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Chapter 12
Cardiovascular Disorders
Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.
Objectives


Describe the etiology and pathophysiology
of atherosclerotic coronary artery disease.
Identify the pathophysiology and clinical
manifestations of acute heart failure.
(continued)
Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.
2
Objectives (continued)


Explain the treatment of selected
cardiovascular disorders: coronary artery
disease, cardiomyopathy, and valvular
disease.
Discuss the nursing priorities for managing
a patient with an acute cardiovascular
disorder.
Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.
3
Coronary Artery Disease


Atherosclerotic disease affects arteries
throughout the body
In the heart, atherosclerotic changes are
known as coronary artery disease (CAD)


This disease process is also known as coronary
heart disease (CHD)
Strong association between risk factors and
the development of CAD
Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.
4
Nonmodifiable CAD Risk Factors




Age
Gender
Race
Family history
Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.
5
Modifiable CAD Risk Factors







Elevated serum lipids
Hypertension
Cigarette smoking
Prediabetes or
diabetes mellitus
Obesity
Chronic kidney
disease
Metabolic syndrome




Diet high in saturated
fat, cholesterol, and
calories
Physical inactivity
Elevated
homocysteine level
Postmenopause
(modification is
controversial)
Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.
6
Women and Heart Disease



Symptoms occur later in life
HRT is no longer recommended for
prevention of atherosclerotic cardiovascular
disease
CV disease kills >500,000 women annually
Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.
7
Pathophysiology of
Coronary Artery Disease

Atherosclerotic plaque narrows lumen of artery



Chronic inflammatory disorder
Plaque rupture and coronary thrombosis
Plaque regression is possible with change
in risk factors
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8
Acute Coronary Syndromes
(ACS)


Term describes array of clinical presentations
Range from unstable angina to acute
myocardial infarction (MI)
Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.
9
Symptoms of ACS

Angina: lack of oxygen causes myocardial
ischemia, which is felt as chest pain



Stable angina: predictable, fixed lesions
Unstable angina: change in previously established
pattern, more intense, indication of plaque
instability
Symptoms of angina may differ in women
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10
Anginal Patterns
FIGURE 12-1 Common Sites for Anginal Pain. A, Upper part of chest. B, Beneath sternum, radiating to neck and jaw.
C, Beneath sternum, radiating down left arm. D, Epigastric. E, Epigastric, radiating to neck, jaw, and arms. F, Neck
and jaw. G, Left shoulder. H, Intrascapular.
Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.
11
Medical Management for Angina



Accurate assessment of chest pain symptoms
ST-segment elevated or new left bundle
branch block—patient will be treated for
myocardial infarction (MI)
Chest pain without electrocardiogram (ECG)
changes—pharmacological management
Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.
12
Nursing Diagnosis Priorities



Acute pain related to transmission and
perception of cutaneous, visceral, muscular,
or ischemic impulses
Ineffective cardiopulmonary tissue perfusion
related to decreased myocardial oxygen
supply or increased myocardial oxygen
demand, or both
Activity intolerance related to
cardiopulmonary dysfunction
(continued)
Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.
13
Nursing Diagnosis Priorities (continued)



Powerlessness related to lack of control over
current situation
Anxiety related to threat to biological,
psychological, or social integrity
Deficient knowledge: discharge regimen
related to lack of previous exposure to
information
Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.
14
Question
The patient with angina should be taught to
avoid which of the following items?
A.
B.
C.
D.
Caffeinated coffee
Aspirin
Physical activity
Valsalva maneuver
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15
Answer
D.
Valsalva maneuver
The patient with angina should be taught the
importance of alerting the nurse to any symptoms of
chest pain or discomfort, and avoiding the Valsalva
maneuver. The Valsalva maneuver causes an
increase in intrathoracic pressure that decreases
venous return to the right side of the heart and is
associated with low blood pressure and symptomatic
bradycardia.
Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.
16
Nursing Management of CAD
and Angina

Nursing priorities include:




Recognizing myocardial ischemia
Controlling chest pain
Maintaining a calm environment
Providing patient education
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Recognizing Myocardial Ischemia

