8A CardiovascularFinalwithdx

8/6/2019 8A CardiovascularFinalwithdx

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Cardiovascular

COMMON LAB TESTS FOR CARDIOVASCULAR DISORDERS

1. Serum Chemistry

2. Serum Electrolytes3. Alanine aminotransferase (AST) 5-40 IU/L4. Creatine kinase CK

Male 55-170U/L Female 30-135 U/L

5. CK - MB (isoenzyme) 0-7 U/L6. Lactic dehydrogenase (LDH)

LDH1 22%-36% LDH2 35%-46% LDH313%-26% LDH4 3%-10% LDH5 2%-9%

7. CBC8. Lipid levels9. Prothrombin time10. Alkaline phosphatase11. ESR12. Arterial Blood Gases13. Troponin

COMPLETE BLOOD COUNT

1. Red blood cell count

a. Men 4.7-6.1 million/mm3b. Women 4.2-5.4 million/mm3c. Infants and children 3.8-5.5 million/mm3

d. Newborns 4.8-7.1 million/mm3

2. White blood cell counta. Adults and children greater than two years of age 5,000-10,000/cm3

b. Children less than two years 6,200-17,000/mm3c. Newborns 9000-30,000/mm3

3. Hematocrita. Men 42-52%b. Women 37-47% (pregnancy>33%)c. Children 31-43%

d. Infants 30-40%e. Newborns 44-64%

4. Hemoglobina. Men 13.5-18.0 g/dlb. Women 12-16 g/dl (pregnancy >11 g/dl)c. Children 11-16 g/dld. Infants 10-15 g/dle. Newborns 14-24 g/dl

5. Erythrocyte indices

a. Mean corpuscular volume (MCV) 86-98 (m3/cell)b. Mean corpuscular hemoglobin (MCH) 27-32 pg/RBCc. Mean corpuscular hemoglobin concentrate. (MCHC) 32-36%

6. Differential white cell counta. Neutrophils 55-70%b. Lymphocytes 20-40%c. Monocytes 2-8%d. Eosinophils 1-4%e. Basophils 0.5-1.0%

7. Examination of peripheral blood cells: examination of size and shape of individual RBCs and platelets


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Electrocardiogram (ECG or EKG):

1. records electromechanical activity of myocardium,electrical axis of the heart2. the ECG records two basic events: depolarization andrepolarization

3. the ECG records electrical activity as specific wavesa. P-wave: sinus node generates impulse; atriadepolarizeb. PR interval: time for impulse to travel from sinusnode through atria to atrioventricular node, the Bundle of His, thebundle branches and the ventricles; range: 0.12-0.20 secondsc. QRS complex: ventricle depolarizes and contracts

(systole)d. T wave: ventricle repolarizes, ready for next systolee. ST segment: time between ventricular depolarization and repolarization

4. used to determine presence of ischemic cardiac diseaseand cardiac conduction disturbances

Exercise stress test

1. records myocardial response to exercise2. used to determine ischemic heart disease andcardiovascular fitness before exercise programs

3. exercise level is progressively raised while ECG ismonitored4. blood pressure and blood gases may be measured5. nursing interventions

a. encourage client to immediately report anysymptoms during and after testb. client should dress for exercise and bring a changeof clothing


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Ambulatory electrocardiography (Holter monitor)

1. records myocardial activity continuously for 24 or 48 hours2. portable device3. used to detect cardiac rhythm disturbances over time4. correlated with client's activity5. specific nursing intervention: client must keep a diary thatrecords both activity and any symptoms during test

Electrophysiology studies

1. an invasive measure of cardiac electrical activity2. electrical catheter is inserted into right atrium via aperipheral vein3. an ECG records each electrical stimulation of heart andhow the heart responds4. used to determine cardiac dysrhythmias

Hemodynamic monitoring: invasive cardiac catheter

a. reflects left ventricular end diastolic pressureb. use of a balloon-tipped, flow-directed catheter to providecontinuous monitoring

c. catheter introduced via subclavian vein or by cutdown andpassed through right side of heart to pulmonary arteryd. may be inserted at the bedside or under fluoroscopye. normal parameters
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f. complications of hemodynamic monitoringi. pneumothoraxii. dysrhythmiasiii. infection, sepsis, thrombophlebitis

g. nursing interventions: monitor values, assess and changedressings, maintain patency with fluids, calibrate equipment, remove lines,obtain specimens, strict asepsis, standard precautions

Intra-arterial pressure

a. catheter in a major artery and attached to transducer b. most common site: radial arteryc. usually inserted at bedside

d. also used to obtain arterial blood gas samples and other diagnostic studiese. normal parameters

i. peak systolic: 100 mm Hgii. end diastolic: 60-80 mm Hgiii. mean 70-90 mm Hg

f. complications: clot formation, decreased or absent pulse,hematoma, infection, hemorrhage

Cardiac output (CO)

a. volume of blood heart beats per minute

b. thermodilution technique using blood temperature changesc. known volume of solution is injected at a specific rate intothe right atriumd. temperature-sensitive probe measures temperature of blood as it passes through cathetere. contraindications: bleeding disorders, immunosuppressionf. cardiac output (CO) (heart rate x stroke volume) 4-8L/ming. nursing care of client with cardiac catheter

i. explain procedure to clientii. obtain baseline vital signs and rhythm stripiii. place client in supine positioniv. calibrate pressure monitor

v. obtain chest x-ray to guide catheter placementvi. obtain arterial blood gases as orderedvii. change dressings and tubing as orderedviii. maintain patency of catheter ix. monitor and record vital signs and pressures as

orderedx. observe for complications

Intraaortic balloon pump (IABP)

a. device that helps blood circulate after myocardial failure1. sausage-shaped balloon is threaded via femoral

artery into aorta2. balloon inflates with diastole and deflates withsystole

b. used to treat cardiogenic shockc. contraindications:

1. aortic regurgitation

2. dissection3. abdominal aortic aneurysm
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d. complications1. insertion site:

1. infection2. bleeding3. hematoma4. diminished or absent pulse

5. thrombus2. generalized

1. aortic dissection or perforation

2. thrombocytopenia3. dysrhythmias4. myocardial failure

e. nursing interventions1. explain procedure to client2. obtain informed consent3. take baseline vital signs, hemodynamic parametersand ECG4. monitor vital signs, hemodynamic status and ECG

as ordered5. monitor client's level of consciousness (LOC)6. obtain arterial blood gases as ordered7. asepsis8. provide emotional support to client and family9. monitor intake and output10. client must not bend leg in which balloon wasinserted11. monitor for complications

