Download REIMBURSEMENT ISSUES

Chapter 8
Care of the Patient with a
Cardiovascular or a Peripheral
Vascular Disorder
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Key Terms
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Aneurysm
Angina pectoris
Arteriosclerosis
Atherosclerosis
Bradycardia
BNP (B-type natriuretic peptide)
Cardioversion
Coronary artery disease (CAD)
Defibrillation
Dysrhythmia
Embolus
Endarterectomy
Heart failure
Hypoexmia
Intermittent claudication
Ischemia
Myocardial infarction (MI)
Occlusion
Orthopnea
Peripheral
Pleural Effusion
Polycythemia
Pulmonary Edema
Tachycardia
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Slide 2
Overview of Anatomy and
Physiology
• Heart

Four-chambered, hollow, muscular organ, not much
bigger than a fist
 Lies in the mediastinum
 Lower border is called the apex
 Heart wall: three layers
• Epicardium (pericardium): double, serous membrane on
the outside of the heart
• Myocardium: constructed of cardiac muscle
• Endocardium: lines the inner surface of the chambers of
the heart
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Slide 3
Figure 8-1
(from Thibodeau, G.A. & Patton, K.T. [2007]. Structure and function of the human body. [13th ed.]. St. Louis: Mosby. )
Heart and major blood vessels viewed from front (anterior).
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Slide 4
Overview of Anatomy and
Physiology
• Septum (divides right and left halves)
• Heart chambers
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Right atrium—receives deoxygenated blood
 Left atrium—receives oxygenated blood
 Right ventricle—pumps deoxygenated blood
 Left ventricle—pumps oxygenated blood
• Heart valves
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Atrioventricular valves
• Tricuspid and bicuspid (mitral) valves
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Semilunar valves
• Pulmonary and aortic semilunar valves
Chordae tendineae
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Slide 5
Figure 8-2
(From Thibodeau, G.A., Patton, K.T. [2007]. Anatomy and physiology. [6th ed.]. St. Louis: Mosby.)
Interior of the heart.
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Slide 6
Overview of Anatomy and
Physiology
• Electrical conduction system
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Automaticity
• An inherent ability of the heart muscle tissue to contract
in a rhythmic pattern
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Irritability
• The ability to respond to a stimulus
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Impulse pattern
• Sinoatrial node to AV node to bundle of His to right and
left bundle branches to Purkinje fibers
* Hormones, ion concentration, and changes in body
temperature can effect conduction, rhythm, and
coordination of heart beat*
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Slide 7
Figure 8-3
(From Thibodeau, G.A., Patton, K.T. [2007]. Anatomy and physiology. [6th ed.]. St. Louis: Mosby.)
Conduction system of the heart.
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Slide 8
Overview of Anatomy and
Physiology
• Cardiac cycle
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A complete heartbeat
• Atria contract while ventricles relax
• Ventricles contract while atria relax
Systole
• Phase of contraction
Diastole
• Phase of relaxation
• Period between contraction of the atria or ventricles during
which the blood enters the relaxed chambers
*Lubb-longer and lower pitch
Dubb-shorter and sharper pitch*
*Murmur (swishing) can be normal or abnormal*
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Slide 9
Figure 8-4
(From Canobbio, M. [1990]. Cardiovascular disorders, Mosby’s clinical nursing series. St. Louis: Mosby.)
Blood flow during systole.
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Slide 10
Figure 8-5
(From Canobbio, M. [1990]. Cardiovascular disorders, Mosby’s clinical nursing series. St. Louis: Mosby.)
Blood flow during diastole.
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Slide 11
Overview of Anatomy and
Physiology
• Blood vessels
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Capillaries
• Tiny blood vessels joining arterioles and venules
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Arteries
• Large vessels carrying blood away from the heart
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arterioles
Veins
• Vessels that convey blood from the capillaries to the
heart
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venules
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Slide 12
Circulation
• Coronary blood supply
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Right and left coronary arteries
• Branch off of the aorta
• Encircle the heart like a crown
• Supply the myocardium with blood
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Coronary veins
• Return the unoxygenated blood to the coronary sinus,
then to the right atrium
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Slide 13
Figure 8-6
(From Canobbio, M. [1990]. Cardiovascular disorders, Mosby’s clinical nursing series. St. Louis: Mosby.)
Arterial coronary circulation (anterior).
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Slide 14
Circulation
• Systemic circulation
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Circulates blood from the left ventricle to all parts of
the body and back to the right atrium
Carries oxygen and nutritive materials to all body
tissues and removes products of metabolism
• Pulmonary circulation
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Circulates blood from the right ventricle to the lungs
and back to the left atrium of the heart
 Carries deoxygenated blood to the lungs to be
reoxygenated and removes the metabolic waste
product, carbon dioxide
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Slide 15
Laboratory and Diagnostic
Examinations
• Number of diagnostic test available to evaluate
cardiovascular function
• Nursing responsibilities
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Physically prepare patient for test or procedure
 Explain examination to patient
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Slide 16
Laboratory and Diagnostic
Examinations
• Radiographic examination
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Film record of heart size, shape and position and outline of
shadows
Lung congestion also shown (Heart failure)
• Diagnostic imaging
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Fluoroscopy (action picture radiograh; pacemaker placement,
intracardial catheter (Swan) placement
Angiogram-series of radiographs after contrast injected; picture
of circulating process
Aortogram-x-ray visual of abdominal aorta and leg arteries
• Cardiac catheterization and angiography
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Measures heart pressures, ejection fraction, visual of valves,
arteries and structure
Sterile procedure; contrast contains iodine; assess circulation
post-operatively (pulses, vitals, EKG, puncture site)
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Slide 17
Laboratory and Diagnostic
Examinations
• Electrocardiography (ECG/EKG)
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Graphic recording of electrical activity of myocardium
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3 distinct waves (deflections); P, QRS, T
Contraction-depolarization
Relaxation-repolarization
12 leads
Supine, exercise stress, Holter
• Cardiac monitors
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Similar to EKG; preset alarms; telemetry monitors
Monitor wires, battery, connection, gel pads, etc.
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Slide 18
Figure 8-7
Normal ECG deflections.
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Slide 19
Laboratory and Diagnostic
Examinations
• Thallium scanning
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Intracellular ion actively transported into normal cells
If cell is ischemic, thallium not picked up
Thallium concentrates in tissue with normal blood flow
Inadequately perfused areas appear dark on scan (cold spots)
Sestamibi in place of thallium diminishes artifact in females
Persantine (dipyridamole) given prior to thallium for patients who
cannot tolerate activity
• Echocardiography-high frequency ultrasound
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EF: normal >60%
• PET (positron emission tomography)-inhaled/injected
radioactive substance displaying color coded images related
to metabolic function
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Slide 20
Laboratory and Diagnostic
Examinations
• Laboratory tests:
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CBC (rbc, wbc, platetets, H&H)
• High WBC
• Low Hgb
• High RBC (polycythemia) d/t hypoexmia
blood cultures
coagulation studies
• Chronic afib, cardioversion, MI d/t thrombus
