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CHAPTER 21
Cardiovascular System
Function, Assessment, and
Therapeutic Measures
Aloha Hand, MSN,RN
HEART
In Mediastinum
 Pericardial Sac: 3 Layers

Fibrous Pericardium
 Parietal Pericardium
 Visceral Pericardium (Epicardium)
 Serous Fluid Between Inner Layers

ANTERIOR HEART VIEW
FRONTAL HEART VIEW
CARDIAC STRUCTURE AND VESSELS

Four Chambers


Right/Left Atrium, Right/Left Ventricle
Cardiac Layers

Epicardium, Myocardium, Endocardium
CARDIAC STRUCTURE AND VESSELS
Coronary Arteries
 Valves


Tricuspid, Pulmonic, Mitral, Aortic
BLOOD FLOW
Vena Cava » Right Atrium » Tricuspid »
Right Ventricle » Pulmonic » Pulmonary
Artery » Lungs » Pulmonary Veins » Left
Atrium » Mitral » Left Ventricle » Aortic
Valve » Aorta
CARDIAC CONDUCTION
SA Node
 AV Node
 Bundle of His
 Right and Left Bundle Branches
 Purkinje Fibers

CARDIAC OUTPUT
Amount of Blood Ejected from the Left Ventricle in 1
Minute
 Stroke Volume × Heart Rate = CO

NERVOUS SYSTEM REGULATION OF
HEART
HORMONES AND HEART

Epinephrine
Increases Heart Rate
 Force of Contraction
 Cardiac Output
 Systolic BP

HORMONES AND HEART (CONT’D)

Aldosterone


Regulates Sodium/Potassium
Atrial Natriuretic Peptide

Excretes Sodium
VESSEL STRUCTURE
BLOOD PRESSURE
Blood Force Against Blood Vessel Walls
 Normal

Systolic 90 to 135 mm Hg
 Diastolic 60 to 85 mm Hg

RENIN-ANGIOTENSINALDOSTERONE MECHANISM
PATHWAYS OF CIRCULATION
Pulmonary
 Systemic

AGING AND THE CARDIOVASCULAR SYSTEM
AGING AND THE CARDIOVASCULAR SYSTEM (CONT’D)
Atherosclerosis
 Arteriosclerosis
 Blood Pressure Increases
 Vein Valves More Incompetent
 Heart Muscle Less Efficient
 Dysrhythmias Common

CARDIOVASCULAR DISEASE
Number 1 Killer
 Lifestyle

Smoking
 Dietary Fat
 2 Servings of Fish Weekly
 Exercise

CARDIOVASCULAR DISEASE (CONT’D)

Go Red for Women
 American Heart Association’s nationwide
movement to celebrate power women have to band
together to wipe out heart disease.
 Color red and red dress linked with this
ability.
CARDIOVASCULAR ASSESSMENT
Symptoms – WHAT’S UP
 Health History
 Past Medical History
 Medications
 Family History
 Health Promotion Methods

OBJECTIVE DATA

Physical Assessment


Vital Signs
Diagnostic Studies
PHYSICAL ASSESSMENT

Inspection





Oxygenation, Skin Color
Extremities – Hair, Skin, Nails, Edema, Color
JVD
Capillary Refill
Clubbing
CLUBBING
PHYSICAL ASSESSMENT

Palpation
Point of Maximum Impulse
 Extremity Temperature


Poikilothermy
Edema
 Homans’ Sign

EDEMA
HOMANS SIGN
PHYSICAL ASSESSMENT

Percussion
Advanced Practitioner
 Cardiac Border

PHYSICAL ASSESSMENT (CONT’D)

Auscultation

Heart Sounds
S1
 S2
 S3
 S4

PHYSICAL ASSESSMENT (CONT’D)

Auscultation
Murmurs
 Pericardial Friction Rub

HEART SOUNDS
NONINVASIVE DIAGNOSTIC STUDIES
Chest X-Ray
 Cardiac Calcium Scan



Shows Areas with Plaque or Calcification
Magnetic Resonance Imaging
ELECTROCARDIOGRAM
Records Cardiac Electrical Activity
 Signal-Averaged ECG



Ambulatory Electrocardiogram Monitoring


Risk For Ventricular Dysrhythmias
Holter Monitoring
Transtelephonic Event Recorders
NONINVASIVE DIAGNOSTIC STUDIES (CONT’D)

Pressure Measurement


BP Readings Along Extremity
Tilt Table Test

Lying to Standing BP and HR
EXERCISE TOLERANCE TESTING
Cardiac Stress Test
Cardiac Response to Exercise and
Increased Oxygen Needs
 Peripheral Vascular Stress Test
Vascular Response to Walking

CARDIAC STRESS TEST
ECHOCARDIOGRAM
Ultrasound
 Records Motion

Heart Structures
 Valves
 Heart Size, Shape, Position

ECHOCARDIOGRAM

Transesophageal Echocardiogram
Probe in Esophagus
 Clearer Picture
 NPO until Gag Reflex Returns

RADIOISOTOPE IMAGING
 Radioisotopes
IV, Gamma Camera Scan
 Detects Cardiac
Ischemia/Damage/Perfusion
 Thallium Imaging
 Technetium Pyrophosphate Scan
 Technetium 99m Sestamibi
 Blood Pool Imaging
 Positron Emission Tomography
BLOOD FLOW ASSESSMENT

Doppler Ultrasound


Impaired Blood Flow Reduces Sound Waves
Plethysmography

Diagnoses Deep Vein Thrombosis/ Pulmonary
Emboli/Peripheral Vascular Disease
BLOOD FLOW ASSESSMENT (CONT’D)

Arterial Stiffness Index

Determines Atherosclerosis/Cardiovascular Disease
CARDIAC BLOOD STUDIES
Homocysteine
 C-reactive Protein
 Myeloperoxidase Antigen
 Cardiac Troponin I and T