Pacemakers

a. a battery-powered pulse generator that stimulates theheart via electrodes that touch myocardiumb. use:

1. hemodynamic and life support2. to correct dysrhythmias

c. types1. atrial pacing2. ventricular pacing3. atrioventricular sequential and physiologic pacing

d. three kinds of pacemakers1. asynchronous (fixed rate): pace at a preset rate,regardless of persons rhythm2. demand (standby): pace only if intrinsic ratedeclines below rate set on pacemaker3. synchronous: sensing circuit detects atrial andventricular activity

e. indications for pacing

1. symptomatic bradyarrhythmia

2. symptomatic tachyarrhythmia3. asystole4. prophylaxis in persons with high risk bradycardia5. diagnosis of dysrhythmias during electrophysiologictesting

f. types of pulse generatorsi. temporary pacemakers transvenous approach is most common:Catheter electrode inserted via peripheral vein andconnected to external pulse generator transthoracic: used primarily during cardiacsurgery; catheter electrode is placed directly into heart
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ii. permanent pacemakers: transvenous catheter electrode is passed through rightheart and connected to small generator generator is implanted subcutaneously onchest wall, usually in upper right quadrant lithium-powered battery can last up to ten

years

f. complications of pacemakersi. infectionii. perforation of myocardium

iii. pneumothorax

iv. hemothoraxv. dysrhythmias

vi. thrombosisvii. failureviii. syncopeix. hypotensionx. pallor xi. hiccupsxii. shortness of breath

g. nursing interventionsi. explain procedure to clientii. initiate preoperative careiii. post-procedure

initiate post-anesthesia care monitor vital signs and ECG as ordered maintain bed rest as ordered observe for signs of complications

iv. teach client pacemaker's set rate how to take pulse (rate and rhythm) findings of pacemaker failure, woundinfection activity limitations hazards: high output electrical generators:welding equipment, radar, microwaves, MRI importance of carrying medical alert jewelryand information need for periodic battery replacement avoidance of contact sports and those thatinvolve swinging arms (golf, hunting) importance of medical follow-up

Automatic implantable cardioverter-defibrillator (AICD)

a. pulse generator implanted in subcutaneous pocket. Whenit detects ventricular tachycardia or ventricular fibrillation, it deliverselectrical shock to heartb. used to treat life-threatening ventricular dysrhythmiasc. complications

i.ii. infectioniii. malfunctioniv. battery failure

d. nursing interventionsi. explain procedure to clientii. care of the surgical clientiii. administer medications as orderediv. monitor ECG as orderedv. provide emotional support and reassurancevi. teach client


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findings of defibrillation discharge importance of routine follow-up findings of complications limit activity as ordered avoid strong magnetic fields wear MedicAlert jewelry and information assure client that no household appliancewill affect AICD shock may be painful

I. Anatomy and PhysiologyA. Anatomy

1. Layersa. pericardium: fibrousb. epicardium: covers surface of heartc. myocardium: muscular portion of the heartd. endocardium: lines cardiac chambers and covers surface

of heart valves2. Chambers of heart

a. right atrium: collecting chamber for incoming systemicvenous system

b. right ventricle: propels blood into pulmonary systemc. left atrium: collects blood from pulmonary venous systemd. left ventricle: thick-walled, high-pressure pump that propels

blood into system

3. Heart valves: membranous openings that allow one way bloodflow

a. atrioventricular valves: prevent backflow from ventricles toatria during systole

b. tricuspid - right heart valvec. mitral - left heart valved. semilunar valves prevent backflow from aorta and

pulmonary arteries into ventricles during diastolei. pulmonicii. aortic


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4. Blood supply to hearta. arteries

i. right coronary artery supplies right ventricle and

part of left ventricleii. left coronary artery supplies mostly left ventricle

b. veinsi. coronary sinus veinsii. thebesian veins

5. Conduction systema. SA (sinoatrial) nodeb. junctional tissuec. bundle branch Purkinje system

Think:

Mighty (or Big) left side of the heart -Mitral (or Bicuspid) valve.

In Contrast: Tiny right side of the heart -Tricuspid valve.


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B. Physiology1. Function of the heart is the transport of oxygen, carbon dioxide,

nutrients and waste products

2. Cardiac cycle consists of:a. systole - the phase of contraction during which the

ventricles eject bloodb. diastole - the phase of relaxation during which the

chambers fill with blood. When heart pumps, myocardiallayer contracts and relaxes.

3. Blood flow:a. deoxygenated blood enters the right atrium through the

superior and inferior vena cavab. enters the right ventricle via the tricuspid valvec. travels through the pulmonic valve to pulmonary arteries

and lungs

d. oxygenated blood returns from lungs through thepulmonary veins into left atrium and enters the left ventriclevia bicuspid (mitral) valve.

e. from the left ventricle, through the aortic valve through theaorta to the systemic circulation

4. The heart itself is supplied with blood by the left and right coronaryarteries

5. The vascular system is a continuous network of blood vessels.


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a. the arterial system consists of arteries, arterioles andcapillaries and delivers oxygenated blood to tissues

b. oxygen, nutrients and metabolic waste are exchanged atthe microscopic level

c. the venous system, veins and venules, returns the blood tothe heart

Blood Flow to the Heart


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II. Heart InfectionsA. Pericarditis

1. Definition and related termsa. in pericarditis, an infection or collagen disease (from a

bacterium, a fungus, Systemic Lupus Erythematosus(SLE), etc.) inflames the pericardium.

b. there may or may not be pericardial effusion orconstrictivepericarditis.

c. Dressler's syndrome, also called postmyocardial infarctionsyndrome, is a combination of pericarditis, pericardialeffusion and constrictive pericarditis. It occurs severalweeks to months after a myocardial infarction. Etiologyunclear.

2. Epidemiologya. may be acute or chronic and may occur at any age.b. pericarditis occurs in up to 15% of persons with a

transmural infarction.

