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Chapter 32
1. Coronary artery disease (CAD) – a progressive atherosclerotic disorder of the
coronary arteries that results in narrowing or complete occlusion of the vessel
lumen
The nurse should know that older age, male gender and genetics are nonmodifiable
risk factors of CAD, assess for and educate patient on modifiable and contributing
risk factors; assess for EKG changes, angina pectoris.
2. Tunica intima – the inner layer of the artery, consisting of endothelial cells,
connective tissue, and smooth muscle cells
The nurse should know that coronary artery disease involves the buildup of plaque
that becomes a part of this innermost layer of the coronary arteries; evaluate patient
using radionuclide imaging, MRI, intravascular US, or cardiac catheterization.
3. Tunica media – the middle layer of the artery that consists of multiple layers of
smooth muscle cells and connective tissue made up of elastic fibers, collagen, and
proteoglycans
The nurse should know that in a Stage II Lesion smooth muscle cells from this layer
invade the intimal lesion, leading to further buildup of plaque and obstruction of
blood flow; evaluate patient using radionuclide imaging, MRI, intravascular US, or
cardiac catheterization.
4. Tunica adventitia – the outer layer of the artery consisting of fibrous tissue made
of collagen and elastic fibers surrounded by collagen bundles
The nurse should know that in a normal artery, this outer layer is flexible and allows
for diameter changes during vasodilation and constriction.
5. Arteriosclerosis – a condition characterized by thickening, reduced elasticity, and
calcification of the arterial wall
The nurse should know that arteriosclerosis of the coronary arteries causes reduced
supply of oxygen and nutrients to the myocardium; assess for pain, EKG changes,
diaphoresis, pallor; patient at risk for MI.
6. Atherosclerosis – a type of arteriosclerosis in which luminal blood flow is
obstructed by buildup of plaque infiltrating the intimal lining of the arterial wall
The nurse should know that atherosclerosis of the coronary arteries results in
reduced blood flow to the myocardium; assess for pain, EKG changes, diaphoresis,
pallor; patient at risk for MI.
7. Ischemia – tissue hypoxia resulting from imbalance of oxygen supply and demand
The nurse should know that myocardial ischemia is a life-threatening condition that
may be caused by CAD; assess for pain, EKG changes, diaphoresis, pallor; treat
suspected MI with MONA – morphine, oxygen, nitroglycerin, aspirin.
8. Atheroma – an accumulation of plaque in the inner lining of an artery
The nurse should know that an atheroma is an accumulation of plaque in the inner
lining of an artery which may lead to decreased lumen diameter and decreased
elasticity of the artery.
9. Fibrous cap- Connective tissue that covers the lipid core in a stage II lesion.
A thin fibrous cap increases the risk of rupture.
Know that the stages are determined by maturation levels of lipid core and
formation of fibrous cap
10. Eccentric- With coronary artery stenosis, eccentric lesions occupy part of the vessel
wall circumference
- Once arterial diameter is reduced, symptoms of CAD are expected such as
angina.
11. Concentric- W/ coronary artery, concentric lesions occupy the whole circumference
- Once arterial diameter is reduced, symptoms of CAD are expected such as
angina.
12. Thrombus- blood clot that forms in a blood vessel and remains at the site of
formation
- If large enough, can stop blood flow causing tissue ischemia and apoptosis
- Having a blood disorder (reduced anticoagulation factors, abnormal platelet
function, etc) combined with plaque development can increase risk or
thrombus formation
13. Myocardial stunning- Temporary dysfunction that occurs in response to artery
occlusion of short duration or transient global hypoperfusion during a limited low
flow state such as shock
- End result: myocardial muscle temporarily has a limited ability to contract
- Know this is an adaptive response to chronic coronary occlusion
- Goal: Establish reperfusion as early as possible to prevent necrosis (clotdissolving agents)
14. Myocardial hibernation- myocardial tissue actually undergoes cellular structural
changes and progressive apoptosis in response to prolonged occlusion
- Hibernating tissue is thought to recover contractile function fully once
perfusion is reestablished
15. Cardiac risk factors- habits, lifestyles, and/or genetic factors that predispose an
individual to the development of CAD
- Promote risk factor reduction, such as smoking cessation, BP control,
exercise, weight reduction, low fat diets, and pharmacologic therapies that
control dyslipidemia
16. Hyperlipidemia- Elevated cholesterol and/or triglyceride levels that permeate the
arterial wall, narrowing the lumen and ultimately decrease blood flow to the cardiac
muscle.
- Draw lipid panels after fasting overnight, including no alcohol
17. Hypercholesterolemia- increased cholesterol level in the blood
- know that this can be inherited as a genetic defect, acquired through diet and
lifestyle.
- Pt teaching: stress risk reduction (lipid screen regularly, diet, exercise, use of
lipid-lowering drugs)
18. Cholesterol- steroid molecule produced primarily by the liver that is essential for
the formation and maintenance of cell membranes.
- Serum cholesterol- indicator of risk for CAD
- levels greater than 250 mg/dl is considered high risk
- Measure every 5 years (more often if above ages 55)
19. Low-density lipoprotein- “bad cholesterol”; major cholesterol carrier in the blood
- Know that oxidized LDL-C cause endothelial damage and aids in
development of plaques
- Pt teaching: dietary control- inquire about food preferences and cultural
factors that influence eating habits
20. High-density lipoprotein- “good cholesterol”; consists of heavier lipoproteins that
bind to cholesterol, transporting it back to the liver, and may actually remove excess
cholesterol from plaque in the arteries.
- Levels greater than 40-50 mg/dl with no CAD risk factors are desirable
21. Triglycerides- form of fat derived and produced by the body from other sources
such as carbohydrates
- Lowering levels to less than 150 mg/dl has become a part of risk prevention
- Reduce factors through exercise, reduce carbohydrate consumption
22. Metabolic syndrome: having three out of the five following conditions: elevated
waist circumference, elevated triglycerides, reduced HDL-C, elevated BP, elevated
fasting glucose (>100 mg/dl)
● correlated with high risk for CAD and type 2 diabetes
● mgmt: target each abnormality with modification of corresponding risk
factors, especially weight reduction and increased physical activity, use of
therapeutic interventions to lower BP, lower serum glucose, and lower
serum lipids
23. Angina pectoris: transient chest pain due to myocardial ischemia caused by
inadequate supply of oxygen and nutrients to the myocardium
● know that CAD is most common cause of decreased blood to myocardium
● clinical manifestations: sudden onset of discomfort in chest, jaw, back or arm
aggravated by exertion or emotional stress and relieved with rest or