CARDIAC BLOOD STUDIES

Cardiac Enzymes

Creatine Kinase
Myoglobin
 Blood Lipids


Triglycerides, Cholesterol, Phospholipids
INVASIVE STUDIES
Angiography
 Cardiac Catheterization
 Hemodynamic Monitoring
 Electrophysiology Study

CARDIAC CATHETERIZATION
PULMONARY ARTERY CATHETER
THERAPEUTIC INTERVENTIONS
Exercise: Walking Program, Cardiac Rehab
 Smoking Cessation
 Balanced Diet, Weight Loss
 Oxygen

THERAPEUTIC INTERVENTIONS

Antiembolism Devices
Elastic Stockings
 Intermittent Pneumatic Compression

THERAPEUTIC INTERVENTIONS

Medications





Cardiac Glycosides
Vasodilators
Antihypertensives
Antidysrhythmics
Antianginals
THERAPEUTIC INTERVENTIONS (CONT’D)

Medications Cont’d
Anticoagulants
 Thrombolytics

LIFESTYLE AND CARDIAC CARE
Risk Factors
 Support Groups
 Sexual Activity

CARDIOPULMONARY BYPASS PUMP
CARDIOPULMONARY BYPASS PUMP
IN USE
CARDIAC SURGERY
Preparation for Surgery
 Cardiopulmonary Bypass



Video-Assisted Thoracoscope
General Procedure for Cardiac Surgery
CHAPTER 22
Nursing Care of Patients with Hypertension
HYPERTENSION
New Guidelines
 Blood Pressure Taken in Seated Position
 Normal BP Is Below 120/80 mm Hg
 Average of 2 or More Readings on
Different
Dates
 Highest Reading Determines Category

TAKING BLOOD PRESSURE
Use Calibrated Instrument
 Seated Quietly 5 Minutes in Chair (Not on Exam
Table) with Feet on Floor, Arm Supported at
Heart Level.
 Use Cuff Bladder Encircling at Least 80 % of
Arm.
 Take 2 BP Measurements.
 Tell Patients BP Reading

CLASSIFICATION OF HYPERTENSION
Systolic
Diastolic
 Pre-Hypertension:
120-139 or 80-89 mm Hg
 Stage 1 Hypertension: 140-159 or 90-99 mm Hg
 Stage 2 Hypertension: >160 or >100 mm Hg
FOLLOW-UP CARE
Normal BP: 2 Years
 Pre-Hypertension: 1 Year
 Stage 1 Hypertension: 2 Months
 Stage 2 Hypertension: 1 Month


>180/110 mm Hg: Immediate Treatment
BLOOD PRESSURE
Pressure Exerted by Blood on Walls of Blood
Vessels
 Determined by Cardiac Output, Peripheral
Vascular Resistance, Vessel Stretch, Blood
Viscosity, Blood Volume

PATHOPHYSIOLOGY

Primary Hypertension


Secondary Hypertension


Unknown Cause
Known Cause
Isolated Systolic Hypertension

SBP Over 140 mm Hg
HYPERTENSION SIGNS/SYMPTOMS

None

“Silent Killer”
Rare — Headache, Bloody Nose, Anxiety, Dyspnea
 Target Organ Disease — Damage to Blood Vessels of
Heart, Kidney, Brain, Eyes

DIAGNOSIS OF HYPERTENSION
History
 Signs and Symptoms
 Kidney or Heart Disease
 Medications
 Blood Pressure Readings

DIAGNOSTIC TESTS
ECG
 Blood Glucose
 Hematocrit
 Potassium
 Calcium
 Lipoprotein, Cholesterol, Triglyceride Levels

HYPERTENSION RISK FACTORS
Nonmodifiable: Unable to be Changed
 Modifiable: Changeable

NONMODIFIABLE RISK FACTORS
Family History of Hypertension
 Age
 Ethnicity
 Diabetes Mellitus

MODIFIABLE RISK FACTORS
 Weight
 Diet



DASH
Limit Sodium
Limit Caffeine
 Alcohol
Use
 Exercise
 Smoking
 Stress
Management
HYPERTENSION TREATMENT
No/Low Risk Hypertensive
 BP >140/90 mm Hg over 6 Months
 Goal of Treatment

>140/90 mm Hg
 >130/80 mm Hg Diabetes/Kidney Disease

HYPERTENSION TREATMENT
(CONT’D)

Lifestyle Changes
and
Antihypertensive Medications
 Initial Therapy: Thiazide-type Diuretics

MEDICATIONS FOR HYPERTENSION
Diuretics
 Alpha Blockers
 Beta Blockers
 Calcium Channel Blockers

MEDICATIONS FOR HYPERTENSION
Angiotensin-converting Enzyme Inhibitors
 Central Agents
 Peripheral Agents
 Vasodilators

COMPLICATIONS OF HYPERTENSION
Atherosclerosis
 Coronary Artery Disease
 Myocardial Infarction
 Left Ventricular Hypertrophy
 Stroke
 Kidney/Eye Damage

HYPERTENSIVE EMERGENCY
SBP >180 mm Hg Systolic
 DBP >120 mm Hg Systolic
 Risk for/Progression for Target Organ Dysfunction
 Immediate Gradual Reduction of BP to Protect Target
Organs
 Treatment: Nitroprusside (Nipride) IV

HYPERTENSIVE URGENCY
Severe BP Elevation Without Target Organ Dysfunction
Progression
 Severe Headaches, Nosebleeds, Shortness of Breath and
Severe Anxiety
 Oral Medication

NURSING PROCESS
Deficient Knowledge
 Ineffective Therapeutic Regimen Management

PATIENT EDUCATION

Lifelong BP control
Self-Care Measures
 Prescribed Medical Regimen

NURSING CARE OF PATIENTS
WITH VALVULAR, INFLAMMATORY,
AND INFECTIOUS CARDIAC OR
VENSOUS DISORDERS
Chapter 23
INFLAMMATORY AND INFECTIOUS CARDIAC
DISORDERS