3. Findingsa. sharp chest pain often relieved by leaning forward

b. pericardial friction rub

c. dyspnead. fever, sweating, chills

e. dysrhythmiasf. pulsus paradoxusg. client cannot lie flat without pain ordyspnea

ASSESSING CLIENTS WITH CARDIOVASCULAR DISORDERS
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4. Managementa. antibiotics to treat underlying infection

b. corticosteroids: usually reserved for clients with pericarditisdue to SLE, or clients who do not respond to NSAID

c. NSAIDS/Asprin for pain and inflammationd. oxygen: to prevent tissue hypoxiae. surgical

i. emergency pericardiocentesis ifcardiac tamponadedevelops

ii. for recurrent constrictive pericarditis, partialpericardiectomy (pericardial window) or totalpericardiectomy

5. Nursing interventionsa. manage pain and anxiety

b. the cardio-care six (refer to box below)c. maintain a pericardiocentesis set at the bedside in case of

cardiac tamponade.d. assess respiratory, cardiovascular, and renal status often.e. observe for findings of infiltration or inflammation at the

venipuncture site, a possible complication of long-term IVadministration. Rotate the IV sites often.

f. client and family teaching - teach the cardio five(refer tobox below)

6. Diagnostic studiesa. EKG changes, arrythmiasb. echocardiography to determine pericardial efusion or

cardiac tamponadec. history and physical exam

THE CARDIO-CARE SIX: A,B,C,D,E,F1. ADL: Help the client with activities of daily living.2. Bed rest3. Commode at bedside (it stresses the heart less than using a bedpan does).

4. Diversions: offer diversions that don't stress the heart.5. Elevate head of bed, or sit client up.6. Feelings: Let clients express concern; reassure when activity will resume.

TEACH THE CARDIO FIVE: TDDDS

1. Tests and treatments: explain them in simple, culturally sensitive ways.2. Drugs, their side effects, and how long client will take them.3. Diet: good nutrition and restrictions (such as low sodium).4. Disease, its treatment, and what signs to report promptly: the 'watch-fors'.5. Smoker? Teach and encourage 'stop smoking'.
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B. Myocarditis1. Definition - an inflammatory condition of the myocardium caused

bya. viral infectionb. bacterial infectionc. fungal infectiond. serum sicknesse. rheumatic feverf. chemical agent

g. as a complication of a collagen disease, i.e. SLE2. Epidemiology

a. may be acute or chronic and may occur at any age

b. usually an acute virus and self-limited, but it may lead toacute heart failure

3. Findingsa. depends on the type of infection, degree of myocardial

damage, capacity of myocardium to recover, and hostresistance

b. may be minor or unnoticed: fatigue and dyspnea,palpitations, occasional precordial discomfort manifestedas a mild chest soreness and persistent fever

c. recent upper-respiratory infection with fever, viralpharyngitis, or tonsillitis

d. cardiac enlargement

e. abnormal heart sounds: murmur, S3 orS4 orfriction rubf. possibly findings ofcongestive heart failure such as pulsus

alternans, dyspnea, and crackles

g. tachycardia disproportionate to the degree of fever

CLASSIFYING HEART MURMURS BY INTENSITY
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4. Diagnostic studiesa. EKG for changes and arrythmiasb. labs

i. increases ESRii. increases myocardial enzymes such as:

AST CK LDH

c. endomyocardial biopsy (EMB)d. myocardial imaging

5. Managementa. antibiotics to treat underlying infectionb. corticosteroids to decrease inflammationc. analgesics for paind. oxygen to prevent tissue hypoxia

6. Nursing interventions

a. the cardio-care six with modified bedrest and less help withADLs

b. assess for edema weigh daily; record intake and output

PITTING EDEMA GRADING SCALE

c. assess cardiovascular status frequently

d. observe for findings of left-sided heart failure (dyspnea,hypotension and tachycardia)

e. check often for changes in cardiac rhythm orconduction;auscultateheart sounds

f. evaluate arterial blood gas levels as needed to ensureadequate oxygenation

g. client and family teaching

i. physical activity may be slowly increased to sittingin chair, walking in room, then outdoors.

ii. avoid pregnancy, alcohol, and competitive sports.iii. immunize against infections.iv. teach client about anti-infective drugs. Stress

importance of taking drugs as ordered.v. teach clients taking digitalis at home to:

PULSE GRADING SCALE(4-Point Scale)

a. No pulse = 0

b. Weak pulse = 1+

c. Difficult to palpate = 2+

d. Normal = 3+

e. Bounding = 4+
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check pulse for one full minute before takingthe dose, and withhold the drug if heart ratefalls below 60 beats/minute.

observe for findings of digitalis toxicity(anorexia, nausea, vomiting, blurred vision,cardiac arrhythmias) and for factors that

may increase toxicity, such as electrolyteimbalance and hypoxia.

vi. teach client to report rapidly beating heart.

C. Endocarditis1. Definition and related terms

a. an infection of the endocardium, heart valves, or cardiacprosthesis resulting from bacterial or fungal invasion.

b. endocarditis can be classified asi. native valve endocarditisii. endocarditis in I.V. drug usersiii. prosthetic valve endocarditis

2. Epidemiologya. with proper treatment about 70% of clients recoverb. the prognosis is worse when endocarditis damages valves

severely or involves a prosthetic valvec. infective endocarditis occurs in 50 to 60% of clients with

previous valvular disorders

d. systemic lupus erythematosus (SLE) often leads tononbacterial endocarditis

e. in 12% to 35% of clients with subacute endocarditis,lesions produce clots that show the findings of splenic,renal, cerebral or pulmonary infarction, or peripheralvascular occlusion

3. Findings of endocarditis

a. cardiac murmurs in 85 to 90% of clientsb. fever c. especially, a murmur that changes suddenly, or a new

murmur that develops in the presence of a fever

d. pericardial friction rub

e. anorexiaf. malaise

g. clubbing of fingersh. neurologic sequelae ofembolusi. petechiae of the skin (especially on the chest)j. splinter hemorrhage under the nails

k. infarction ofspleen: pain in the upper left quadrant,radiating to the left shoulder, and abdominal rigidity

l. infarction in kidney: hematuria, pyuria, flank pain, anddecreased urine output

PULSE SITES (LANDMARKS FOR PULSE)

1. Temporal: found over temporal bone lateral to eye2. Apical: found between fourth and fifth intercostal space usually

mid-clavicular line3. Carotid: found over the carotid artery in neck4. Brachial: found in the antecubital area of arm5. Radial: found on thumb side of wrist

6. Ulnar: found medial wrist7. Femoral: found below the inguinal ligament8. Popliteal: found behind the knee9. Posterior tibial: found on inner side of each ankle10. Dorsalis pedis: found along top of foot
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m. infarction in brain: hemiparesis, aphasia, and otherneurologic deficits

n. infarction in lung: cough, pleuritic pain, pleural friction rub,dyspnea and hemoptysis

o. peripheral vascular occlusion: numbness and tingling in anarm, leg, finger, or toe, or signs of impending peripheralgangrene