nitroglycerin
● chest pain is burning, crushing, suffocating, or pt. may feel pressure; pain is
not localized to a defined spot
● women may not experience pain the same way; express pain in less severe
terms and often ascribe pain to cause other than cardiac issues
24. Stable angina: less serious angina triggered by a predictable degree of exertion or
emotions, and there is a pattern in what brings it on, its duration, its intensity of
symptoms, and how to relieve it
● subsides by taking away precipitating factor and using SL nitroglycerin
25. Variant/Prinzmetal, or vasospastic angina: occurs when single or multiple sites in
major coronary arteries and their large branches experience vasospasm; cause is
unknown
● symptoms are episodic, may last several minutes, and are often associated
with exercise and can occur frequently at night
26. Myocardial perfusion imaging (MPI): nuclear imaging technique to detect significant
CAD
● In patients with physical limitations not suitable for standard exercise stress
test, imaging combined with basic stress test improve the ability to detect
significant CAD
● nurse to know contraindications to stress/exercise test (so imaging is used
instead): MI within 2 days, unstable angina, aortic stenosis, symptomatic
heart failure, uncontrolled arrhythmias, active endocarditis, uncontrolled
HTN
27. Multislice helical CT: tool for visualization of general cardiac structure, the great
vessels, and the coronary arteries; allows visualization of fine details of the coronary
anatomy such as small branches and aterosclerotic plaques
● Review pt & family’s understanding of procedure; Provide teaching if
necessary
● Keep pt NPO prior to procedure
28. Magnetic resonance imaging (MRI): imaging using radiofrequency pulses from a
large powerful magnet to disrupt normal spin of certain atoms within the body
temporarily. Used to evaluate patients with presumed congential heart diseases, to
image heart structures, and enable assessment of myocardial viability
● provide patient teaching on MRI procedure to reduce anxiety related to lack
of knowledge
● nurse may also administer anti-anxiety medication (claustrophobia)
29. Myocardial viability: info about areas of the myocardium that appear to have normal
functioning as well as areas that appear to be dysfunctional and may improve with
revascularization (gathered from MRI)
● know normal v. abnormal scans
30. Cardiac catheterization: commonly performed procedure done using x-ray where
catheter is inserted thru a sheath and advanced into the left and/or right side of the
heart to provide anatomical and hemodynamic information about the heart and
great vessels
● Nurse to know contraindications to catheterization: severe CHF, severe
electrolyte imbalances, bleeding diathesis, serum creatinine > 1.5 mg/dl,
poor pt. cooperation
31. Percutaneous coronary intervention (PCI) - catheter-based interventions available
for the treatment of CAD
a. Review pt & family’s understanding of procedure; Provide teaching if
necessary
b. Ask pt & family about any meds prior to procedure
c. Keep pt NPO prior to procedure
d. Assess ECG
e. Monitor patient closely to ensure a safe environment for the
procedure
f. Monitor & assess VS, distal pulses, and pain
32. Stents - metallic mesh-like structures that are inserted permanently inside the
coronary artery, compressing plaque and providing structural support of the vessel
a. Review pt & family’s understanding of procedure
b. Ask pt & family about any meds prior to procedure
c. Post-op: assess distal pulses
d. Assess CV, vital signs, and ECG to avoid complications
33. Restenosis - accumulation of smooth muscle cells at the site of the original
procedure that occurs because of the artery’s response to the injury from the PCI
a. Recognize that stents reduce possibility
b. Ensure pt knows of complication prior to PCI
c. Assess distal pulses frequently
34. Pseudoaneurysm - extravascular cavity communicating w/ femoral artery by a
channel or neck at the needle puncture site
a. Monitor for localized tenderness, palpable & pulsatile mass, & bruit
b. Use doppler imaging
c. Monitor for retroperitoneal hemorrhage or hematoma (potential
complication)
d. Monitor for s/sx of infection at access site
e. Discharge teaching: care of access site, what to do w/ angina or other
Sx associated w/ CAD, not stopping meds
35. Arteriovenous (AV) fistula - direct communication between the artery & vein that
results in a high-velocity jet from the artery into the vein
a. Monitor for bruit
b. Monitor for retroperitoneal hemorrhage or hematoma (potential
complication)
c. Use doppler ultrasound to diagnose
d. Monitor lab values
e. Discharge teaching: care of access site, what to do w/ angina or other
Sx associated w/ CAD, not stopping meds
f. Monitor for s/sx of infection at access site
36. Dyskinesia - abnormal heart contractility: impaired muscle movement
a. Know that this is can be a result of poor coronary perfusion
b. assess for any risk factors or s/sx associated with ACS
37. Akinesia - abnormal heart contractility: severe loss or no muscle movement
a. Know that this is can be a result of poor coronary perfusion
b. assess for any risk factors or s/sx associated with ACS
38. Hypokinesia - abnormal heart contractility: hypoactive muscle movement
a. Know that this is can be a result of poor coronary perfusion
b. assess for any risk factors or s/sx associated with ACS
39. Acute coronary syndrome (ACS) - myocardial infarction, myocardial ischemia, and
infarction-related complications
a. Know when & how to decrease heart’s workload with oxygen
b. Promote progression of activity as tolerated
c. Administer appropriate meds (as ordered) - MONA
d. Assess lab tests, evaluate serial ECG, & serum cardiac markers
e. Continuous cardiac monitoring.
f. Encourage pt to inform nurse of any new s/sx
40. Unstable angina (UA) - transitory syndrome falling between stable angina & MI in
which thrombus forms in an area of arterial stenosis but is subsequently fully or
partially lysed, or dissolved, by endogenous antithrombotic mechanisms
a. Monitor for onset of new symptoms
b. Recognize that blood markers & ECG will be normal
c. Nurses should know when and how to decrease heart’s workload ->
Monitor signs for adequate myocardial oxygen supply. Administer &
titrate meds to balance O2 supply and demand.
41. Myocardial infarction (MI) - loss of myocytes; myocardial apoptosis as a result of
prolonged muscle ischemia
a. Assess lab tests, evaluate serial ECG, & serum cardiac markers
b. Administer appropriate drugs (MONA)
c. Monitor signs for adequate myocardial oxygen supply. Administer &
titrate meds to balance O2 supply and demand
d. Continuous cardiac monitoring.
e. Encourage pt to inform nurse of any new s/sx
f. If pt. has a lot of complications & risk factors, use hemodynamic
monitoring
42. NSTEMI - Non-ST segment elevation myocardial infarction
a. Assess lab tests, evaluate serial ECG, & serum cardiac markers
b. Monitor ECG - recognize persistent changes & presence of serum
markers can be indicative of serious myocardial injury
c. Encourage pt to inform nurse of any new s/sx
43. STEMI - myocardial injury associated with ST segment elevation on the ECG
