Cardiovascular COMMON LAB TESTS FOR CARDIOVASCULAR DISORDERS 1. Serum Chemistry 2. Serum Electrolytes 3. Alanine aminotransferase (AST) 5-40 IU/L 4. Creatine kinase CK Male 55-170U/L Female 30-135 U/L 5. CK - MB (isoenzyme) 0-7 U/L 6. Lactic dehydrogenase (LDH) LDH1 22%-36% LDH2 35%-46% LDH313%-26% LDH4 3%-10% LDH5 2%-9% 7. CBC 8. Lipid levels 9. Prothrombin time 10. Alkaline phosphatase 11. ESR 12. Arterial Blood Gases 13. Troponin COMPLETE BLOOD COUNT 1. Red blood cell count a. Men 4.7-6.1 million/mm3 b. Women 4.2-5.4 million/mm3 c. Infants and children 3.8-5.5 million/mm3 d. Newborns 4.8-7.1 million/mm3 2. White blood cell count a. Adults and children greater than two years of age 5,000-10,000/cm3 b. Children less than two years 6,200-17,000/mm3 c. Newborns 9000-30,000/mm3 3. Hematocrit a. Men 42-52% b. Women 37-47% (pregnancy>33%) c. Children 31-43% d. Infants 30-40% e. Newborns 44-64% 4. Hemoglobin a. Men 13.5-18.0 g/dl b. Women 12-16 g/dl (pregnancy >11 g/dl) c. Children 11-16 g/dl d. Infants 10-15 g/dl e. Newborns 14-24 g/dl 5. Erythrocyte indices a. Mean corpuscular volume (MCV) 86-98 (m3/cell) b. Mean corpuscular hemoglobin (MCH) 27-32 pg/RBC c. Mean corpuscular hemoglobin concentrate. (MCHC) 32-36% 6. Differential white cell count a. Neutrophils 55-70% b. Lymphocytes 20-40% c. Monocytes 2-8% d. Eosinophils 1-4% e. Basophils 0.5-1.0% 7. Examination of peripheral blood cells: examination of size and shape of individual RBCs and platelets Electrocardiogram (ECG or EKG): 1. records electromechanical activity of myocardium, electrical axis of the heart 2. the ECG records two basic events: depolarization and repolarization 3. the ECG records electrical activity as specific waves a. P-wave: sinus node generates impulse; atria depolarize b. PR interval: time for impulse to travel from sinus node through atria to atrioventricular node, the Bundle of His, the bundle branches and the ventricles; range: 0.12-0.20 seconds c. QRS complex: ventricle depolarizes and contracts (systole) d. T wave: ventricle repolarizes, ready for next systole e. ST segment: time between ventricular depolarization and repolarization 4. used to determine presence of ischemic cardiac disease and cardiac conduction disturbances Exercise stress test 1. records myocardial response to exercise 2. used to determine ischemic heart disease and cardiovascular fitness before exercise programs 3. exercise level is progressively raised while ECG is monitored 4. blood pressure and blood gases may be measured 5. nursing interventions a. encourage client to immediately report any symptoms during and after test b. client should dress for exercise and bring a change of clothing Ambulatory electrocardiography (Holter monitor) 1. records myocardial activity continuously for 24 or 48 hours 2. portable device 3. used to detect cardiac rhythm disturbances over time 4. correlated with client's activity 5. specific nursing intervention: client must keep a diary that records both activity and any symptoms during test Electrophysiology studies 1. an invasive measure of cardiac electrical activity 2. electrical catheter is inserted into right atrium via a peripheral vein 3. an ECG records each electrical stimulation of heart and how the heart responds 4. used to determine cardiac dysrhythmias Hemodynamic monitoring: invasive cardiac catheter a. reflects left ventricular end diastolic pressure b. use of a balloon-tipped, flow-directed catheter to provide continuous monitoring c. catheter introduced via subclavian vein or by cutdown and passed through right side of heart to pulmonary artery d. may be inserted at the bedside or under fluoroscopy e. normal parameters f. complications of hemodynamic monitoring i. pneumothorax ii. dysrhythmias iii. infection, sepsis, thrombophlebitis g. nursing interventions: monitor values, assess and change dressings, maintain patency with fluids, calibrate equipment, remove lines, obtain specimens, strict asepsis, standard precautions Intra-arterial pressure a. catheter in a major artery and attached to transducer b. most common site: radial artery c. usually inserted at bedside d. also used to obtain arterial blood gas samples and other diagnostic studies e. normal parameters i. peak systolic: 100 mm Hg ii. end diastolic: 60-80 mm Hg iii. mean 70-90 mm Hg f. complications: clot formation, decreased or absent pulse, hematoma, infection, hemorrhage Cardiac output (CO) a. volume of blood heart beats per minute b. thermodilution technique using blood temperature changes c. known volume of solution is injected at a specific rate into the right atrium d. temperature-sensitive probe measures temperature of blood as it passes through catheter e. contraindications: bleeding disorders, immunosuppression f. cardiac output (CO) (heart rate x stroke volume) 4-8L/min g. nursing care of client with cardiac catheter i. explain procedure to client ii. obtain baseline vital signs and rhythm strip iii. place client in supine position iv. calibrate pressure monitor v. obtain chest x-ray to guide catheter placement vi. obtain arterial blood gases as ordered vii. change dressings and tubing as ordered viii. maintain patency of catheter ix. monitor and record vital signs and pressures as ordered x. observe for complications Intraaortic balloon pump (IABP) a. device that helps blood circulate after myocardial failure 1. sausage-shaped balloon is threaded via femoral artery into aorta 2. balloon inflates with diastole and deflates with systole b. used to treat cardiogenic shock c. contraindications: 1. aortic regurgitation 2. dissection 3. abdominal aortic aneurysm d. complications 1. insertion site: 1. infection 2. bleeding 3. hematoma 4. diminished or absent pulse 5. thrombus 2. generalized 1. aortic dissection or perforation 2. thrombocytopenia 3. dysrhythmias 4. myocardial failure e. nursing interventions 1. explain procedure to client 2. obtain informed consent 3. take baseline vital signs, hemodynamic parameters and ECG 4. monitor vital signs, hemodynamic status and ECG as ordered 5. monitor client's level of consciousness (LOC) 6. obtain arterial blood gases as ordered 7. asepsis 8. provide emotional support to client and family 9. monitor intake and output 10. client must not bend leg in which balloon was inserted 11. monitor for complications Pacemakers a. a battery-powered pulse generator that stimulates the heart via electrodes that touch myocardium b. use: 1. hemodynamic and life support 2. to correct dysrhythmias c. types 1. atrial pacing 2. ventricular pacing 3. atrioventricular sequential and physiologic pacing d. three kinds of pacemakers 1. asynchronous (fixed rate): pace at a preset rate, regardless of person’s rhythm 2. demand (standby): pace only if intrinsic rate declines below rate set on pacemaker 3. synchronous: sensing circuit detects atrial and ventricular activity e. indications for pacing 1. symptomatic bradyarrhythmia 2. symptomatic tachyarrhythmia 3. asystole 4. prophylaxis in persons with high risk bradycardia 5. diagnosis of dysrhythmias during electrophysiologic testing f. types of pulse generators i. temporary pacemakers transvenous approach is most common: Catheter electrode inserted via peripheral vein and connected to external pulse generator transthoracic: used primarily during cardiac surgery; catheter electrode is placed directly into heart ii. permanent pacemakers: transvenous catheter electrode is passed through right heart and connected to small generator generator is implanted subcutaneously on chest wall, usually in upper right quadrant lithium-powered battery can last up to ten years g. complications of pacemakers i. infection ii. perforation of myocardium iii. pneumothorax iv. hemothorax v. dysrhythmias vi. thrombosis vii. failure viii. syncope ix. hypotension x. pallor xi. hiccups xii. shortness of breath h. nursing interventions i. explain procedure to client ii. initiate preoperative care iii. post-procedure initiate post-anesthesia care monitor vital signs and ECG as ordered maintain bed rest as ordered observe for signs of complications iv. teach client pacemaker's set rate how to take pulse (rate and rhythm) findings of pacemaker failure, wound infection activity limitations hazards: high output electrical generators: welding equipment, radar, microwaves, MRI importance of carrying medical alert jewelry and information need for periodic battery replacement avoidance of contact sports and those that involve swinging arms (golf, hunting) importance of medical follow-up Automatic implantable cardioverter-defibrillator (AICD) a. pulse generator implanted in subcutaneous pocket. When it detects ventricular tachycardia or ventricular fibrillation, it delivers electrical shock to heart b. used to treat life-threatening ventricular dysrhythmias c. complications i. ii. infection iii. malfunction iv. battery failure d. nursing interventions i. explain procedure to client ii. care of the surgical client iii. administer medications as ordered iv. monitor ECG as ordered v. provide emotional support and reassurance vi. teach client findings of defibrillation discharge importance of routine follow-up findings of complications limit activity as ordered avoid strong magnetic fields wear MedicAlert jewelry and information assure client that no household appliance will affect AICD shock may be painful I. Anatomy and Physiology A. Anatomy 1. Layers a. pericardium: fibrous b. epicardium: covers surface of heart c. myocardium: muscular portion of the heart d. endocardium: lines cardiac chambers and covers surface of heart valves 2. Chambers of heart a. right atrium: collecting chamber for incoming systemic venous system b. right ventricle: propels blood into pulmonary system c. left atrium: collects blood from pulmonary venous system d. left ventricle: thick-walled, high-pressure pump that propels blood into system 3. Heart valves: membranous openings that allow one way blood flow a. atrioventricular valves: prevent backflow from ventricles to atria during systole b. tricuspid - right heart valve c. mitral - left heart valve d. semilunar valves prevent backflow from aorta and pulmonary arteries into ventricles during diastole i. pulmonic ii. aortic Think: Mighty (or Big) left side of the heart - Mitral (or Bicuspid) valve. In Contrast: Tiny right side of the heart - Tricuspid valve. 4. Blood supply to heart a. arteries i. right coronary artery supplies right ventricle and part of left ventricle ii. left coronary artery supplies mostly left ventricle b. veins i. coronary sinus veins ii. thebesian veins 5. Conduction system a. SA (sinoatrial) node b. junctional tissue c. bundle branch Purkinje system B. Physiology 1. Function of the heart is the transport of oxygen, carbon dioxide, nutrients and waste products 2. Cardiac cycle consists of: a. systole - the phase of contraction during which the ventricles eject blood b. diastole - the phase of relaxation during which the chambers fill with blood. When heart pumps, myocardial layer contracts and relaxes. 3. Blood flow: a. deoxygenated blood enters the right atrium through the superior and inferior vena cava b. enters the right ventricle via the tricuspid valve c. travels through the pulmonic valve to pulmonary arteries and lungs d. oxygenated blood returns from lungs through the pulmonary veins into left atrium and enters the left ventricle via bicuspid (mitral) valve. e. from the left ventricle, through the aortic valve through the aorta to the systemic circulation 4. The heart itself is supplied with blood by the left and right coronary arteries 5. The vascular system is a continuous network of blood vessels. a. the arterial system consists of arteries, arterioles and capillaries and delivers oxygenated blood to tissues b. oxygen, nutrients and metabolic waste are exchanged at the microscopic level c. the venous system, veins and venules, returns the blood to the heart Blood Flow to the Heart II. Heart Infections A. Pericarditis 1. Definition and related terms a. in pericarditis, an infection or collagen disease (from a bacterium, a fungus, Systemic Lupus Erythematosus (SLE), etc.) inflames the pericardium. b. there may or may not be pericardial effusion or constrictive pericarditis. c. Dressler's syndrome, also called postmyocardial infarction syndrome, is a combination of pericarditis, pericardial effusion and constrictive pericarditis. It occurs several weeks to months after a myocardial infarction. Etiology unclear. 2. Epidemiology a. may be acute or chronic and may occur at any age. b. pericarditis occurs in up to 15% of persons with a transmural infarction. 