4. Management - clients at risk for prosthetic valves

a. prophylaxis - to prevent endocarditis; i.e. MVP, cardiaclesionsb. antibiotics - to treat underlying infectionc. antipyretics - to control feverd. anticoagulants - to prevent embolizatione. oxygen - to prevent tissue hypoxiaf. surgical - possible valve replacement


a. the cardio-care sixb. observe for findings of infiltration or inflammation at

venipuncture site; rotate sites often.c. client and family teaching

i. explain all procedures in a simple and culturallysensitive manner.ii. involve the client and family in scheduling the daily

routine activities. Allow client and family toparticipate in care.

iii. teach client relaxation techniques (meditation,visualization, or guided imagery) to cope withstress, pain, or insomnia.

iv. explain endocarditis and the need for long-termtherapy.

v. explain the need for prophylactic antibiotics beforedental work and other invasive procedures.

vi. teach client to report fever, tachycardia, dyspneaand shortness of breath.6. Diagnostic studies

a. health historyb. lab data

i. CBCii. blood culturesiii. ESR

SIGNS OF VENOUS INSUFFICIENCY IN THE EXTREMITIES

1. Skin color reddish brown or cyanotic if extremity lowered2. Normal temperature3. Normal pulse4. Often marked edema, usually foot to calf5. Brown pigmentation around ankles

SIGNS OF ARTERIAL INSUFFICIENCY IN THE EXTREMITIES

1. Pale color on elevation, dusky red color when lowered2. Cool to touch3. Decreased or absent peripheral pulses4. Little or no edema5. Thin, shiny skin and decreased growth of hair6. Thickened nails7. Pain unrelieved by rest and/or activity8. Chronic pain may be either steady or intermittent

9. Claudication pain as tight feeling, burning, fatigue, ache or cramping
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c. CXR - to detect CHFd. EKG - transesophageal echocardiogram to detect

vegetation and abscess on valves

D. Rheumatic heart disease (rheumatic endocarditis)1. Definition and related terms

a. rheumatic heart disease is damage to the heart by one ormore episodes of rheumatic fever. Pathogen is a group Astreptococci.

b. rheumatic endocarditis is damage to the heart, particularlythe valves, resulting in valve leakage (regurgitation) and/orstenosis. To compensate, the heart's chambers enlargeand walls thicken.

2. Epidemiologya. worldwide, 15 to 20 million new cases of rheumatic fever

are reported each year.

b. rheumatic fever follows a group A streptococcal infection.We could prevent it by finding and treating streptococcalpharyngitis.

c. where malnutrition and crowded living are common,rheumatic fever is commonest in children between ages 5and 15.

d. rheumatic fever strikes most often during cool, dampweather. In the U.S., it is most common in the northernstates.

e. it is unknown how and why group A streptococcalinfections cause the lesions called Aschoff bodies.

f. damage depends on site of infection: most often the mitralvalve in females and the aortic valve in males.

g.malfunction of these valves leads to severe pericarditis,and sometimes pericardial effusion and fatal heart failure.Of those who survive this complication, about 20% diewithin ten years.

3. Findingsa. streptococcal pharyngitis

I. sudden sore throat

II. throat reddened with exudateIII. swollen, tender lymph nodes at angle of jawIV. headache and fever to 104 degrees Fahrenheit

b. polyarthritis manifested by warm and swollen joints

c. carditis

d. choreae. erythema marginatum (wavy, thin red-line rash on trunkand extremities)

f. subcutaneous nodulesg. fever to 104 degrees Fahrenheit

h. heart murmurs pericardial friction rub and pericardial rubi. no lab test confirms rheumatic fever, but some support the

diagnosis.4. Management

a. give antibiotics steadily to maintain level in blood.b. provide analgesics - for pain/inflammationc. oxygen to prevent tissue hypoxia.

d. surgical - commissurotomy, valvuloplasty, prosthetic heartvalve


a. the cardio-care sixb. help the client with chorea to grasp objects; prevent falls.c. encourage family and friends to spend time with client and

fight boredom during the long, tedious convalescence.d. client and family teaching
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I. explain all tests and treatmentsII. nutritionIII. hygienic practicesIV. to resume ADLs slowly and schedule rest periodsV. to report penicillin reaction: rash, fever, chillsVI. to report findings of streptococcal infection

i. sudden sore throatii. diffuse throat redness and

oropharyngeal exudateiii. swollen and tender cervical lymph

glandsiv. pain on swallowingv. temperature of 101 to 104 degree

Fahrenheitvi. headachevii. nausea

VII. keep client away from people with respiratoryinfections

VIII. explain necessity of long-term antibioticsIX. arrange for a visiting nurse if necessaryX. help the family and client cope with temporary

chorea6. Diagnostic studies

a. antistreptolysin 0 titer - increasedb. ESR - increasedc. throat culture - positive for streptococcid. WBC count - increasede. RBC parameters - normocytic, normochromic anemiaf. C-reactive protein - positive for streptococci

III. Valve Disorders

A. Mitral stenosis1. Definition - mitral valve thickens and gets narrower, blocking blood

flow from the left atrium to left ventricle.b. physiology

i. function of the heart is the transport ofoxygen, carbon dioxide, nutrients and wasteproducts

ii. cardiac cycle consists of: systole - the phase of contraction

during which the chambers eject

blood diastole - the phase of relaxation

during which the chambers fill withblood. When heart pumps,myocardial layer contracts andrelaxes.

iii. blood flow: deoxygenated blood enters the right

atrium through the superior andinferior vena cava

enters the right ventricle via thetricuspid valve

travels through the pulmonic valve topulmonary arteries and lungs

oxygenated blood returns from lungsthrough the pulmonary veins into leftatrium and enters the left ventriclevia bicuspid (mitral) valve.


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from the left ventricle, through theaortic valve through the aorta to thesystemic circulation

iv. the heart itself is supplied with blood by theleft and right coronary arteries

v. the vascular system is a continuous network

of blood vessels. the arterial system consists of

arteries, arterioles and capillariesand delivers oxygenated blood totissues

oxygen, nutrients and metabolicwaste are exchanged at the cellularlevel

the venous system, veins andvenules, returns the blood to theheart

2. Epidemiology

a. of clients with mitral stenosis, 2/3 are femaleb. most cases of mitral stenosis are caused by rheumatic fever

2. Findingsa. mild - no findingsb. moderate to severe

i. dyspnea on exertionii. paroxysmal nocturnal

dyspneaiii. orthopneaiv. weakness, fatigue, and

palpitations

c. peripheral and facial cyanosis in severe casesd. jugular vein distention

e. with severe pulmonary hypertension or tricuspid stenosis -ascites

f. edemag. hepatomegaly

h. diastolic thrill at the cardiac apexi. when client lies on left side, loud S1 or opening snap and a

diastolic murmurat the apexj. crackles in lungs

3. Managementa. antiarrhythmics if needed

b. if medication fails, atrial fibrillation is treated withcardioversion.

c. low-sodium diet - to prevent fluid retentiond. oxygen if needed - to prevent hypoxiae. surgery - mitral commissurotomy or valvotomy


a. the cardio-care sixb. observe closely for findings of heart failure, pulmonary edema,

and reactions to drug therapy.c. if client has had surgery, watch for hypotension, arrhythmias,

and thrombus formation.

d. monitor the cardio sevene. client and family (teach the cardio-five:TDDS)i. explain the need for long-term antibiotic therapy

and the need for additional antibiotics before dentalcare.

ii. report early findings of heart failure such asdyspnea or a hacking, nonproductive cough.