• PT, INR PTT
ESR-inflammatory infective conditions (MI, endocarditis,
rheumatic fever)
Electrolytes; Na, K+, Ca, Mg
Lipids; LDL, HDL, VLDL
arterial blood gases; PaO2, PaCO2, pH
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Slide 21
Laboratory and Diagnostic
Examinations
• cardiac markers
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Proteins released into blood from necrotic heart muscle after
infarction
Cardiac serum enzymes
• CK(creatine kinase
• CK-MB (creatine phosphokinase)-gold standard
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also found in skeletal muscle
Can be elevated from surgery, trauma, diease
Not specific for MI
Rise within 2-3 hours of injury, peak 24 hours, return to normal
24-40 hours
Troponin I
• Myocardial muscle protein released after MI
• Not influenced by skeletal muscle injury
• Rises 3 hours, peaks 14-18 hours, normal 5-7 days
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Slide 22
Laboratory and Diagnostic
Examinations
• B-type Natriuretic Peptide (BNP)
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Neurohormone secreted by the heart in response to
ventricular expansion
Elevated in heart failure; higher the number, more
sever the HF
• Homocysteine
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Amino acid produced during protein digestion
Elevated levels may act as independent risk factor for
heart disease
Deficiency in B6, B12, and folate most common cause
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Slide 23
Disorders of the Cardiovascular
System
• Major health concern
• Normal aging patterns
• Risk factors
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Nonmodifiable factors
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Family history
Age
Sex (gender)
Race
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Slide 24
Disorders of the Cardiovascular
System
• Risk factors (continued)
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Modifiable factors
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Smoking
Hyperlipidemia
Hypertension
Diabetes mellitus
Obesity
Sedentary lifestyle
Stress
Oral contraceptives
Psychosocial factors
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Slide 25
Disorders of the Cardiovascular
System
• Cardiac dysrhythmias
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Any cardiac rhythm that deviates from normal sinus
rhythm
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Sinus tachycardia
Sinus bradycardia
Supraventricular tachycardia
Atrial fibrillation
Atrioventricular block
Premature ventricular contractions
Ventricular tachycardia
Ventricular fibrillation
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Slide 26
Disorders of the Cardiovascular
System
• Cardiac Arrest
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The sudden cessation of cardiac output and
circulatory process
 Cause: ventricular tachycardia, ventricular fibrillation,
and ventricular asystole
 Signs and symptoms: abrupt loss of consciousness
with no response to stimuli; gasping respirations
followed by apnea; absence of pulse and blood
pressure; pupil dilation; pallor and cyanosis
 Treatment: cardiopulmonary resuscitation (CPR) and
advanced cardiac life support (ACLS)
• pacemaker
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Slide 27
Disorders of the Heart
• Coronary atherosclerotic heart disease
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Coronary artery disease (CAD)
• A variety of conditions that obstruct blood flow in the
coronary arteries
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Atherosclerosis
• A common arterial disorder characterized by yellowish
plaques of cholesterol, lipids, and cellular debris in the
inner layers of the walls of the arteries; the primary
cause of atherosclerotic heart disease (ASHD)
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Slide 28
Figure 8-10
(From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2007]. Medical-surgical nursing: assessment and
management of clinical problems. [7th ed.]. St. Louis: Mosby.)
Progressive development of coronary atherosclerosis.
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Slide 29
Disorders of the Heart
• Angina pectoris
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Etiology/pathophysiology
• Cardiac muscle is deprived of oxygen
• Increased workload on the heart
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Clinical manifestations/assessment
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Pain (usually relieved by rest)
Dyspnea
Anxiety; apprehension
Diaphoresis
Nausea
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Slide 30
Disorders of the Heart
• Angina pectoris (continued)
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Medical management/nursing interventions
• Correct cardiovascular risk factors
• Avoid precipitating factors
• Pharmacological management
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Dilate coronary arteries and decrease workload of heart
o Nitroglycerin
o Beta-adrenergic blocking agents
o Calcium channel blockers
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Slide 31
Disorders of the Heart
• Angina pectoris (continued)
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Medical management/nursing interventions
• Surgical interventions
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Coronary artery bypass graft (CABG)
Percutaneous transluminal coronary angioplasty (PTCA)
Stent placement
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Slide 32
Disorders of the Heart
• Myocardial infarction
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Etiology/pathophysiology
• Occlusion of a major coronary artery or one of its
branches with subsequent necrosis of myocardium
• Most common cause is atherosclerosis
• Ability of the cardiac muscle to contract and pump blood
is impaired
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Slide 33
Figure 8-16
(From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2007]. Medical-surgical nursing: assessment and
management of clinical problems. [7th ed.]. St. Louis: Mosby.)
Four common locations where myocardial infarctions occur.
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Slide 34
Disorders of the Heart
• Myocardial infarction (continued)
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Clinical manifestations/assessment
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Asymptomatic (silent MI)
Pain (not relieved by rest, position, or nitroglycerin)
Nausea
SOB; dizziness; weakness
Diaphoresis
Pallor—ashen color
Sense of impending doom
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Slide 35
Figure 8-11
(From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2007]. Medical-surgical nursing: assessment and
management of clinical problems. [7th ed.]. St. Louis: Mosby.)
Sites to which ischemic myocardial pain may be referred.
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Slide 36
Disorders of the Heart
• Myocardial infarction (continued)
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Medical management/nursing interventions
• Oxygen
• Fibrinolytic agents
• Percutaneous transluminal coronary angioplasty
(PTCA)
• Coronary artery bypass graft surgery
• Pharmacological management
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Vasopressors, analgesics, nitrates, beta-adrenergic
blockers, calcium channel blockers, antidysrhythmics,
diuretics, inotropic agents, diuretics, stool softeners
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Slide 37
Figure 8-12
(A, from Urden LD, et al [2006]. Thelan’s critical care nursing: Diagnosis and management. [5th ed.]. St. Louis: Mosby. B,
from Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2007]. Medical-surgical nursing: assessment and management of clinical
problems. [7th ed.]. St. Louis: Mosby.)
A, Saphenous vein. B, Saphenous aortocoronary artery bypass.
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Slide 38
Figure 8-13
(from Monahan, F.D., et al. [2007]. Phipps’ medical-surgical nursing: health and illness perspectives.
[8th ed.]. St. Louis: Mosby. )
Coronary artery bypass graft.
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Slide 39
Disorders of the Heart
• Heart failure
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Etiology/pathophysiology
• Abnormal condition characterized by circulatory
congestion resulting from the heart’s inability to act as
an effective pump
• Left ventricular failure
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Most common
• Right ventricular failure
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Usually caused by left ventricular failure
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Slide 40
Disorders of the Heart
• Heart failure (continued)
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Clinical manifestations/assessment