3. Findings a. sharp chest pain often relieved by leaning forward b. pericardial friction rub c. dyspnea d. fever, sweating, chills e. dysrhythmias f. pulsus paradoxus g. client cannot lie flat without pain or dyspnea ASSESSING CLIENTS WITH CARDIOVASCULAR DISORDERS 4. Management a. antibiotics to treat underlying infection b. corticosteroids: usually reserved for clients with pericarditis due to SLE, or clients who do not respond to NSAID c. NSAIDS/Asprin for pain and inflammation d. oxygen: to prevent tissue hypoxia e. surgical i. emergency pericardiocentesis if cardiac tamponade develops ii. for recurrent constrictive pericarditis, partial pericardiectomy (pericardial window) or total pericardiectomy 5. Nursing interventions a. manage pain and anxiety b. the cardio-care six (refer to box below) c. maintain a pericardiocentesis set at the bedside in case of cardiac tamponade. d. assess respiratory, cardiovascular, and renal status often. e. observe for findings of infiltration or inflammation at the venipuncture site, a possible complication of long-term IV administration. Rotate the IV sites often. f. client and family teaching - teach the cardio five (refer to box below) 6. Diagnostic studies a. EKG changes, arrythmias b. echocardiography to determine pericardial efusion or cardiac tamponade c. history and physical exam THE CARDIO-CARE SIX: A,B,C,D,E,F 1. ADL: Help the client with activities of daily living. 2. Bed rest 3. Commode at bedside (it stresses the heart less than using a bedpan does). 4. Diversions: offer diversions that don't stress the heart. 5. Elevate head of bed, or sit client up. 6. Feelings: Let clients express concern; reassure when activity will resume. TEACH THE CARDIO FIVE: TDDDS 1. Tests and treatments: explain them in simple, culturally sensitive ways. 2. Drugs, their side effects, and how long client will take them. 3. Diet: good nutrition and restrictions (such as low sodium). 4. Disease, its treatment, and what signs to report promptly: the 'watch-fors'. 5. Smoker? Teach and encourage 'stop smoking'. B. Myocarditis 1. Definition - an inflammatory condition of the myocardium caused by a. viral infection b. bacterial infection c. fungal infection d. serum sickness e. rheumatic fever f. chemical agent g. as a complication of a collagen disease, i.e. SLE 2. Epidemiology a. may be acute or chronic and may occur at any age b. usually an acute virus and self-limited, but it may lead to acute heart failure 3. Findings a. depends on the type of infection, degree of myocardial damage, capacity of myocardium to recover, and host resistance b. may be minor or unnoticed: fatigue and dyspnea, palpitations, occasional precordial discomfort manifested as a mild chest soreness and persistent fever c. recent upper-respiratory infection with fever, viral pharyngitis, or tonsillitis d. cardiac enlargement e. abnormal heart sounds: murmur, S3 or S4 or friction rub f. possibly findings of congestive heart failure such as pulsus alternans, dyspnea, and crackles g. tachycardia disproportionate to the degree of fever CLASSIFYING HEART MURMURS BY INTENSITY 4. Diagnostic studies a. EKG for changes and arrythmias b. labs i. increases ESR ii. increases myocardial enzymes such as: AST CK LDH c. endomyocardial biopsy (EMB) d. myocardial imaging 5. Management a. antibiotics to treat underlying infection b. corticosteroids to decrease inflammation c. analgesics for pain d. oxygen to prevent tissue hypoxia 6. Nursing interventions a. the cardio-care six with modified bedrest and less help with ADLs b. assess for edema weigh daily; record intake and output PITTING EDEMA GRADING SCALE c. assess cardiovascular status frequently d. observe for findings of left-sided heart failure (dyspnea, hypotension and tachycardia) e. check often for changes in cardiac rhythm or conduction; auscultate heart sounds f. evaluate arterial blood gas levels as needed to ensure adequate oxygenation g. client and family teaching i. physical activity may be slowly increased to sitting PULSE GRADING SCALE in chair, walking in room, then outdoors. (4-Point Scale) ii. avoid pregnancy, alcohol, and competitive sports. iii. immunize against infections. a. No pulse =0 iv. teach client about anti-infective drugs. Stress importance of taking drugs as ordered. b. Weak pulse = 1+ v. teach clients taking digitalis at home to: check pulse for one full minute before taking c. Difficult to palpate = 2+ the dose, and withhold the drug if heart rate falls below 60 beats/minute. d. Normal = 3+ observe for findings of digitalis toxicity (anorexia, nausea, vomiting, blurred vision, e. Bounding = 4+ cardiac arrhythmias) and for factors that may increase toxicity, such as electrolyte imbalance and hypoxia. vi. teach client to report rapidly beating heart. PULSE SITES (LANDMARKS FOR PULSE) 1. Temporal: found over temporal bone lateral to eye 2. Apical: found between fourth and fifth intercostal space usually mid-clavicular line 3. Carotid: found over the carotid artery in neck 4. Brachial: found in the antecubital area of arm 5. Radial: found on thumb side of wrist 6. Ulnar: found medial wrist 7. Femoral: found below the inguinal ligament 8. Popliteal: found behind the knee 9. Posterior tibial: found on inner side of each ankle 10. Dorsalis pedis: found along top of foot C. Endocarditis 1. Definition and related terms a. an infection of the endocardium, heart valves, or cardiac prosthesis resulting from bacterial or fungal invasion. b. endocarditis can be classified as i. native valve endocarditis ii. endocarditis in I.V. drug users iii. prosthetic valve endocarditis 2. Epidemiology a. with proper treatment about 70% of clients recover b. the prognosis is worse when endocarditis damages valves severely or involves a prosthetic valve c. infective endocarditis occurs in 50 to 60% of clients with previous valvular disorders d. systemic lupus erythematosus (SLE) often leads to nonbacterial endocarditis e. in 12% to 35% of clients with subacute endocarditis, lesions produce clots that show the findings of splenic, renal, cerebral or pulmonary infarction, or peripheral vascular occlusion 3. Findings of endocarditis a. cardiac murmurs in 85 to 90% of clients b. fever c. especially, a murmur that changes suddenly, or a new murmur that develops in the presence of a fever d. pericardial friction rub e. anorexia f. malaise g. clubbing of fingers h. neurologic sequelae of embolus i. petechiae of the skin (especially on the chest) j. splinter hemorrhage under the nails k. infarction of spleen: pain in the upper left quadrant, radiating to the left shoulder, and abdominal rigidity l. infarction in kidney: hematuria, pyuria, flank pain, and decreased urine output m. infarction in brain: hemiparesis, aphasia, and other neurologic deficits n. infarction in lung: cough, pleuritic pain, pleural friction rub, dyspnea and hemoptysis o. peripheral vascular occlusion: numbness and tingling in an arm, leg, finger, or toe, or signs of impending peripheral gangrene SIGNS OF VENOUS INSUFFICIENCY IN THE EXTREMITIES 1. Skin color reddish brown or cyanotic if extremity lowered 2. Normal temperature 3. Normal pulse 4. Often marked edema, usually foot to calf 5. Brown pigmentation around ankles SIGNS OF ARTERIAL INSUFFICIENCY IN THE