Rheumatic Carditis
Affects Entire Heart
 Layers of the Heart


Endocarditis, Myocarditis, Pericarditis
LAYERS OF HEART
RHEUMATIC CARDITIS

Etiology/Pathophysiology
Rheumatic Fever Complication
 2–3 Weeks After
 Autoimmune Reaction to Upper Respiratory BetaHemolytic Streptococci Infection
 Heart Layers Inflamed

RHEUMATIC CARDITIS (CONT’D)

Etiology/Pathophysiology

Endocardial Vegetations
RHEUMATIC CARDITIS (CONT’D)

Signs and Symptoms





Tachycardia
Heart Murmur
Pericardial Friction Rub
Chest Pain
Heart Enlargement
RHEUMATIC CARDITIS (CONT’D)

Signs and Symptoms
ECG Changes
 Heart Failure

RHEUMATIC CARDITIS (CONT’D)

Prevention
Treat streptococcal infections.
 After rheumatic fever, lifelong prophylactic
antibiotics for dental/invasive procedures to prevent
endocarditis.

RHEUMATIC CARDITIS (CONT’D)

Therapeutic Interventions
Antibiotics
 Analgesics, Aspirin, Corticosteroids
 Limited Activity
 Supportive Care

RHEUMATIC CARDITIS (CONT’D)

Nursing Management
History of Infections
 Vital Signs
 Heart Failure Symptoms
 Pain Relief

RHEUMATIC CARDITIS (CONT’D)

Nursing Management
Anxiety Relief
 Education

INFECTIVE ENDOCARDITIS

Infection of Endocardium
INFECTIVE ENDOCARDITIS (CONT’D)

Pathophysiology
Invading Organism Attaches to Endocardium
 Vegetative Lesion Forms
 Damages Valve Leaflets
 Emboli/Heart Failure Possible

INFECTIVE ENDOCARDITIS ETIOLOGY
Entry of Organism into Bloodstream
 Risk Factors

IV Drug Use
 Immunocompromised
 Congenital/Valvular Heart Disease
 Gingival Gum Disease

INFECTIVE ENDOCARDITIS

Prevention
Oral/Dental Care
 Prophylactic Antibiotics per Criteria

INFECTIVE ENDOCARDITIS
SIGNS AND SYMPTOMS
Fever
 Murmur
 Splinter Hemorrhages
 Petechiae
 Janeway Lesions
 Osler’s Nodes

PETECHIAE
INFECTIVE ENDOCARDITIS (CONT’D)

Complications
Vegetative Emboli
 Heart valve Stenosis/Regurgitation
 Heart Failure

INFECTIVE ENDOCARDITIS (CONT’D)

Diagnostic Tests
Blood Cultures
 Echocardiography

INFECTIVE ENDOCARDITIS (CONT’D)

Therapeutic Interventions
IV Antimicrobial Drug
 Rest/Supportive Care
 Home IV Antimicrobial Therapy
 Surgical Valve Replacement/Repair

INFECTIVE ENDOCARDITIS (CONT’D)

Nursing Management
Vital Signs/Cardiac Function
 Report Heart Failure/Emboli Signs
 Teach

Good Hygiene, Oral/Dental Care
 Report Symptoms: Fever, Chills, Sweats

PERICARDITIS

Inflammation of Pericardium
Acute
 Chronic

PERICARDITIS (CONT’D)

Pathophysiology
Inflammation of the Pericardium
 Ventricular Filling Reduced


Decreased Cardiac Output and BP
PERICARDITIS ETIOLOGY
Infections, Lyme Disease
 Drug Reactions
 Connective Tissue Disorders
 Neoplastic Disease
 Postmyocardial Infarction
 Renal Disease or Uremia
 Trauma

PERICARDITIS (CONT’D)

Signs and Symptoms

Chest Pain; Substernal, Radiates, Grating
Increases with Deep Inspiration
 Relieved by Sitting Up/Forward

Pericardial Friction Rub
 Dyspnea

PERICARDITIS

Signs and Symptoms
Low-Grade Fever
 Cough

PERICARDITIS DIAGNOSTIC TESTS
ECG
 Echocardiogram
 WBC
 Pericardial Fluid
 CT Scan
 MRI

PERICARDITIS THERAPEUTIC
INTERVENTIONS
Pericardiocentsis
 Treat Cause

Antibiotics
 Hemodialysis
 Pericardial Window
 Pericardiectomy

PERICARDITIS THERAPEUTIC
INTERVENTIONS (CONT’D)
Bed Rest
 NSAIDs

PERICARDIOCENTSIS
PERICARDITIS

Complications
Pericardial Effusion
 Cardiac Tamponade


Immediate Pericardiocentesis
PERICARDITIS NURSING MANAGEMENT
Vital Signs
 Cardiac Function/Tamponade Signs
 Pain Relief




NSAIDs, Corticosteroids
Position of Comfort
Education
MYOCARDITIS

Pathophysiology and Etiology
Inflammation of Myocardium
 Rare
 Often Follows Virus

VENOUS DISORDERS

Thrombophlebitis
THROMBOPHLEBITIS
Clot formation
 Inflammation Within Vein

THROMBOPHLEBITIS (CONT’D)

Pathophysiology
Clot formation and Inflammation Within Vein
 Superficial Veins
 Deep Veins (DVT)
 Emboli Danger

THROMBOPHLEBITIS (CONT’D)

Etiology

Venous Stasis


Reduced Blood Flow
Damage to Vein Lining

IV Catheters
THROMBOPHLEBITIS (CONT’D)

Etiology (Cont’d)

Increased Blood Coagulation
Smoking
 Oral Contraceptives
 Estrogen Therapy
 Hematological Disorders

THROMBOPHLEBITIS (CONT’D)

Prevention





Identify Risk Factors
Prevent Dehydration
Prophylactic Antiembolism Devices
Early Ambulation
Range-of-Motion Exercises
THROMBOPHLEBITIS (CONT’D)

