruct regular follow-upInstruct regular follow-up

Nursing InterventionNursing Intervention

4. Manage hypertensive emergency 4. Manage hypertensive emergency and urgency properly and urgency properly

ANEURYSMANEURYSM

Dilation involving an artery Dilation involving an artery formed at a weak point in formed at a weak point in the vessel wallthe vessel wall

ANEURYSMANEURYSM

SaccularSaccular= when one side of the vessel = when one side of the vessel is affected is affected

FusiformFusiform= when the entire segment = when the entire segment becomes dilatedbecomes dilated

ANEURYSMANEURYSM

RISK FACTORSRISK FACTORS

1.1. AtherosclerosisAtherosclerosis

2.2. Infection= syphilisInfection= syphilis

3.3. Connective tissue disorderConnective tissue disorder

4.4. Genetic disorder= Marfan’s Genetic disorder= Marfan’s SyndromeSyndrome

ANEURYSMANEURYSM

Damage to the intima and mediaDamage to the intima and media weaknessweakness outpouching of vessel outpouching of vessel wallwall

Dissecting aneurysmDissecting aneurysm tear in the tear in the intima and media with dissection intima and media with dissection of blood through the layersof blood through the layers

ANEURYSMANEURYSM

ASSESSMENTASSESSMENT

1.1. AsymptomaticAsymptomatic

2.2. Pulsatile sensation on the Pulsatile sensation on the abdomenabdomen

3.3. Palpable bruit Palpable bruit

ANEURYSMANEURYSM

LABORATORY:LABORATORY: CT scanCT scan UltrasoundUltrasound X-rayX-ray AortographyAortography

ANEURYSMANEURYSM

Medical Management:Medical Management: Anti-hypertensivesAnti-hypertensives Synthetic graftSynthetic graft

ANEURYSMANEURYSM

Nursing Management:Nursing Management: Administer medicationsAdminister medications Emphasize the need to avoid Emphasize the need to avoid

increased abdominal pressureincreased abdominal pressure No deep abdominal palpationNo deep abdominal palpation Remind patient the need for serial Remind patient the need for serial

ultrasound to detect diameter ultrasound to detect diameter changeschanges

PERIPHERAL ARTERIAL PERIPHERAL ARTERIAL OCCLUSIVE DISEASEOCCLUSIVE DISEASE

Refers to arterial insufficiency of Refers to arterial insufficiency of the extremities usually the extremities usually secondary to peripheral secondary to peripheral atherosclerosis.atherosclerosis.

Usually found in males age 50 Usually found in males age 50 and aboveand above

The legs are most often affectedThe legs are most often affected

ARTERIOSCLEROSIS OF THE

EXTREMITIES

Arteriosclerosis of the extremities is a disease of the peripheral blood vessels that is characterized by narrowing and hardening of the arteries that supply the legs and feet. The narrowing of the arteries causes a decrease in blood flow. Symptoms include leg pain, numbness, cold legs or feet and muscle pain in the thighs, calves or feet.

Risk factors for Peripheral Arterial Risk factors for Peripheral Arterial occlusive diseaseocclusive disease

Non-ModifiableNon-Modifiable 1. Age1. Age 2. gender2. gender 3. family predisposition3. family predisposition

Risk factors for Peripheral Arterial Risk factors for Peripheral Arterial occlusive diseaseocclusive disease

ModifiableModifiable 1. Smoking1. Smoking 2. HPN2. HPN 3. Obesity3. Obesity 4. Sedentary lifestyle4. Sedentary lifestyle 5. DM5. DM 6. Stress6. Stress

WALANG ORIGINA-LITY! HHMMPP!

