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Transcript of Chapter 47 Care of the Patient with a Cardiovascular or a Peripheral Vascular Disorder All items and...
Chapter 47
Care of the Patient with a Cardiovascular or a Peripheral
Vascular Disorder
All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
The Heart
About the size of a fist Located within the mediastinum Pumps approximately 1000 gallons of blood
every day Divided into four chambers
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Chambers of the Heart
deoxygenated Right atrium
Receives deoxygenated blood from the body
Pumps blood to the right ventricle
Right ventricle Pumps blood into the
pulmonary artery
oxygenated Left atrium
Receives oxygenated blood from the pulmonary vein
Pumps blood to the left ventricle
Left ventricle Pumps oxygenated blood
to the body through the aorta
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Valves of the Heart
The tricuspid valve is located between the right atrium and right ventricle
The pulmonary semilunar valve is located between the right ventricle and the pulmonary artery
The bicuspid valve is located between the left atrium and left ventricle
The aortic semilunar valve is located between the left ventricle and the aorta
The opening and closing of the AV valves creates the characteristic “lubb,” first heart sound
The opening and closing of the semilunar valves creates the characteristic “dubb,” or second heart sound
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The Conduction System of the Heart
Sinoatrial (SA) node—the pacemaker of the heart
Atrioventricular (AV) node slows the impulse to allow the atria to fill the ventricles
The AV node also serves as a secondary pacemaker
The bundle of His Purkinje fibers
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Coronary Blood Flow
Blood enters coronary blood flow through the right and left coronary arteries
Flows through coronary circulation
Returns to systemic circulation via coronary veins
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Diagnostic Tests (PTEC 150 Obj.#1)
A number of diagnostic tests are used to evaluate coronary function Diagnostic imaging Cardiac catheterization and angiography Electrocardiography Cardiac monitors Thallium scanning Echocardiography Positron emission tomography MUGA scan Laboratory tests
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Diagnostic Imaging
Radiography Angiogram Aortogram
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Cardiac Catheterization and Angiography
An invasive procedure used to visualize the heart’s chambers, valves, great vessels, and coronary arteries
Used to measure Pressure within the heart Blood-volume relationship to cardiac competence
Valvular defects, arterial occlusion, and congenital anomalies are determined
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Electrocardiography
ECG or EKG A graphic study of the electrical activities of
the myocardium to determine transmission of cardiac impulses through the muscles and conduction tissue
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Cardiac Monitors
Telemetry Exercise stress ECG, or stress test Thallium scanning Echocardiography PET scan MUGA scan
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Laboratory Tests
CBC PT/INR Erythrocyte sedimentation rate Serum electrolytes Serum lipids Arterial blood gases Serum cardiac markers B-type natriuretic peptide (BNP) Homocysteine C-reactive protein
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Risk Factors for Cardiovascular Disease
PTEC 150 Obj.#4
Non-modifiable Risk FactorsFamilyGenderAgeEthnicity
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Risk Factors for Cardiovascular Disease cont’d
Modifiable Risk FactorsSmokingHyperlipidemiaHypertensionDiabetes mellitusObesitySedentary lifestyleStressPsychosocial
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PTEC 150 Obj. #3
Describe at least 5 common DO of the heat and related nursing care
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Cardiac Dysrhythmias
A dysrhythmia (or arrhythmia) refers to any cardiac rhythm that deviates from normal sinus rhythm
Normal sinus rhythm Rate: 60-100 bpm P waves: precede each QRS complex (atrial depolarization) P-R interval: interval between atrial and ventricular
repolarization QRS complex: ventricular depolarization T wave: ventricular repolarization Rhythm: regular
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Cardiac Dysrhythmias cont’d
Sinus tachycardia Sinus bradycardia Supraventricular tachycardia Atrial fibrillation Atrioventricular block Premature ventricular contractions Ventricular tachycardia Ventricular fibrillation
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Angina PectorisTable 8-3 p. 334
Refers to thoracic pain or choking caused by decreased oxygen of the myocardium
Atherosclerosis of the coronary arteries is the most common cause