EXTREMITIES 1. Pale color on elevation, dusky red color when lowered 2. Cool to touch 3. Decreased or absent peripheral pulses 4. Little or no edema 5. Thin, shiny skin and decreased growth of hair 6. Thickened nails 7. Pain unrelieved by rest and/or activity 8. Chronic pain may be either steady or intermittent 9. Claudication pain as tight feeling, burning, fatigue, ache or cramping 4. Management - clients at risk for prosthetic valves a. prophylaxis - to prevent endocarditis; i.e. MVP, cardiac lesions b. antibiotics - to treat underlying infection c. antipyretics - to control fever d. anticoagulants - to prevent embolization e. oxygen - to prevent tissue hypoxia f. surgical - possible valve replacement 5. Nursing interventions a. the cardio-care six b. observe for findings of infiltration or inflammation at venipuncture site; rotate sites often. c. client and family teaching i. explain all procedures in a simple and culturally sensitive manner. ii. involve the client and family in scheduling the daily routine activities. Allow client and family to participate in care. iii. teach client relaxation techniques (meditation, visualization, or guided imagery) to cope with stress, pain, or insomnia. iv. explain endocarditis and the need for long-term therapy. v. explain the need for prophylactic antibiotics before dental work and other invasive procedures. vi. teach client to report fever, tachycardia, dyspnea and shortness of breath. 6. Diagnostic studies a. health history b. lab data i. CBC ii. blood cultures iii. ESR c. CXR - to detect CHF d. EKG - transesophageal echocardiogram to detect vegetation and abscess on valves D. Rheumatic heart disease (rheumatic endocarditis) 1. Definition and related terms a. rheumatic heart disease is damage to the heart by one or more episodes of rheumatic fever. Pathogen is a group A streptococci. b. rheumatic endocarditis is damage to the heart, particularly the valves, resulting in valve leakage (regurgitation) and/or stenosis. To compensate, the heart's chambers enlarge and walls thicken. 2. Epidemiology a. worldwide, 15 to 20 million new cases of rheumatic fever are reported each year. b. rheumatic fever follows a group A streptococcal infection. We could prevent it by finding and treating streptococcal pharyngitis. c. where malnutrition and crowded living are common, rheumatic fever is commonest in children between ages 5 and 15. d. rheumatic fever strikes most often during cool, damp weather. In the U.S., it is most common in the northern states. e. it is unknown how and why group A streptococcal infections cause the lesions called Aschoff bodies. f. damage depends on site of infection: most often the mitral valve in females and the aortic valve in males. g. malfunction of these valves leads to severe pericarditis, and sometimes pericardial effusion and fatal heart failure. Of those who survive this complication, about 20% die within ten years. 3. Findings a. streptococcal pharyngitis I. sudden sore throat II. throat reddened with exudate III. swollen, tender lymph nodes at angle of jaw IV. headache and fever to 104 degrees Fahrenheit b. polyarthritis manifested by warm and swollen joints c. carditis d. chorea e. erythema marginatum (wavy, thin red-line rash on trunk and extremities) f. subcutaneous nodules g. fever to 104 degrees Fahrenheit h. heart murmurs pericardial friction rub and pericardial rub i. no lab test confirms rheumatic fever, but some support the diagnosis. 4. Management a. give antibiotics steadily to maintain level in blood. b. provide analgesics - for pain/inflammation c. oxygen to prevent tissue hypoxia. d. surgical - commissurotomy, valvuloplasty, prosthetic heart valve 5. Nursing interventions a. the cardio-care six b. help the client with chorea to grasp objects; prevent falls. c. encourage family and friends to spend time with client and fight boredom during the long, tedious convalescence. d. client and family teaching I. explain all tests and treatments II. nutrition III. hygienic practices IV. to resume ADLs slowly and schedule rest periods V. to report penicillin reaction: rash, fever, chills VI. to report findings of streptococcal infection i. sudden sore throat ii. diffuse throat redness and oropharyngeal exudate iii. swollen and tender cervical lymph glands iv. pain on swallowing v. temperature of 101 to 104 degree Fahrenheit vi. headache vii. nausea VII. keep client away from people with respiratory infections VIII. explain necessity of long-term antibiotics IX. arrange for a visiting nurse if necessary X. help the family and client cope with temporary chorea 6. Diagnostic studies a. antistreptolysin 0 titer - increased b. ESR - increased c. throat culture - positive for streptococci d. WBC count - increased e. RBC parameters - normocytic, normochromic anemia f. C-reactive protein - positive for streptococci III. Valve Disorders A. Mitral stenosis 1. Definition - mitral valve thickens and gets narrower, blocking blood flow from the left atrium to left ventricle. b. physiology i. function of the heart is the transport of oxygen, carbon dioxide, nutrients and waste products ii. cardiac cycle consists of: systole - the phase of contraction during which the chambers eject blood diastole - the phase of relaxation during which the chambers fill with blood. When heart pumps, myocardial layer contracts and relaxes. iii. blood flow: deoxygenated blood enters the right atrium through the superior and inferior vena cava enters the right ventricle via the tricuspid valve travels through the pulmonic valve to pulmonary arteries and lungs oxygenated blood returns from lungs through the pulmonary veins into left atrium and enters the left ventricle via bicuspid (mitral) valve. from the left ventricle, through the aortic valve through the aorta to the systemic circulation iv. the heart itself is supplied with blood by the left and right coronary arteries v. the vascular system is a continuous network of blood vessels. the arterial system consists of arteries, arterioles and capillaries and delivers oxygenated blood to tissues oxygen, nutrients and metabolic waste are exchanged at the cellular level the venous system, veins and venules, returns the blood to the heart 2. Epidemiology a. of clients with mitral stenosis, 2/3 are female b. most cases of mitral stenosis are caused by rheumatic fever 3. Findings a. mild - no findings b. moderate to severe i. dyspnea on exertion ii. paroxysmal nocturnal dyspnea iii. orthopnea iv. weakness, fatigue, and palpitations c. peripheral and facial cyanosis in severe cases d. jugular vein distention e. with severe pulmonary hypertension or tricuspid stenosis - ascites f. edema g. hepatomegaly h. diastolic thrill at the cardiac apex i. when client lies on left side, loud S1 or opening snap and a diastolic murmur at the apex j. crackles in lungs 4. Management a. antiarrhythmics if needed b. if medication fails, atrial fibrillation is treated with cardioversion. c. low-sodium diet - to prevent fluid retention d. oxygen if needed - to prevent hypoxia e. surgery - mitral commissurotomy or valvotomy 5. Nursing interventions a. the cardio-care six b. observe closely for findings of heart failure, pulmonary edema, and reactions to drug therapy. c. if client has had surgery, watch for hypotension, arrhythmias, and thrombus formation. d. monitor the cardio seven e. client and family (teach the cardio-five:TDDS) i. explain the need for long-term antibiotic therapy and the need for additional antibiotics before dental care. ii. report early findings of heart failure such as dyspnea or a hacking, nonproductive cough. 