ASSESSMENT FINDINGSASSESSMENT FINDINGS 1. 1. INTERMITTENT CLAUDICATION-INTERMITTENT CLAUDICATION-

the hallmark of PAODthe hallmark of PAOD This is PAIN described as aching, This is PAIN described as aching,

cramping or fatiguing discomfort cramping or fatiguing discomfort consistently reproduced with the consistently reproduced with the same degree of exercise or activitysame degree of exercise or activity

ASSESSMENT FINDINGSASSESSMENT FINDINGS 1. 1. INTERMITTENT INTERMITTENT

CLAUDICATION- CLAUDICATION- the hallmark of the hallmark of PAODPAOD

This pain is RELIEVED by RESTThis pain is RELIEVED by REST This commonly affects the This commonly affects the

muscle group below the arterial muscle group below the arterial occlusionocclusion

Assessment FindingsAssessment Findings 2. Progressive pain on the 2. Progressive pain on the

extremity as the disease extremity as the disease advancesadvances

3. Sensation of cold and 3. Sensation of cold and numbness of the extremitiesnumbness of the extremities

ARTERIOSCLEROSIS OF THE EXTREMITIES

Assessment FindingsAssessment Findings 4. Skin is pale when elevated 4. Skin is pale when elevated

and cyanotic and ruddy when and cyanotic and ruddy when placed on a dependent positionplaced on a dependent position

5. Muscle atrophy, leg ulceration 5. Muscle atrophy, leg ulceration and gangreneand gangrene

Diagnostic FindingsDiagnostic Findings 1. Unequal pulses between the 1. Unequal pulses between the

extremitiesextremities 2. Duplex ultrasonography2. Duplex ultrasonography 3. Doppler flow studies3. Doppler flow studies

PAODPAOD

Medical ManagementMedical Management

1. Drug therapy1. Drug therapy Pentoxyfylline (TrentalPentoxyfylline (Trental) reduces ) reduces

blood viscosity and improves blood viscosity and improves supply of O2 blood to musclessupply of O2 blood to muscles

Cilostazol (Pletaal) Cilostazol (Pletaal) inhibits platelet inhibits platelet aggregation and increases aggregation and increases vasodilatationvasodilatation

2. Surgery- Bypass graft and 2. Surgery- Bypass graft and anastomosesanastomoses

Nursing InterventionsNursing Interventions

1. Maintain Circulation to the extremity1. Maintain Circulation to the extremity Evaluate regularly peripheral pulses, Evaluate regularly peripheral pulses,

temperature, sensation, motor function temperature, sensation, motor function and capillary refill timeand capillary refill time

Administer post-operative care to patient Administer post-operative care to patient who underwent surgerywho underwent surgery

Administer heat modalities to the leg Administer heat modalities to the leg cautiously to promote vasodilatationcautiously to promote vasodilatation

Nursing InterventionsNursing Interventions2. Monitor and manage 2. Monitor and manage

complicationscomplications Note for bleeding, hematoma, and Note for bleeding, hematoma, and

decreased urine outputdecreased urine output Elevate the legs to diminish edemaElevate the legs to diminish edema Encourage exercise of the extremity Encourage exercise of the extremity

while on bedwhile on bed Teach patient to avoid leg-crossing Teach patient to avoid leg-crossing

3. Promote Home management3. Promote Home management Encourage lifestyle changesEncourage lifestyle changes Instruct to AVOID smokingInstruct to AVOID smoking Instruct to avoid leg crossingInstruct to avoid leg crossing

BUERGER’S DISEASEBUERGER’S DISEASE

Thromboangiitis obliteransThromboangiitis obliterans A disease characterized by A disease characterized by

recurring inflammation of the recurring inflammation of the medium and small medium and small arteries and arteries and veinsveins of the lower extremities of the lower extremities

Thromboangiitis obliteransThromboangiitis obliterans Occurs in MEN ages 20-35 Occurs in MEN ages 20-35 RISK FACTOR: SMOKING!RISK FACTOR: SMOKING!