• Decreased cardiac output
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Fatigue
Angina
Anxiety; restlessness
Oliguria
Decreased GI motility
Pale, cool skin
Weight gain
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Slide 41
Disorders of the Heart
• Heart failure (continued)
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Clinical manifestations/assessment (continued)
• Left ventricular failure
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Pulmonary congestion
o Dyspnea
o Paroxysmal nocturnal dyspnea
o Cough; frothy, blood-tinged sputum
o Orthopnea
o Pulmonary crackles
o Pleural effusion (x-ray)
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Slide 42
Disorders of the Heart
• Heart failure (continued)
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Clinical manifestations/assessment (continued)
• Right ventricular failure
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Distended jugular veins
Anorexia, nausea, and abdominal distention
Liver enlargement
Ascites
Edema in feet, ankles, sacrum; may progress up the legs
into thighs, external genitalia, and lower trunk
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Slide 43
Disorders of the Heart
• Heart failure (continued)
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Medical management/nursing interventions
• Pharmacological management
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Increase cardiac efficiency
o Digitalis
o Vasodilators
o ACE inhibitors (decrease blood pressure)
Bed rest, HOB elevated
Oxygen
Treat edema and pulmonary congestion
Monitor fluid retention (weigh daily; strict I&O)
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Slide 44
Disorders of the Heart
• Pulmonary edema
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Etiology/pathophysiology
• Accumulation of fluid in lung tissues and alveoli
• Complication of congestive heart failure (CHF)
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Clinical manifestations/assessment
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Restlessness
Agitation
Disorientation
Diaphoresis
Dyspnea and tachypnea
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Slide 45
Disorders of the Heart
• Pulmonary edema (continued)
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Clinical manifestations/assessment (continued)
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Tachycardia
Pallor or cyanosis
Cough—large amounts of blood-tinged, frothy sputum
Wheezing, crackles
Cold extremities
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Slide 46
Disorders of the Heart
• Pulmonary edema (continued)
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Medical management/nursing interventions
• Pharmacological management
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Morphine sulfate
Nitroglycerin
Diuretics
Inotropic agents
Vasodilators
• High Fowler’s or orthopneic position
• Oxygen
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Slide 47
Disorders of the Heart
• Valvular heart disease
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Etiology/pathophysiology
• Heart valves are compromised and do not open and
close properly
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Stenosis
Insufficiency
• Causes may be:
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Congenital
Rheumatic fever
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Slide 48
Disorders of the Heart
• Valvular heart disease (continued)
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Clinical manifestations/assessment
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Fatigue
Angina
Oliguria
Pale, cool skin
Weight gain
Restlessness
Abnormal breath sounds
Edema
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Slide 49
Disorders of the Heart
• Valvular heart disease (continued)
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Medical management/nursing interventions
• Pharmacological management
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Diuretics
Digoxin
Antidysrhythmics
• Restrict activities
• Sodium-restricted diet
• Surgery
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Open mitral commissurotomy
Valve replacement
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Slide 50
Disorders of the Heart
• Rheumatic heart disease
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Etiology/pathophysiology
• Rheumatic fever
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Inflammatory disease that is a delayed childhood reaction
to inadequately treated childhood upper respiratory tract
infection of beta-hemolytic streptococci
Causes scar tissue in the heart
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Slide 51
Disorders of the Heart
• Rheumatic heart disease (continued)
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Clinical manifestations/assessment
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Elevated temperature
Elevated heart rate
Epistaxis
Anemia
Joint pain and stiffness
Nodules on the joints
Specific to valve affected
Heart murmur
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Slide 52
Disorders of the Heart
• Rheumatic heart disease (continued)
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Medical management/nursing interventions
• Pharmacological management
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NSAIDs
• Prevention
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Treat infections rapidly and completely
• Bed rest
• Application of heat
• Dietary recommendations
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Well-balanced diet
Supplement with vitamins B and C
• Encourage fluids
• Commissurotomy or valve replacement
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Slide 53
Disorders of the Heart
• Pericarditis
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Etiology/pathophysiology
• Inflammation of the membranous sac surrounding the
heart
• May be acute or chronic
• Bacterial, viral, or fungal
• Noninfectious conditions
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Azotemia, MI, neoplasms, scleroderma, trauma, systemic
lupus erythematosus (SLE), radiation, drugs
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Slide 54
Disorders of the Heart
• Pericarditis (continued)
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Clinical manifestations/assessment
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Debilitating pain
Dyspnea
Fever
Chills
Diaphoresis
Leukocytosis
Pericardial friction rub
Pericardial effusion
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Slide 55
Disorders of the Heart
• Pericarditis (continued)
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Medical management/nursing interventions
• Pharmacological management
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Analgesics
Salicylates
Antibiotics
Anti-inflammatory agents
Corticosteroids
• Oxygen
• IV fluids
• Surgery: pericardial window, pericardial tap
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Slide 56
Disorders of the Heart
• Endocarditis
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Etiology/pathophysiology
• Infection or inflammation of the inner membranous
lining of the heart
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Clinical manifestations/assessment
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Influenza-like symptoms
Petechiae on the conjunctiva, mouth, and legs
Anemia
Splinter hemorrhages under nails
Weight loss
Heart murmur
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Slide 57
Disorders of the Heart
• Endocarditis (continued)
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Medical management/nursing interventions
• Bed rest
• Antibiotics
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IV for 1 to 2 months
• Prophylactic antibiotics for “high-risk” patients
• Surgical repair of diseased valves or valve replacement
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Slide 58
Disorders of the Heart
• Myocarditis
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Etiology/pathophysiology
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Inflammation of the myocardium
Rheumatic heart disease
Viral, bacterial, or fungal infection
Endocarditis
Pericarditis
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Slide 59
Disorders of the Heart
• Myocarditis (continued)
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Medical management/nursing interventions
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Bed rest
Oxygen
Antibiotics; anti-inflammatory agents
Assessment and correction of dysrhythmias
Clinical manifestations/assessment
• Vary according to site of infection
• Cardiac enlargement
• Murmur; gallop; tachycardia
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Slide 60
Disorders of the Heart
• Cardiomyopathy