a. Assess lab tests, evaluate serial ECG, & serum cardiac markers
b. If on thrombolytic therapy, monitor for signs of reperfusion
i. signs: chest pain & ST segment elevation
c. Encourage pt to inform nurse of any new s/sx
44. Sudden cardiac death (SCD) - unexpected cardiac arrest that results in death w/i an
hour of the onset of symptoms
a. Nurse should recognize pt. with CAD are at risk for SCD
b. Recognize S/Sx of MI quickly
c. Monitor vital signs for changes
d. Recognize not everyone experiencing a MI has chest pain
45. Troponins - biochemical markers for cardiac disease
a. Monitor for high levels. High levels can indicate MI
b. Notify MD if suspected MI
46. Troponin T - found in cardiac muscle during periods of cardiac ischemia
a. Monitor for high levels. High levels can indicate MI
b. Notify MD if suspected MI
47. Troponin I - found in cardiac muscle during periods of cardiac ischemia
a. Monitor for high levels. High levels can indicate MI.
b. Notify MD if suspected MI
48. Creatine kinase (CK) - enzyme found in high concentrations in the heart & skeletal
muscle & in smaller concentrations in the brain (isoforms: CK-MM, CK-BB, CK-MB)
a. Recognize & monitor CK-MB for cardiac ischemia & infarction
49. Myoglobin - heme-containing, oxygen-binding protein that is exclusive to striated &
nonstraited muscle
a. Monitor for muscle damage
b. do not rely on only this value for heart damage; look at other markers
too
50. MONA - morphine, oxygen, nitroglycerin, and aspirin; protocol for treatment of
patients with suspected MI
a. Administer & titrate drugs per order
b. Monitor for angina
c. Discharge teaching: cardiac risk factors, s/sx of MI, how & when to
access emergency medical services, & med regimen
51. Remodeling - process of replacing nonviable heart muscle tissue with nonelastic
fibrinous collagen
a. Nurses should know when and how to decrease heart’s workload ->
Monitor signs for adequate myocardial oxygen supply. Administer &
titrate meds to balance O2 supply and demand. Continuous cardiac
monitoring.
52. Coronary artery bypass grafting (CABG) - surgery used as a treatment for CAD
a. Nurse should provide post-op care to promote recovery & prevent
complications (early mobilization, assess neuro status, OOB to chair
POD 1)
b. Receive appropriate report from OR
c. If extubated, prevent patient from removing the tube themselves
d. Wean patient off of intravenous drips & convert to PO meds
Chapter 33 Terms
allograft valve
A valve obtained from human cadaver donations; used
primarily to replace the aortic and pulmonic valves. Also
called a homograft valve.
annuloplasty
A surgery done to correct valve regurgitation by repairing
the enlarged annulus.
*NI: Educate patient that this procedure requires open
heart surgery and cardiopulmonary bypass and is done
when the valve leaflets are normal, but the valve fails to
close due to enlargement.
*NI: Elevate HOB, encourage turning, C&DB postop, and
change dressings using aseptic technique.
annulus
The fibrous ring at the junction of the cardiac valve leaflets
and the muscular wall.
aortic valve
regurgitation
Incomplete closure of the aortic valve, which causes blood
to regurgitate back into the left ventricle through a valve;
results from abnormal valve cusps or aortic root.
*NI: Assess for palpitation and diastolic murmur that is
heard best at the 2nd right intercostal space and radiating
to the left sternal border.
*NI: Look at end of section for more NI.
aortic valve stenosis
A narrowing of the aortic valve orifice, which results in an
obstruction to blood flow from the left ventricle to the
aorta during systole.
*NI: Assess for dyspnea, angina, exertional syncope,
increased pulmonary artery pressure, and harsh
crescendo-decrescendo systolic murmur developing due to
the valve orifice becoming one-third of its normal size.
*NI: Look at end of section for more NI.
arrhythmogenic right
ventricular
cardiomyopathy
(ARVC)
An electrical disturbance that develops when the muscle
tissue in the right ventricle is replaced with fibrous scar
and fatty tissues.
*NI: Educate patient that the only cure is a heart
transplant.
*NI: Assess for palpitations, light-headedness, and
fatigue, and sudden cardiac death may be the first sign
*NI: Right: prominent neck veins, distention of liver,
swollen legs; Left: fatigue, SOB
autograft valve
Valve obtained from the patient's own pulmonic valve and
pulmonary artery. Also called autologous valve.
Beck's triad
Classic assessment findings for the patient with cardiac
tamponade, consisting of decreased blood pressure,
muffled heart sounds, and jugular venous distention.
biologic valve
Valve obtained from other species, most commonly from
pigs (porcine valves), although cow valves (bovine) also
are used. Also referred to as xenografts.
cardiac tamponade
Bleeding into the pericardial sac. As the accumulation of
blood increases, it compresses the atria and ventricles,
decreasing venous return and filling pressure. This leads to
decreased cardiac output, myocardial hypoxia, and cardiac
failure
*NI: Monitor for anxiety, CP (sharp, stabbing, radiating to
shoulder, back or abdomen), cyanosis, palpitations,
tachypnea, weak or absent pulse
*NI: Assess for Beck’s triad
*NI: Know that it is worsened by deep breathing or
coughing
cardiomyopathies
(CMPs)
Diseases of the myocardial muscle fibers that result in
progressive structural and functional abnormalities of the
myocardium.
*NI: Caused by alcohol intake, hypertension, CAD, or may
be idiopathic
commissure
The site where cardiac valve leaflets meet each other.
commissurotomy
Surgical procedure used to separate fused heart valve
leaflets.
constrictive
pericarditis
Occurs when the pericardial layers adhere to each other as
a result of fibrosis of the pericardial sac.
*NI: Develops from TB, in people with AIDS, surgery,
uremia, or radiation
dilated
A disorder of the myocardium characterized by dilation
cardiomyopathy (DCM) and impaired contraction of one or more ventricles; the
most common form of cardiomyopathy.
*NI: Conserve patient’s energy and decrease heart’s
workload by reduced activity, positioning, and oxygen
therapy.
*NI: Continuous monitoring for changes in mental status,
fluid status, peripheral perfusion, and heart rate and
rhythm.
Dressler's syndrome
Condition characterized by fever, pericarditis, chest pain,
and pericardial and pleural effusions. Believed to be an
autoimmune response, it occurs in 5% to 15% of patients
1 to 4 weeks after a myocardial infarction.
echocardiography
The noninvasive assessment of the structures and function
of the heart and great vessels utilizing high-frequency
(ultrasound) sound waves.
effusion
Abnormal accumulation of fluid.
homograft valve
See allograft valve.
hypertrophic
A disorder of the sarcomere, the contractile element of the
cardiomyopathy (HCM) cardiac muscle; characterized by left ventricular and
occasionally right ventricular hypertrophy, with greater
hypertrophy occurring in the septum. Also referred to as
idiopathic hypertrophic subaortic stenosis (IHSS).
*NI: Administer beta-adrenergic blocking agents and
calcium antagonists as prescribed
*NI: Stress the importance of consistent and normal
