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
Internal Anatomy of the Heart
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3
Conduction System of the Heart
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4
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 5
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 6
Overview of Anatomy and
Physiology
• Septum (divides right and left halves)
• Heart chambers

Right atrium—receives deoxygenated blood
 Left atrium—receives oxygenated blood
 Right ventricle—pumps deoxygenated blood
 Left ventricle—pumps oxygenated blood
• Heart valves

Atrioventricular valves
• Tricuspid and bicuspid (mitral) valves

Semilunar valves
• Pulmonary and aortic semilunar valves
Chordae tendineae
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Slide 7
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 8
Overview of Anatomy and
Physiology
• Electrical conduction system

Automaticity
• An inherent ability of the heart muscle tissue to contract
in a rhythmic pattern

Irritability
• The ability to respond to a stimulus

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 9
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 10
Overview of Anatomy and
Physiology
• Cardiac cycle



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 11
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 12
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 13
Overview of Anatomy and
Physiology
• Blood vessels

Capillaries
• Tiny blood vessels joining arterioles and venules

Arteries
• Large vessels carrying blood away from the heart


arterioles
Veins
• Vessels that convey blood from the capillaries to the
heart

venules
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Slide 14
Circulation
• Coronary blood supply

Right and left coronary arteries
• Branch off of the aorta
• Encircle the heart like a crown
• Supply the myocardium with blood

Coronary veins
• Return the unoxygenated blood to the coronary sinus,
then to the right atrium
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Slide 15
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 16
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

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 17
Laboratory and Diagnostic
Examinations
• Number of diagnostic test available to evaluate
cardiovascular function
• Nursing responsibilities

Physically prepare patient for test or procedure
 Explain examination to patient
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Slide 18
Laboratory and Diagnostic
Examinations
• Radiographic examination


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


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 19
Laboratory and Diagnostic
Examinations
• Electrocardiography (ECG/EKG)

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


Similar to EKG; preset alarms; telemetry monitors
Monitor wires, battery, connection, gel pads, etc.
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Slide 20
Figure 8-7
Normal ECG deflections.
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Slide 21
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

EF: normal >60%
• PET (positron emission tomography)-inhaled/injected
radioactive substance displaying color coded images related
to metabolic function
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Slide 22
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 23
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 24
Laboratory and Diagnostic
Examinations
• B-type Natriuretic Peptide (BNP)


Neurohormone secreted by the heart in response to
ventricular expansion
Elevated in heart failure; higher the number, more
severe the HF
• Homocysteine



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 25
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 26
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 27
Disorders of the Cardiovascular
System
• Cardiac dysrhythmias

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 28
Meds for dysrhythmias
• Cardioglycoside- digoxin
• Antidysrhythmics –
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Class I: disopyramide, procainamide, quinidine
Lengthen the refractory period
Decrease cardiac excitability
• Beta blockers – end in (-olol)

Class II: acebutolol, esmolol, propranolol

Reduce sympathetic excitation (reduce loading)
• Amiodarone - Class III: Lengthen the time it takes for one cell
to fire and recover (K+ channel)
• Calcium channel blockers –Class IV: verapamil

Blocks calcium entry into the myocardium, prolongs resting phase
• Inotropic agents – dopamine, dobutamine
• Anticoagulants - warfarin
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Slide 29
Disorders of the Cardiovascular
System
• Cardiac Arrest

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 30
Cardiovascular Disease
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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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31
Disorders of the Heart
• Coronary atherosclerotic heart disease

Coronary artery disease (CAD)
• A variety of conditions that obstruct blood flow in the
coronary arteries

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 32
Atherosclerosis
• 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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Slide 33
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 34
Atherosclerotic Plaque
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35
Risk Factors (p. 382)
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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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36
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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37
Disorders of the Heart
• Angina pectoris

Etiology/pathophysiology
• Cardiac muscle is deprived of oxygen
• Increased workload on the heart

Clinical manifestations/assessment
•
•
•
•
•
Pain (usually relieved by rest)
Dyspnea
Anxiety; apprehension
Diaphoresis
Nausea
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Slide 38
Disorders of the Heart
• Angina pectoris (continued)

Medical management/nursing interventions
• Correct cardiovascular risk factors
• Avoid precipitating factors
• Pharmacological management

Dilate coronary arteries and decrease workload of heart
o Nitroglycerin (stay with patient; take BP, give 1 pill,
wait 5 minutes; assess pain, take BP, give 1 pill, wait
5 minutes; take BP, give 1 pill, wait 5 minutes; if still
having pain call MD)
o Beta-adrenergic blocking agents
o Calcium channel blockers
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Slide 39
Disorders of the Heart
• Angina pectoris (continued)

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 40
Coronary Arteries
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41
Coronary Arteries
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42
Antianginals and Peripheral
Vasodilators
Antianginals
 Nitrates: “Universal Vasodilators”
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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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43
Antianginals and Peripheral
Vasodilators (cont.)
Action and Uses
 Nitrates (-nitr) coronary vessel dilators

