Download Heart and Peripheral Vascular System

Chapter 12
Heart and Peripheral
Vascular System
Kevin Dobi, MSN, APRN
Kevin Dobi, MSN, APRN
revised 7/2013
Concept Overview
• Perfusion:
• Mechanisms that facilitate and impair perfusion of
oxygenated blood
• All tissues require perfusion of oxygenated blood.
• All of these physiologic concepts are interrelated.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
2
Anatomy and Physiology
• Cardiovascular system:
•
•
•
•
Transports oxygen
Transports nutrients
Transports other substances to body’s tissues
Carries metabolic waste products to kidneys and
lungs
• This dynamic system is able to adjust to
changing demands for blood by:
• Constricting or dilating blood vessels
• Altering cardiac output
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
3
Anatomy and Physiology:
The Heart and Great Vessels
• Heart is a pump:
• Beats 60 to 100 times a minute without rest.
• Responds to both external and internal demands.
• Each side has two chambers:
• Atrium
• Ventricle
• Right side:
• Receives blood from superior and inferior venae cavae.
• Pumps blood through pulmonary arteries to pulmonary
circulation.
• Left side:
• Receives blood from pulmonary veins.
• Pumps blood through aorta into systemic circulation.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
4
Anatomy and Physiology:
The Heart and Great Vessels (contd.)
• Upper part of heart is base.
• Lower left ventricle is apex.
• Heart lies behind sternum and above
diaphragm in mediastinum.
• Lies at an angle so right ventricle makes up
most of anterior surface and left ventricle lies
left and posteriorly.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
5
Anatomy and Physiology:
The Heart and Great Vessels (contd.)
• Pulmonary arteries and aorta are termed the
great vessels.
• Aorta curves upward out of left ventricle and
bends posteriorly and downward just above
the sternal angle.
• Pulmonary arteries emerge from superior
aspect of right ventricle near third intercostal
space.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
6
7
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Anatomy and Physiology:
Pericardium and Cardiac Muscle
• Heart wall has three layers: Pericardium,
myocardium, and endocardium.
• Heart encased in pericardium, which has a fibrous
layer and two serous layers.
• Fibrous layer, fibrous pericardium, is fibrous sac of
elastic connective tissue shielding heart from
trauma and infection.
• One of serous layers lies next to fibrous pericardium
and other serous layer lies next to myocardium.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
8
Anatomy and Physiology:
Pericardium and Cardiac Muscle (contd.)
9
• Pericardial space lies between fibrous pericardium and
serous pericardium and contains pericardial fluid to
reduce friction as myocardium contracts and relaxes.
• Serous pericardium, or epicardium, covers heart surface
and extends to great vessels.
• Middle layer, or myocardium, is thick muscular tissue
that contracts to eject blood from ventricles.
• Endocardium lines inner chambers and valves.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
10
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Anatomy and Physiology: Blood Flow
through the Heart – The Cardiac Cycle
11
• Four valves govern blood flow through four chambers of
heart:
• Tricuspid valve on right.
• Mitral valve on left termed atrioventricular (AV)
valves because they separate atria from ventricles.
• Aortic valve opens from left ventricle into aorta.
• Pulmonic valve opens from right ventricle into
pulmonary artery; aortic and pulmonic valves are
termed semilunar valves because of their half-moon
shape.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
12
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Anatomy and Physiology: Blood Flow Through
the Heart – The Cardiac Cycle
Diastole
13
• Diastole: Ventricles relax and fill with blood from left
and right atria.
• Movement of blood from atria to ventricles is accomplished
when pressure of blood in atria becomes higher than pressure
in ventricles.
• Higher atrial pressures passively open AV valves, allowing blood
to fill ventricles.
• About 80% of blood from atria flows into relaxed ventricles.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Anatomy and Physiology: Blood Flow Through
the Heart – The Cardiac Cycle Diastole
(contd.)
14
• Diastole:
• Contraction of atria forces remaining 20% of blood into
ventricles.
• This added atrial thrust is termed the atrial kick.
• At end of diastole, ventricles are filled with blood.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
15
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Anatomy and Physiology: Blood Flow
Through the Heart – The Cardiac Cycle
Systole
16
• Systole: Ventricles contract creating pressure that closes
AV valves, preventing backflow of blood into atria.