hydration and educate on activities, foods and drinks that
cause dehydration
*NI: Monitor patient’s hemodynamic status as disease
progresses
infective endocarditis
(IE)
An infection of the cardiac endocardial layer of the heart,
which may include one or more heart valves, the mural
endocardium, and/or a septal defect; previously known as
bacterial endocarditis.
*NI: Assess for peripheral manifestations such as splinter
hemorrhage, roth’s spots, janeway’s lesions
*NI: Assess for new or changing murmurs, embolic
events, and skin manifestations
mechanical valve
Commercially manufactured heart valve.
mitral valve
prolapse (MVP)
Occurs when one or more of the valve leaflets bulge or
prolapse into the left atrium during systole. This prolapse
of the valve results in valve regurgitation.
*NI: Assess for sharp stabbing chest pain during rest or
periods of stress, panic attacks, chronically cold hands and
feet.
*NI: Look at end of this section for more interventions.
Note: these patient’s have no activity restriction except
those necessitated by clinical manifestations
mitral valve
regurgitation
An inability of the mitral valve to close due to an
abnormality in the structure and function of the valve.
*NI: If acute, assess for sudden onset of dyspnea, blowing
high-pitched, systolic murmur and thready peripheral
pulses.
*NI: If chronic, assess for gradual onset of dyspnea,
peripheral edema, S3 and pansystolic murmur at the apex
radiating to the left axilla.
*NI: Look at end of this section for more interventions
mitral valve stenosis
Occurs when the mitral valve assumes an abnormal funnel
shape due to thickening and shortening of the valve
structures as a result of calcification. Contractures develop
between the junctions or commissures (leaflets) of the
valve. The stenosis narrows the opening of the valve,
which obstructs blood flow from the left atrium to the left
ventricle.
*NI: Assess for dyspnea, orthopnea, afib, and loud first
heart sound (S1)
*NI: Look at end of this section for more interventions.
myocarditis
A focal or diffuse inflammation of the myocardium or heart
muscle; an uncommon disorder that is frequently
associated with pericarditis.
*NI: Promote healing by resting the heart by spacing
activities and providing pain relief, provide emotional
support, and quiet environment.
*NI: Educate pt to avoid excessive fatigue and stop all
activities immediately when light-headedness, dyspnea, or
faintness occurs
*NI: Outline specific manifestations of heart and failure
and reinforce that the patient must seek medical care if
they occur
pancarditis
Inflammation of all three layers of the heart: the
endocardium, myocardium, and pericardium.
pericardial effusion
An excess buildup of pericardial fluid that is a threat to
normal cardiac function. The fluid buildup is the result of
an accumulation of infectious exudates or toxins and/or
blood.
pericardial friction rub A grating, scraping, squeaking, or crunching sound that is
the result of friction between the roughened, inflamed
layers of the pericardium.
*Auscultate for grating, scraping, or crunching sound over
pericardial sac.
pericardial window
An opening in the pericardial sac that allows fluid from
effusion and tamponade to drain.
pericardiectomy
Removal of the pericardial sac to allow fluid to drain from
around the heart.
pericarditis
Inflammation of the pericardial sac due to an inflammatory
process in which the two layers of the pericardium become
inflamed and roughened, causing fluid to build up
*NI: Assess for pericardial friction rub or pericardial
effusion
pulmonic valve
regurgitation
The inability of the pulmonic valve to completely close,
causing blood to regurgitate back into the right ventricle.
*NI: Assess for high-pitched diastolic blowing murmur
along left sternal border, dyspnea, and afib.
*NI: Look at end of this section for more interventions.
pulmonic valve
stenosis
A narrowing of the cardiac valve orifice that restricts blood
flow due to an inability of the valve to completely open,
thus obstructing blood from the right ventricle from
flowing into the pulmonary vasculature during systole.
*NI: Assess for systolic crescendo-decrescendo murmur
heard in 2nd left intercostal space and tall peaked T waves
from atrial hypertrophy.
*NI: Look at end of this section for more interventions.
pulsus paradoxus
A greater-than-10 mmHg drop in systolic blood pressure
during inspiration.
restrictive
A disorder characterized by endometrial scarring that
cardiomyopathy (RCM) usually affects one or both ventricles and restricts filling of
blood, resulting in systolic dysfunction. The ventricle has
normal wall thickness, but the walls are rigid, producing
elevated filling pressures and dilated atria.
*NI: decrease workload of heart and conserve energy
*NI: teach patient to avoid situations that impair venous
filling or lower CO
*NI: Assess for S3 systolic murmur, syncope, exercise
intolerance, signs of pulmonary and systemic congestions
rheumatic fever
A pharyngeal infection caused by Lancefield group A betahemolytic streptococci. In 3% of the cases it leads to
rheumatic heart disease.
*NI: Risk factors include poor inner-city neighborhoods,
damp weather, crowded living conditions, malnutrition
*NI: Be sure to treat pharyngeal infection because if left
untreated may result in rheumatic fever.
*NI: Assess for fever, headache, swollen tender joints with
small bony protuberances, SOB, elevated WBC.
rheumatic heart
disease
An inflammatory disease of the heart that causes longterm damage, scarring, and malfunction of the heart
valves.
*NI: Document and report heart failure manifestations and
change in murmur volume
*NI: Educate patient to decrease myocardial oxygen
demand/cardiac workload
*NI: Provide emotional support, pain relief and encourage
rest
*NI: Administer antibiotics as prescribed to eradicate
infecting organism
stress
echocardiography
Refers to the use of echocardiography to detect coronary
artery disease.
transesophageal
echocardiography
(TEE)
Echocardiogram performed using a miniaturized
transducer advanced down the esophagus. Because the
esophagus passes directly behind the posterior surface of
the heart, TEE affords excellent views of the posterior
structures of the heart and great vessels.
tricuspid valve
regurgitation
Inability of a heart valve to completely close, resulting in a
backflow of blood from the right ventricle to the right
atrium.
*NI: Increased risk factors include rheumatic heart
disease, inferior MI, blunt chest trauma, and IE.
*NI: Assess for high-pitched blowing systolic murmur
heard over xiphoid process, prominent waves in the neck
veins, and tall P waves in normal sinus rhythm.
*NI: Look at end of this section for more interventions.
tricuspid valve
stenosis
Obstruction of blood flow between the right atrium and the
right ventricle due to a narrowed valve orifice.
*NI: Low-pitched rumbling diastolic murmur heard over
4th intercostal space of left sternal border, prominent
waves in the neck veins, and tall P waves in normal sinus
rhythm.
*NI: Occurs w/ rheumatic heart disease, IV drug use, and
concurrently w/ mitral stenosis
*NI: Look at end of this section for more interventions.