Etiology/pathophysiology
• A group of heart muscle diseases that primarily affects
the structural or functional ability of the myocardium
• Not associated with CAD, hypertension, vascular
disease, or pulmonary disease
• Primary—unknown cause
• Secondary—infective, metabolic, nutritional, alcohol,
peripartum, drugs, radiation, SLE, rheumatoid arthritis
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Slide 61
Disorders of the Heart
• Cardiomyopathy (continued)

Clinical manifestations/assessment
•
•
•
•
•
•
Angina
Syncope
Fatigue
Dyspnea on exertion
Severe exercise intolerance
Signs and symptoms of left- and right-sided CHF
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Slide 62
Disorders of the Heart
• Cardiomyopathy (continued)

Medical management/nursing interventions
• Pharmacological management



Diuretics
ACE inhibitors
Beta-adrenergic blocking agents
• Treat underlying cause
• Internal defibrillator
• Cardiac transplant
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Slide 63
Disorders of the Peripheral
Vascular System
• Arterial assessment

PATCHES
•
•
•
•
•
•
•
P = Pulses
A = Appearance
T = Temperature
C = Capillary refill
H = Hardness
E = Edema
S = Sensation
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 64
Disorders of the Peripheral
Vascular System
• Venous assessment

First symptom is usually edema
 Dark pigmentation
 Dryness and scaling
 Ulcerations
 Pain, aching, and cramping
• Usually relieved by rest or elevation
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 65
Disorders of the Peripheral
Vascular System
• Diagnostic tests

Noninvasive procedures
•
•
•
•

Treadmill test
Plethysmography
Digital subtraction angiography (DSA)
Doppler ultrasound
Invasive procedures
• Phlebography or venography
• 125I-fibrinogen uptake test
• Angiography
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Slide 66
Disorders of the Peripheral
Vascular System
• Arteriosclerosis