Chest pain assessment

Intensity
 Location
 Duration
 Quality
 Radiation
 Precipitating factors

12-lead ECG
Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.
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Evaluation of Prehospital
Chest Pain
FIGURE 12-2 Evaluation of Prehospital Chest Pain, ACS and Treatment Options. STEMI, ST elevation myocardial
infarction; EMS, emergency medical services; PCI, percutaneous catheter intervention. (Illustration modifi ed from
Antman EM, et al: ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction –
executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice
Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial
Infarction), Circulation 110(9):e82).
Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.
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Controlling Chest Pain



Supplemental oxygen
Nitrates
Analgesia


Morphine
Aspirin
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Myocardial Infarction

Irreversible necrosis due to an abrupt
decrease or total cessation of coronary
blood flow



Plaque rupture
New coronary artery thrombosis
Coronary artery spasm close to ruptured plaque
Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.
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Cardiovascular Disorders




Ischemia: T-wave inversion
Injury: elevated ST-segments
Infarction: development of pathological
Q waves
MI: evolution occurs over 6 weeks
after infarction
Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.
22
Zones of Ischemia, Injury,
and Infarction
FIGURE 12-3 Zone of ischemia, zone of injury, and zone of infarction are shown through ECG
waveforms and reciprocal waveforms corresponding to each zone.
Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.
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ECG Changes
FIGURE 12-4 ECG Changes Indicative of Ischemia, Injury, and Infarction (Necrosis) of the Myocardium. A, Normal
ECG. B, Ischemia indicated by inversion of the T wave. C, Ischemia and current of injury indicated by T-wave inversion and
ST-segment elevation. The ST segment may be elevated above or depressed below the baseline, depending on whether
the tracing is from a lead facing toward or away from the infarcted area and depending on whether epicardial or
endocardial injury occurs. Epicardial injury causes STsegment elevation in leads facing the epicardium. D, Ischemia, injury,
and myocardial necrosis. The Q wave indicates necrosis of the myocardium.
Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.
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Acute MI-Classification


Transmural MI
Non-Q-wave MI



Subendocardial
Subepicardial
12-lead ECG in transmural MI

New pathological Q-waves
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25
Acute MI-Location
FIGURE 12-5 Location of Infarctions in Myocardium.
Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.
26
MI Location





Anterior wall infarction
Left lateral wall infarction
Inferior wall infarction
Right ventricular infarction
Posterior wall infarction
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Correlations among Ventricular Surfaces,
Electrocardiographic Leads, and
Coronary Arteries
Surface of Left
Ventricle
Electrocardiographic Coronary Artery
Leads
Usually Involved
Inferior
II, III, aVF
Right coronary artery
Lateral
V5-V6, I, aVL
Left circumflex
Anterior
V2-V4
Left anterior
descending
Anterior lateral
V1-V6, I, aVL
Left main coronary
artery
Septal
V1-V2
Left anterior
descending
Posterior
V1-V2
Left circumflex or right
coronary artery
(reciprocal changes)
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Anterior Wall MI
FIGURE 12-6 Changes Seen on a 12-Lead ECG with An Anterior Wall MI. A, Infarction location on the cardiac wall.
B, ECG leads with expected ST-segment elevation. C, A 12-lead ECG from a patient experiencing left anterior wall
MI. LAD, left anterior descending artery.
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Lateral Wall MI
FIGURE 12-6 Changes Seen on a 12-Lead ECG with An Anterior Wall MI. A, Infarction location on the cardiac
wall. B, ECG leads with expected ST-segment elevation. C, A 12-lead ECG from a patient experiencing left
anterior wall MI. LAD, left anterior descending artery.
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30
Inferior Wall MI
FIGURE 12-8 Changes Seen on a 12-Lead ECG with an Inferior Wall MI. A, Infarction location on cardiac
wall. B, ECG leads with expected ST-segment elevation. C, A 12-lead ECG from a patient experiencing
inferior wall MI.
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Acute MI