5. Diagnostic studies/findings
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a. history and physical examb. EKG- for changes of left atrial enlargement and right ventricle

enlargementc. echocardiogram - for restricted movement of the mitral valves

and diastolic turbulance

B. Mitral insufficiency (or regurgitation)1. Definition and related terms

a. a damaged mitral valve allows blood from the left ventricleto flow back into the left atrium during systole.

b. to handle the backflow, the atrium enlarges. So does theleft ventricle, in part to make up for its lower output of

blood.2. Epidemiology

a. follows birth defects such as transposition of the greatarteries.

b. in older clients, the mitral annulus may have becomecalcified.

c. cause unknown; may be linked to a degenerative process.d. occurs in 5 to 10% of adults.

3. Findingsa. client may be asymptomatic

b. orthopnea, dyspnea, fatigue, weakness, weight lossc. chest pain and palpitations

d. jugular vein distentione. peripheral edema

4. Managementa. low-sodium diet - to prevent fluid retentionb. oxygen as needed - to prevent tissue hypoxiac. antibiotics - to treat infectiond. prophylactic antibiotics - to prevent infectione. surgery - mitral valvuloplasty or valve replacement

MONITOR THE CARDIO SEVEN:

Charlie's Ex packed Ruth in Granny's VW.


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a. the cardio-care six

b. monitor the cardio sevenc. monitor for left-sided heart failure, pulmonary edema,

adverse reactions to drug therapy, and cardiacdysrhythmias especially atrial and ventricular fibrillation

d. if client has surgery, monitor postoperatively forhypotension, arrhythmias and thrombus formation

e. client and family teaching1. diet restrictions and drugs2. explain tests and treatments3. prepare client for long-term antibiotic and follow-up

care.4. stress the need for prophylactic antibiotics during

dental care.5. teach client and family to report findings of heart

failure:dyspnea and hacking, nonproductive cough.

6. Diagnostic findingsa. EKG for arrythmias and changes of left atrial enlargementb. echocardiogram - to visualize regurgitant jets and flail

chordae/leafletsc. cardiac cath shows regurgitation of blood from left ventricle

to left atrium

C. Tricuspid stenosis1. Definition: narrowing of the tricuspid valve between right atrium

and right ventricle2. Epidemiology

a. relatively uncommonb. usually associated with lesions of other valves

c. caused by rheumatic fever3. Findings

a. dyspnea, fatigue, weakness, syncopeb. peripheral edemac. jaundice with severe peripheral edema and ascites can

mean that tricuspid stenosis has led to right ventricularfailure

d. may appear malnourishede. distended jugular vein

4. Management: surgery - valvulotomy or valve replacement;valvuloplasty


a. the cardio-care sixb. monitor the cardio sevenc. monitor for findings of heart failure, pulmonary edema, and

adverse reactions to the drug therapyd. post valve surgery, monitor client for hypotension,

arrhythmias and thrombus formatione. when client sits, elevate legs - to prevent dependent

edema
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f. client and family teaching

1. teach the cardio five

2. client must comply with long-term antibiotic andfollow up care

3. emphasize the need for prophylactic antibioticsduring dental care

6. Diagnostic findingsa. EKG - for arrythmiasb. echocardiogram - right ventricular dilation and paradoxic

septal motionD. Tricuspid insufficiency (regurgitation)

1. Definition - tricuspid valve lets blood leak from the right ventricleback into the right atrium

2. Epidemiologya. results from dilation of the right ventricle and tricuspid

valve ringb. most common in late stages of heart failure from rheumatic

or congenital heart disease

3. Findingsa. dyspnea, fatigue, weakness and syncopeb. peripheral edema may cause discomfort

4. Management: surgical - valve replacement5. Nursing interventions

a. the cardio-care sixb. monitor for cardio sevenc. monitor for findings of heart failure, pulmonary edema, and

adverse reactions to the drug therapyd. post-op monitor client for hypotension, arrhythmias and

thrombus formatione. when sitting, client should raise legs - to prevent

dependent edemaf. client and family teaching

1. the cardio five2. emphasize the need for prophylactic antibiotics

during dental care3. instruct client to raise legs when sitting - to prevent

dependent edema

E. Pulmonic stenosis

1. Definition - obstructed right ventricular outflow resulting in rightventricular hypertrophy

2. Epidemiologya. usually congenital, often with other birth defects such astetralogy of Fallot

b. rare among the elderlyc. may result from rheumatic fever

3. Findingsa. dyspnea, fatigue, chest pain and syncopeb. peripheral edema may cause discomfort

4. Management: surgical - replace the valve via balloon and cardiaccatheter

5. Nursing interventionsa. same as tricuspid stenosis and tricuspid insufficiency

b. monitor for findings of heart failure, pulmonary edema, andadverse reactions to to the drug therapyc. post-op: monitor client for hypotension, dysrhythmias and

thrombus formation

d. monitor the cardio sevene. client and family teaching - same as tricuspid stenosis and

tricuspid insufficiencyF. Pulmonic insufficiency (regurgitation)
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1. Definition - pulmonary valve fails to close, so that blood flows backinto the right ventricle

2. Epidemiologya. a birth defect, or a result of pulmonary hypertensionb. rarely, result of prolonged use of a pressure-monitoring

catheter in the pulmonary artery

3. Findingsa. dyspnea, fatigue, chest pain and syncopeb. peripheral edema may cause discomfort

c. if advanced:jaundice with ascites and peripheral edemad. possible malnourished appearance

4. Managementa. diuretics - to mobilize edematous fluid to reduce pulmonary

venous pressureb. sodium-restricted diet - to control underlying heart diseasec. anticoagulants - to prevent blood clotsd. digitalis - to increase the force or strength of cardiac

contractions (inotropic action)

e. surgery for severe cases: valvulotomy or valvereplacement


a. the cardio-care sixb. monitor the cardio seven

c. monitor for findings of heart failure, pulmonary edema, andadverse reactions to drug therapy

d. post-op: monitor client forhypotension, arrhythmias andthrombus formation

e. provide rest periodsf. when client sits, raise legs

g. client and family teaching: (same as tricuspid stenosis,tricuspid insufficiency, and pulmonic stenosis)

1. the cardio five2. client's dentist must give client prophylactic

antibiotics to prevent infection3. instruct client to raise legs when sitting to prevent

dependent edemaG. Aortic stenosis

1. Definition - aortic valve narrows. left ventricle must work harder,so needs more oxygen, and may sufferischemia and heart failure.