valvular regurgitation
Inability of a heart valve to completely close, resulting in a
backflow of blood through the incompetent valve orifice
into the previous chamber.
*Look at end of section for NI.
valvuloplasty
A surgical procedure to repair torn or damaged leaflets,
chordae tendineae, or papillary muscle.
*NI: Educate patient that this procedure is surgically
repairing a valve leaflet under general anesthesia and
cardiopulmonary bypass.
Chapter 34 Terms
Ascites: an abnormal intraperitoneal accumulation of fluid containing large amounts of
protein and electrolytes
Nursing: nurse will know ascites is a clinical manifestation of heart failure and
will assess for other signs such as, hypotension, rales, tachypnea, confusion,
pitting edema etc
Biventricular heart failure: global inability of both ventricles of the heart to pump
blood effectively. Forward blood is compromised and lead to left and right heart failure
symptoms; type of systolic heart failure.
S/S: generalized malaise, activity intolerance, poor concentration, elevated neck
veins, abd ascites, poor appetite, N&V, pulm congestion, cough, orthopnea,
crackles,
Nursing: same for all types of heart failure- treat congestion and monitor patients
response to therapy by: I&O, daily weight, dysrhythmias, O2 sats, assess neuro;
encourage pt to increase level of activity, preform ADLS, admin O2
Cardiomegaly: enlargement of the heart
Nursing: this is found in stage B of heart failure- these patients are usually
asymptomatic; treatment if a cardiomegaly along with other signs of stage B heart
failure are found is admin ACE inhibitors, ARBs and beta blockers to prevent
further damage to the myocardium
Crackles: common abnormal sound heard on auscultation of the lungs from the
movement of fluid or exudate
Nursing: crackles may or may not be present in patients with chronic heart
failure- crackles are absent in over 80 % of people with elevated filling pressures;
usually associated with Left sided heart failure or biventricular heart failure; nurse
will recognize this and look for other s/s of heart failure (look above);
Diastolic dysfunction: heart failure with preserved LVEF (not under 40 %) – slowing of
ventricular relaxation and elevated filling pressures
Nursing: nurse will know that this type of heart failure most often effects older
women and patients with HTN, diabetes, obesity and A Fib; treatment focuses on
controlling HTN, ischemia and ventricular rate when A Fib is present and
minimizing congestion
Euvolemia: when the body is in a state of equal fluid balance without fluid retention
Nursing: A heart failure patient will need to maintain this; we do this by sodium
and fluid restriction and diuretics; nurse will teach patient about the importance
of compliance to these interventions and educate about the mechanisms of
diuretics as well as how to maintain a dry weight
Heart failure: a complex and denilitating clinical syndrome caused by cardiac
dysfunction, resulting in left ventricular dilation, hypertrophy or both.
Nurisng: critical thinking and good judgment skills to assess and recognize
subtle and late symptoms; treating congestion and monitoring response to
therapy by I&O, daily weights, dysthymias, O2 sats, and neuro status, as well as
encouraging increased activity, preforming ADLS, and enhancing pts knowledge
of disease,
S/S: subtle: edema, cool forearms and legs, crackles (sometimes); abrupt decline:
narrowed pulse pressure, altered mentation, hypotension, resting tach, oliguria,
tachypnea
Hepatojugular reflex: an increase in jugular venous pressure when pressure is applied
over the abdomen
Nursing: this is suggestive of R sided heart failure, and may be present of
volume overload is found in the periphery; assess for other manifestations of
heart failure
Hypertrophy: an increase in the size of an organ caused by an increase in the size of the
cells, rather than an increase in the number of cells
Nursing Application: hypertrophy of the heart is a part of the neurohormonal
response to heart failure, and is a compensatory mechanism; the nurse will
recognize that hypertrophy is a sign of heart failure and will assess for other signs
of neurohormonal response such as chamber dialation, increased myocardial
oxygen consumption, and pulmonary and systemic congestion
Left-sided heart failure: impaired pumping of left side of heart which backs the blood
up into the pulmonary circulation
S/S: fatigue, activity intolerance, SOB, cough, pulmonary congestion, crackles,
orthopnea, poor concentration
Nursing: determine if the signs/symptoms are associated with heart failure. Rule
out other disorders such as neurological. Look for cool arms and legs and signs of
poor perfusion
Left Ventricular Ejection Fraction (LVEF): the proportion of blood ejected during
each ventricular contraction compared with the total ventricular filling volume.
Normal LVEF: 55%-70%
Dysfunctional LVEF: below 40%
Nursing: nurse will know that a dysfunctional LVEF correlates with systolic
dysfunction and will be aware that the heart will be unable to pump blood to
sustain metabolic demands and if damage is extensive Left, Right or biventricular
HF can occur- watch for symptoms of HF and determine type
New York Heart Association Classification System (NYHA): categorizes patients
subjective symptoms into 4 classes based on the degree of dyspnea the patient has upon
exertion
Class 1: no symptoms
Class 2: patient has symptoms with ordinary exertion
Class 3: patient has symptoms with less than ordinary exertion
Class 4: patient has symptoms at rest
Pitting: the indentation that remains for a short time after on skin with edema. Can be
measured based on seconds it takes for skin to return to normal, or how deep the
indentation of the skin is
Nursing: nurse will know pitting edema is a clinical manifestation of heart failure
and will assess for other signs such as, hypotension, rales, tachypnea, confusion,
pitting edema etc
Right-sided heart failure: impaired pumping ability of the right side of the heart leading
to backup of blood followed by congestion and elevated pressure in systemic veins and
capillaries. Most commonly brought on due to left-sided heart failure.
S/S: ascites, edema, elevated neck veins, lower extremity swelling
Nursing: determine if the signs/symptoms are associated with heart failure. Rule
out other disorders such as neurological
S3: Abnormal third hart sound in the cardiac cycle. May be present with volume overload
S4: Abnormal fourth heart sound in the cardiac cycle. May be heard when pt has
significant hypertension
Systolic Dysfunction: left ventricular systolic dysfunction (LVSD) results in volume
overload and decreased contractility. The heart is unable to pump enough blood to
sustain the body’s metabolic demands and can result in heart failure. Most commonly
caused by CAD & HTN.
Tachypnea: rapid breathing >20 breaths per minute. Clinical manifestation of heart
failure
Nursing: obtain O2 sat, assess for cyanosis, asses neurological status, place pt on
O2 or increase level of O2 flow
Chapter 35 Terms
Aneurysm: diseased segment of an artery that becomes thin and dilated because of degenerative
changes in the tunic media layer.