• Ventricular pressure also forces semilunar valves to open,
resulting in ejection of blood into aorta from left ventricle and
pulmonary arteries from right ventricle.
• As blood is ejected ventricular pressure decreases, causing
semilunar valves to close.
• Ventricles relax to begin diastole.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
17
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
18
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Anatomy and Physiology:
Electric Conduction
• Heart stimulated by electric impulse
originating in sinoatrial (SA) node in superior
aspect of right atrium and travels in internodal
tracts to AV node.
• SA node, termed cardiac pacemaker, normally
discharges 60 to 100 impulses per minute.
• Electric impulses stimulate contractions of both
atria and then the flow to AV node in inferior aspect
of right atrium.
• Impulses are then transmitted through series of
branches and Purkinje fibers in myocardium, which
results in ventricular contraction.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
19
Anatomy and Physiology:
Electric Conduction (contd.)
• AV node prevents excessive atrial impulses
from reaching ventricles.
• If SA node fails to discharge, AV node can
generate ventricular contraction at slower
rate of 40 to 60 impulses per minute.
• If both SA and AV nodes are ineffective, bundle
branches may contract, but at very slow rate
of 20 to 40 impulses per minute.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
20
21
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Anatomy and Physiology:
Peripheral Vascular System
• Arteries, capillaries, and veins provide blood
flow to and from tissues.
• Tough and tensile arteries; their smaller
branches, arterioles, are subjected to
remarkable pressure generated from
myocardial contraction.
• They maintain blood pressure by constricting
or dilating in response to stimuli.
• PVR- Peripheral Vascular Resistance.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
22
Anatomy and Physiology:
Peripheral Vascular System (contd.)
• The more passive veins and smaller branches,
venules, are less sturdy, but more expansible,
enabling them to act as reservoir for extra
blood, if needed, to decrease workload on
heart.
• Pressure within veins is low, compared with
arterial circulation.
• Valves in each vein keep blood flowing in a
forward direction toward heart. (IV Issues)
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
23
24
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Anatomy and Physiology:
Lymph System
• Lymph system works in collaboration with
peripheral vascular system in removing fluid
from interstitial spaces.
• As blood flows from arterioles into venules,
oxygen and nutrient-rich fluid is forced out at
arterial end of capillary into interstitial space,
and then into cells.
• Waste products from cells flow through
interstitial spaces to venous end of capillary.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
25
Lymphatics
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
26
Anatomy and Physiology:
Lymph System (contd.)
• Excess fluid left in interstitial spaces is
absorbed by lymph system and carried to
lymph nodes throughout body.
• Lymphatic fluid is clear, composed mainly of
water and a small amount of protein, mostly
albumin.
• Lymph nodes are tiny oval clumps of lymphatic
tissue, usually located in groups along blood
vessels.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
27
Anatomy and Physiology:
Lymph System (contd.)
• In peripheral vascular system, lymph node
locations of interest are arm, groin, and leg.
• Epitrochlear nodes on medial surface of arm
above elbow are palpable.
• These nodes receive fluid via radial, ulnar, and
median lymph vessels.
• In upper thigh, inguinal lymph nodes are
superficial; they receive most of lymph
drainage from great and small saphenous
lymphatic vessels in legs.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
28
Anatomy and Physiology:
Lymph System (contd.)
• In men, lymph from penile and scrotal surfaces
drains to inguinal nodes, but nodes of the
testes drain into abdomen.
• In posterior surface of leg, behind knee, are
popliteal nodes, which receive lymph from
medial portion of lower leg.
• Ducts from lymph nodes empty into subclavian
veins.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
29
30
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
31
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Assessment
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
32
General Health History:
Present Health Status
• Do you have any chronic illnesses such as
diabetes mellitus, renal failure, chronic
hypoxia, or hypertension?
• Are you taking medications?
• What are you taking, and when did you start?
• Have you experienced any side effects?
• Do you take medications as prescribed?
• What over-the-counter drugs do you take?
• Do you take an aspirin on a regular basis to
help thin your blood?
• Do you take herbal medications?
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
33
General Health History:
Family Health Status
• Is there anyone in your family with a history of
diabetes mellitus, renal failure, chronic
hypoxia, or hypertension?