2. Epidemiology

a. most significant valvular lesion seen among elderly people.

It usually leads to left-sided heart failureb. incidence increases with agec. occurs in 1% of the populationd. about 80% of these people are malee. 20% of them die suddenly, around age 60

3. Findings

a. classic triad: dyspnea, syncope, angina (see AssessingClients with Cardiovascular Disorders)

b. fatigue

c. palpitations

d. left-sided heart failure may bring on orthopnea, paroxysmalnocturnal dyspnea, and peripheral edema

4. Managementa. nitroglycerin to relieve chest painb. low-sodium diet - to prevent fluid retentionc. diuretics - to mobilize edematous fluid and to reduce

pulmonary venous pressured. digitalis - to increase the force or strength of cardiac

contractions (inotropic action)e. oxygen - to prevent hypoxia
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f. surgery - percutaneous balloon valvuloplasty, then valvereplacement


a. the cardio-care sixb. monitor the cardio sevenc. monitor for findings of heart failure, pulmonary edema, and

adverse reactions to the drug therapyd. post-op: monitor client for hypotension, arrhythmias and

clotse. when client sits, raise legs to prevent dependent edemaf. client and family teaching: (same as tricuspid stenosis,

tricuspid insufficiency, pulmonic stenosis and pulmonicinsufficiency)

1. the cardio five2. client's dentist must administer prophylactic

antibiotics3. client should raise legs when sitting

H. Aortic insufficiency (regurgitation)1. Definition

a. blood flows back into the left ventricle during diastoleoverloading the ventricle and causing it to hypertrophy.

b. extra blood also overloads the left atrium and, eventually,the pulmonary system.

2. Epidemiologya. by itself, most common among malesb. with mitral valve disease, more common among females

c. may accompany Marfan's syndrome, ankylosingspondylitis, syphilis, essential hypertension or a defect of

the ventricular septum3. Findingsa. uncomfortable awareness of heartbeat

b. palpitations along with a pounding headc. dyspnea with exertion

d. paroxysmal nocturnal dyspnea, with diaphoresis,orthopnea and cough

e. fatigue and syncope with exertion or emotionf. anginal chest pain unrelieved by sublingual nitroglycering. heartbeat that seems to jar the client's entire bodyh. client's nailbeds appear to be pulsatingi. if nail tip is pressed, the root will flush and then pale

(Quincke's sign)j. if left ventricle fails, client may show ankle edema and

ascitesk. pulsus biferiens

4. Managementa. digitalis - increases the heart's contractility (inotropic

action)b. diuretics - to mobilize edematous fluids and to reduce

pulmonary venous pressurec. sodium-restricted diet - to prevent fluid retentiond. anticoagulant agents - to prevent blood clotse. surgical - valve replacement. however, aortic insufficiency

often damages the ventricle before it is detected.5. Nursing interventions

a. same as all other valve disorders - the cardio-care sixexcept don't need to elevate head unless pulmonaryproblems have begun.

b. monitor the cardio sevenc. monitor for signs ofheart failure, pulmonary edema, and

drug reactions.
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d. post-op: monitor client forhypotension, arrhythmias andclots.

e. client and family teaching

1. same as all other valve disorders - the cardio five2. emphasize the need for prophylactic antibiotics

during dental care3. instruct client to raise legs when sitting

IV. Failures of the Heart Muscle

A. Myocardial infarction (MI)

1. Definition - insufficient oxygen supply kills (causes necrosis of)myocardial tissue. MI may be sudden or gradual. total event takes3 to 6 hours.

2. Epidemiologya. almost equal for men and womenb. client history of smoking, obesity, high cholesterol/low

density lipoprotein diet, physical/emotional stressc. a common killer in North America and Western Europed. mortality about 25%. Of the sudden deaths from MI, more

than half happen within an houre. of those who survive the initial MI and recover, up to 10%

die within the first year3. Findings

a. persistent, crushing substernal chest painb. pain that may radiate to the left arm, jaw, neck and

shoulder blades, with a feeling of impending doomc. pain may persist for 12 hours or mored. some clients report no pain, or call it mild indigestion

e. fatigue, nausea, vomiting and shortness of breathf. sudden death

g. within the first hour after an anterior MI, about 25% ofclients experience tachycardia orhypertension.

h. up to 50% of clients with an inferior MI experience theopposite: bradycardia orhypotension.

i. women may experience fatigue, achiness, flu-likesymptoms

4. Managementa. cardiac monitoring for arrythmiasb. oxygen - to prevent tissue hypoxiac. bed rest - to decrease the workload of the heart

d. pharmacologic agents - to stabilize cliente. stool softeners - to decrease the workload of the heartcaused by straining, which can cause vagal stimulationproducing bradycardia and arrythmias

f. narcotic analgesics - to reduce pain, anxiety and fear anddecrease the workload of the heart

g. beta-blocking agents - to slow heart rateh. sedatives - to decrease anxiety and fear and to decrease

the workload of the hearti. antiarrhythmic - to prevent arrythmias which are the most

common complications after an MIj. thrombolytic agents - to dissolve the thrombus in the

coronary artery and reperfuse the myocardiumk. nitrates - to decrease pain and decrease preload andafterload while increasing the myocardial oxygen supply

l. anticoagulants - to prevent blood clotsm. Swan-Ganz catheter to monitor pressure in pulmonary

artery (measure functioning of left ventricle)

n. intra-aortic balloon counterpulsation may be used forcardiogenic shock
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o. cardiac catheterization may be performed forPTCAp. surgery - coronary atherectomy or graft of a coronary

artery bypass5. Diagnostic studies

a. history and physicalb. EKG - monitor for changes, arrythmias

c. serum cardiac markers (CK - MB) - rises 4-6 degrees afteracute MI; Returns to normal in three to four days. Troponin- rises quickly but remains elevated for two weeks.