6. Diagnostic studies/findings a. history and physical exam b. EKG- for changes of left atrial enlargement and right ventricle enlargement c. echocardiogram - for restricted movement of the mitral valves and diastolic turbulance MONITOR THE CARDIO SEVEN: Charlie's Ex packed Ruth in Granny's VW. B. Mitral insufficiency (or regurgitation) 1. Definition and related terms a. a damaged mitral valve allows blood from the left ventricle to flow back into the left atrium during systole. b. to handle the backflow, the atrium enlarges. So does the left ventricle, in part to make up for its lower output of blood. 2. Epidemiology a. follows birth defects such as transposition of the great arteries. b. in older clients, the mitral annulus may have become calcified. c. cause unknown; may be linked to a degenerative process. d. occurs in 5 to 10% of adults. 3. Findings a. client may be asymptomatic b. orthopnea, dyspnea, fatigue, weakness, weight loss c. chest pain and palpitations d. jugular vein distention e. peripheral edema 4. Management a. low-sodium diet - to prevent fluid retention b. oxygen as needed - to prevent tissue hypoxia c. antibiotics - to treat infection d. prophylactic antibiotics - to prevent infection e. surgery - mitral valvuloplasty or valve replacement 5. Nursing interventions a. the cardio-care six b. monitor the cardio seven c. monitor for left-sided heart failure, pulmonary edema, adverse reactions to drug therapy, and cardiac dysrhythmias especially atrial and ventricular fibrillation d. if client has surgery, monitor postoperatively for hypotension, arrhythmias and thrombus formation e. client and family teaching 1. diet restrictions and drugs 2. explain tests and treatments 3. prepare client for long-term antibiotic and follow-up care. 4. stress the need for prophylactic antibiotics during dental care. 5. teach client and family to report findings of heart failure: dyspnea and hacking, nonproductive cough. 6. Diagnostic findings a. EKG for arrythmias and changes of left atrial enlargement b. echocardiogram - to visualize regurgitant jets and flail chordae/leaflets c. cardiac cath shows regurgitation of blood from left ventricle to left atrium C. Tricuspid stenosis 1. Definition: narrowing of the tricuspid valve between right atrium and right ventricle 2. Epidemiology a. relatively uncommon b. usually associated with lesions of other valves c. caused by rheumatic fever 3. Findings a. dyspnea, fatigue, weakness, syncope b. peripheral edema c. jaundice with severe peripheral edema and ascites can mean that tricuspid stenosis has led to right ventricular failure d. may appear malnourished e. distended jugular vein 4. Management: surgery - valvulotomy or valve replacement; valvuloplasty 5. Nursing interventions a. the cardio-care six b. monitor the cardio seven c. monitor for findings of heart failure, pulmonary edema, and adverse reactions to the drug therapy d. post valve surgery, monitor client for hypotension, arrhythmias and thrombus formation e. when client sits, elevate legs - to prevent dependent edema f. client and family teaching 1. teach the cardio five 2. client must comply with long-term antibiotic and follow up care 3. emphasize the need for prophylactic antibiotics during dental care 6. Diagnostic findings a. EKG - for arrythmias b. echocardiogram - right ventricular dilation and paradoxic septal motion D. Tricuspid insufficiency (regurgitation) 1. Definition - tricuspid valve lets blood leak from the right ventricle back into the right atrium 2. Epidemiology a. results from dilation of the right ventricle and tricuspid valve ring b. most common in late stages of heart failure from rheumatic or congenital heart disease 3. Findings a. dyspnea, fatigue, weakness and syncope b. peripheral edema may cause discomfort 4. Management: surgical - valve replacement 5. Nursing interventions a. the cardio-care six b. monitor for cardio seven c. monitor for findings of heart failure, pulmonary edema, and adverse reactions to the drug therapy d. post-op monitor client for hypotension, arrhythmias and thrombus formation e. when sitting, client should raise legs - to prevent dependent edema f. client and family teaching 1. the cardio five 2. emphasize the need for prophylactic antibiotics during dental care 3. instruct client to raise legs when sitting - to prevent dependent edema E. Pulmonic stenosis 1. Definition - obstructed right ventricular outflow resulting in right ventricular hypertrophy 2. Epidemiology a. usually congenital, often with other birth defects such as tetralogy of Fallot b. rare among the elderly c. may result from rheumatic fever 3. Findings a. dyspnea, fatigue, chest pain and syncope b. peripheral edema may cause discomfort 4. Management: surgical - replace the valve via balloon and cardiac catheter 5. Nursing interventions a. same as tricuspid stenosis and tricuspid insufficiency b. monitor for findings of heart failure, pulmonary edema, and adverse reactions to to the drug therapy c. post-op: monitor client for hypotension, dysrhythmias and thrombus formation d. monitor the cardio seven e. client and family teaching - same as tricuspid stenosis and tricuspid insufficiency F. Pulmonic insufficiency (regurgitation) 1. Definition - pulmonary valve fails to close, so that blood flows back into the right ventricle 2. Epidemiology a. a birth defect, or a result of pulmonary hypertension b. rarely, result of prolonged use of a pressure-monitoring catheter in the pulmonary artery 3. Findings a. dyspnea, fatigue, chest pain and syncope b. peripheral edema may cause discomfort c. if advanced: jaundice with ascites and peripheral