• If so, who?
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
34
General Health History:
Personal and Psychosocial History
• Do you use cocaine?
• Other street drugs?
• How often do you use drugs?
• Do you exercise?
• What kind of exercise?
• How often?
• How would you describe your personality type?
• How do you deal with stress?
• How often do you take time to relax?
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
35
General Health History:
Personal and Psychosocial History
(contd.)
• Describe your usual eating habits:
• How often do you eat red meat?
• Do you monitor your fat and salt intakes?
• Do you eat whole grains each day?
• Do you drink alcoholic beverages?
• What type of alcohol do you drink?
• How much? How often?
• Do you consume caffeine?
• Do you smoke, or have you been a smoker in past?
• Are you interested in quitting smoking?
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
36
General Health History:
Past Medical History
• During childhood did you have “growing
pains,” unexplained joint pains?
• Rheumatic fever?
• Heart murmur?
• Have you been told you have high levels of
cholesterol or elevated triglycerides?
• Have you ever had surgery on heart?
• On blood vessels?
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
37
Problem-Based History:
Chest Pain
•
•
•
•
Where are you feeling the chest pain?
What does it feel like? Sharp, dull, ache?
Does pain radiate to any location?
When did pain start?
• Is pain intermittent or constant?
• What symptoms have you noticed with pain?
•
•
•
•
•
•
Sweating?
Turning pale or gray?
Heart skipping beats or racing?
Shortness of breath?
Vomiting?
Anxiety?
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
38
Problem-Based History:
Chest Pain (contd.)
• What factors preceded pain?
•
•
•
•
Exercise?
Rest?
Highly emotional situations?
Sexual intercourse?
• What makes pain worse?
• What relieves pain?
• Rest?
• Nitroglycerin?
• How many nitroglycerin tablets does it take to
relieve chest pain?
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
39
Problem-Based History:
Shortness of Breath
• How long have you had shortness of breath?
• Do you feel short of breath now?
• When does shortness of breath happen?
• How often?
• How long does it last?
• Does shortness of breath interfere with your
daily activities?
• Do you have other symptoms with shortness of
breath (e.g., do your feet swell during day)?
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
40
Problem-Based History:
Shortness of Breath (contd.)
• What makes shortness of breath worse?
• Walking upstairs?
• Lying down?
• How many pillows do you require when you lie down
to sleep?
• Do you sleep in recliner?
• When episodes of shortness of breath occur,
what do you do to breathe more easily?
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
41
Problem-Based History:
Cough
• When did your cough start?
• How often do you cough?
• Do you cough up anything? (productive or nonproductive?)
• What does it look like?
• Is cough associated with position?
• More coughing when lying down?
• With anxiety?
• Talking or activity?
• What makes it worse?
• What actions do you take to relieve cough?
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
42
Problem-Based History:
Urinating During the Night
• For how long have you been getting up during
night to urinate?
• How many times a night do you get up to urinate?
• What have you done to prevent this from
happening?
• How successful have your efforts been?
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
43
Problem-Based History:
Fatigue
• When do you notice fatigue?
• Was onset sudden or gradual?
• Is it worse in morning or evening?
• Are you too tired to take part in normal activities?
• Do you take iron pills?
• Do you eat foods with iron, such as green leafy
vegetables and liver?
• For women: Do you have heavy menstrual flow?
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
44
Problem-Based History:
Fatigue (contd.)
• Have you had any other symptoms associated
with fatigue?
• Rapid heart rate?
• Headache?
• Pale skin?
• Have you noticed any unusual feelings in your
feet and hands, muscle weakness, or trouble
thinking?
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
45
Problem-Based History:
Fainting
• What were you doing just before you fainted?
• Did you feel dizzy?
• Did you lose consciousness?
• Has this happened to you before?
• Was fainting preceded by any other symptoms?
•
•
•
•
•
Nausea?
Chest pain?
Headache?
Rapid heart rate?
Confusion?
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
46
Problem-Based History:
Swelling of Extremities
• Where is swelling located?
• Arms or legs?
• Unilateral or bilateral?
• What makes swelling go away?
• Does elevating your arms or feet reduce swelling?
• Does swelling disappear after night’s sleep?