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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44
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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45
Disorders of the Heart
• Myocardial infarction

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 46
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 47
Disorders of the Heart
• Myocardial infarction (continued)

Clinical manifestations/assessment
•
•
•
•
•
•
•
Asymptomatic (silent MI)
Pain (not relieved by rest, position, or nitroglycerin)
Nausea
SOB; dizziness; weakness
Diaphoresis
Pallor—ashen color
Sense of impending doom
• Cardiac catheterization
http://www.youtube.com/watch?v=WiN776pyEZM
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Slide 48
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 49
Disorders of the Heart
• Myocardial infarction (continued)

Medical management/nursing interventions
• Oxygen
• Fibrinolytic agents
• Percutaneous transluminal coronary angioplasty
(PTCA)
• Coronary artery bypass graft surgery
• Pharmacological management

Vasopressors, analgesics, nitrates, beta-adrenergic
blockers, calcium channel blockers, antidysrhythmics,
diuretics, inotropic agents, diuretics, stool softeners
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Slide 50
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 51
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 52
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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53
Disorders of the Heart
• Heart failure

Etiology/pathophysiology
• Abnormal condition characterized by circulatory
congestion resulting from the heart’s inability to act as
an effective pump
• Left ventricular failure

Most common
• Right ventricular failure

Usually caused by left ventricular failure
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Slide 54
Disorders of the Heart
• Heart failure (continued)

Clinical manifestations/assessment
• Decreased cardiac output







Fatigue increases with severity of failure
Angina
Anxiety; restlessness
Oliguria
Decreased GI motility
Pale, cool skin
Weight gain
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Slide 55
Disorders of the Heart
• Heart failure (continued)

Clinical manifestations/assessment (continued)
• Left ventricular failure

Pulmonary congestion
o Dyspnea progresses to dyspnea at rest
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 56
Disorders of the Heart
• Heart failure (continued)

Clinical manifestations/assessment (continued)
• Right ventricular failure





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 57
Disorders of the Heart
• Heart failure (continued)

Medical management/nursing interventions
• Pharmacological management

•
•
•
•
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 58
Heart Failure (p. 388)

Objective: control of pulmonary edema



Fluid shift mechanism
Hormonal alterations
Principles of diet therapy





Sodium restriction
Fluid restriction
Texture to add fiber
Nutritional adequacy
Little or no alcohol
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59
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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60
Cardiotonics (cont.)
Adverse Reactions



Digitalis toxicity: serum digoxin levels verify; will see
nausea and vomiting followed by diplopia and later halos
around lights
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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61
Disorders of the Heart
• Pulmonary edema

Etiology/pathophysiology
• Accumulation of fluid in lung tissues and alveoli
• Complication of congestive heart failure (CHF)

Clinical manifestations/assessment
•
•
•
•
•
Restlessness
Agitation
Disorientation
Diaphoresis
Dyspnea and tachypnea
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 62
Disorders of the Heart
• Pulmonary edema (continued)

Clinical manifestations/assessment (continued)
•
•
•
•
•
Tachycardia
Pallor or cyanosis
Cough—large amounts of blood-tinged, frothy sputum
Wheezing, crackles
Cold extremities
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 63
Disorders of the Heart
• Pulmonary edema (continued)

Medical management/nursing interventions
• Pharmacological management





Morphine sulfate
Nitroglycerin
Diuretics
Inotropic agents
Vasodilators
• High Fowler’s or orthopneic position
• Oxygen
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 64
Disorders of the Heart
• Valvular heart disease

Etiology/pathophysiology
• Heart valves are compromised and do not open and
close properly


Stenosis
Insufficiency
• Causes may be:


Congenital
Rheumatic fever
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 65
Disorders of the Heart
• Valvular heart disease (continued)

Clinical manifestations/assessment
•
•
•
•
•
•
•
•
Fatigue
Angina
Oliguria
Pale, cool skin
Weight gain
Restlessness
Abnormal breath sounds
Edema
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 66
Disorders of the Heart
• Valvular heart disease (continued)

Medical management/nursing interventions
• Pharmacological management



Diuretics
Digoxin
Antidysrhythmics
• Restrict activities
• Sodium-restricted diet
• Surgery


Open mitral commissurotomy
Valve replacement
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 67
Disorders of the Heart
• Rheumatic heart disease

Etiology/pathophysiology
• Rheumatic fever


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
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 68
Disorders of the Heart
• Rheumatic heart disease (continued)

Clinical manifestations/assessment
•
•
•
•
•
•
•
•
Elevated temperature
Elevated heart rate
Epistaxis
Anemia
Joint pain and stiffness
Nodules on the joints
Specific to valve affected
Heart murmur
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 69
Disorders of the Heart
• Rheumatic heart disease (continued)

Medical management/nursing interventions
• Pharmacological management

NSAIDs
• Prevention

Treat infections rapidly and completely
• Bed rest
• Application of heat
• Dietary recommendations