edema d. possible malnourished appearance 4. Management a. diuretics - to mobilize edematous fluid to reduce pulmonary venous pressure b. sodium-restricted diet - to control underlying heart disease c. anticoagulants - to prevent blood clots d. digitalis - to increase the force or strength of cardiac contractions (inotropic action) e. surgery for severe cases: valvulotomy or valve replacement 5. Nursing interventions a. the cardio-care six b. monitor the cardio seven c. monitor for findings of heart failure, pulmonary edema, and adverse reactions to drug therapy d. post-op: monitor client for hypotension, arrhythmias and thrombus formation e. provide rest periods f. when client sits, raise legs g. client and family teaching: (same as tricuspid stenosis, tricuspid insufficiency, and pulmonic stenosis) 1. the cardio five 2. client's dentist must give client prophylactic antibiotics to prevent infection 3. instruct client to raise legs when sitting to prevent dependent edema G. Aortic stenosis 1. Definition - aortic valve narrows. left ventricle must work harder, so needs more oxygen, and may suffer ischemia and heart failure. 2. Epidemiology a. most significant valvular lesion seen among elderly people. It usually leads to left-sided heart failure b. incidence increases with age c. occurs in 1% of the population d. about 80% of these people are male e. 20% of them die suddenly, around age 60 3. Findings a. classic triad: dyspnea, syncope, angina (see Assessing Clients with Cardiovascular Disorders) b. fatigue c. palpitations d. left-sided heart failure may bring on orthopnea, paroxysmal nocturnal dyspnea, and peripheral edema 4. Management a. nitroglycerin to relieve chest pain b. low-sodium diet - to prevent fluid retention c. diuretics - to mobilize edematous fluid and to reduce pulmonary venous pressure d. digitalis - to increase the force or strength of cardiac contractions (inotropic action) e. oxygen - to prevent hypoxia f. surgery - percutaneous balloon valvuloplasty, then valve replacement 5. Nursing interventions a. the cardio-care six b. monitor the cardio seven c. monitor for findings of heart failure, pulmonary edema, and adverse reactions to the drug therapy d. post-op: monitor client for hypotension, arrhythmias and clots e. when client sits, raise legs to prevent dependent edema f. client and family teaching: (same as tricuspid stenosis, tricuspid insufficiency, pulmonic stenosis and pulmonic insufficiency) 1. the cardio five 2. client's dentist must administer prophylactic antibiotics 3. client should raise legs when sitting H. Aortic insufficiency (regurgitation) 1. Definition a. blood flows back into the left ventricle during diastole overloading the ventricle and causing it to hypertrophy. b. extra blood also overloads the left atrium and, eventually, the pulmonary system. 2. Epidemiology a. by itself, most common among males b. with mitral valve disease, more common among females c. may accompany Marfan's syndrome, ankylosing spondylitis, syphilis, essential hypertension or a defect of the ventricular septum 3. Findings a. uncomfortable awareness of heartbeat b. palpitations along with a pounding head c. dyspnea with exertion d. paroxysmal nocturnal dyspnea, with diaphoresis, orthopnea and cough e. fatigue and syncope with exertion or emotion f. anginal chest pain unrelieved by sublingual nitroglycerin g. heartbeat that seems to jar the client's entire body h. client's nailbeds appear to be pulsating i. if nail tip is pressed, the root will flush and then pale (Quincke's sign) j. if left ventricle fails, client may show ankle edema and ascites k. pulsus biferiens 4. Management a. digitalis - increases the heart's contractility (inotropic action) b. diuretics - to mobilize edematous fluids and to reduce pulmonary venous pressure c. sodium-restricted diet - to prevent fluid retention d. anticoagulant agents - to prevent blood clots e. surgical - valve replacement. however, aortic insufficiency often damages the ventricle before it is detected. 5. Nursing interventions a. same as all other valve disorders - the cardio-care six except don't need to elevate head unless pulmonary problems have begun. b. monitor the cardio seven c. monitor for signs of heart failure, pulmonary edema, and drug reactions. d. post-op: monitor client for hypotension, arrhythmias and clots. e. client and family teaching 1. same as all other valve disorders - the cardio five 2. emphasize the need for prophylactic antibiotics during dental care 3. instruct client to raise legs when sitting IV. Failures of the Heart Muscle A. Myocardial infarction (MI) 1. Definition - insufficient oxygen supply kills (causes necrosis of) myocardial tissue. MI may be sudden or gradual. total event takes 3 to 6 hours. 2. Epidemiology a. almost equal for men and women b. client history of smoking, obesity, high cholesterol/low density lipoprotein diet, physical/emotional stress c. a common killer in North America and Western Europe d. mortality about 25%. Of the sudden deaths from MI, more than half happen within an hour e. of those who survive the initial MI and recover, up to 10% die within the first year 3. Findings a. persistent, crushing substernal chest pain b. pain that may radiate to the left arm, jaw, neck and shoulder blades, with a feeling of impending doom c. pain may persist for 12 hours or more d. some clients report no pain, or call it mild indigestion e. fatigue, nausea, vomiting and shortness of breath f. sudden death g. within the first hour after an anterior MI, about 25% of clients experience tachycardia or hypertension. h. up to 50% of clients with an inferior MI experience the opposite: bradycardia or hypotension. i. women may experience fatigue, achiness, flu-like symptoms 4. Management a. cardiac monitoring for arrythmias b. oxygen - to prevent tissue hypoxia c. bed rest - to decrease the workload of the heart d. pharmacologic agents - to stabilize client e. stool softeners - to decrease the workload of the heart caused by straining, which can cause vagal stimulation producing bradycardia and arrythmias f. narcotic analgesics - to reduce pain, anxiety and fear and decrease the workload of the heart g. beta-blocking agents - to slow heart rate h. sedatives - to decrease anxiety and fear and to decrease the workload of the heart i. antiarrhythmic - to prevent arrythmias which are the most common complications after an MI j. thrombolytic agents - to dissolve the thrombus in the coronary artery and reperfuse the myocardium k. nitrates - to decrease pain and decrease preload and afterload while increasing the myocardial oxygen supply l. anticoagulants - to prevent blood clots m. Swan-Ganz catheter to monitor pressure in pulmonary artery (measure functioning of left ventricle) n. intra-aortic balloon counterpulsation may be used for cardiogenic shock o. cardiac catheterization may be performed for PTCA p. surgery - coronary atherectomy or graft of a coronary artery bypass 5. Diagnostic studies a. history and physical b. EKG - monitor for changes, arrythmias c. serum cardiac markers (CK - MB) - rises 4-6 degrees after acute MI; Returns to normal in three to four days. Troponin - rises quickly but remains elevated for two weeks. 