• Are there any symptoms associated with
swelling?
• Shortness of breath?
• Weight gain?
• For women: Is swelling associated with your
menstrual period?
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
47
Problem-Based History:
Leg Cramps or Pain
• Describe pain and its location.
• What makes pain worse?
• What relieves the pain?
• Have you noticed any changes in skin of your
legs?
•
•
•
•
•
•
Coldness
Pallor
Hair loss
Sores
Redness or warmth over the veins
Visible veins
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
48
PE: Physical Examination
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
49
Examination:
Procedures with Normal Findings
• Assess general appearance.
• Inspect patient for general appearance, skin
color, and breathing effort.
• Palpate temporal and carotid pulses for
amplitude.
• Inspect jugular vein for pulsations. JVD
• Measure blood pressure. Auscultate
• Inspect and palpate upper extremities for skin
turgor and symmetry.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
50
Examination:
Procedures with Normal Findings (contd.)
51
• Inspect and palpate upper extremities for:
•
•
•
•
Symmetry
Skin integrity
Color and temperature
Capillary refill
• Palpate brachial and radial pulses for:
•
•
•
•
Rate
Rhythm
Amplitude
Contour
• Inspect and palpate lower extremities for skin turgor and
symmetry.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
52
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Apical Impulse
Palpate over the Apex: 5th-6th ICS at MCL
(left side)
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
53
54
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Examination:
Procedures with Normal Findings
(contd.)
55
• Inspect and palpate lower extremities for symmetry,
skin integrity, color and temperature, hair distribution,
capillary refill, color and angle of nail beds,
tenderness, and superficial veins.
• Palpate lower extremities for femoral, popliteal,
posterior tibial pulses, and dorsalis pedis pulses for
amplitude.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Examination:
Cardiac Assessment
• Inspect anterior chest wall for:
•
•
•
•
•
Contour
Pulsations
Lifts
Heaves
Retractions
• Auscultate S1 and S2 heart sounds for:
•
•
•
•
Rate
Rhythm
Pitch
Splitting
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
56
Heart Sounds: S1
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
S2
57
Landmarks
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
58
Landmarks
59
• Aortic: 2nd-3rd ICS
at left sternal border
• Pulmonic:
rd
2nd3 ICS at right sternal
border
• Tricuspid:
5th
ICS
at left sternal border
• Mitral: 5th ICS and
left MCL (apex)
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
• All
• Patients
• Take
• Meds
Examination: Special Circumstances
or Advanced Practice
• Peripheral vascular system:
• Auscultate carotid artery for bruits.
• Estimate jugular venous pressure for
pulsations.
• Palpate epitrochlear lymph nodes for size,
consistency, mobility, borders, tenderness,
and warmth.
• Palpate inguinal lymph nodes for size,
consistency, mobility, borders, tenderness,
and warmth.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
60
Examination: Special Circumstances
or Advanced Practice (contd.)
• Peripheral vascular system:
61
• Calculate the ankle brachial index to estimate arterial
occlusion.
• Perform Trendelenburg’s test to evaluate competence of venous
valves in patients who have varicose veins.
• APRNs----Don’t worry about this technique
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Examination: Special Circumstances
or Advanced Practice (contd.)
• Cardiac assessment:
• Palpate precordium for
pulsations, thrills, lifts, and
heaves.
• Percuss heart borders for heart size……NO!
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
62
Age-Related Variations:
Infants, Children, and Adolescents
• There are several differences in assessment of
cardiovascular system for infants and young
children:
• Equipment used to measure blood pressure is
smaller, sequence of exam may be different, and
findings may differ based on anatomic differences.
• Assessment of older child and adolescent follows
same procedures and reveals similar expected
findings.
• One exception in exam is electrocardiography,
which is not typically performed.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
63
Age-Related Variations:
Older Adults
• Assessing cardiovascular status of older adults
usually follows same procedures as for all
adults.
• Expected variations may be found in heart
rate and blood pressure.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
64
Common Problems and Conditions:
Cardiac Disorders –
Valvular Heart Disease
65
• Valvular heart disease (VHD) is an acquired or congenital
disorder of heart valve characterized by:
• Stenotic valve, which does not open completely.
• Incompetent valve, which does not close completely.
