Download Cardiovascular Disorders

Cardiovascular Disorders
Nursing II
Topics
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Hypertension
Coronary Heart Disease
Angina
Stable Myocardial Infarction
Peripheral Vascular Disease
Deep Vein Thrombosis
Raynaud’s Disease
Review
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Identify cultural considerations that impact care for clients with hypertension.
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What role does ethnicity play in the treatment of hypertension?
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What is your teaching plan for a client with hypertension?
Atherosclerosis
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Arteriosclerosis
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Atherosclerosis
Page 778 -783
Pathophysiology
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Etiology unknown
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Theories
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Atherosclerosis development and cardiac complications
Factors Causing Arterial Injury
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Intimal Injury
Mechanical injury
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Chemical injury
Incidence & Prevalence
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Peripheral Atherosclerosis
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Men vs. Women
Laboratory
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Cholesterol
< 200 mg/dL
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High density lipoprotein (HDL)
Desirable level > 40 mg/dL
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Low density lipoprotein (LDL)
Desirable level < 100 mg/dL
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Triglycerides
200 mg/dL indicates hypertriglyceridema
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Homocysteine
↑ levels indicates ↑ risk for premature development of PVD and CAD (> 15 µmo/L)
Interventions
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Diet Therapy
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Smoking Cessation
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Exercise
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Drug Therapy
Nursing Care
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Health Promotion - #1 priority
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Teaching
Hypertension
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Blood Pressure
Tension or pressure exerted by blood against arterial walls
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Hypertension (HTN or HTP)
Excess pressure in arterial portion of systemic circulation
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Types of Hypertension
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Essential HTN
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Secondary HTN
Regulation of Blood Pressure
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Arterial Baroreceptors
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Regulation of Body Fluid Volume
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Renin-Angiotensin- Aldosterone System
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Atrial Natriuretic Peptide
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Epinephrine & Norepinephrine
Incidence/Prevalence
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50 million Americans, 1 in 4 adults
↑ incidence in African Americans
↑ incidence in southeastern US
↑ mortality with ↑ age
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What is the your greatest concern regarding hypertension?
Assessment
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Manifestations
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Laboratory
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Radiographic
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EKG
Complications of HTN
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Myocardial Infarction
Brain attack (CVA)
Peripheral Vascular
Disease
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Renal Failure
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Malignant HTN
Enlarged Left Ventricle
Malignant HTN
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Clinical Manifestations
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Requires immediate treatment
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Treatment goal
Treatment
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Education
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Life Style Modification
Recommendations
Single Drug, once-a-day
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Start with diuretic or beta-blocker
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ACE inhibitor for clients with diabetes or have HF or history of MI
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Considerations for selection
of medication & treatment
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After 1-3 months, if no chg in BP, ↑ dose or substitute for different class of
antihypertensive
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After 1 yr of effective control → ↓ dose or # of medications
Antihypertensive Drugs
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Diuretics
Prevent tubular reabsorption of sodium → water & sodium excretion & ↓ blood
volume
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Thiazide (HCTZ)
Loop (Lasix)
K+ Sparing
- Spironolactone (Aldactone)
- Eplerenone (Inspra)
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Nursing Implications
Page 788 - 791
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Alpha Adrenergic Blockers
Block alpha receptors in vascular smooth muscle
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↓ vasomotor tone & vasoconstriction
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Dozaxicin (Cardura)
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Beta-adrenergic Blocking Agents
Prevent beta-receptor stimulation in the heart → ↓ HR & C.O.
Metoprolol (Lopressor, Toprol XL)
Propanolol (Inderal)
- Not used with hx of asthma or bronchospasm
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Side Effects
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Nursing Implication
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Calcium Channel Blocker
Inhibit the flow of calcium ions across the cell membrane of vascular tissue &
cardiac cells → relaxation of arterial smooth muscle, ↓ PVR through vasodilation
Diltiazem (Cardizem SR)
Norvasc
Cardizem
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Nursing Implications
*No grape fruit juice
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Side Effects
Effective in older adults & African Americans
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ACE Inhibitors
Prevent conversion of Angio I to Angio II preventing vasoconstriction &
water/Na retention
Capoten (Captopril)
Lisinopril (Prinivil, Zestril)
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Nursing Implications
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Side Effects
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Angiotensin II Receptor Antagonists
Same effect as ACE inhibitor but act by blocking the effect of angio II on
receptors
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Losartan (Cozaar)
- Nursing Implication
- Assess for orthostatic hypotension
Vasodilators
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Relax vascular smooth muscle & ↓ PVR
Loniten, Apresoline,
Used in combination with diuretic or beta-blocker
Not used in mgmt of chronic HTN
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Antianginal (Nitrates)
Nitroglycerin (Nitrostat SL)
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Side Effects
Nursing Implications
Antilipemic Agents
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HMG-Coal Reeducates Inhibitors (Statins)
Simvastatin (Zocor)
Atovastatin (Lipitor)
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Side Effects
Nursing Implications
Nursing Diagnoses
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Ineffective Health Maintenance
Risk for Noncompliance
Imbalanced Nutrition: > body requirements
Excess Fluid Volume
Home Care
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Take active role in disease management
Angina
and
Coronary Heart Disease
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What layer of the heart is damaged when a person has a heart attack?