Prevention (Cont’d)

Prophylactic Medication
Low Molecular Weight Heparin
 Enoxaparin (Lovenox)
 Heparin
 Warfarin (Coumadin)

THROMBOPHLEBITIS (CONT’D)

Signs and Symptoms
None
 Superficial Veins


Redness, Warmth, Swelling, Tenderness
THROMBOPHLEBITIS (CONT’D)

Signs and Symptoms

Deep Veins
Leg Usually
 Swelling, Edema, Pain, Warmth, Tenderness
 Homans’ Sign in 40% of Cases

THROMBOPHLEBITIS (CONT’D)

Complications

Pulmonary Embolism

Life-Threatening Emergency
Chronic Venous Insufficiency
 Varicose Veins
 Recurrent Deep Vein Thrombosis

THROMBOPHLEBITIS (CONT’D)

Diagnostic Tests
Duplex Ultrasound
 Impedance Plethysmography
 Magnetic Resonance Imaging (MRI)
 Venography


D-Dimer and Coagulation Tests
THROMBOPHLEBITIS (CONT’D)

Therapeutic Interventions

Superficial Veins
Warm, Moist Heat
 Analgesics
 NSAIDs
 Compression Stockings

THROMBOPHLEBITIS (CONT’D)

Therapeutic Interventions
Deep Veins
Low-Molecular Weight Heparin/Heparin
 Warfarin (Coumadin)
 Bedrest (Elevate Extremity)
 Warm, Moist Heat
 Compression Stocking Therapy

THROMBOPHLEBITIS (CONT’D)

Therapeutic Interventions
Deep Veins
Thrombolytic Therapy
 Thrombectomy
 Vena Cava Filter

VENA CAVA FILTER
THROMBOPHLEBITIS (CONT’D)

Nursing Diagnoses
Acute Pain
 Impaired Skin Integrity
 Anxiety
 Deficient Knowledge

NURSING INTERVENTIONS (CONT’D)
Identify Risk Factors
 Monitor Those at Risk for Signs
 Administer Meds per INR/PT
 Relieve Pain
 Monitor for Pulmonary Embolism
 Educate

CARDIAC VALVULAR DISORDERS
Mitral Valve Prolapse
 Mitral Stenosis
 Mitral Regurgitation
 Aortic Stenosis
 Aortic Regurgitation

STENOSED, INSUFFICIENT AND
NORMAL VALVE
TERMS TO KNOW

Stenosis
Narrowed, Valve Does Not Open Completely
 Forward Blood Flow Hindered
 Decreases Cardiac Output

TERMS TO KNOW (CONT’D)

Regurgitation (Insufficiency)
Valve Does Not Close Completely
 Blood Flow Backs Up

MITRAL VALVE PROLAPSE (MVP)
PATHOPHYSIOLOGY
During ventricular systole, mitral valve flaps normally
closed.
 In mitral valve prolapse one/both flaps bulge into left
atrium.
 If bulging flaps do not fit together, mitral regurgitation
occurs.

MITRAL VALVE PROLAPSE

Etiology
Unknown
 Hereditary
 Women 20-55 Years of Age

MITRAL VALVE PROLAPSE (CONT’D)

Signs and Symptoms





Often None
Anxiety
Chest Pain
Dysrhythmias
Dyspnea
MITRAL VALVE PROLAPSE (CONT’D)

Signs and Symptoms
Fatigue
 Palpitations

MITRAL VALVE PROLAPSE (CONT’D)

Diagnostic Tests
Murmur Heard
 2-D Or Doppler Echocardiogram
 Coronary Angiogram

MITRAL VALVE PROLAPSE (MVP)
THERAPEUTIC INTERVENTION
None, Unless Symptoms
 Healthy Lifestyle
 Avoid Stimulants/Caffeine
 Stress Management
 Beta Blockers for Tachycardia
 Valve Surgery for Severe MVP

MVP

Complications
Dilation of Left Side of Heart
 Heart Failure
 Infective Endocarditis
 Emboli

MITRAL STENOSIS

Pathophysiology
Mitral Valve Thickening/Chordae Tendineae
Shortening
 Narrows Valve Opening
 Blood Flow Obstructed from Left Atrium
 Left Atrium Enlarges

MITRAL STENOSIS (CONT’D)

Pathophysiology (cont’d)
Backward Pressure Occurs until Right Ventricle
Dilates/Fails
 Cardiac Output Reduced

MITRAL STENOSIS ETIOLOGY
Prior Rheumatic Fever Common
 Congenital Defects
 Tumors
 Rheumatoid Arthritis
 Systemic Lupus Erythematosus
 Rheumatic Endocarditis

MITRAL STENOSIS (CONT’D)

Continuous and Progressive
MITRAL STENOSIS (CONT’D)

Signs and Symptoms





None Early
Murmur
Exertional Dyspnea, Cough, Hemoptysis
Fatigue
Palpitations
MITRAL STENOSIS (CONT’D)

Signs and Symptoms (cont’d)
Atrial Fibrillation
 Chest Pain

MITRAL STENOSIS (CONT’D)

Diagnostic Tests
ECG: P-Wave Changes
 Chest X-Ray: Enlarged Chambers
 2-D and Doppler Echocardiography
 Coronary Angiogram

MITRAL STENOSIS (CONT’D)

Therapeutic Intervention
Prophylactic Antibiotics per Criteria
 Anticoagulants: Atrial Fibrillation
 Percutaneous Balloon Valvuloplasty

PERCUTANEOUS BALLOON
VALVULOPLASTY
MITRAL STENOSIS (CONT’D)