Thickening, loss of elasticity, and calcification of
arterial walls, resulting in decreased blood supply
• Atherosclerosis


Narrowing of the artery due to yellowish plaques of
cholesterol, lipids, and cellular debris in the inner
layers of the walls of large- and medium-sized arteries
A type of arteriosclerosis
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Slide 67
Disorders of the Peripheral
Vascular System
• Hypertension

Etiology/pathophysiology
• A sustained elevated systolic blood pressure greater
than 140 mm Hg and/or a sustained elevated diastolic
blood pressure greater than 90 mm Hg.
• Vasoconstriction (increases blood pressure )
• Essential (primary) hypertension

90% to 95% of all diagnosed cases
• Secondary hypertension

Attributed to an identifiable medical diagnosis
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Slide 68
Disorders of the Peripheral
Vascular System
• Hypertension (continued)

Clinical manifestations/assessment
• Headache; blurred vision
• Epistaxis
• Angina

Medical management/nursing interventions
• Pharmacological management

Antihypertensive medications; diuretics
• Dietary recommendations

Weight control, reduction of saturated fats, and low
sodium
• No smoking
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Slide 69
Disorders of the Peripheral
Vascular System
• Arteriosclerosis obliterans

Etiology/pathophysiology
• Narrowing or occlusion of the blood vessel with plaque
formation—little or no blood flow to the affected
extremity

Clinical manifestations/assessment
•
•
•
•
•
Pain—intermittent claudication
Pulselessness
Pallor
Paresthesia
Paralysis
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Slide 70
Disorders of the Peripheral
Vascular System
• Arteriosclerosis obliterans (continued)

Medical management/nursing interventions
• Anticoagulants
• Fibrinolytics
• Surgery





Embolectomy
Endarterectomy
Arterial bypass
Percutaneous transluminal angioplasty
Amputation
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Slide 71
Disorders of the Peripheral
Vascular System
• Arterial embolism

Etiology/pathophysiology
• Blood clots in the arterial bloodstream
• May originate in the heart
• Foreign substances

Clinical manifestations/assessment
•
•
•
•
Pain
Absent distal pulses
Pale, cool, and numb extremity
Necrosis
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Slide 72
Disorders of the Peripheral
Vascular System
• Arterial embolism (continued)

Medical management/nursing interventions
• Pharmacological management


Anticoagulants
Fibrinolytics
• Endarterectomy
• Embolectomy
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Slide 73
Disorders of the Peripheral
Vascular System
• Arterial aneurysm

Etiology/pathophysiology
• Enlarged, dilated portion of an artery
• Causes: arteriosclerosis; trauma; congenital

Clinical manifestations/assessment
• Asymptomatic
• Large pulsating mass
• Pain, if large enough to press on other structures
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Slide 74
Figure 8-20
(From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2007]. Medical-surgical nursing: assessment and
management of clinical problems. [7th ed.]. St. Louis: Mosby.)
Types of aneurysms. A, Fusiform. B, Saccular.
C, Dissecting.
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Slide 75
Disorders of the Peripheral
Vascular System
• Arterial aneurysm (continued)

Medical management/nursing interventions
• Assess for signs and symptoms of rupture, thrombi,
ischemia
• Control hypertension
• Surgery


Ligation
Grafts
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Slide 76
Disorders of the Peripheral
Vascular System
• Thromboangitis obliterans (Buerger’s disease)

Etiology/pathophysiology
• Occlusive vascular condition in which the small and
medium-sized arteries become inflamed and thrombotic

Clinical manifestations/assessment
•
•
•
•
Pain; sensitivity to cold
Skin cold and pale
Ulcerations on feet or hands; gangrene
Superficial thrombophlebitis
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Slide 77
Disorders of the Peripheral
Vascular System
• Thromboangitis obliterans (Buerger’s disease)
(continued)

Medical management/nursing interventions
• No smoking
• Exercise to develop collateral circulation
• Surgery


Amputation of gangrenous fingers and toes
Sympathectomy
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Slide 78
Disorders of the Peripheral
Vascular System
• Raynaud’s disease

Etiology/pathophysiology
• Intermittent arterial spasms
• Primarily affects fingers, toes, ears, and nose
• Exposure to cold or emotional stress

Clinical manifestations/assessment
• Chronically cold hands and feet
• Pallor, coldness, numbness, cyanosis, and pain during
spasms; erythema following a spasm
• Ulcerations on the fingers and toes
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Slide 79
Disorders of the Peripheral
Vascular System
• Raynaud’s disease (continued)

Medical management/nursing interventions
• Pharmacological management



•
•
•
•
Vasodilators
Calcium antagonists
Muscle relaxants
Surgery: sympathectomy
No smoking
Avoid exposure to cold
Amputation for gangrene
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Slide 80
Disorders of the Peripheral
Vascular System
• Thrombophlebitis

Etiology/pathophysiology
• Inflammation of a vein in conjunction with the formation
of a thrombus
• Risk factors: venous stasis, hypercoagulability, trauma
of a blood vessel, immobilization after surgery

Clinical manifestations/assessment
•
•
•
•
Pain
Edema
Positive Homans’ sign
Erythema, warmth, and tenderness along the vein
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Slide 81
Figure 8-23
(From Kamal, A., Brockelhurst, J.C. [1991]. Color atlas of geriatric medicine. [3rd ed.]. St. Louis: Mosby-Year
Book —Europe.)
Deep vein thrombophlebitis.
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Slide 82
Disorders of the Peripheral
Vascular System
• Thrombophlebitis (continued)