6. Nursing Interventionsa. The cardio-care six plus monitor the following to prevent

heart failure, infections and complications

i. temperatureii. daily weightiii. intake and outputiv. respiratory ratev. breath sounds

vi. blood pressurevii. serum enzyme levelsviii. EKG readingsix. Heart sounds especially S3 and S4

b. Assess pain and give analgesics as ordered. Record theseverity, location, type and duration of pain.

c. Do NOT give IM injections, or CK will be falsely elevatedd. Watch for crackles, cough, tachypnea and edema which

may predict left ventricle is failing.e. Use antiembolism stockings to prevent venostasis and

thrombophlebitis.f. Assistance with range of motion exercises

g. Client and family teaching

i. the cardio-fiveii. explain the ICU or coronary careunit, routine and machineryiii. ask dietician to speak with the clientand family to reinforce teaching

iv. encourage client to join the cardiacrehab exercise programv. counsel gradual resumption ofsexual activity, taking nitroglycerin beforesex may prevent chest painvi. advise client to report typical oratypical chest painvii. describe postmyocardial infarctionsyndrome ; have client report it to physicianviii. stress that client must modify high-risk behaviors

EKG MEASURES ELECTRICAL ACTIVITY OF HEART

A. Electrocardiogram = (ECG) = (EKG); do not confuse with echocardiogram

B. An EKG is a graphic recording of the electrical currents of the heart.

C. The EKG records two basic events - depolarization and repolarization as a series of waves:

1. P-wave

2. P-R Interval

3. QRS complex

4. T wave

5. S-T interval

6. U wave

7. PVCs

D. An EKG can show these conditions:

a. sinus tachycardia

b. ventricular tachycardia

c. sinus bradycardia
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CARDIAC MECHANICS AND HEART SOUNDS

Cardiac cycle

Systole: contraction Diastole: relaxation

Cardiac cycle: one systole and its diastole. Average time: four-fifths of a second Normal: 60-100 cycles (heart beats) per minute; faster in infants, slower in elderly

Cardiac output (CO)

Volume of blood ejected by ventricle per minute CO = Stroke volume times heart rate

Preload: capacity of ventricle at height of diastoleAfterload: force required to overcome arterial resistance and empty the ventricle

Blood pressure

Systolic pressure is maximum force of blood against arteries at systole Diastolic pressure is force of blood against arteries at diastole. BP is measured indirectly by Sphygmomanometer or Doppler echocardiography, or directly by arterial

catheter

Body controls cardiac output and blood pressure Starling's law of heart Baroreceptors Chemoreceptors

Cause: Blood moves from regions of greater to lesser pressure

Variations in Pressure: Pressure highest in left ventricle and aorta: fresh from heart.Pressure lowest in central veins, vena cava, and right atrium: coming back to heart.

Heart sounds

NormalS1 closure of mitral and tricuspid valves marking the beginning of systoleS2 closure of aortic and pulmonic valves

Exceptional

S3 - sound produced when blood first rushes into a stiff or loaded ventricle. S3 sounds areearly signs of left-sided heart failureS4 - sound produced during late phase of filling an overloaded ventricle, associated withhypertensionPressure too low: not enough blood (and oxygen) to brain and heart.Pressure too high: vessels damage and rupture.


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B. Congestive heart failure1. Definition/etiology

a. heart fails to pump enough blood to support the body'sfunctions

b. types of CHF depend on which part of the heart fails: the

left half that pumps to the body, or the right half that pumpsto the lungs.

c. etiology

i. coronary artery disease
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ii. myocarditisiii. cardiomyopathyiv. infiltrative disorders: amyloidosis, tumors,

sarcoidosis

v. collagen-Vascular disease: systemic lupuserythematosus, scleroderma

vi. dysrhythmias that reduce cardiac filling time

vii. disorders that increase cardiac workload:hypertension, valve disease, anemia,

hyperthyroidismviii. cardiac tamponade

2. Findings of Left CHF and Right CHF

3. Managementa. objective: to restore balance between myocardial oxygen

supply and demand

b. treatments include oxygen, digitalis, vasodilators, nitratesantihypertensives, cardiac glycosides, diuretics, intra-aorticballoon counterpulsation, ventricular assist pumping, etc.


a. the cardio care sixb. administer medications as orderedc. administer oxygen as ordered - to prevent tissue hypoxiad. monitor hemodynamic indicators

e. monitor for findings ofhyponatremia, hypokalemiaf. restrict fluids and assess for findings of fluid retention

g. client and family teachingi. medications and side effects

ii. how to conserve energy and thus oxygeniii. teach client to report

weight gain of more than two pounds in 24hours (equals 1 liter)

dyspnea decreased exercise tolerance

iv. importance of sodium-restricted diet
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5. Diagnostic findings - the primary goal is to determine theunderlying cause of the heart failure

a. history and physical examb. CXR - to determine heart size and pleural effusionsc. EKG for changes, arrythmiasd. echocardiogram to measure valvular abnormalities

e. nuclear imaging - to determine myocardial contractility,myocardial perfusion, and acute cell injury

f. hemodynamic monitoring of arterial blood pressure,pulmonary artery pressure, pulmonary artery wedgepressure and cardiac output

C. Cardiac tamponade1. Definition/etiology

a. fluid quickly fills pericardial sac and limits cardiac output;cardiac tamponade is a medical emergency

b. etiologyi. acute pericarditis

ii. post-op after cardiac surgeryiii. pericardial effusionsiv. chest traumav. myocardial rupturevi. aortic dissectionvii. anticoagulant therapy

2. Findings: classic triad of findingsa. hypotension withb. muffled heart sounds with

c. high jugular venous pressure (increased CVP)3. Diagnosis (above)4. Management

a. pericardiocentesis: needle aspiration of pericardial sac5. Nursing interventions

a. bed rest with elevated head of bedb. prepare client for pericardiocentesisc. provide emotional support

V. Disorders of the Circulatory System:

PRINCIPLES OF CARDIOPULMONARY RESUSCITATION (CPR) -ADVANCED CARDIAC LIFE SUPPORT

Early access

Early CPR

Early defibrillation

Early advanced cardiac life support

Give drugs afterdefibrillation (in the adult)

For drug delivery, antecubital veins are first choice because central-line placement wouldinterrupt CPR