Surgery

Mitral Valve Repair
Commissurotomy
 Annuloplasty


Mitral Valve Replacement
MITRAL VALVE REPLACEMENT
MITRAL STENOSIS

Complications
Stroke
 Seizures

MITRAL REGURGITATION

Pathophysiology
Mitral Valve Incomplete Closure
 Backflow of Blood to Left Atrium
 Left Atrium Dilates, Extra Volume to Left Ventricle
 Left Ventricle Dilates from Extra Volume, Eventually
May Fail

MITRAL REGURGITATION (CONT’D)

Etiology





Rheumatic Heart Disease (Most)
Endocarditis
Congenital Defects
Chordae Tendineae Dysfunction
MVP
MITRAL REGURGITATION (CONT’D)

Signs and Symptoms





None Early
Murmur
Dyspnea, Cough, Hemoptysis
Fatigue
Palpitations
MITRAL REGURGITATION (CONT’D)

Signs And Symptoms (cont’d)
Atrial Fibrillation
 Chest Pain

MITRAL REGURGITATION (CONT’D)

Diagnostic Tests
ECG: P-Wave Changes
 Chest X-Ray: Enlarged Chambers
 2-D and Doppler Echocardiography
 Coronary Angiogram

MITRAL REGURGITATION (CONT’D)

Therapeutic Intervention





None, Unless Symptoms
Prophylactic Antibiotics per Criteria
ACE Inhibitors
Anticoagulants: Atrial Fibrillation
Mitral Valve Repair/Replacement
AORTIC STENOSIS

Pathophysiology





Aortic Valve Narrowed
Left Ventricle Contracts More Forcefully
Left Ventricle Hypertrophies
Decreased Cardiac Output
Eventual Heart Failure
AORTIC STENOSIS (CONT’D)

Etiology
Congenital Defects
 Rheumatic Heart Disease
 Calcification with Aging

AORTIC STENOSIS (CONT’D)

Signs And Symptoms
 None Early
 Angina
 Murmur
 Syncope
Orthopnea
 Dyspnea on
Exertion
 Fatigue
 Pulmonary Edema

AORTIC STENOSIS (CONT’D)

Diagnostic Tests
ECG
 Chest X-Ray: Enlarged Left Ventricle
 2-D and Doppler Echocardiography
 Serial Echocardiography
 Cardiac Catheterization

AORTIC STENOSIS (CONT’D)

Therapeutic Intervention

Surgery
Aortic Valve Replacement
 Valvotomy (Young Adults)

Treat Heart Failure Symptoms
 Prophylactic Antibiotics per Criteria

AORTIC REGURGITATION
PATHOPHYSIOLOGY
Aortic Valve Does Not Close
 Left Ventricle’s Volume Increases
 Left Ventricle Dilates
 Left Ventricle Fails

Decreased Cardiac Output
 Pulmonary Edema

AORTIC REGURGITATION

Etiology





Rheumatic Heart Disease (Most)
Congenital Defects
Syphilis
Endocarditis
Severe Hypertension
AORTIC REGURGITATION (CONT’D)

Etiology (cont’d)
Rheumatoid Arthritis
 Aortic Dissection

AORTIC REGURGITATION (CONT’D)

Signs and Symptoms





None Early
Exertional Dyspnea, Fatigue
Corrigan’s Pulse: Palpated Pulse Forceful, Quickly
Collapses
Widened Pulse Pressure
Angina At Night
AORTIC REGURGITATION (CONT’D)

Diagnostic Tests
ECG
 Chest X-Ray
 2-D and Doppler Echocardiography
 Coronary Angiogram

AORTIC REGURGITATION (CONT’D)

Therapeutic Intervention
Vasodilator
 Prophylactic Antibiotic Therapy
 Surgical Valve Replacement

NURSING PROCESS: VALVULAR DISORDERS

Nursing Assessment
History
 Vital Signs
 Signs andSymptoms

NURSING DIAGNOSES
Pain
 Decreased Cardiac Output
 Activity Intolerance
 Excess Fluid Volume
 Ineffective Therapeutic Regimen Management

PLANNING
Pain Management Relieves Pain
 Maintain Vital Signs/Oxygen Saturation
 Maintain Desired Activities
 Maintain Clear Lung Sounds
 Understand Disease/Treatment

NURSING INTERVENTIONS

Pain Relief
Rating Scale
 NTG
 Pace Activities

NURSING INTERVENTIONS (CONT’D)

Normal Cardiac Function






Vital Signs
Intake and Output
Daily Weights
Sodium Restriction
Smoking Cessation
Medications as Ordered
NURSING INTERVENTIONS (CONT’D)

Improve Quality of Life
Assist ADLs
 Rest Periods
 Energy Conservation

NURSING INTERVENTIONS (CONT’D)

Maintain Fluid Volume
Daily Weights
 Assess for Edema
 Intake/Output
 Diuretics as Ordered


Monitor Potassium Levels
NURSING INTERVENTIONS (CONT’D)

Education
Medications
 Anticoagulants

Monthly INR/PT Tests
 Medic Alert Identification

NURSING INTERVENTIONS (CONT’D)

Education (cont’d)
Include Caregivers for Elderly
 Endocarditis Prevention - Prophylactic Antibiotics

EVALUATION
Reports Satisfactory Pain Relief
 Vital Signs Normal/No Heart Failure Signs
 Reports Reduced Fatigue, Task Completion
 Remains Free of Edema, Maintains Weight,
Clear Lung Sounds

EVALUATION

Verbalizes Understanding of Teaching/with No
Symptom Recurrence
CARDIAC VALVULAR SURGERY

Traditional

Open Cardiac Surgery with Cardiopulmonary Bypass
CARDIAC VALVULAR SURGERY (CONT’D)

Exploring Less Invasive Options
Transseptal Stitch Repair and Coronary Sinus Tucking
 Mini Thoracotomy
 Robotic Devices

HEART VALVE REPAIRS

Stenosed Valve Repair
Commissurotomy
 Balloon Valvotomy


Insufficent Valve Repair

Annuloplasty
HEART VALVE REPLACEMENT

Mechanical
Durable
 Creates Turbulent Blood Flow



Lifelong Anticoagulation
Used For Younger Adults
MECHANICAL HEART VALVES
HEART VALVE REPLACEMENT