Medical management/nursing interventions
• Superficial




Pharmacological management
o NSAIDs
Bed rest
Moist heat
Elevate extremity
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Slide 83
Disorders of the Peripheral
Vascular System
• Thrombophlebitis (continued)

Medical management/nursing interventions
• Deep





Pharmacological management
o Anticoagulants
o Fibrinolytics
Bed rest
Elevate extremity
Antiembolism stockings
Surgery: thrombectomy; vena cava umbrella (Greenfield
filter)
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Slide 84
Disorders of the Peripheral
Vascular System
• Varicose veins

Etiology/pathophysiology
• Tortuous, dilated vein with incompetent valves

Clinical manifestations/assessment
•
•
•
•
•
Dark, raised, tortuous veins
Fatigue; dull aches
Cramping of the muscles
Heaviness or pressure of extremity
Edema, pain, changes in skin color, and ulcerations
with venous stasis
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Slide 85
Disorders of the Peripheral
Vascular System
• Varicose veins (continued)

Medical management/nursing interventions
•
•
•
•
•
Elastic stockings
Rest
Elevate legs
Sclerotherapy
Surgery

Vein ligation and stripping
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Slide 86
Disorders of the Peripheral
Vascular System
• Venous stasis ulcers

Etiology/pathophysiology
• Ulcerations of the legs from chronic deep vein
insufficiency and stasis of blood in the venous system
of the legs
• Open necrotic lesion due to an inadequate supply of
oxygen-rich blood to the tissue
• Causes

Varicose veins, burns, trauma, sickle cell anemia,
diabetes mellitus, neurogenic disorders, and hereditary
factors
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Slide 87
Disorders of the Peripheral
Vascular System
• Venous stasis ulcers (continued)

Clinical manifestations/assessment
• Pain
• Ulceration with dark pigmentation
• Edema

Medical management/nursing interventions
•
•
•
•
Diet: increased protein; vitamins A and C and zinc
Debridement of necrotic tissue
Antibiotics
Unna boot
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Slide 88
Figure 8-17
(From Canobbio, M. [1990]. Cardiovascular disorders, Mosby’s clinical nursing series. St. Louis: Mosby.)
Scale for pitting edema depth.
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Slide 89
Nursing Process
• Nursing diagnoses

Activity intolerance
 Anxiety
 Decreased cardiac output
 Ineffective coronary tissue perfusion
 Fluid volume excess
 Impaired gas exchange
 Knowledge, deficient
 Pain
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Slide 90
Chapter 15
Cardiovascular and Renal Medications
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91
Chapter 15
Lesson 15.1
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92
Learning Objectives



Identify the approved way to give different
forms of antianginal therapy
Discuss the uses and general actions of
cardiac drugs used to treat dysrhythmias
Describe the common treatment for various
types of lipoprotein disorders
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93
Cardiovascular System:
Major Arteries
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94
Question 1
Arteries move blood from the heart to tissues
using smaller branches called:
1.
2.
3.
4.
Arterioles.
Bronchioles.
Nerves.
Venules.
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95
Cardiovascular System:
Major Veins
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96
Urinary System
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97
Antianginals and Peripheral
Vasodilators
Antianginals
 Nitrates: “Universal Vasodilators”




Directly cause vascular smooth muscle to relax in
arterial and venous circulation
Decrease myocardial oxygen use
Increase collateral-vessel circulation to the heart
Calcium Channel Blockers


Dilate coronary arteries and arterioles
Reduce response of electrical conduction system
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98
Question 2
Which are the best drugs for treating
coronary artery disease?
1.
2.
3.
4.
Beta blockers
Calcium channel blockers
Diuretics
Nitrates
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99
Main Components of
Microcirculation
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100
Antianginals and Peripheral
Vasodilators (cont.)
Action and Uses
 Nitrates

Acute and chronic anginal attacks
 Reduce the workload of the heart

Peripheral Vasodilators


Relax the smooth muscles of peripheral arterial
vessels to increase peripheral circulation
Used to treat leg pain caused by vasoconstriction
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101
Site of Action of Peripheral
Vasodilators
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102
Antianginals and Peripheral
Vasodilators (cont.)
Adverse Reactions
 Nitrates: Flushing, postural hypotension,
tachycardia, confusion, dizziness, fainting,
headache, lightheadedness, vertigo, weakness,
drug rash, localized pruritus, skin lesions, eye
and mouth edema, local burning in mouth,
nausea and vomiting
 Peripheral Vasodilators: Headache, weakness,
tachycardia, flushing, postural hypotension,
dysrhythmias, confusion, severe rash,
nervousness, tingling, and sweating
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Antidysrhythmics
Four Classes

Class I: disopyramide, procainamide, quinidine



Class II: acebutolol, esmolol, propranolol


Reduce sympathetic excitation (reduce loading)
Class III: amiodarone


Lengthen the refractory period
Decrease cardiac excitability
Lengthen the time it takes for one cell to fire and recover
Class IV: verapamil

Blocks calcium entry into the myocardium, prolongs resting
phase
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104
Conduction System of the Heart
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105
Antidysrhythmics (cont.)
Action and Uses
 Quinidine and Procainamide


Bretylium


Treat rapid and irregular dysrhythmias by
decreasing the excitability of myocardial cells
Slows conduction rate in the ventricles, slows
norepinephrine release in the myocardium
Disopyramide

Slows the depolarization of cardiac cells
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106
Antidysrhythmics (cont.)