• Rheumatic fever and endocarditis account for most cases of
acquired VHD.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Common Problems and Conditions:
Cardiac Disorders –
Angina Pectoris
• Angina pectoris is chest pain due to ischemia of
myocardium.
66
• Usually caused by atherosclerosis within coronary arteries.
• Can occur during activity, stress, or exposure to intense cold
because of an increased demand on heart.
• Can also occur during rest as result of spasms of coronary
arteries.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Common Problems and Conditions:
Cardiac Disorders –
Angina Pectoris (contd.)
67
• Clinical findings: Patients describe pain as squeezing,
suffocating, or constricting.
• May be significant hypertension, but hypotension may also
occur.
• The duration of angina is important to determine:
• If precipitated by exertion and patient rests
promptly, may last less than 3 minutes.
• If it follows heavy meal or caused by anger, may
last 15 to 20 minutes.
• Angina lasting more than 30 minutes is unusual,
may indicate developing myocardial infarction.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Common Problems and Conditions:
Cardiac Disorders – Myocardial Infarction
68
• Myocardial infarction occurs when myocardial ischemia
is sustained, resulting in death of myocardial cells
(necrosis).
• Left ventricle more commonly affected, but right
ventricle may also be affected.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Common Problems and Conditions:
Cardiac Disorders – Myocardial
Infarction (contd.)
69
• Clinical findings: Patients describe pain as worst chest
pain ever experienced, pain lasts longer than 5 minutes.
• May radiate to left shoulder, jaw, arm, or other areas
of chest; it is not relieved by rest or nitroglycerin.
• Dysrhythmias are common; heart sounds may be
distant with a thready pulse.
• Women report different symptoms; they report pain
or discomfort in center of chest and shortness of
breath, cold sweat, nausea, vomiting, or
lightheadedness.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Common Problems and Conditions:
Cardiac Disorders – Heart Failure
• Heart failure occurs when either ventricle fails
to pump blood efficiently into aorta or
pulmonary arteries.
• Heart failure may occur in left or right
ventricle or both.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
70
Common Problems and Conditions:
Cardiac Disorders – Heart Failure
Left Ventricular Failure
71
• Left ventricular failure is caused by :
• Increased resistance that occurs with aortic stenosis or
hypertension, when ventricle can no longer compensate for
increased workload, or
• Weakening of left ventricular contraction occurring after
myocardial infarction when death of myocardial cells may result
in an ineffective contraction.
• Because left ventricle cannot pump sufficient blood
forward, some blood backs up into left atrium and
eventually into pulmonary capillaries, causing pulmonary
edema.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Common Problems and Conditions:
Cardiac Disorders –
Left Ventricular Failure (contd.)
• Clinical findings: Patient complains of fatigue and
shortness of breath, including orthopnea, dyspnea on
exertion, and paroxysmal nocturnal dyspnea.
• Findings may reveal precordial movement, displaced apical
pulse, palpable thrill, S3, and systolic murmur at apex.
• In acute phase, patient usually has crackles bilaterally from
pulmonary edema.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
72
Common Problems and Conditions:
Cardiac Disorders –
Right Ventricular Failure
73
• Right ventricular failure caused by hypertrophy from
pulmonary hypertension or from necrosis from
myocardial infarction.
• Failure of right ventricle to pump blood into pulmonary arteries
causes a backflow of blood into inferior and superior venae
cavae.
• Right ventricular failure caused by pulmonary disease is termed
cor pulmonale.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Common Problems and Conditions:
Cardiac Disorders –
Right Ventricular Failure (contd.)
• Clinical findings:
74
• Findings may include precordial movement at xiphoid or left
sternal border, elevated jugular venous pressure, dependent
peripheral edema, S3 at lower left sternal border, systolic
murmur, and weight gain.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Common Problems and Conditions: Cardiac
Disorders –
Ineffective Endocarditis
75
• Infective endocarditis is infection of endothelial layer of
heart, including cardiac valves:
• Develops when endocardial surface is damaged by turbulent
blood flow as result of valvular heart disease, congenital lesions,
or direct injury from intravenous lines or injections, cardiac
catheterization, or artificial valves.