Biological

Types
Porcine (Pig)
 Bovine (Cow)
 Allografts (Human)
 Cultural Considerations

HEART VALVE REPLACEMENT (CONT’D)

Biological
Not as Durable as Mechanical Valves
 No Lifelong Anticoagulation
 Used For Older Adults

VALVE REPLACEMENT COMPLICATIONS

Biological Valves


Degenerative Changes
Calcification
VALVE REPLACEMENT COMPLICATIONS
(CONT’D)

Mechanical Valves
INR/PT Monitoring for Bleeding Risk
 Thrombus/Embolism Formation
 Anemia
 Endocarditis

NURSING PROCESS:
CARDIAC SURGERY
PREPARATION

Data Collection
Circulatory Status
 Pain Control Needs
 Diagnostic Tests
 Typing And Crossmatching of Blood Needed

PREOPERATIVE VASCULAR NURSING
DIAGNOSES
Acute or Chronic Pain
 Anxiety
 Deficient Knowledge

CARDIAC SURGERY PREPARATION

Teaching





Pain Management
Endotracheal Tube/Ventilator
Communicating
Chest Tubes
Coughing/Deep Breathing
CARDIAC SURGERY PREPARATION
(CONT’D)

Teaching
IV Lines
 Urinary Catheter

CARDIAC SURGERY PREPARATION
(CONT’D)
Preoperative Medications
 Antiseptic Scrub Showers
 NPO

POSTOPERATIVE CARDIAC SURGERY NURSING
DIAGNOSES
Pain
 Ineffective Airway Clearance
 Impaired Gas Exchange
 Decreased Cardiac Output
 Risk for Infection
 Deficient Knowledge

POSTOPERATIVE CARDIAC SURGERY NURSING
CARE
Pain/Provide Relief
 Vital Signs, ECG
 ABGs
 Intake and Output
 Lung Sounds
 Incision

POSTOPERATIVE CARDIAC SURGERY NURSING
CARE (CONT’D)

Promote Lung Expansion



Cough and Deep Breathe
Turn
Ambulate
POSTOPERATIVE CARDIAC SURGERY NURSING
CARE (CONT’D)

Prevent Infection




Hand Hygiene
Cleanse Stethoscope
Sterile Technique
Monitor Temperature
POSTOPERATIVE CARDIAC SURGERY NURSING
CARE (CONT’D)

Teaching




Pain Management
Medications
Activity
Follow-up Monitoring/Care
CHAPTER 24
Nursing Care of Patients with Occlusive
Cardiovascular Disorders
ARTERIOSCLEROSIS
 Artery/Arteriole
Walls
 Thicken
 Harden
 Lose
Elasticity
ATHEROSCLEROSIS
ATHEROSCLEROSIS (CONT’D)
Type
of Arteriosclerosis
Plaque Formation in Arterial
Wall
Childhood Onset
ATHEROSCLEROSIS (CONT’D)
Non-modifiable
Risk Factors
 Age
 Gender
 Ethnicity
 Genetic
Predisposition for
Hyperlipidemia
ATHEROSCLEROSIS (CONT’D)
 Modifiable

Risk Factors
Diabetes Mellitus
Hypertension
Smoking
Obesity
Sedentary Lifestyle

Increased Serum Homocysteine




ATHEROSCLEROSIS (CONT’D)
 Modifiable
Risk Factors (cont’d)
 Increased Serum Iron Levels
 Infection
 Depression
 Hyperlipidemia
 Elevated
Apolipoprotein B
 Excessive
Alcohol Intake
ATHEROSCLEROSIS (CONT’D)
 Diagnostic
Tests for Increased CVD
 Cholesterol
Elevated Increases Risk
 Low-density Lipoproteins (LDL)
Increased risk
 High-density Lipoproteins (HDL)
Protective
ATHEROSCLEROSIS (CONT’D)
 Diagnostic
Tests (cont’d)
 Lp(a) Cholesterol
Elevated Increases Risk
 Apolipoprotein B > Apolipoprotein
A
Increased Risk
 Triglycerides
Increased Risk
ATHEROSCLEROSIS (CONT’D)
 Diagnostic
Tests (cont’d)
 C-reactive Protein
Inflammation in C.A.
Shows Increased Risk
 Elevated Leukocyte Count in
Women
Increased Risk
ATHEROSCLEROSIS (CONT’D)
 Therapeutic
Interventions
 Low-fat Diet
 Avoid Smoking
 Exercise
 Lipid-lowering Agents
CORONARY ARTERY DISEASE (CAD)
 Obstruction
of Coronary Artery
Blood Flow Typically from
Atherosclerosis
 Contributes to
 Angina
 Myocardial Infarction
 Sudden Death
CAD PREVENTION

Modify Risk Factors
Low-cholesterol Diet
 Lipid-lowering Agents


Low Dose Aspirin
ANGINA PECTORIS
Symptom of Ischemia
 Chest Pain
 Causes: CAD, Vasospasm, Valvular Heart
Disease, Hypertension, Heart Failure

TYPES OF ANGINA

Stable Angina
Arteries Cannot Increase Blood to Heart
Increased Activity
 Usually Stops with Rest/Vasodilator

During
TYPES OF ANGINA (CONT’D)

Variant Angina (Prinzmetal’s Angina)





Longer Duration
Can Occur at Rest
Often Same Time Each Day
Coronary Artery Spasm Cause
Serious
ANGINA SIGNS AND SYMPTOMS

Pain
Heaviness, Tightness, Viselike, Crushing Pain in
Chest Center
 In the Morning
 Radiation

ANGINA SIGNS AND SYMPTOMS
(CONT’D)
Pale
 Diaphoretic
 Dyspneic

FEMALE ANGINA SIGNS AND SYMPTOMS
Chest Pain, Jaw Pain, Heartburn
 Atypical Symptoms