Interventions/ significance:
o Mostly abdominal aortic aneurysms (AAA)
o Localized area of aorta that is weakened due to decreased elastin in the medial
layer causing thinning of the vessel wall.
o Assess for pulsatile abdominal mass near the umbilicus in the lean patient.
o Auscultation of a bruit can be heard due to the widened and thinned area of the
aorta.
o Report to physician if patient experiences any: restlessness, abdominal pain and
tenderness, hypotension, and shock.
Ankle-brachial index (ABI): a noninvasive test used to diagnose PAD.

Interventions/ significance:
o ABI tests should be done on those with exertional leg pain or unhealed ulcers,
older than 65yrs, those with diabetes, or smokers.
o Procedure:



Take BP of bother arms with Dopple and take the higher reading.
Take Dopple and record posterior tibialis and dorsalis pedis pulses and
take the BP of these and take the higher of the two.
Highest ankle BP/ highest arm BP = ABI
 ABI > 1.0 = normal
 ABI <0.9 = PAD
 ABI <0.4 = Severe arterial ischemia
Aortic dissection (AD): life threatening condition whereby a tear in the intimal layer of the
lumen of the aorta allows blood to flow into the medial layer which serves as a false lumen that
may become filled and block or diminish flow through the true lumen.

Interventions/ significance:
o Chronic stress from hypertension appears to play a significant role in the
deterioration of the aortic wall.
o Assess patients for signs of ischemia due to obliteration of blood flow such as
stroke, anuria, or extremity ischemia.
 Patients will typically have syncope or ALOC
o Report to physician if patient experiences any: restlessness, abdominal pain and
tenderness, hypotension, and shock.
o Nurse should continue to monitor for signs of excessive blood loss such as low
H/H, ALOC, pallor, hypovolemia, or shock and report to the physician
immediately
o Careful for endoleaks after surgical/medical treatment.
Blood pressure (BP): pressure created by the circulating blood through the arteries, veins, and
the chambers of the heart.