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What effect will a blood pressure of 85/40 have on the heart?
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What effect does parasymapathetic stimulation have on the heart?
Pathophysiology
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Chest pain causes decreased coronary blood flow
Ischemia results & cell function altered
Anaerobic metabolism result
Only have 30 minutes to
restore perfusion
Page 839 - 847
Coronary Blood Flow
Cardiac Output
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Stroke volume
Preload
Afterload
Contractility
Heart rate
SV x HR = CO
Page - 680
Types of Coronary Heart Disease
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Chronic ischemic heart disease
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Coronary Syndrome (ACS)
Types of Angina
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Stable
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Silent myocardial ischemia
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Prinzmetal’s Angina
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Unstable Angina
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Risk Factors
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Smoking
Diet
Exercise
Hypertension
Diabetes
Clinical Manifestations
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Chest pain
Tachycardia
Pallor
Dyspnea
Anxiety
Chest Pain
Angina
MI
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Sudden, associated with other factors
Squeezing, vice like
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Substernal, may radiate to back or arms
Usually lasts < 15 min
Relieved with rest, nitrates, or oxygen
Sudden, without precipitating factors
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Intense, stabbing, vice like pressure, severe
Substernal, may radiate to back, arms, jaw, neck
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Lasts > 30 min
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Relieved with opioids
Diagnostic Exams
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EKG
Thallium scan
Exercise stress test
Echocardiogram
Coronary angiography
Cardiac enzymes
CBC, CMP, Coagulation studies, lipid profile, cholesterol, C-reactive protein
Medications for CHD
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Lipid/cholesterol lowering agents
Statins
Bile acids
Nicotinic acid
Fibric Acid
Medications for Angina
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Nitrates
Treat anginal attacks
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Prevent attacks
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Adverse Effects
Medications for Angina
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Beta Blockers
What is the therapeutic effect of this medication?
What are the nursing implications for a client receiving this medication?
Medications for Angina
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Calcium Channel Blockers
What is the therapeutic effect of this medication?
What are the nursing implications for a client receiving this medication?
Assessment of Chest Pain
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Location
Character
Timing
Precipitating factors
Intensity
Aggravating and relieving factors
Other signs and symptoms
Needed Cardiac Assessment
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Vitals sign
Cardiac output
Apical – radial pulse
Lungs sounds
Skin
Peripheral circulation
Nursing Care
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Discuss your teaching plan for this client
What would be the appropriate nursing care?
Nursing Diagnoses
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Ineffective tissue perfusion
Activity Intolerance
Ineffective coping
Ineffective health maintenance
Altered sexual patterns
Myocardial Infarction
MI Statistics
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Leading cause of death in the US
Most deaths occur in the first hour
40% of those outside of the hospital
Usually have CHD prior
Risk factors are the same for CHD and angina
Pathophysiology
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Interruption of blood flow to the myocardium
Cellular death and tissue necrosis
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Starts in the subendocardium progress to all layers of the myocardium
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“Stunned” surrounding tissue
Coronary Arteries
Cardiac Cath
Picture of an Ischemic Clot
Signs and Symptoms of MI
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Chest pain
Describe the cardinal chest pain of a MI.
Describe chest pain for a women and elderly clients.
More Signs and Symptoms
Complications of MI
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Dysrhythmias
Decreased cardiac output
Cardiogenic shock
Pericarditis
Diagnostics for MI
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Cardiac Enzymes
EKG
CXR
Echo
CBC, Coag Studies, CMP
Stress Test
Cardiac Cath
Muga Scan
Cardiac Enzymes
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Troponin
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CPK MB (CK MB)
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LDH isoenzymes
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Myoglobin
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C-Reactive protein
Goals for Treatment
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Relieve chest pain
Cardiac stability
Decrease size of infarct
Decrease workload of the heart
Prevent complications
Care of an MI Client
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What is the appropriate nursing care for this client?
