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Cardiovascular Disorders Nursing II Topics Hypertension Coronary Heart Disease Angina Stable Myocardial Infarction Peripheral Vascular Disease Deep Vein Thrombosis Raynaud’s Disease Review Identify cultural considerations that impact care for clients with hypertension. What role does ethnicity play in the treatment of hypertension? What is your teaching plan for a client with hypertension? Atherosclerosis Arteriosclerosis Atherosclerosis Page 778 -783 Pathophysiology Etiology unknown Theories Atherosclerosis development and cardiac complications Factors Causing Arterial Injury Intimal Injury Mechanical injury Chemical injury Incidence & Prevalence Peripheral Atherosclerosis Men vs. Women Laboratory Cholesterol < 200 mg/dL High density lipoprotein (HDL) Desirable level > 40 mg/dL Low density lipoprotein (LDL) Desirable level < 100 mg/dL Triglycerides 200 mg/dL indicates hypertriglyceridema Homocysteine ↑ levels indicates ↑ risk for premature development of PVD and CAD (> 15 µmo/L) Interventions Diet Therapy Smoking Cessation Exercise Drug Therapy Nursing Care Health Promotion - #1 priority Teaching Hypertension Blood Pressure Tension or pressure exerted by blood against arterial walls Hypertension (HTN or HTP) Excess pressure in arterial portion of systemic circulation Page 783 - 793 Types of Hypertension Essential HTN Secondary HTN Regulation of Blood Pressure Arterial Baroreceptors Regulation of Body Fluid Volume Renin-Angiotensin- Aldosterone System Atrial Natriuretic Peptide Epinephrine & Norepinephrine Incidence/Prevalence 50 million Americans, 1 in 4 adults ↑ incidence in African Americans ↑ incidence in southeastern US ↑ mortality with ↑ age What is the your greatest concern regarding hypertension? Assessment Manifestations Laboratory Radiographic EKG Complications of HTN Myocardial Infarction Brain attack (CVA) Peripheral Vascular Disease Renal Failure Malignant HTN Enlarged Left Ventricle Malignant HTN Clinical Manifestations Requires immediate treatment Treatment goal Treatment Education Life Style Modification Recommendations Single Drug, once-a-day Start with diuretic or beta-blocker ACE inhibitor for clients with diabetes or have HF or history of MI Considerations for selection of medication & treatment After 1-3 months, if no chg in BP, ↑ dose or substitute for different class of antihypertensive After 1 yr of effective control → ↓ dose or # of medications Antihypertensive Drugs Diuretics Prevent tubular reabsorption of sodium → water & sodium excretion & ↓ blood volume Thiazide (HCTZ) Loop (Lasix) K+ Sparing - Spironolactone (Aldactone) - Eplerenone (Inspra) Nursing Implications Page 788 - 791 Alpha Adrenergic Blockers Block alpha receptors in vascular smooth muscle ↓ vasomotor tone & vasoconstriction Dozaxicin (Cardura) 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 Side Effects Nursing Implication 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 Nursing Implications *No grape fruit juice Side Effects Effective in older adults & African Americans ACE Inhibitors Prevent conversion of Angio I to Angio II preventing vasoconstriction & water/Na retention Capoten (Captopril) Lisinopril (Prinivil, Zestril) Nursing Implications Side Effects Angiotensin II Receptor Antagonists Same effect as ACE inhibitor but act by blocking the effect of angio II on receptors Losartan (Cozaar) - Nursing Implication - Assess for orthostatic hypotension Vasodilators Relax vascular smooth muscle & ↓ PVR Loniten, Apresoline, Used in combination with diuretic or beta-blocker Not used in mgmt of chronic HTN Antianginal (Nitrates) Nitroglycerin (Nitrostat SL) Side Effects Nursing Implications Antilipemic Agents HMG-Coal Reeducates Inhibitors (Statins) Simvastatin (Zocor) Atovastatin (Lipitor) Side Effects Nursing Implications Nursing Diagnoses Ineffective Health Maintenance Risk for Noncompliance Imbalanced Nutrition: > body requirements Excess Fluid Volume Home Care Take active role in disease management Angina and Coronary Heart Disease What layer of the heart is damaged when a person has a heart attack? What effect will a blood pressure of 85/40 have on the heart? What effect does parasymapathetic stimulation have on the heart? Pathophysiology 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 Stroke volume Preload Afterload Contractility Heart rate SV x HR = CO Page - 680 Types of Coronary Heart Disease Chronic ischemic heart disease Coronary Syndrome (ACS) Types of Angina Stable Silent myocardial ischemia Prinzmetal’s Angina Unstable Angina Page 840 - 846 Risk Factors Smoking Diet Exercise Hypertension Diabetes Clinical Manifestations Chest pain Tachycardia Pallor Dyspnea Anxiety Chest Pain Angina MI Sudden, associated with other factors Squeezing, vice like Substernal, may radiate to back or arms Usually lasts < 15 min Relieved with rest, nitrates, or oxygen Sudden, without precipitating factors Intense, stabbing, vice like pressure, severe Substernal, may radiate to back, arms, jaw, neck Lasts > 30 min Relieved with opioids Diagnostic Exams EKG Thallium scan Exercise stress test Echocardiogram Coronary angiography Cardiac enzymes CBC, CMP, Coagulation studies, lipid profile, cholesterol, C-reactive protein Medications for CHD Lipid/cholesterol lowering agents Statins Bile acids Nicotinic acid Fibric Acid Medications for Angina Nitrates Treat anginal attacks Prevent attacks Adverse Effects Medications