Pain is the characteristic symptom of angina pectoris
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Angina Pectoris cont’d
AssessmentSubjective data
Patient reports of pain Feeling of impending doom
Objective data Signs of pain Increased pulse Increased blood pressure Increased respiratory rate Anxiety Diaphoresis
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Angina Pectoris cont’d
Diagnostic TestsECG may reveal ischemia and rhythm changesExercise stress test may show ischemic changesCoronary angiography may show changes
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Angina Pectoris cont’d
Medical Management and Surgical InterventionsAntiplateletsVasodilatorsBeta blockersCalcium channel blockersNitratesCoronary artery bypass graftPercutaneous transluminal angiography
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Angina Pectoris cont’dPTEC 150 Obj.# 2
Nursing InterventionsPromote comfortPromote tissue perfusionPromote restReduce anxietyPromote feelings of well-beingProvide patient education**** Reduce the workload of the heart****
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Myocardial InfarctionTable 8-3 p 334
An occlusion of a major coronary artery or one of its branches with subsequent necrosis of myocardium caused by atherosclerosis or an embolus
An asymptomatic MI may occur Pain is the leading symptom of MI Pain not relieved by nitroglycerin or rest
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Myocardial Infarction cont’d
AssessmentPain (OPQRST)TachycardiaWeak pulseHypotensionDiaphoresisVomiting Pale skinLabored respirationsCardiac dysrhythmias
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Referred pain - MI
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MI - Women
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Myocardial Infarction cont’d
Diagnostic TestsTroponin TTroponin IECG12-lead ECGEchocardiogramPET scanMUGA scan
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Myocardial Infarction cont’d
Medical ManagementFocuses on preventing further tissue injuryMONA: Morphine, oxygen, nitroglycerine, aspirinBeta blockersCalcium channel blockersFibrinolyticsPTCACABG“Time is muscle”
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Myocardial Infarction cont’d
Nursing interventionsAdminister medicationsAvoid excess fatigueAssist with ADLsEncourage and provide education about cardiac dietPrevent complicationsEncourage patient to discuss feelings
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Heart Failure
When the heart has become unable to meet the metabolic demands of the body
Patient may have Left ventricular failure PE Right ventricular failure CHF
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Heart Failure cont’d
AssessmentDyspneaOrthopneaJugular venous distention (JVD)Fluid retentionAscitesPeripheral edemaWeight gain is the most sensitive indicator
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Heart Failure cont’d
Diagnostic TestsCBC – complete blood countBMP – basic metabolic panel – electrolytes,etcBNP - B type natriuretic peptide hormoneABGs - Arterial blood gassesECHO- sonogram of the heartECG – electrical conductionMUGA scan – cardiac function, ejection fractionBUN - Blood Urea Nitrogen – decreased glomerular filtration
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Heart Failure cont’d
Medical ManagementLoop diureticsThiazide diuretics
Diuretics work to reduce fluid build up – treat edema & pulmonary congestion
Nitrates: medications used for treating or preventing chest pain (angina) caused by heart disease, usually of the arteries in the heart. Nitrates are vasodilators (dilators of blood vessels that increase their diameter) that allow blood to flow more easily.
Digoxin – increase cardiac efficiency
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ACE inhibitors: Angiotensin-converting enzyme (ACE) inhibitors help relax blood vessels. ACE inhibitors prevent an enzyme in your body from producing angiotensin II, a substance in your body that affects your cardiovascular system by narrowing your blood vessels and releasing hormones that can raise your blood pressure. This narrowing can cause high blood pressure and force your heart to work harder.
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Beta blockers: also known as beta-adrenergic blocking agents, are medications that reduce your blood pressure. Beta blockers work by blocking the effects of the hormone epinephrine, also known as adrenaline. When you take beta blockers, the heart beats more slowly and with less force, thereby reducing blood pressure
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ARBs: Angiotensin II receptor blockers (ARBs) are medications that block the action of angiotensin II by preventing angiotensin II from binding to angiotensin II receptors on the muscles surrounding blood vessels. As a result, blood vessels enlarge (dilate) and blood pressure is reduced.