Pain Control
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Nitroglycerin (NTG)
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Morpine Sulfate (MS)
Other Medications
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Aspirin and antiplatelets medications
Plavix
Anticoagulants
Heparin or Lovenox
Thrombolytics
Antidysrhythmics
Beta blockers
Lopressor
ACE inhibitors
Captopril
Stool softeners
Antianxiety medications
NANDAs
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Acute pain R/T
Decreased cardiac output R/T
Ineffective tissue perfusion R/T
Ineffective coping R/T
Fear R/T
Preparing for Discharge
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Cardiac rehab
What would be an appropriate teaching plan for this client?
Peripheral Vascular Disease
Incidence of PVD
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Usually over age 60
Men more than women
Black women more than
white women
Review
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What is the function and structure of an artery?
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What is the function and structure of a vein?
Peripheral Vascular Disease
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Disorders that alter the natural flow of blood through the arteries and veins of
peripheral circulation
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Affects lower and upper extremities
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Peripheral artery disease (PAD)
Pathophysiology
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PAD
Chronic condition
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Partial or total arterial occlusion
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Arterial Obstruction
Pain Assessment
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Intermittent Claudication
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Rest Pain
Clinical Manifestations
Physical Assessment
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Palpate pulses
Arterial Ulcers
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Arterial ulcers
Diagnostic Assessment
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Arteriography
Segmental systolic BP measurements
Exercise tolerance testing
Plethysmography
Doppler ultrasound
Duplex doppler
Venous Stasis Ulcer
Interventions
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Non-invasive
Smoking cessation
Exercise
Positioning
Vasodilation promotion
Drug therapy
ASA
Trental
Plavix
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Invasive
Percutaneous Transluminal angioplasty (PTA)
Laser-assisted angioplasty
Atherectomy
Endarterectomy
Surgical Intervention
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Revascularization
Bypass graft
Autologous saphenous vein
Gortex or Dacron graft
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Preoperative Care
Mark peripheral pulses for baseline
Surgical Intervention
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Postoperative Care
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Assess for graft patency
Treatment of Graft Occlusion
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Notify surgeon immediately
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Emergency thrombolectomy
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Local thrombolytic therapy
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Platelet inhibitor infusion (Reo-pro)
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Compartment Syndrome
Goals for Care
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How would you promote graft patency?
Home Care for PVD
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Follow foot care instructions
Quit Smoking
Maintain dietary restrictions
Exercise
Avoid exposure to extreme cold or heat
Avoid constrictive clothing
Acute Peripheral Arterial Occlusion
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Emboli originating from heart
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Severe pain below occlusion
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Cool or cold extremity, pulseless, mottled
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Six “P’s” of ischemia
Interventions
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Immediate intervention
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Anticoagulant therapy
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Surgical thrombolectomy or embolectomy
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Post-operative care
Deep Vein Thrombosis (DVT)
Deep Vein Thrombosis
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Thrombophlebitis
Definition
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All Refer Health - Deep Venous Thrombosis, Ileofemoral - Deep Venous
Thrombosis Pictures & Images (Blood Clot in the Legs, DVT)
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Deep vein thrombosis
↑ risk for pulmonary embolism
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Stasis of blood flow, endothelial injury &/or hypercoagulability
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Risk factors
Diagnostics
For DVT
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Doppler flow study
Venogram
MRI
D- Dimer
Coagulation studies
Physical exam
Signs and Symptoms
of DVT
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Asymptomatic
Calf or groin tenderness & pain
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Sudden onset of unilateral swelling
Pain upon dorsiflexion (Homan’s sign) not recommended
Warmth & edema at site
Interventions
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Non-surgical
Rest
Anticoagulants
Heparin
Lovenox
Coumadin
Thrombolytic therapy
T-PA
Platelet Inhibitors
Reo-pro
Surgical
Prevent Pulmonary Embolis
Inferior Vena Caval Interruption
“Umbrella”
Greenfield filter
Ligation or External Clips
Abdominal Laparotomy
Home Care
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Anticoagulant teaching
Raynaud’s Phenomenon
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Raynaud’s Disease
- A primary vasospastic disease
- small arteries & arterioles
- cause unknown
- exaggerated response of vasomotor
controls to cold & emotion
Raynaud’s cont.
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Symptoms
- affect digits of hands bilaterally (most often)
- color changes occur in sequence
(pallor, cyanosis & red)
Cont.
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Initially
- numbness & sensation of cold
- red phase (throbbing & paresthesia)
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Long-term
- may develop atrophy of skin & subc tissue, brittle nails & skin ulcerations or
gangrene
Cont.
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Management
- Maintain warmth in the extremities.
- Avoid cold materials & prolonged exposure to cold environments.
- Avoid use of tobacco.
Cont.
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Treatment
- vasodilator drugs
- calcium channel blockers
- sympathectomy (not always successful)