Interventions/ significance:
o Nurse should assess BP q4h in normal patients
o Blood pressure readings are classified into: normal tension, prehypertension,
stage 1 hypertension, and stage 2 hypertension.
o 30 minutes before and 30 minutes after administration of blood pressure
medications
o BP is an indicator of peripheral vascular resistance
o Blood pressures below 90/50 and above 160/90 are disconcerning readings.
o Take blood pressure in different orthostatic positions to assess for orthostatic
hypotension.
o Wait at least 3 minutes between blood pressure readings to get accurate results.
o Avoid taking blood pressure on arms with IV’s and/or dialysis grafts in place.
DASH diet: low in sodium, saturated fat, cholesterol, and total fat.

Interventions/ significance:
o Having a patient on a DASH diet has been proven to lower blood pressure by
lowering sodium intake and lowering fat intake which reduces risk of
hyperlipidemia.
o
Encourage for patients with stage 1 or stage 2 hypertension along with lifestyle
changes and exercise.
Deep venous thrombosis: clot that forms in the deep veins

Interventions/ significance:
o Promote ambulation to prevent venous stasis.
o Elevate LE as tolerated to promote venous return and discourage venous stasis.
o Apply TEDs or SCDs if on bed rest to provide external compression to promote
venous return.
o Perform Homan’s sign to assess for presence of DVT
Diastolic blood pressure: reflexts cardiax relaxation; thus it is the minimum pressure in the
arteries that occurs prior to the next cycle of ventricular contraction.

Intervention/ significance:
o Increased diastolic pressure is a better indicator of the stage of hypertension.
o Diastolic blood pressure is also a good indicator of blood volume (increased
blood volume = increased pressure in arteries when ventricles are relaxed)
o Much like systolic, diastolic pressure also rises when there is more resistance in
the arteries such as a narrow lumen.
Embolectomy: mechanical removal of a clot.

Interventions/ significance:
o Continually monitor and follow up with patient following embolectomy to assess
for reformation of blood clots.
o Carefully monitor for VTE or PE in case a piece of the clot was not removed and
dislodged and got into circulation.
Endoleaks: continued leaking of blood into aneurysmal sac after an endovascular stent graft
repair.

Interventions/ significance:
o Nurse should continually be assessing client’s condition note for any changes in
health status.
o Nurse should continue to monitor for signs of excessive blood loss such as low
H/H, ALOC, pallor, hypovolemia, or shock and report to the physician
immediately
Hypertension: average blood pressure that is higher than the accepted norm over a period of time
consisting of two or more consecutive office visits.

Interventions/ significance:
o Nurse should be able to determine the stage of hypertension that the patient is in:
prehypertension, normal tension, stage 1 hypertension, and stage 2 hypertension.
o Nurse should administer antihypertensives as ordered.

o
o
Take BP 30 min before and 30 min follow up when giving
antihypertensives.
Treatment depends on patient’s stage of hypertension:
 Diet & Exercise (DASH diet)
 Weight control
 Stress Reduction
 Alcohol Consumption
 Medications
Collaborate with clinical dietitians, fitness/ exercise leaders, and the pharmacist
when devising a plan of care for the patient with hypertension.
Hypertensive crisis: rare and sometimes fatal occurrence in which there is a sudden onset of
DBP between 120-130mmHg.

Interventions/ significance:
o Clinical Manifestations:
 Target organ vascular damage
 Structural organ changes
 Acute vascular damage
 Catecholamines released and RAA activated
 Unstable angina
 Pulmonary edema
 MI
 Eclampsia
 Stroke
o Management:
 Bring BP down within 1hr without dropping too low
 Administer titratable IV meds such as labetalol, nicardipine,
nitroglycerin, or nitroprusside.
Hypertensive encephalopathy: very dangerous state of multifocal cerebral ischemia due to
severely acute or subacute elevated blood pressure.

Interventions/ significance:
o Requires immediate and urgent treatment.
o U6/8
 Bring BP down within 1hr without dropping too low
 Administer titratable IV meds such as labetalol, nicardipine,
nitroglycerin, or nitroprusside.
Intermittent claudication (IC): exercise-induced leg pain.

Interventions/ significance:
o IC is caused by atherosclerosis or lesions in the vasculature proximal to the
sensation of pain.
 A pain in the calf is typically caused by stenosis or occlusion in the
femoral or popliteal arteries.
o Assessment of IC would include that exercise-induced pain is relieved when at
rest due to a decrease in metabolic demand.
o
o
o
Pain is a result of hypoperfusion to the leg muscles being hypoperfused therefore
they must resort to anaerobic metabolism resulting in lactic acid production
Pain even at rest is a sign of severe ischemia and should be reported immediately.
Patient’s more comfortable with legs in a dependent position because gravity
enhances arterial circulation.
Lymphangitis: acute inflammation of the lymphatic channels most commonly cause by an
infection in one of the extremities.

Interventions/ significance:
o Assess for enlarged and tender lymph nodes to determine site of infection.
o Administer antibiotics, analgesics, and anti-inflammatory agents as ordered.
o Most commonly associated with a streptococcal infection of the skin.
Lymphedema: swelling due to obstruction of the lymphatic system.

Interventions/ significance:
o Presented as bilateral or diffuse edema, which may occur in the lower
extremities.
o Should not be confused with DVT due to the bilateral edema while DVT is
unilateral edema.
Paresthesia: abnormal sensation such as pricking, tingling, or numbness

Interventions/ significance:
o Can be associated with problems with arterial blood flow causing a lack of O2
supply to peripheral tissues causing “tingling or numbness”.
o Continually assess abnormal sensation to determine whether it is a vascular
problem or a nerve problem.
Peripheral arterial disease (PAD): “vascular disease caused primary by atherosclerosis and
thromboembolic pathophysiological processes that alter the normal structure of the aorta, its
visceral branches, and the arteries of the lower extremities.”

Interventions/ significance:
o PAD increases with age
o Risk factors: smoking, diabetes, hyperlipidemia, hypertension, elevated Creactive protein, and elevated homocystein levels.
o Clinical Manifestations:
 Intermittent claudication
 Poor hair growth
 Cool skin
 Resting limb pain
 Paresthsia
 Poor healing of sores or ulcers
o Management:
 Antiplatelet therapy with aspirin
 Endovascular repair for endoluminal damage
 Angioplasty, stenting, and radiation therapy
Majority of PAD patients also have coronary artery disease
Obtain health history of: smoking, hyperlipidemia, diabetes, activity
level, and any pertinent family history.
Skin color in various orthostatic positions:
 Pallor when elevated, deep red when in dependent position.
PAD is a lifelong disease so patient education is extremely important.


o
o
Peripheral vascular resistance: the resistance to the flow of blood as determined by the vascular
musculature and the diameter of the blood vessels.