Lidocaine


Adenosine


Increases the strength of electrical impulses
Stops the heart for several seconds to allow it to
convert to normal sinus rhythm
Beta-adrenergic blockers (propranolol)

Decrease the heart’s beta-receptor response to
epinephrine and norepinephrine
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107
Antihyperlipidemics
Types of Lipoproteins

Chylomicrons (mostly triglycerides)


Very low-density lipoproteins (VLDLs)


Made up of large amounts of triglycerides that were made in the
liver (pre-beta lipoproteins)
Low-density lipoproteins (LDLs)


Formed from absorption of dietary fat in intestine
Breakdown of VLDLs linked with cholesterol and protein
High-density lipoproteins (HDLs)

Clear out excess cholesterol from tissue
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108
Path of Lipid Metabolism
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109
Antihyperlipidemics (cont.)

HMG-CoA Reductase Inhibitors


Fibric Acid Derivatives


Highly effective for lowering triglyceride and
increasing HDL levels
Bile Acid Sequestrants


Highly effective for lowering LDL levels
Form an insoluble compound with bile salts to reduce
serum cholesterol levels
Niacin

Effective at lowering LDL levels and increasing HDLs
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110
Chapter 15
Lesson 15.2
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111
Learning Objectives



List the general uses and actions of
cardiotonic drugs
Explain the actions of different categories of
drugs used to treat hypertension
Identify indications for electrolyte replacement
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112
Internal Anatomy of the Heart
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113
Coronary Arteries
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114
Coronary Arteries
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115
Cardiotonics
Actions
 Increase the contraction strength or force
(positive inotropic action)
 Slow the heart rate
Uses
 Treatment of CHF and rapid or irregular
heartbeats (atrial fibrillation, atrial flutter,
frequent PVCs or paroxysmal atrial
tachycardia)
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116
Cardiotonics (cont.)
Adverse Reactions



Digitalis toxicity: serum digoxin levels verify
The amount of medication that is helpful (therapeutic)
and the amount that is harmful (toxic) are not very
different.
Don’t confuse the sound-alikes digoxin and digitoxin
Drug Interactions
Nursing Implications and Patient Teaching
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117
Antihypertensives, Diuretics, and Other
Drugs Affecting the Urinary Tract
Diuretics
 Indirectly reduce blood pressure by producing
sodium and water loss and lowering the tone
or rigidity of the arteries
 Types



Thiazide and sulfonamide diuretics
Loop diuretics
Potassium-sparing diuretics
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118
Antihypertensives, Diuretics, and Other
Drugs Affecting the Urinary Tract (cont.)
Adrenergic Inhibitors
 Beta-adrenergic blockers



Central adrenergic inhibitors


Nonselective; block beta1 and beta2 sites
Selective; block beta1 sites
Cause vascular relaxation and lower blood
pressure
Peripheral adrenergic antagonists

Limit norepinephrine release, prevent
vasoconstriction
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119
Antihypertensives, Diuretics, and Other
Drugs Affecting the Urinary Tract (cont.)

Alpha1-adrenergic inhibitors


Lower peripheral resistance and blood pressure
Combined alpha- and beta-adrenergic blockers
Angiotensin-Related Agents


Angiotensin-converting enzyme inhibitors
Angiotensin II receptor antagonists
Vasodilators
Calcium Channel Blocking Agents
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120
High Blood Pressure



Stage I: Lifestyle Changes
Stage II: Drug Therapy
Adverse Reactions


Drug specific
Drug Interactions
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121
Drugs Useful in Treating Urinary
Problems

Urinary incontinence


Benign prostatic hyperplasia


Treatment: anticholinergics/antispasmodics, alphaadrenergic agonists, estrogens, cholinergic agonists,
and alpha-adrenergic antagonists
Treatment: alpha1-adrenergic receptor blockers
Analgesia

Treatment: phenazopyridine
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122
Question 3
___________ is an electrolyte that helps
move electrical impulses through cardiac
tissue.
1.
2.
3.
4.
Calcium
Iron
Hemoglobin
Oxygen
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123
Williams' Basic Nutrition & Diet
Therapy
14th Edition
Chapter 19
Coronary Heart Disease and
Hypertension
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124
Lesson 19.1: Cardiovascular
Disease



Cardiovascular disease is the leading cause of death
in the United States.
Several risk factors contribute to the development of
coronary heart disease and hypertension, many of
which are preventable by improved food habits and
lifestyle behaviors.
Other risk factors are nonmodifiable, such as age,
gender, family history, and race.
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125
Introduction (p. 379)

Coronary heart disease




Leading cause of death in the United States
More than 615,000 deaths each year
Similar in other Western developed nations
More than 1 million live with various forms of
rheumatic and congestive heart disease
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126
Atherosclerosis (p. 379)






Major cause of CVD
Fatty fibrous plaques develop into fatty streaks on
inside lining of major blood vessels
Plaques largely composed of cholesterol
Narrows interior part of the blood vessel
If affected vessel is major artery supplying heart
muscle, result could be myocardial infarction
Local area of dead tissue is an infarct
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127
Atherosclerosis (cont’d) (p. 379)

If affected vessel is major artery supplying brain,
result could be cerebrovascular accident
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128
Atherosclerosis (cont’d) (p. 379)


Identified as coronary heart disease
Common symptom is angina pectoris, chest pain
usually radiating down the arm, sometimes brought
on by excitement or physical effort
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129
Key Terms Related to
Atherosclerosis (p. 380)