6. Nursing Interventions a. The cardio-care six plus monitor the following to prevent heart failure, infections and complications i. temperature ii. daily weight iii. intake and output iv. respiratory rate v. breath sounds vi. blood pressure vii. serum enzyme levels viii. EKG readings ix. Heart sounds especially S3 and S4 b. Assess pain and give analgesics as ordered. Record the severity, location, type and duration of pain. c. Do NOT give IM injections, or CK will be falsely elevated d. Watch for crackles, cough, tachypnea and edema which may predict left ventricle is failing. e. Use antiembolism stockings to prevent venostasis and thrombophlebitis. f. Assistance with range of motion exercises g. Client and family teaching i. the cardio-five ii. explain the ICU or coronary care unit, routine and machinery iii. ask dietician to speak with the client and family to reinforce teaching iv. encourage client to join the cardiac rehab exercise program v. counsel gradual resumption of sexual activity, taking nitroglycerin before sex may prevent chest pain vi. advise client to report typical or atypical chest pain vii. describe postmyocardial infarction syndrome ; have client report it to physician viii. stress that client must modify high-risk behaviors EKG MEASURES ELECTRICAL ACTIVITY OF HEART A. Electrocardiogram = (ECG) = (EKG); do not confuse with echocardiogram B. An EKG is a graphic recording of the electrical currents of the heart. C. The EKG records two basic events - depolarization and repolarization as a series of waves: 1. P-wave 2. P-R Interval 3. QRS complex 4. T wave 5. S-T interval 6. U wave 7. PVCs D. An EKG can show these conditions: a. sinus tachycardia b. ventricular tachycardia c. sinus bradycardia d. atrial fibrillation e. ventricular fibrillation f. asystole CARDIAC MECHANICS AND HEART SOUNDS Cardiac cycle Systole: contraction Diastole: relaxation Cardiac cycle: one systole and its diastole. Average time: four-fifths of a second Normal: 60-100 cycles (heart beats) per minute; faster in infants, slower in elderly Cardiac output (CO) Volume of blood ejected by ventricle per minute CO = Stroke volume times heart rate Preload: capacity of ventricle at height of diastole Afterload: force required to overcome arterial resistance and empty the ventricle Blood pressure Systolic pressure is maximum force of blood against arteries at systole Diastolic pressure is force of blood against arteries at diastole. BP is measured indirectly by Sphygmomanometer or Doppler echocardiography, or directly by arterial catheter Body controls cardiac output and blood pressure Starling's law of heart Baroreceptors Chemoreceptors Cause: Blood moves from regions of greater to lesser pressure Variations in Pressure: Pressure highest in left ventricle and aorta: fresh from heart. Pressure lowest in central veins, vena cava, and right atrium: coming back to heart. Heart sounds Normal S1 closure of mitral and tricuspid valves marking the beginning of systole S2 closure of aortic and pulmonic valves Exceptional S3 - sound produced when blood first rushes into a stiff or loaded ventricle. S3 sounds are early signs of left-sided heart failure S4 - sound produced during late phase of filling an overloaded ventricle, associated with hypertension Pressure too low: not enough blood (and oxygen) to brain and heart. Pressure too high: vessels damage and rupture. B. Congestive heart failure 1. Definition/etiology a. heart fails to pump enough blood to support the body's functions b. types of CHF depend on which part of the heart fails: the left half that pumps to the body, or the right half that pumps to the lungs. c. etiology i. coronary artery disease ii. myocarditis iii. cardiomyopathy iv. infiltrative disorders: amyloidosis, tumors, sarcoidosis v. collagen-Vascular disease: systemic lupus erythematosus, scleroderma vi. dysrhythmias that reduce cardiac filling time vii. disorders that increase cardiac workload: hypertension, valve disease, anemia, hyperthyroidism viii. cardiac tamponade 2. Findings of Left CHF and Right CHF 3. Management a. objective: to restore balance between myocardial oxygen supply and demand b. treatments include oxygen, digitalis, vasodilators, nitrates antihypertensives, cardiac glycosides, diuretics, intra-aortic balloon counterpulsation, ventricular assist pumping, etc. 4. Nursing interventions a. the cardio care six b. administer medications as ordered c. administer oxygen as ordered - to prevent tissue hypoxia d. monitor hemodynamic indicators e. monitor for findings of hyponatremia, hypokalemia f. restrict fluids and assess for findings of fluid retention g. client and family teaching i. medications and side effects ii. how to conserve energy and thus oxygen iii. teach client to report weight gain of more than two pounds in 24 hours (equals 1 liter) dyspnea decreased exercise tolerance iv. importance of sodium-restricted diet 5. Diagnostic findings - the primary goal is to determine the underlying cause of the heart failure a. history and physical exam b. CXR - to determine heart size and pleural effusions c. EKG for changes, arrythmias d. echocardiogram to measure valvular abnormalities e. nuclear imaging - to determine myocardial contractility, myocardial perfusion, and acute cell injury f. hemodynamic monitoring of arterial blood pressure, pulmonary artery pressure, pulmonary artery wedge pressure and cardiac output C. Cardiac tamponade 1. Definition/etiology a. fluid quickly fills pericardial sac and limits cardiac output; cardiac tamponade is a medical emergency b. etiology i. acute pericarditis ii. post-op after cardiac surgery iii. pericardial effusions iv. chest trauma v. myocardial rupture vi. aortic dissection vii. anticoagulant therapy 2. Findings: classic triad of findings a. hypotension with b. muffled heart sounds with c. high jugular venous pressure (increased CVP) 3. Diagnosis (above) 4. Management a. pericardiocentesis: needle aspiration of pericardial sac 5. Nursing interventions a. bed rest with