Interventions/significance:
o Deficiencies in the musculature of the ventricles and their ability to withstand the
pressure of ventricular contraction affect the peripheral vascular resistance.
o The artery’s elasticity affects the ability of the peripheral vessels resistance to the
force of blood by ventricular contraction.
o Peripheral vascular resistance can be controlled by neural regulation in response
to arterial baroreceptors.
o Peripheral vascular resistance can also be affected by chemoreceptors, regulation
of fluid volume, and humoral regulation.
Prehypertension

Interventions/ significance:
o Treatment depends on patient’s stage of hypertension:
 Diet & Exercise (DASH diet)
 Weight control
 Stress Reduction
 Alcohol Consumption
 Medications
o Collaborate with clinical dietitians, fitness/ exercise leaders, and the pharmacist
when devising a plan of care for the patient with hypertension.
Pulmonary embolism: presence of a thrombus or blood clot in the pulmonary vessels that
obstructs blood flow and impedes gas exchange.

Interventions/ significance:
o Assess patients lung sounds
o Have patient C & DB and provide O2 therapy to maintain oxygenation.
o Assess patients PaCO2 levels to determine oxygenation and gas exchange.
o Assess patients PaO2/ FiO2 ratio to determine oxygenation and gas exchange.
o Get a CT scan, MRI or US to determine presence of a PE.
Pulse pressure: pulse pressure is the difference between the systolic and the diastolic

Interventions/ significance:
o It represents the force in mmHg that the heart generates with each contraction.
o
o
o
Elevated pulse pressure could indicate stiffness of major arteries, aortic
regurgitation, or a arteriovenous malformation.
Antihypertensives may increase pulse pressure, while ACE inhibitors can lower
pulse pressure.
Chronic high pulse pressure increases the risk for heart disease.
Raynaud’s disease (RD): arterial vasospastic disorder caused by emotional distress or cold




Transient spasm of arteries and arterioles, which result in decreased blood flow to
affected extremity.
Associated with RA, scleroderma, SLE, leukemia, or polycythemia rubra vera.
Associated with occupational or environmental conditions: cold exposure, repetitive
trauma, or excessive vibration injury.
Management:
o Avoid known stressors (cold, emotional stress)
o Assess characteristics of RD attacks such as pain, numbness, color changes, and
frequency of attacks.
o Get history of patient medications that may trigger spasms.
o Stress management
o Patient education extremely important since there is no cure.
Stage 1 hypertension: BP of 140-159 systolic, 90-99 diastolic on multiple office visits

Interventions/ significance:
o Treatment depends on patient’s stage of hypertension:
 Diet & Exercise (DASH diet)
 Weight control
 Stress Reduction
 Alcohol Consumption
 Medications
o Collaborate with clinical dietitians, fitness/ exercise leaders, and the pharmacist
when devising a plan of care for the patient with hypertension.
Stage 2 hypertension: BP of 160+ systolic, 100+ diastolic on multiple office visits

Interventions/ significance:
o Treatment depends on patient’s stage of hypertension:
 Diet & Exercise (DASH diet)
 Weight control
 Stress Reduction
 Alcohol Consumption
 Medications
o Collaborate with clinical dietitians, fitness/ exercise leaders, and the pharmacist
when devising a plan of care for the patient with hypertension.
Sympathectomy: removal of sympathetic ganglia.

Interventions/ significance:
o
o
Can be done for patients with severe Raynaud’s Disease symptoms.
Interrupts SNS stimulation in the affected vessels to prevent the vasospasms.
Systolic blood pressure: maximum pressure in the aorta and major arteries.

Interventions/ significance:
o Systolic blood pressure is more indicative of vascular disease
o SBP typically increases with age as arteries become more stiff causing more
resistance therefore increasing the pressure in the aorta and arteries.
o A person with elevated systolic, but normal diastolic can benefit from treatment
immensely.
Thoracic outlet syndrome: rare disorder in which there is a compression of the nerves and
arteries in the thoracic outlet (between the thorax and clavicle)

Interventions/ significance:
o To assess for thoracic outlet syndrome an elevated arm stress test (EAST) can be
done.
 Patient place both arms in 90-degree abduction and externally rotate for
3 minutes.
 Positive test occurs when there is a reproduction of exacerbated
symptoms.
o Treatment options are mostly directed towards nonsurgical interventions such as:
 Collaboration with physical therapy
 Pain management (NSAIDS)
 Moist heat
 Massage
Unna’s boot: rigid bandage that is used to treat venous ulcers which also prevent edema while
promoting healing and is worn for several days at a time.



This is a type of compression therapy which doesn’t impede in ADL’s very much.
Should still assess for signs of DVT.
Typically used for patient’s who are able to walk around and move on their own and
NOT for patients who are confined to bedrest or wheelchairs.
Varicose veins: dilated, tortous veins that occur in the lower extremities as a result of
incompetence of valves of the deep and superficial venous system, which leads to valve reflux.

Interventions/ significance:
o Risk factors include constipation/ low fiber-diet, smoking, hypertension,
pregnancy, and injury.
o Nurse can perform Tredelenburg test to assess the competency of the valves in
the superficial and deep veins of the lower extremities.
Venous thromboembolism (VTE): two conditions: DVT and pulmonary embolism.

Interventions/ significance:
o Assess for signs of PE
o Provide anticoagulation medications as ordered
o Promote use of SCDs and TEDs to prevent DVT from ever occurring.
o Promote ambulation to prevent venous stasis.
o Elevate LE as tolerated to promote venous return and discourage venous stasis.
o Perform Homan’s sign to assess for presence of DVT
Virchow’s triad: venous stasis, damage of the endothelium, and hypercoagulability.

Interventions/ significance:
o The triad represents the three factors that are associated with DVT formation.
 If any of these factors increase, then the patient will be at an increased
risk for the formation of a DVT.