Endotracheal tube placement

Intraosseous route for drugs is alternative (in children)
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A. Hypertension1. Definitions

a. hypertension - systolic blood pressure of 140 mm Hg orgreater, diastolic blood pressure of 90 mm Hg or greater,or taking antihypertensive medication

b. chronic hypertension of pregnancy - high blood pressure

already present before week 20 of gestationc. accelerated hypertension - a hypertensive crisis: blood

pressure rises very rapidly, threatening the brain

2. Etiology and epidemiologya. essential hypertension: cause unknown.b. possible factors include:

i. family history- immediate family: mother, father,siser, brother

ii. race- African American, Hispanic, Native American,more susceptible

iii. stressiv. obesity- 20% more than ideal weightv. a diet high in sodium or saturated fatvi. use of tobaccovii. use of hormonal contraceptivesviii. sedentary life-styleix. aging

c. besides hypertension, most individuals have other riskfactors for cardiovascular disease (CVD).

d. secondary hypertension may result fromi. renovascular diseaseii. renal parenchymal disease

EIGHT FACTORS THAT AFFECT ARTERIAL BLOOD PRESSURES

1. Cardiac output2. Resistance in peripheral vessels (arterioles)3. Arterial elasticity: Elastic vessels let blood flow at lower pressures; rigid, sclerotic vessels

require higher pressures.4. Viscosity

a. Too many red blood cells (RBCs) or plasma proteins increases pressure.b. Lower viscosity, from anemia or lack of RBCs, decreases pressure

5. Age: newborns have low blood pressure, which increases with age6. Weight: the higher your weight, the higher your blood pressure7. Exercise: faster heart rate means higher systolic blood pressure8. Autonomic Nervous System: The sympathetic nervous system speeds the heart rate; the

parasympathetic (via the vagus nerve ) slows the heart rate.
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iii. cushing's syndromeiv. diabetes mellitus

v. dysfunction of the thyroid, pituitary, or parathyroidvi. coarctation of the aortavii. pregnancyviii. neurologic disorders

3. Findingsa. may be asymptomaticb. findings reflect the effect of hypertension on organ systemsc. occipital headache, blurred vision, dizzinessd. dizziness, palpitations, weakness, fatigue, and impotencee. nosebleedsf. bloody urine

g. chest pain and dyspnea, if heart is involved4. Diagnosis

a. based on the average of two or more blood pressurereadings, two minutes apart, at each of two or more visitsafter an initial screening visit

b. classification of adult hypertension

HOW THE BODY CONTROLS BLOOD PRESSURE

Arterial blood pressure (BP): increases with increase in: cardiac output , peripheral resistanceor blood volume.

Intrinsic control: hour by hour, chemoreceptors control blood flow according to the tissues' useof oxygen and the amount of carbon dioxide in the brain.

Extrinsic control: overrides intrinsic control when necessary.

1. For rapid, short-term adjustments, the body monitors blood pressure via stretchreceptors (baroreceptors) in the walls of the carotid sinus and the aortic arch .

2. Control of blood pressure begins in vasomotor centers in medulla oblongata, throughthe autonomic nervous system, the kidneys, and hormones such as epinephrine andangiotensin.

a. If arterial pressure increases above normal, the body lowers BP by decreasingheart rate (mediated by acetylcholine , the neurotransmitter of theparasympathetic nervous system.)

b. If arterial pressure falls, it is raised by increasing cardiac output (mediated by

epinephrine, the neurotransmitter of the sympathetic nervous system)3. Slow, long-term control of blood pressure is achieved through:a. excretion of sodium and water by the kidneyb. by the activity of the renin-angiotensin systemc. by the atrial natriuretic factord. and antidiuretic hormone
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c. hypertension is classified according to its cause:i. primary or essential hypertension (about 90% of

clients)ii. secondary hypertension (results from another

disease; about 5% to 10% of clients)

iii. accelerated hypertension - a hypertensive crisis

5. Managementa. pharmacological

i. initial therapy - for uncomplicated hypertension, it isrecommended to start with a diuretic orBeta-adrenergic blocking agent

ii. oxygen PRN in acute crisis

iii. angiotensin-converting enzyme (ACE) inhibitors areused to treat left-sided heart failure and preferred ifclient is diabetic

iv. antilipemics

b. goals of treatmenti. BP


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B. Coronary artery disease1. Definition - fatty deposits in coronary arteries (atheroma or plaque)

narrow the artery (by 75% or more) and cut flow of blood andoxygen to the heart muscle.

2. Epidemiology and etiology

a. CAD is epidemic in the western world.b. more than 30% of men age 60 or older show signs of CAD

on autopsy.c. most common cause: Atherosclerosisd. risk factors:

i. over 40 white maleii. family history of CADiii. high blood pressure

iv. high cholesterol (see cholesterol levelclassification)

v. smokers are twice as likely to have a myocardialinfarction and four times as likely to die suddenly.

The risk drops sharply within one year aftersmoking ceases.

vi. obesity (waist predominance); [added weightincreases the risk ofdiabetes, hypertension andhigh cholesterol]

vii. sedentary life style

3. Findings: angina

TYPES OF ANGINA

A. Angina, especially after physical exertion, is the classic symptom of Coronary ArteryDisease.

B. Angina appears commonly with nausea, vomiting, fainting, sweating, and coolextremities

C. Angina may follow excitement, a large meal, or exposure to extreme cold or heat.D. Types of angina

1. Nocturnal angina2. Angina predictable and relieved by nitroglycerine: stable angina.3. More frequent and lasting angina: unstable angina.4. Effort-induced pain that occurs more and more often: crescendo angina5. Severe angina at rest: Prinzmetal's angina - associated with coronary artery

spasm
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4. Managementa. pharmacology

i. nitrates such as nitroglycerin, isosorbide dinitrate(Isordil), or beta-adrenergic neuron-blocking agents

ii. oxygen - to prevent hypoxia

iii. diuretics and beta-adrenergic blocking agentsiv. aspirin - decreases platelet aggregation

v. antilipemics - to decrease circulating lipidsb. diet: reduce calories, salts, fats, cholesterol

c. cardiac catheterization

i.after cardiac catheterization and percutaneoustransluminal coronary angioplasty (PTCA), maintainheparinization; observe for bleeding systemically atthe site, and keep the affected leg straight andimmobile for six to 12 hours.

ii. check for distal pulses.iii. to counter the diuretic effect of the dye, increase IV

fluids and make sure client drinks plenty of fluids.iv. assess potassium level- observe for dysrhythmiasv. observe findings of hypotension, bradycardia,

diaphoresis, dizziness; give atropine and lay theclient flat.

d.rotational ablation

i. after rotational ablation, monitor the client for chestpain, hypotension, coronary artery spasm andbleeding from the catheter site.

ii. provide heparin and antibiotic therapy for 24 to 48hours or as ordered.

e. laser coronary angioplasty

f. surgical treatment - coronary artery bypass graft (CABG)

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