Describe Less Severe Pain
 Fatigue
 Nausea
 Breathlessness

DIAGNOSTIC TESTS
ECG
 Exercise ECG (Stress Test)
 Graded Exercise Testing
 Stress Echocardiography
 Chemical Stress Testing
 Radioisotope Imaging
 Coronary Angiography

THERAPEUTIC INTERVENTIONS
Weight Reduction
 Low-fat, Low-cholesterol Diet
 Stress Reduction
 Medications

THERAPEUTIC INTERVENTIONS (CONT’D)

Vasodilators


Calcium Channel Blockers


Nitroglycerin (NTG)
Diltiazem, Amlodipine
Beta blockers

Propranolol, Metoprolol, Atenolol
THERAPEUTIC INTERVENTIONS (CONT’D)

ACEI


Statins


Captopril, Lisinopril, Ramipril, Enalapril
Atorvastatin, Fluvastatin, Lovastatin, Pravastatin,
Simvastatin, Rosuvastin
Antiplatelets

Aspirin, Clopridogrel (Plavix)
NURSING CARE

Acute Pain Interventions





Oxygen
Vital Signs
Sublingual NTG
Remain with Patient
Emotional Support
ACUTE CORONARY SYNDROMES
Caused by Lack of Oxygen to Heart Muscle
 Conditions

Unstable Angina
 Myocardial Infarction

UNSTABLE ANGINA
Worsening CAD
 Rest Does Not Relieve
 Can Occur at Rest
 Increasing Frequency
 Risk for Cardiac Damage/Death

MYOCARDIAL INFARCTION (MI)
Death of Heart Muscle
 Pathophysiology

Coronary Artery Blockage
 Decreased Cardiac Blood Supply


Types


Non-ST Segment Elevation Myocardial Infarction
ST Segment Elevation Myocardial Infarction
MYOCARDIAL INFARCTION (MI)
(CONT’D)
SILENT ISCHEMIA

Myocardial Ischemia Without Chest Pain
SUDDEN CARDIAC DEATH

Cardiac Arrest Triggered by Lethal Ventricular
Dysrhythmias or Asystole from an Abrupt
Occlusion of a Coronary Artery
SIGNS AND SYMPTOMS

Crushing, Viselike Pain

Radiates to Arm/Shoulder/Neck/Jaw
Shortness of Breath
 Restlessness
 Dizziness, Fainting
 Nausea
 Sweating

SIGNS AND SYMPTOMS (CONT’D)

Atypical – Women/Older Adult





Absence of Classic Pain
Dyspnea
Fatigue
Anxiety
Chest Cramping, Epigastric or Abdominal Pain
SIGNS AND SYMPTOMS (CONT’D)

Atypical – Women/Older Adult (cont’d)
Restlessness
 Falling

OLDER ADULTS AND MI
Report Shortness of Breath, Fatigue,
Fast/Slow Heartbeats, Chest Discomfort
 Silent MI
 Collateral Circulation

TIMELY MEDICAL CARE
 “Act
in Time to Heart Attack
Signs”
Call 9-1-1 (or Local Emergency Number)
www.nhlbi.nih.gov/actintime/


National Heart Attack Alert Program
 “60 Minutes to Treatment”

www.nhlbi.nih.gov/about/nhaap
WOMEN AND MI
Leading Cause of Death
 African American Women at Higher Risk
 Higher Mortality Rate, More Complications Than
Men
 Prodromal Symptoms the Month Before MI


Unusual Fatigue, Sleep Disturbances, Dyspnea
WOMEN AND MI (CONT’D)
Delay Treatment
 Less Aggressive Treatment Given

DIAGNOSTIC TESTS
Consider Patient History
 Serial ECG
 Cardiac Troponin I or T
 Myoglobin
 CK-MB
 C-reactive Protein
 Magnesium

ECG CHANGES WITH MI
PRE-HOSPITAL CARE
“Time is Muscle”
 Chew One Uncoated Adult Aspirin
 Call 911 in 5 Minutes for Unrelieved Chest Pain
 Do Not Drive Self

EMERGENCY PERCUTANEOUS CORONARY
INTERVENTION

Mission: Lifeline


www.americanheart.org/
Door-to-Balloon Time: 90 Minutes

www.d2balliance.org/
THERAPEUTIC INTERVENTIONS
Oxygen
 Aspirin
 Morphine Sulfate
 Thrombolytics

Vasodilators
 Nitrates
 Beta Blockers
 Antidysrhythmic

INVASIVE PROCEDURES

PCI
Balloon Angioplasty
 Coronary Artery Stents

PCI: BALLOON ANGIOPLASTY
CORONARY ARTERY STENT
THERAPEUTIC INTERVENTIONS (CONT’D)
Bedrest/Bedside Commode
 Intra-aortic Balloon Pump
 Glucose Control
 Daily Weight
 Low-sodium Clear Liquids
 Low-fat, Low-cholesterol, Low-sodium Diet

THERAPEUTIC INTERVENTIONS (CONT’D)
No Caffeine
 Fluid Restriction
 Weight Loss
 Smoking Cessation

THERAPEUTIC INTERVENTIONS (CONT’D)

Fab Four Cardiac Drugs
Antiplatelets
 Statins
 ACEIs
 Beta Blockers

MYOCARDIAL REVASCULARIZATION

Coronary Artery Bypass Graft
Coronary Artery Occlusions Bypassed with
Vein/Artery Grafts
 Increases Blood Flow/Oxygen to Myocardium

MIDCAB
Thoracoscope
 No Cardiopulmonary Bypass
 Small Incisions
 Two Coronary Arteries Maximum

PORT-ACCESS CORONARY ARTERY
BYPASS

Combines Peripheral Cardiopulmonary Bypass
(CPB) with Minimally Invasive Heart Access
NURSING CARE
Monitor Vital Signs
 Report Symptoms
 Incisional Care