Well-balanced diet
Supplement with vitamins B and C
• Encourage fluids
• Commissurotomy or valve replacement
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 70
Disorders of the Heart
• Pericarditis

Etiology/pathophysiology
• Inflammation of the membranous sac surrounding the
heart
• May be acute or chronic
• Bacterial, viral, or fungal
• Noninfectious conditions

Azotemia, MI, neoplasms, scleroderma, trauma, systemic
lupus erythematosus (SLE), radiation, drugs
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 71
Disorders of the Heart
• Pericarditis (continued)

Clinical manifestations/assessment
•
•
•
•
•
•
•
•
Debilitating pain
Dyspnea
Fever
Chills
Diaphoresis
Leukocytosis
Pericardial friction rub
Pericardial effusion
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 72
Disorders of the Heart
• Pericarditis (continued)

Medical management/nursing interventions
• Pharmacological management





Analgesics
Salicylates
Antibiotics
Anti-inflammatory agents
Corticosteroids
• Oxygen
• IV fluids
• Surgery: pericardial window, pericardial tap
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 73
Disorders of the Heart
• Endocarditis

Etiology/pathophysiology
• Infection or inflammation of the inner membranous
lining of the heart

Clinical manifestations/assessment
•
•
•
•
•
•
Influenza-like symptoms
Petechiae on the conjunctiva, mouth, and legs
Anemia
Splinter hemorrhages under nails
Weight loss
Heart murmur
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 74
Disorders of the Heart
• Endocarditis (continued)

Medical management/nursing interventions
• Bed rest
• Antibiotics

IV for 1 to 2 months
• Prophylactic antibiotics for “high-risk” patients
• Surgical repair of diseased valves or valve replacement
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 75
Disorders of the Heart
• Myocarditis

Etiology/pathophysiology
•
•
•
•
•
Inflammation of the myocardium
Rheumatic heart disease
Viral, bacterial, or fungal infection
Endocarditis
Pericarditis
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 76
Disorders of the Heart
• Myocarditis (continued)

Medical management/nursing interventions
•
•
•
•

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
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 77
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
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 78
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
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 79
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
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 80
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 81
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 82
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
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 83
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
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 84
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
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 85
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
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 86
Mrs. M’s Guide to HTN Treatment
•
•
•
•
•
•
Ax2= ACE’s and ARB’s
B = Beta blockers
C = Calcium channel blockers
D = Diuretics
E = Exercise
F = F’s diet – fish, fluid, fiber and fruit
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 87
High Blood Pressure






Prehypertension: focus on lifestyle
modifications
Stage I: Lifestyle Changes
Stage 1 hypertension: diet therapy and drugs
as needed
Stage II: Drug Therapy
Stage 2 hypertension: diet therapy and
vigorous drug therapy
Drug Interactions
Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.
88
Essential Hypertension

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”
Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
89
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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90
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
Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.
91
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
Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.
92
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
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 93
Disorders of the Peripheral
Vascular System
• Arteriosclerosis obliterans (continued)

Medical management/nursing interventions
• Anticoagulants
• Fibrinolytics
• Surgery





Embolectomy
Endarterectomy
Arterial bypass
Percutaneous transluminal angioplasty
Amputation
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 94
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
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 95
Disorders of the Peripheral
Vascular System
• Arterial embolism (continued)

Medical management/nursing interventions
• Pharmacological management


Anticoagulants
Fibrinolytics
• Endarterectomy
• Embolectomy
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 96
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
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 97
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 98
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
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 99
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
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide
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
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide
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
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide
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
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide
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
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide
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.
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide
Disorders of the Peripheral
Vascular System
• Thrombophlebitis (continued)

Medical management/nursing interventions
• Superficial




Pharmacological management
o NSAIDs
Bed rest
Moist heat
Elevate extremity
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide
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 to unaffected leg
Surgery: thrombectomy; vena cava umbrella (Greenfield
filter)
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide
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
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide
Disorders of the Peripheral
Vascular System
• Varicose veins (continued)

Medical management/nursing interventions
•
•
•
•
•
Elastic stockings
Rest
Elevate legs
Sclerotherapy
Surgery

Vein ligation and stripping
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide
Site of Action of Peripheral
Vasodilators
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110
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
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide
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
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide
Figure 8-17
(From Canobbio, M. [1990]. Cardiovascular disorders, Mosby’s clinical nursing series. St. Louis: Mosby.)
Scale for pitting edema depth.
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide
Nursing Process
• Nursing diagnoses

Activity intolerance
 Anxiety
 Decreased cardiac output
 Ineffective coronary tissue perfusion
 Fluid volume excess
 Impaired gas exchange
 Knowledge, deficient
 Pain
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide
Types of Lipoproteins

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
Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
115
Cholesterol and Lipoprotein
Profile (p. 383)
Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
116
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
Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
117
Principles of Medical Nutrition
Therapy




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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118
Education and Prevention

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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119