Diet Fluid restriction Oxygen
Heart Failure cont’d
Nursing InterventionsMonitor vital signsMonitor fluid statusAssess lung soundsMonitor urinary outputAssess edema – lower extremity - sacrumAssess for signs and symptoms of pulmonary edemaDaily weight 1Liter fluid = 1 kg or 2.2 lbs.So, a weight gain of 2.2 lbs. means the patient has a liter of excess fluid
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Valvular Heart Disease
Stenosis – definition? Insufficiency
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Valvular Heart Disease cont’d
AssessmentFatigueWeaknessPainNocturnal dyspneaOrthopneaCracklesEdema
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Valvular Heart Disease cont’d
Medical Management and Nursing InterventionsCommissurotomy is an open-heart surgery that repairs a mitral valve that is narrowed from mitral valve stenosis. During this surgery, a person is put on a heart-lung bypass machine. The surgeon removes calcium deposits and other scar tissue from the valve leaflets.Valve replacementAssist with ADLsAdminister prescribed medicationsAssess oxygenation status – O2 Sat
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Patient Teaching for Cardiac Disorders
Diet Medications Procedures Rest Smoking cessation Exercise
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Cardiac Rehabilitation
Cardiac rehabilitation has two major parts Exercise training to help the patient learn how to
exercise safely, strengthen muscles, and improve stamina
Education, counseling, and training to help the patient understand his or her heart condition and find ways to reduce the risk of future heart problems
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Pulmonary Edema
The accumulation of extravascular fluid in lung tissues and alveoli, most often caused by heart failure (HF)
An acute and extensive life-threatening complication of HF caused by severe left ventricular dysfunction
See blue box 8-5 & 8-6 & green table 8-7
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Pulmonary Edema cont’d
Clinical Manifestations and Medical ManagementSevere respiratory distressPink sputumFrothy sputumFor assessment see Box 47-5Diagnosed by radiograph of the chestMedical management involves simultaneous interventions to promote oxygenation, improve cardiac output, and reduce pulmonary congestion
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Pulmonary Edema cont’d
Nursing InterventionsPromote oxygenationPromote venous return to the heartPromote adequate respirationMonitor I&OMonitor electrolytes
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Rheumatic Heart Disease
Is a result of rheumatic fever Arises from group A or group B streptococcus
infection – strep throat! Characterized by fever, epistaxis, tachycardia, and
nodules on joints Assessment will reveal joint pain, chest pain, or other
manifestations associated with complications Valvular manifestations will mimic valvular disease It is diagnosed through signs and symptoms and lab
values
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Rheumatic fever
Sydenham chorea is a major sign of acute rheumatic fever. The person may currently or recently have had the disease.
may be the only sign of rheumatic fever in some patients.
occurs most often in girls before puberty, but may be seen in boys.
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Erythema marginatum – rheumatic fever
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Rheumatic Heart Disease cont’d
Medical ManagementPrevention is the best managementNSAIDsAntibioticsIf needed, valve repair or replacement
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Rheumatic Heart Disease cont’d
Nursing InterventionsPromote rest as indicated by patient’s conditionAdminister prophylactic antibiotics as prescribedProvide patient education regarding dental procedures
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Pericarditis
Inflammation of the pericardium caused by bacteria, fungus, or virus
Characterized by retrosternal chest pain that is worse when lying supine
Chest pain should be thoroughly assessed Patient should be assessed for general aches and fatigue Diagnosis made through careful assessment and lab values The nurse should evaluate the patient and monitor vital signs Supportive care should be provided
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Endocarditis
Inflammation of the endocardium IV drug abusers are the most frequently affected Patient complains of flulike symptoms and chest pain,
and may have splinter hemorrhages or petechiae Treatment involves rest and antibiotics Surgery may be required Nursing interventions are aimed at symptom control
and promoting rest and comfort
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Cardiomyopathy
Cardiomyopathy is a term used to describe a group of heart muscle diseases that primarily affect the structural or functional ability of the myocardium Dilated Hypertrophic Restrictive
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Cardiomyopathy cont’d
CausesInfectionMetabolic disordersSevere nutritional disordersAlcohol abusePeripartal disordersDrugsRadiation therapyLupusRheumatoid arthritisCocaine abuse
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Cardiomyopathy cont’d
Clinical ManifestationsThe patient may have symptoms of heart failure, edema, or hepatic dysfunctionMedical management includes ACE inhibitors, antidysrhythmics, or beta blockersHeart transplantation