Non-ST-segment elevation MI




ST segment not elevated in every acute MI
Known as a NSTEMI
Need to be treated aggressively to prevent
damage
Cardiac biomarkers
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32
Cardiac Biomarkers
FIGURE 12-9 Cardiac Biomarkers During MI. (From Antman EM, et al: ACC/AHA guidelines for the management of
patients with ST-elevation myocardial infarction – executive summary: a report of the American College of
Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999
Guidelines for the Management of Patients with Acute Myocardial Infarction), Circulation 110(9):e82, 2004.)
Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.
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Complications of
Myocardial Infarction







Dysrhythmias
Ventricular aneurysm
Ventricular septal rupture
Papillary muscle rupture
Cardiac wall rupture
Pericarditis
Heart failure
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Ventricular Aneurysm
FIGURE 12-10 Ventricular Aneurysm After Acute Myocardial Infarction. LA, left atrium; LV, left
ventricle; PA, pulmonary artery; RA, right atrium; RV, right ventricle.
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Ventricular Septal Rupture
FIGURE 12-11 Ventricular Septal Rupture After Acute Myocardial Infarction. LA, left atrium; LV, left
ventricle; PA, pulmonary artery; RA, right atrium; RV, right ventricle.
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36
Papillary Muscle Rupture
FIGURE 12-12 Papillary Muscle Rupture After Acute Myocardial Infarction. LA,
left atrium; LV, left ventricle; PA, pulmonary artery; RA, right atrium; RV, right
ventricle.
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37
Question
The RN is caring for a patient with an acute MI.
Upon auscultation of the chest the nurse notes that
the patient had developed a pericardial friction rub.
The RN suspects the patient is developing:
heart failure.
B. papillary muscle rupture.
C. pericarditis.
D. ventricular septal wall dysfunction.
A.
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38
Answer
C.
Pericarditis.
Pericarditis is inflammation of the pericardial sac. It
can occur after an acute MI. The damaged
epicardium becomes rough and inflamed and irritates
the pericardium lying adjacent to it, precipitating
pericarditis. Pericardial friction rub is a common initial
sign. It is best auscultated at the sternal border and is
described as a grating, scraping, or leathery
scratching.
Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.
39
Medical Management of AMI

Recanalization of the coronary artery






Fibrinolytic therapy
Percutaneous coronary intervention (PCI)
Anticoagulation
Dysrhythmia prevention
Tight glucose control
Prevention of ventricular remodeling
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40
Nursing Diagnosis Priorities




Acute pain related to transmission and perception
of cutaneous, visceral, muscular, or ischemic
impulses
Decreased cardiac output related to alterations in
preload
Decreased cardiac output related to alterations in
afterload
Decreased cardiac output related to alterations in
contractility
(continued)
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41
Nursing Diagnosis Priorities (continued)




Decreased cardiac output related to alterations in
heart rate or rhythm
Activity intolerance related to cardiopulmonary
dysfunction
Ineffective cardiopulmonary tissue perfusion
related to decreased myocardial oxygen supply
or increased myocardial oxygen demand, or both
Disturbed sleep pattern related to fragmented
sleep
(continued)
Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.
42
Nursing Diagnosis Priorities (continued)




Anxiety related to threat to biological,
psychological, or social integrity
Ineffective coping related to situational crisis
and personal vulnerability
Powerlessness related to lack of control over
current situation or disease progression
Deficient knowledge: discharge regimen related
to lack of previous exposure to information
Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.
43
Nursing Management of AMI

Nursing priorities include:



Balancing myocardial oxygen supply and demand
Preventing complications
Providing patient education
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44
Cardiac Arrest and Sudden
Cardiac Death


Between 400,000 and 460,000 people die
suddenly of cardiac causes each year
When the onset of symptoms is rapid, the most
likely mechanism of death is ventricular
tachycardia (VT), which degenerates into
ventricular fibrillation (VF)


Known as sudden cardiac death
Strategies to improve outcomes

Community-wide programs for cardiopulmonary
resuscitation (CPR)
 Automated external defibrillators (AEDs)
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45
Therapeutic Hypothermia