PATIENT EDUCATION
Disease Information
 Medications
 Diet
 Activity
 Rehabilitation

CARDIAC REHABILITATION
Optimizes Functioning
 Begins in Hospital
 Protocols Specify Activities
 Outpatient Program After Discharge

PERIPHERAL VASCULAR DISEASE
Arterial
 Venous

ARTERIAL THROMBOSIS/EMBOLISM
Arterial Blood Clot Can Become Embolus
ARTERIAL THROMBOSIS/EMBOLISM
(CONT’D)

Six Ps






Pain
Pulselessness
Paralysis
Pallor
Paresthesia
Poikilothermia
ARTERIAL THROMBOSIS/EMBOLISM
(CONT’D)

Therapeutic Interventions
Anticoagulants
 Thrombolytics
 Thrombectomy
 Embolectomy

PERIPHERAL ARTERIAL DISEASE

Pathophysiology
Chronic, Progressive Arterial Narrowing
 Reduced Blood Supply
 Ischemia Develops

SIGNS AND SYMPTOMS
Intermittent Claudication
 Cool Skin
 Reddish-purple When Dependent
 Pale When Elevated
 Diminished/Absent Pulses

DIAGNOSTIC TESTS
Ankle-brachial Index
 Doppler Ultrasound
 MRI
 Arteriography

THERAPEUTIC INTERVENTIONS
Low-fat, Low-cholesterol, Low-calorie Diet
 Medications

Lipid-lowering Agents
 Pentoxifylline (Trental)
 Thrombolytics

THERAPEUTIC INTERVENTIONS
(CONT’D)

Invasive Therapies
Percutaneous Transluminal Angioplasty (PTA)
 Atherectomy
 Stents
 Aortic-femoral Bypass

AORTIC-FEMORAL BYPASS
RAYNAUD’S DISEASE
Vasoconstriction with Cold/Stress Causing
Ischemia
 Mainly Affects Hands
 Phases: Blanching, Pain, Reddening
 Therapeutic Intervention: Keep Warm, Avoid
Vasoconstriction, Take Vasodilators

RAYNAUD’S DISEASE (CONT’D)

Nursing Care: Education
BUERGER’S DISEASE
Recurring Inflammation of Small and Medium
Arteries and Veins of Hands/Feet
 Vasospasms, Ischemia, Gangrene
 Cause is Unknown
 Heavy Cigarette Smoking Contributes

BUERGER’S DISEASE (CONT’D)

Signs and Symptoms
Intermittent Claudication
 Six Ps
 Lower Extremities Red or Cyanotic in
Dependent Position

BUERGER’S DISEASE (CONT’D)

Therapeutic Interventions
Smoking Cessation
 Calcium Channel Blockers
 Skin Assessment

ANEURYSMS
Dilation at Weakened Area of Artery
 Cause Unknown
 Abdominal Aorta Most Common

TYPES OF ANEURYSMS (CONT’D)
SIGNS AND SYMPTOMS
None Early
 Back/Flank Pain Classic
 Pulsating Abdominal Mass
 Rupture



Severe, Sudden Back, Flank, or Abdominal Pain
Shock
DIAGNOSTIC TESTS
CT Scan
 Abdominal Ultrasound
 Aortography

THERAPEUTIC INTERVENTIONS
Control Hypertension
 Bypass Graft

Open
 Endovascular

NURSING CARE

Education
Medication
 Avoid Lifting
 Reduce Stress


Postoperative Care
VARICOSE VEINS
Elongated, Tortuous, Dilated Veins
 Cause is Unknown
 Hereditary
 Varicosities



Primary
Secondary
VARICOSE VEINS (CONT’D)

Contributing Factors
Prolonged Standing
 Pregnancy
 Obesity

VARICOSE VEINS (CONT’D)

Signs and Symptoms
Disfigurement of Lower Extremity
 Dull Pain
 Edema
 Ulceration

VARICOSE VEINS (CONT’D)

Therapeutic Interventions






Reduce Contributing Factors
Compression Stockings
Injection Sclerotherapy
Radiofrequency Ablation
Laser
Surgical Intervention
VENOUS INSUFFICIENCY
Damaged/Aging Valves Cause Pooling of Blood in
Lower Extremities
 Chronic

VENOUS STASIS ULCERS
Result of Chronic Venous Insufficiency
 Leg/Foot: Edema; Brownish Discoloration;
Hardened, Leathery Skin
 Stasis Ulcers at Ankle
 Patient’s Quality of Life Affected

THERAPEUTIC INTERVENTIONS
Goal: Decrease Edema/Heal Ulcerations
 Compression Wraps
 Bedrest with Elevation of Legs
 Avoid Prolonged Standing/Sitting
 Walk
 Skin Ulcers: Unna Boot, Skin Grafts

NURSING INTERVENTIONS
Wound Care
 Emotional Support

EMBOLECTOMY AND THROMBECTOMY
Restores Blood Flow and Oxygenation
 Can Be Surgical Emergency

VASCULAR BYPASSES AND GRAFTS
Bypass: Graft Anastomosed to Artery Above and
Below Occlusion
 Graft Repair: Diseased Area of Blood Vessel
Replaced with Graft

VASCULAR BYPASSES AND GRAFTS
(CONT’D)

Video-assisted Aortofemoral Bypass
ENDARTERECTOMY
Arteriosclerotic Plaques Dissected
 Carotid Artery Common

ANGIOPLASTY
Open Plaque-blocked Arteries
 Balloon or Laser

STENTS

Support to the Artery Walls to Keep Them Open
COMPLICATIONS OF VASCULAR SURGERIES
Bleeding and Hemorrhage
 Re-occlusion
 Hematoma
 Neurological Dysfunction
 Volume Deficit

POSTOPERATIVE THERAPEUTIC
INTERVENTIONS
Neurological Checks
 Neurovascular Checks
 Incision Care
 Fluid Status