• Clinical findings:
• Heart sounds normal during early infection; in late infection,
murmur is heard if valve damage occurs.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
76
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Common Problems and Conditions: Cardiac
Disorders –
Pericarditis
77
• Pericarditis is inflammation of parietal and visceral
layers of pericardium and outer myocardium.
• May be idiopathic or the result of myocardial infarction,
uremia, cancer, trauma, infections, cardiac surgery, or
autoimmune reaction.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Common Problems and Conditions:
Cardiac Disorders –
Pericarditis (contd.)
78
• Clinical findings: Two classic findings are pericardial friction
rub and chest pain.
• Pericardial friction rub develops as inflamed layers of
pericardium move against each other.
• Friction rub is best heard with patient leaning forward so
that heart is closer to chest wall.
• Listen in second, third, or fourth intercostal spaces at left
sternal border or at apex; louder during inspiration.
• Pain described as sharp pleuritic pain aggravated by deep
breathing, lying supine, or coughing.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
79
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Common Problems and Conditions:
Peripheral Vascular Disease
Hypertension
80
• Hypertension is diagnosed on the basis of mean of two
or more properly measured seated blood pressure
readings on each of two or more occasions above 120/80
mm Hg in an adult over 18 years of age.
• Pressure in arteries can become elevated due to constriction of
blood vessels or fluid volume overload or both.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Common Problems and Conditions:
Peripheral Vascular Disease –
Hypertension (contd.)
81
• Clinical findings: Hypertension
• Normal blood pressure values are less than
120 mm Hg systolic and less than 80 mm Hg
diastolic.
• Because there are no specific symptoms of
hypertension, periodic screening is
important.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Common Problems and Conditions:
Peripheral Vascular Disease –
Venous Thrombosis and Thrombophlebitis
82
• Venous thrombosis occurs when a thrombus (clot)
develops within a vein.
• Thrombophlebitis is inflammation of vein that may or
may not be accompanied by clot.
• Triad of venous stasis, damage to inner layer of veins, and
hypercoagulability are usually responsible for both.
• Either may occur in lower extremity, usually in deep veins.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Common Problems and Conditions:
Peripheral Vascular Disease –
Thrombosis and Thrombophlebitis (contd.)
83
• Clinical findings: Thrombosis
• Sometimes recognized by dilated superficial veins,
edema and redness of involved extremity, and
increased circumference of involved leg.
• In upper extremity, venous thrombosis and
thrombophlebitis may occur in superficial veins and
are recognized by redness, warmth, and tenderness
over affected area. (can happen from IV therapy)
• Veins may be visible and palpable.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
84
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Common Problems and Conditions:
Peripheral Vascular Disease –
Aneurysm
• Aneurysm is localized dilation of artery caused by
weakness in arterial wall.
• Can occur anywhere along aorta and iliac vessels.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
85
Common Problems and Conditions: Peripheral
Vascular Disease –
Aneurysm (contd.)
86
• Clinical findings:
• Depend on location of aneurysm.
• Abdominal aortic aneurysms are most common.
• Thoracic, usually asymptomatic with deep, diffuse chest pain
reported by some patients.
• Aorta and aortic arch aneurysms can produce hoarseness from
pressure on laryngeal nerve or dysphagia from pressure on
esophagus.
• A pulsatile mass may be palpated in periumbilical area.
• A thrill or bruit may be noted over aneurysm.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Question 1
A patient has been admitted to the medical-surgical
unit for exacerbation of congestive heart failure.
The nurse notes bilateral +2 pitting edema and dry
scaling skin. As the nurse assesses the dorsalis pedis
pulse, the nurse is unable to detect it and notes that
both feet are warm. What is the best action for the
nurse to take?
A.
B.
C.
D.
Call the physician immediately.
Assess skin turgor over the clavicle.
Use a Doppler and assess capillary refill.
Use a Doppler and assess for renal artery stenosis.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
87
Question 2
In the cardiac unit, a patient awaits surgery for
mitral valve repair. As the nurse auscultates the
patient’s heart, the nurse will expect to hear a
murmur that is:
A.
B.
C.
D.
Most pronounced at the base of the heart.
Most pronounced over the carotid arteries.
Heard best at the left sternal border.
Heard best over the left midclavicular line.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
88
The End
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
89