Depending on the length of time the patient
was unconscious following the cardiac arrest,
cognitive defects can occur


Caused by lack of cerebral blood flow and
resultant hypoxia to the brain
For comatose patients at high risk for hypoxic
brain injury after cardiac arrest, therapeutic
hypothermia to about 33° centigrade is
initiated for several hours to preserve brain
function
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46
Heart Failure

Description


The number of patients with heart failure is
increasing in the United States
More than five million Americans have a diagnosis
of heart failure, and about 550,000 new cases are
diagnosed each year
(continued)
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47
Heart Failure (continued)

Pathophysiology




Heart failure is a condition in which the heart
cannot pump blood at a volume required to meet
the body’s needs
Any condition that impairs the ability of the
ventricles to fill or eject blood can cause heart
failure
CAD and MI are most frequent
Other causes include valvular dysfunction,
infection, cardiomyopathy, and hypertension
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48
New York Heart Association Functional
Classification of Heart Failure
I
Normal daily activity does not initiate
symptoms.
II Normal daily activities initiate onset of
symptoms, but symptoms subside with rest.
III Minimal activity initiates symptoms; patients
are usually symptom-free at rest.
IV Any type of activity initiates symptoms, and
symptoms are present at rest.
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49
Clinical Manifestations of
Left Heart Failure

Signs


Tachypnea
 Tachycardia
 Cough
 Bibasilar crackles
 Gallop rhythms
 Increased PAP
 Hemoptysis
 Cyanosis
 Pulmonary edema
Symptoms

Fatigue
 Dyspnea
 Orthopnea
 Paroxysmal
nocturnal dyspnea
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50
Clinical Manifestations of
Right Heart Failure

Signs


Peripheral edema
 Hepatomegaly
 Splenomegaly
 Hepatojugular reflux
 Ascites
 Jugular venous
distention
 Increased CVP
 Pulmonary hypertension
Symptoms

Weakness
 Anorexia
 Indigestion
 Weight gain
 Mental changes
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51
Systolic vs. Diastolic
Heart Failure

Systolic heart failure


Decreased contractility of left ventricle
Diastolic heart failure

Decreased relaxation, stretching, or filling of left
ventricle during diastole
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52
Acute vs. Chronic
Heart Failure

Acute heart failure



Sudden onset
No compensatory mechanisms
Chronic heart failure


Ongoing syndrome
Can deteriorate into acute heart failure
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53
Neuro-Hormonal Compensatory
Mechanisms




Sympathetic nervous system
Renin-angiotensin-aldosterone system
Ventricular hypertrophy
Ventricular remodeling
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54
RAAS in Heart Failure
FIGURE 12-14 Renin-Angiotensin-Aldosterone System (RAAS),
its Role in Heart Failure, and Drug Actions.
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55
Complications of Heart Failure

Shortness of breath






Dyspnea
Orthopnea
Paroxysmal nocturnal dyspnea
Cardiac asthma
Pulmonary edema
Dysrhythmias
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56
Pulmonary Edema
FIGURE 12-15 As Pulmonary Edema Progresses, it Inhibits Oxygen and Carbon Dioxide Exchange at the Alveolar
Capillary Interface. A, Normal relationship. B, Increased pulmonary capillary hydrostatic pressure causes fluid to move
from the vascular space into the pulmonary interstitial space. C, Lymphatic flow increases in an attempt to pull fluid
back into the vascular or lymphatic space. D, Failure of lymphatic flow and worsening of left-sided heart failure results in
further movement of fluid into the interstitial space and the alveoli.
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57
Medical Management of
Heart Failure



Relief of symptoms and enhancement of
cardiac performance
Correct precipitating causes
Palliative care for end-stage heart failure
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58
Nursing Diagnosis Priorities




Impaired gas exchange related to ventilation/
perfusion mismatch or intrapulmonary shunting
Decreased cardiac output related to alterations
in preload
Decreased cardiac output related to alterations
in contractility
Decreased cardiac output related to alterations
in heart rate or rhythm
(continued)
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59
Nursing Diagnosis Priorities (continued)