Myocardial infarction
Cerebrovascular accident
Coronary heart disease
Angina pectoris
Lipids
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130
Atherosclerotic Plaque (p. 381)
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131
Relation to Fat Metabolism
(p. 381)

Elevated blood lipids associated with
coronary heart disease



Triglycerides: Simple fats in body or food
Cholesterol: Fat-related compound produced in
body; also in foods from animals
Lipoproteins: “Packages” wrapped with protein
that carry fat in the bloodstream
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132
Types of Lipoproteins (p. 381)

Chylomicrons


Very-low-density lipoproteins (VLDLs)


After VLDLs deposit triglycerides, IDLs remain in circulation
Low-density lipoproteins (LDLs)


Carry large load of fat to cells
Intermediate-density lipoproteins (IDLs)


Lipoprotein particles that carry absorbed dietary triglycerides
to fat and tissues
Carry two thirds of total plasma cholesterol to body tissues
High-density lipoproteins (HDLs)

Carry less total fat and more protein
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133
Cholesterol and Lipoprotein
Profile (p. 383)
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134
Risk Factors (p. 382)






Gender: CVD more common in men until women
reach menopause
Age: risk increases with age
Family history
Heredity: certain ethnic groups
Compounding diseases: type 2 diabetes,
hypertension, metabolic syndrome
Blood cholesterol profile: high total and LDL and low
HDL cholesterol
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135
Case Study

Mr. Elliott is a 68-year-old male who is referred to the
dietitian for a fat-controlled meal plan. Mr. Elliott is 5
feet 10 inches tall and weighs 250 lbs. His blood
pressure is 155/95. Recent labs reveal a total
cholesterol of 245 mg/dL, LDL 171 mg/dL, HDL 36
mg/dL, and TG 200 mg/dL.
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136
Case Study (cont’d)



List Mr. Elliott’s risk factors for heart disease.
Which risk factors can be modified?
What additional information would be helpful to look
at risk factors?
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137
Case Study (cont’d)

What other lab value and assessment data would you
consider in assessing Mr. Elliott? Why?
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138
Dietary Recommendations
(p. 383)

Dietary recommendations for reduced risk



Reduce fat and cholesterol
National Cholesterol Education Program (NCEP): reduce
high blood cholesterol
Therapeutic Lifestyle Changes (TLC):
• Total energy intake equals energy expenditure
• Exercise to expend at least 200 kcal/day
• Total fat no more than 25% to 35% of intake
• Avoid trans-fatty acids
• Carbohydrates equal 50% to 60% of energy intake
• Protein equals about 15% of energy intake
• Total cholesterol intake less than 200 mg/day
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139
Drug Therapy (p. 386)


NCEP ATP III guidelines: drug therapy initiated
depending on risk factors
TLC guidelines should be continued as adjunct
therapy
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140
Case Study (cont’d)

Discuss interventions that could assist Mr. Elliott in
reducing his cardiovascular risk.
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141
Acute Cardiovascular Disease
(p. 387)

Acute cardiovascular disease: myocardial
infarction


Cardiac rest: analgesics
Principles of medical nutrition therapy
• Energy intake reduced to reduce load on heart
• Soft or easily digested foods
• Fat: Mediterranean-type diet
• Limited sodium
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142
Heart Failure (p. 388)

Objective: control of pulmonary edema



Fluid shift mechanism
Hormonal alterations
Principles of diet therapy





Sodium restriction
Fluid restriction
Texture
Nutritional adequacy
Little or no alcohol
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143
Lesson 19.2: Hypertension



Hypertension, or chronically elevated blood pressure,
may be classified as essential (primary) or secondary
hypertension.
Hypertension damages the endothelium of blood
vessels.
Early education is critical for the prevention of
cardiovascular disease.
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144
Essential Hypertension (p. 389)

Incidence and nature




31% of American adults have high blood pressure
(hypertension)
Injury to inner lining of blood vessel wall appears
to be underlying link to cause
Secondary hypertension is symptom or side effect
of another primary condition
Hypertension called the “silent disease”
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145
Hypertensive Blood Pressure
Levels (p. 390)



Prehypertension: focus on lifestyle modifications
Stage 1 hypertension: diet therapy and drugs as
needed
Stage 2 hypertension: diet therapy and vigorous drug
therapy
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146
Case Study (cont’d)

What stage of hypertension does Mr. Elliott have?
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147
Principles of Medical Nutrition
Therapy (p. 391)




Weight management: lose excess weight and
maintain healthy weight
Sodium control: limit sodium to 1500 to 2400 mg/day
DASH diet: lower blood pressure through diet alone
Additional lifestyle factors: limit alcohol, stop
smoking, reduce saturated fat, increase aerobic
activity
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148
Case Study (cont’d)

Discuss additional nutrition factors that may assist
Mr. Elliott in controlling his blood pressure.
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149
Education and Prevention
(p. 393)

Food planning and purchasing



Control energy intake; read labels
Eat fresh foods with small selection of processed
foods
Food preparation

Use less salt and fat
 Use seasonings instead (herbs, spices, lemon,
onion, garlic, etc.)

Special needs

Personal desires, ethnic diets, food habits
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150
Education Principles (p. 396)

Start early


Focus on high-risk groups


Prevention begins in childhood, especially with
children in high-risk families
Direct education to people and families with risk of
heart disease and hypertension
Use variety of resources

National organizations, community programs,
registered dietitians
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151