for Angina Beta Blockers What is the therapeutic effect of this medication? What are the nursing implications for a client receiving this medication? Medications for Angina 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 Location Character Timing Precipitating factors Intensity Aggravating and relieving factors Other signs and symptoms Needed Cardiac Assessment Vitals sign Cardiac output Apical – radial pulse Lungs sounds Skin Peripheral circulation Nursing Care Discuss your teaching plan for this client What would be the appropriate nursing care? Nursing Diagnoses Ineffective tissue perfusion Activity Intolerance Ineffective coping Ineffective health maintenance Altered sexual patterns Myocardial Infarction MI Statistics 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 Interruption of blood flow to the myocardium Cellular death and tissue necrosis Starts in the subendocardium progress to all layers of the myocardium “Stunned” surrounding tissue Coronary Arteries Cardiac Cath Picture of an Ischemic Clot Signs and Symptoms of MI 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 Dysrhythmias Decreased cardiac output Cardiogenic shock Pericarditis Diagnostics for MI Cardiac Enzymes EKG CXR Echo CBC, Coag Studies, CMP Stress Test Cardiac Cath Muga Scan Cardiac Enzymes Troponin CPK MB (CK MB) LDH isoenzymes Myoglobin C-Reactive protein Goals for Treatment Relieve chest pain Cardiac stability Decrease size of infarct Decrease workload of the heart Prevent complications Care of an MI Client What is the appropriate nursing care for this client? Pain Control Nitroglycerin (NTG) Morpine Sulfate (MS) Other Medications Aspirin and antiplatelets medications Plavix Anticoagulants Heparin or Lovenox Thrombolytics Antidysrhythmics Beta blockers Lopressor ACE inhibitors Captopril Stool softeners Antianxiety medications NANDAs Acute pain R/T Decreased cardiac output R/T Ineffective tissue perfusion R/T Ineffective coping R/T Fear R/T Preparing for Discharge Cardiac rehab What would be an appropriate teaching plan for this client? Peripheral Vascular Disease Incidence of PVD Usually over age 60 Men more than women Black women more than white women Review What is the function and structure of an artery? What is the function and structure of a vein? Peripheral Vascular Disease Disorders that alter the natural flow of blood through the arteries and veins of peripheral circulation Affects lower and upper extremities Peripheral artery disease (PAD) Pathophysiology PAD Chronic condition Partial or total arterial occlusion Arterial Obstruction Pain Assessment Intermittent Claudication Rest Pain Clinical Manifestations Physical Assessment Palpate pulses Arterial Ulcers Arterial ulcers Diagnostic Assessment Arteriography Segmental systolic BP measurements Exercise tolerance testing Plethysmography Doppler ultrasound Duplex doppler Venous Stasis Ulcer Interventions Non-invasive Smoking cessation Exercise Positioning Vasodilation promotion Drug therapy ASA Trental Plavix Invasive Percutaneous Transluminal angioplasty (PTA) Laser-assisted angioplasty Atherectomy Endarterectomy Surgical Intervention Revascularization Bypass graft Autologous saphenous vein Gortex or Dacron graft Preoperative Care Mark peripheral pulses for baseline Surgical Intervention Postoperative Care Assess for graft patency Treatment of Graft Occlusion Notify surgeon immediately Emergency thrombolectomy Local thrombolytic therapy Platelet inhibitor infusion (Reo-pro) Compartment Syndrome Goals for Care How would you promote graft patency? Home Care for PVD Follow foot care instructions Quit Smoking Maintain dietary restrictions Exercise Avoid exposure to extreme cold or heat Avoid constrictive clothing Acute Peripheral Arterial Occlusion Emboli originating from heart Severe pain below occlusion Cool or cold extremity, pulseless, mottled Six “P’s” of ischemia Interventions Immediate intervention Anticoagulant therapy Surgical thrombolectomy or embolectomy Post-operative care Deep Vein Thrombosis (DVT) Deep Vein Thrombosis Thrombophlebitis Definition All Refer Health - Deep Venous Thrombosis, Ileofemoral - Deep Venous Thrombosis Pictures & Images (Blood Clot in the Legs, DVT) Deep vein thrombosis ↑ risk for pulmonary embolism Stasis of blood flow, endothelial injury &/or hypercoagulability Risk factors Diagnostics For DVT Doppler flow study Venogram MRI D- Dimer Coagulation studies Physical exam Signs and Symptoms of DVT Asymptomatic Calf or groin tenderness & pain Sudden onset of unilateral swelling Pain upon dorsiflexion (Homan’s sign) not recommended Warmth & edema at site Interventions 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 Anticoagulant teaching Raynaud’s Phenomenon Raynaud’s Disease - A primary vasospastic disease - small arteries & arterioles - cause unknown - exaggerated response of vasomotor controls to cold & emotion Raynaud’s cont. Symptoms - affect digits of hands bilaterally (most often) - color changes occur in sequence (pallor, cyanosis & red) Cont. Initially - numbness & sensation of cold - red phase (throbbing & paresthesia) Long-term - may develop atrophy of skin & subc tissue, brittle nails & skin ulcerations or gangrene Cont. Management - Maintain warmth in the extremities. - Avoid cold materials & prolonged exposure to cold environments. - Avoid use of tobacco. Cont. Treatment - vasodilator drugs - calcium channel blockers - sympathectomy (not always successful)