Activity intolerance related to cardiopulmonary
dysfunction
Anxiety related to threat to biological,
psychological, or social integrity
(continued)
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60
Nursing Diagnosis Priorities (continued)



Ineffective coping related to situational crisis
and personal vulnerability
Disturbed sleep pattern related to circadian
desynchronization
Deficient knowledge: discharge regimen
related to lack of previous exposure to
information
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61
Nursing Management of
Heart Failure

Nursing priorities include:

Optimizing cardiopulmonary function
 Promoting comfort and emotional support
 Monitoring effectiveness of pharmacological
therapy
 Providing adequate nutrition
 Providing patient education
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62
Cardiomyopathy


Disease of the heart muscle
Categories:



Hypertrophic
Restrictive
Dilated
(continued)
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63
Cardiomyopathy (continued)
FIGURE 12-16 Types of Cardiomyopathies and Differences in Ventricular Diameter during Systole and Diastole
Compared with a Normal Heart. A, Hypertrophic. B, Restrictive. C, Dilated. D, Normal.
Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.
64
Hypertrophic Obstructive
Cardiomyopathy


Genetically inherited disease affecting the
myocardial sarcomere
Left ventricle becomes stiff, noncompliant,
and hypertrophied
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65
Dilated Cardiomyopathy


Characterized by gross dilation of both
ventricles without hypertrophy
Types:




Ischemic dilated cardiomyopathy
Familial dilated cardiomyopathy
Acquired dilated cardiomyopathy
Other causes
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66
Restrictive Cardiomyopathy


Least common
Results in ventricular wall rigidity due to
myocardial fibrosis
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67
Nursing Diagnosis Priorities




Decreased cardiac output related to
alterations in preload
Decreased cardiac output related to
alterations in afterload
Decreased cardiac output related to
alterations in contractility
Decreased cardiac output related to
alterations in heart rate or rhythm
(continued)
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68
Nursing Diagnosis Priorities (continued)


Impaired gas exchange related to ventilation/
perfusion mismatch or intrapulmonary
shunting
Activity intolerance related to
cardiopulmonary dysfunction
(continued)
Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.
69
Nursing Diagnosis Priorities (continued)



Anxiety related to threat to biological,
psychological, or social integrity
Powerlessness related to lack of control over
current situation or disease progression
Deficient knowledge: discharge regimen
related to lack of previous exposure to
information
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70
Nursing Management of
Cardiomyopathy

Nursing priorities focus on:




Achieving a stable fluid balance
Monitoring effects of pharmacological therapy
Increasing mobility
Providing patient and family education
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71
Valvular Heart Disease


Structural and/or functional abnormalities of
single or multiple cardiac valves, resulting in
alteration of blood flow across valve
Two types:


Stenotic
Regurgitant (insufficient)
(continued)
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72
Valvular Heart Disease (continued)

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Mitral valve stenosis
Mitral valve regurgitation
Aortic valve stenosis
Aortic valve regurgitation
Tricuspid valve stenosis
Tricuspid valve regurgitation
Pulmonic valve disease
Mixed valvular lesions
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Question
Which of the following physical signs is
indicative of mitral stenosis?
A.
B.
C.
D.
Diastolic murmur and LV hypertrophy
Diastolic murmur and atrial fibrillation
Systolic murmur and P mitrale
Systolic murmur and LV hypertrophy
Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.
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Answer
Diastolic murmur and atrial fibrillation
Physical signs of mitral stenosis include:
B.
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Chest radiograph: pulmonary congestion, redistribution of
blood flow to upper lobes
ECG: Atrial fibrillation/other atrial dysrhythmias
Auscultation: diastolic murmur
Catheterization: elevated pressure gradient across valve;
increased LAP, PAOP, and PAP; low CO
Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.
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Medical Management of Valvular
Disease
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Pharmacological
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To control symptoms of heart failure
Surgical
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To replace or repair affected valve
Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.
76
Nursing Management of Valvular
Disease
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Nursing priorities focus on:
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

Maintaining adequate cardiac output
Optimizing fluid balance
Providing patient education
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