PATHOPHYSIOLOGYPATHOPHYSIOLOGY Cause is UNKNOWNCause is UNKNOWN Probably an Autoimmune Probably an Autoimmune

diseasedisease Inflammation of the arteries Inflammation of the arteries

and veinsand veins thrombus thrombus formationformation occlusion of the occlusion of the vesselsvessels

1. 1. Leg PAINLeg PAIN Foot cramps in the arch Foot cramps in the arch

((INSTEP CLAUDICATIONINSTEP CLAUDICATION) after ) after exerciseexercise

Relieved by restRelieved by rest Aggravated by smoking, emotional Aggravated by smoking, emotional

disturbance and cold chillingdisturbance and cold chilling

2. Digital rest pain not changed by 2. Digital rest pain not changed by activity or restactivity or rest

ASSESSMENT FINDINGSASSESSMENT FINDINGS 3. Intense 3. Intense RUBORRUBOR (reddish-blue (reddish-blue

discoloration), progresses to discoloration), progresses to CYANOSIS as disease advancesCYANOSIS as disease advances

4. Paresthesias4. Paresthesias

Diagnostic StudiesDiagnostic Studies1. Duplex ultrasonography1. Duplex ultrasonography2. Contrast angiography2. Contrast angiography

1. Assist in the medical and surgical 1. Assist in the medical and surgical managementmanagement Bypass graftBypass graft amputationamputation

2. Strongly advise to AVOID smoking2. Strongly advise to AVOID smoking

3. Manage complications appropriately3. Manage complications appropriately

Nursing InterventionsNursing InterventionsPost-operative care: after Post-operative care: after amputationamputation Elevate stump for the FIRST 24 HOURS to Elevate stump for the FIRST 24 HOURS to

minimize edema and promote venous minimize edema and promote venous returnreturn

Place patient on PRONE position after 24 Place patient on PRONE position after 24 hours several times a dayhours several times a day

Assess skin for bleeding and hematomaAssess skin for bleeding and hematoma Wrap the extremity with elastic bandageWrap the extremity with elastic bandage

RAYNAUD’S DISEASERAYNAUD’S DISEASE

A form of intermittent arteriolar A form of intermittent arteriolar VASOCONSTRICTION that results in VASOCONSTRICTION that results in coldness, pain and pallor of the coldness, pain and pallor of the fingertips or toesfingertips or toes

Cause : UNKNOWNCause : UNKNOWN Most commonly affects WOMEN, Most commonly affects WOMEN,

16- 40 years old16- 40 years old

ASSESSMENT FINDINGSASSESSMENT FINDINGS1. 1. Raynaud’s phenomenonRaynaud’s phenomenon A localized episode of A localized episode of

vasoconstriction of the small vasoconstriction of the small arteries of the hands and feet arteries of the hands and feet that causes color and that causes color and temperature changes temperature changes

W-B-R is the acronym for the color W-B-R is the acronym for the color changechange

Pallor- due to vasoconstriction, Pallor- due to vasoconstriction, then then

Blue- due to pooling of Blue- due to pooling of Deoxygenated bloodDeoxygenated blood

Red- due to exaggerated reflow or Red- due to exaggerated reflow or hyperemiahyperemia

ASSESSMENT FINDINGSASSESSMENT FINDINGS2. Tingling sensation2. Tingling sensation

3. Burning pain on the hands 3. Burning pain on the hands and feetand feet

Medical managementMedical management Drug therapy with the use of Drug therapy with the use of

CALCIUM channel blockersCALCIUM channel blockersTo prevent vasospasmsTo prevent vasospasms

RAYNAUD’S DISEASERAYNAUD’S DISEASENursing InterventionsNursing Interventions 1. instruct patient to avoid situations 1. instruct patient to avoid situations

that may be stressfulthat may be stressful 2. instruct to avoid exposure to cold and 2. instruct to avoid exposure to cold and

remain indoors when the climate is coldremain indoors when the climate is cold 3. instruct to avoid all kinds of nicotine3. instruct to avoid all kinds of nicotine 4. instruct about safety. Careful handling 4. instruct about safety. Careful handling

of sharp objectsof sharp objects

Bisaya 1: " Gara ng kutsi, siguro kay MiyurBisaya 1: " Gara ng kutsi, siguro kay Miyur

iyan."!iyan."!Bisaya 2: " Dili bay!"Bisaya 2: " Dili bay!"Bisaya 1: " Kay Hipi?"Bisaya 1: " Kay Hipi?"Bisaya 2: " Tuntu ka man. Kay FATHER Bisaya 2: " Tuntu ka man. Kay FATHER iyan. Gisulat niya saiyan. Gisulat niya sa

likud o,"'SAFARI'."likud o,"'SAFARI'."