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Effects of Aging on the Heart
Blood vessels become thicker and less compliant
Peripheral vascular resistance increases, causing a rise in blood pressure
Atherosclerotic changes in the blood vessels increase
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PTEC 150 obj #6
Describe at least 4 Dos of the blood vessels ad discuss related nursing care
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Arterial Disorders Assessment
Intermittent claudication Strength of pulses PATCHES mnemonic
Pulses Appearance Temperature Capillary refill Hardness Edema
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Arterial DOs
Atherosclerosis Arteriosclerosis Sometimes used interchangeably
Thickened narrowed arteries Plaques, Hardened calcified vessel walls
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PAD: peripheral arterial dz
5 P’s Pain Pulselessness Pallor Paresthesia Paralysis Pp. 362-363 clinical manifestations
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Venous Disorders Assessment
Chronic edema Stasis ulcers Peripheral pulses are present
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Hypertension
Essential Secondary Malignant
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Hypertension cont’d
Essential hypertension (HTN)—there is no underlying cause
Accounts for 90-95% of HTN cases Secondary HTN occurs as the result of a
comorbidity Malignant HTN is a severe, rapidly
progressive elevation in blood pressure that causes damage to the small arterioles in major organs
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Hypertension cont’d
Medical management Medications Lifestyle modification Diet Smoking cessation Stress management Treat underlying causes of secondary HTN
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Arterial Aneurysm
An aneurysm is an enlarged, dilated portion of an artery that exceeds 3 cm
Aneurysms may be the result of arteriosclerosis, trauma, or a congenital defect
Aortic aneurysms are most common in men in their 60s and 70s
Other risk factors are smoking, hypertension, atherosclerosis, family history of aortic aneurysm, infarction, and trauma
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Arterial Aneurysm cont’d
Clinical Manifestations and Diagnostic ExamsPalpating mass in the abdomenChest painShortness of breathDysphagiaPain in lower back or anusDiagnosed with CT scan, X-ray, Aortograph, MRI
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Arterial Aneurysm cont’d
Medical Management and Nursing InterventionsControl hypertensionGraftRemoval of aneurysmThe nurse should monitor patient status and report changes quicklyTreat anxietyTreat painReport sudden changes to the provider rapidly
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Buerger’s Disease
Thromboangiitis obliterans (Buerger’s disease) is an occlusive vascular condition in which the small- and medium-sized arteries become inflamed and thrombotic
Most often affects men ages 25-40 who smoke Characterized by pain and sometimes ulceration There are no specific tests for this condition Treatment focuses mainly on modifying risk factors
and stopping smoking Nursing interventions focus on managing risk factors
and promoting circulation
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Buerger’s disease
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Raynaud’s Disease
Caused by intermittent arterial spasms Raynaud’s is either primary or secondary
Primary—the cause is not known and the condition is usually mild
Secondary—when symptoms occur as a result of other conditions
The patient typically complains of cold hands and feet and may have discoloration
Medical management is aimed at prevention Nursing interventions focus on promoting comfort and
preventing the disease
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Thrombophlebitis
Inflammation of the vein with formation of a thrombus Pain and edema occur when the vein is occluded Active dorsiflexion of the foot may result in calf pain Diagnosed via ultrasound Treatment is anticoagulant therapy Nursing interventions are aimed at controlling pain
and administering prescribed medications
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Varicose Veins
Tortuous, dilated veins with incompetent valves Poor posture, prolonged standing, and constrictive clothing are
risk factors Often the only symptom is the appearance of darkened veins on
the patient’s legs Patient should be assessed for predisposing factors and
varicosities Controlled with elastic stockings, rest periods, and leg elevation Sclerotherapy Nursing interventions focus on care of the patient after a
surgical procedure
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Stasis Ulcer
Ulcers occur from chronic deep vein insufficiency and stasis of blood in the venous system of the leg
Patient may report varying levels of pain Obvious stasis ulcer on the leg Pedal pulses are present Diagnosis made via venography and ultrasound Management focuses on promoting wound healing
and preventing infection Nursing interventions are aimed at promoting wound
healing and providing patient education
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4 stages of a CVA:cardiovascular accident
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Stages of CVA
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