VARICOSE VEINSVARICOSE VEINS

THESE are dilated veins THESE are dilated veins usually in the lower usually in the lower extremitiesextremities

Predisposing FactorsPredisposing FactorsPregnancyPregnancyProlonged standing or Prolonged standing or

sittingsittingIncompetent venous valvesIncompetent venous valves

PathophysiologyPathophysiologyFactors Factors venous venous stasisstasis increased increased hydrostatic pressure hydrostatic pressure edemaedema

Assessment findingsAssessment findingsTortuous superficial veins Tortuous superficial veins on the legson the legs

Leg pain and HeavinessLeg pain and HeavinessDependent edemaDependent edema

Laboratory findingsLaboratory findingsVenographyVenographyDuplex scan Duplex scan pletysmographypletysmography

Medical managementMedical managementPharmacological therapyPharmacological therapyLeg vein stripping and Leg vein stripping and ligationligation

Anti-embolic stockingsAnti-embolic stockings

Nursing managementNursing management1. Advise patient to elevate 1. Advise patient to elevate

the legs with pillow to the legs with pillow to increase venous returnincrease venous return

2. Caution patient to avoid 2. Caution patient to avoid prolonged standing or prolonged standing or sittingsitting

Nursing managementNursing management3. Provide high-fiber foods 3. Provide high-fiber foods

to prevent constipationto prevent constipation4. Teach simple exercise to 4. Teach simple exercise to

promote venous returnpromote venous return

Nursing managementNursing management5. Caution patient to 5. Caution patient to

avoid constrictive avoid constrictive clothingclothing

Nursing managementNursing management6. Apply anti-embolic 6. Apply anti-embolic

stockings as directedstockings as directed7. 7. Avoid massage on the Avoid massage on the

affected areaaffected area

DVT- Deep Vein ThrombosisDVT- Deep Vein Thrombosis

Inflammation of the deep Inflammation of the deep veins of the lower extremities veins of the lower extremities and the pelvic veinsand the pelvic veins

The inflammation results to The inflammation results to formation of blood clots in formation of blood clots in the areathe area

Predisposing factorsPredisposing factors Prolonged immobilityProlonged immobility VaricositiesVaricosities Traumatic proceduresTraumatic procedures Increased age Increased age MalignancyMalignancy Estrogen therapyEstrogen therapy SmokingSmoking

ComplicationComplicationPULMONARY PULMONARY thromboembolismthromboembolism

Assessment findingsAssessment findingsLeg tendernessLeg tendernessLeg pain and edemaLeg pain and edemaPositive Positive HOMAN’s SIGNHOMAN’s SIGN

HOMAN’s SIGNHOMAN’s SIGN The foot is FLEXED upward The foot is FLEXED upward

(dorsiflexed) , there is a sharp pain (dorsiflexed) , there is a sharp pain felt in the calf of the legfelt in the calf of the leg indicative of indicative of venous inflammation venous inflammation

Laboratory findingsLaboratory findingsVenographyVenographyDuplex scanDuplex scan

Medical managementMedical managementAntiplatelets- aspirinAntiplatelets- aspirinAnticoagulantsAnticoagulantsVein stripping and graftingVein stripping and graftingAnti-embolic stockingsAnti-embolic stockings

Nursing managementNursing management

1. Provide measures to avoid 1. Provide measures to avoid prolonged immobilityprolonged immobilityRepositioning Q2Repositioning Q2Provide passive ROMProvide passive ROMEarly ambulationEarly ambulation

Nursing managementNursing management2. Provide skin care to prevent 2. Provide skin care to prevent

the complication of leg the complication of leg ulcersulcers

3. Provide anti-embolic 3. Provide anti-embolic stockingsstockings

Nursing managementNursing management4. Administer anticoagulants as 4. Administer anticoagulants as

prescribedprescribed

5. Monitor for signs of 5. Monitor for signs of pulmonary embolismpulmonary embolism sudden respiratory distresssudden respiratory distress

The EndThe End

Thank You!Thank You!

Cardio Nursing- Course Audit 2[1]

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