elevated head of bed b. prepare client for pericardiocentesis c. provide emotional support PRINCIPLES OF CARDIOPULMONARY RESUSCITATION (CPR) - ADVANCED CARDIAC LIFE SUPPORT Early access Early CPR Early defibrillation Early advanced cardiac life support Give drugs after defibrillation (in the adult) For drug delivery, antecubital veins are first choice because central-line placement would interrupt CPR Endotracheal tube placement Intraosseous route for drugs is alternative (in children) V. Disorders of the Circulatory System: A. Hypertension 1. Definitions a. hypertension - systolic blood pressure of 140 mm Hg or greater, diastolic blood pressure of 90 mm Hg or greater, or taking antihypertensive medication b. chronic hypertension of pregnancy - high blood pressure already present before week 20 of gestation c. accelerated hypertension - a hypertensive crisis: blood pressure rises very rapidly, threatening the brain EIGHT FACTORS THAT AFFECT ARTERIAL BLOOD PRESSURES 1. Cardiac output 2. Resistance in peripheral vessels (arterioles) 3. Arterial elasticity: Elastic vessels let blood flow at lower pressures; rigid, sclerotic vessels require higher pressures. 4. Viscosity a. Too many red blood cells (RBCs) or plasma proteins increases pressure. b. Lower viscosity, from anemia or lack of RBCs, decreases pressure 5. Age: newborns have low blood pressure, which increases with age 6. Weight: the higher your weight, the higher your blood pressure 7. Exercise: faster heart rate means higher systolic blood pressure 8. Autonomic Nervous System: The sympathetic nervous system speeds the heart rate; the parasympathetic (via the vagus nerve ) slows the heart rate. 2. Etiology and epidemiology a. essential hypertension: cause unknown. b. possible factors include: i. family history- immediate family: mother, father, siser, brother ii. race- African American, Hispanic, Native American, more susceptible iii. stress iv. obesity- 20% more than ideal weight v. a diet high in sodium or saturated fat vi. use of tobacco vii. use of hormonal contraceptives viii. sedentary life-style ix. aging c. besides hypertension, most individuals have other risk factors for cardiovascular disease (CVD). d. secondary hypertension may result from i. renovascular disease ii. renal parenchymal disease iii. cushing's syndrome iv. diabetes mellitus v. dysfunction of the thyroid, pituitary, or parathyroid vi. coarctation of the aorta vii. pregnancy viii. neurologic disorders HOW THE BODY CONTROLS BLOOD PRESSURE Arterial blood pressure (BP): increases with increase in: cardiac output , peripheral resistance or blood volume. Intrinsic control: hour by hour, chemoreceptors control blood flow according to the tissues' use of oxygen and the amount of carbon dioxide in the brain. Extrinsic control: overrides intrinsic control when necessary. 1. For rapid, short-term adjustments, the body monitors blood pressure via stretch receptors (baroreceptors) in the walls of the carotid sinus and the aortic arch . 2. Control of blood pressure begins in vasomotor centers in medulla oblongata, through the autonomic nervous system, the kidneys, and hormones such as epinephrine and angiotensin. a. If arterial pressure increases above normal, the body lowers BP by decreasing heart rate (mediated by acetylcholine , the neurotransmitter of the parasympathetic nervous system.) b. If arterial pressure falls, it is raised by increasing cardiac output (mediated by epinephrine, the neurotransmitter of the sympathetic nervous system) 3. Slow, long-term control of blood pressure is achieved through: a. excretion of sodium and water by the kidney b. by the activity of the renin-angiotensin system c. by the atrial natriuretic factor d. and antidiuretic hormone 3. Findings a. may be asymptomatic b. findings reflect the effect of hypertension on organ systems c. occipital headache, blurred vision, dizziness d. dizziness, palpitations, weakness, fatigue, and impotence e. nosebleeds f. bloody urine g. chest pain and dyspnea, if heart is involved 4. Diagnosis a. based on the average of two or more blood pressure readings, two minutes apart, at each of two or more visits after an initial screening visit b. classification of adult hypertension c. hypertension is classified according to its cause: i. primary or essential hypertension (about 90% of clients) ii. secondary hypertension (results from another disease; about 5% to 10% of clients) iii. accelerated hypertension - a hypertensive crisis 5. Management a. pharmacological i. initial therapy - for uncomplicated hypertension, it is recommended to start with a diuretic or Beta- adrenergic blocking agent ii. oxygen PRN in acute crisis iii. angiotensin-converting enzyme (ACE) inhibitors are used to treat left-sided heart failure and preferred if client is diabetic iv. antilipemics b. goals of treatment i. BP <130/85 mm Hg ii. control dyslipidemia, obesity, inactivity iii. control diabetes mellitus, if indicated 6. Nursing interventions: reinforce client and family teaching regarding: a. client to use self-monitoring blood pressure cuff b. client to record readings at least twice weekly in a journal or calendar for review by care provider during visits c. client to set up routine for taking antihypertensive medications d. the need to warn against high-sodium antacids, and cold or sinus remedies with vasoconstrictors such as antihistamines e. diet low in sodium, cholesterol (see cholesterol level classification) and saturated fat f. when client is to report extremely high blood pressure readings g. lifestyle modifications i. optimize body weight ii. drink alcohol based on current guidelines iii. moderate dietary sodium (two gm sodium diet) iv. exercise: regular moderately intense aerobic activity v. avoid tobacco products vi. manage stress triggers and responses to triggers CHOLESTEROL LEVEL CLASSIFICATION (Source: Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults, Summary of the Second Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III), Journal of the American Medical Association 285 (2001): 2486-2497) B. Coronary artery disease 1. Definition - fatty deposits in coronary arteries (atheroma or plaque) narrow the artery (by 75% or more) and cut flow of blood and oxygen to the heart muscle. 2. Epidemiology and etiology a. CAD is epidemic in the western world. b. more than 30% of men age 60 or older show signs of CAD on autopsy. c. most common cause: Atherosclerosis d. risk factors: i. over 40 white male ii. family history of CAD iii. high blood pressure iv. high cholesterol (see cholesterol level classification) v. smokers are twice as likely to have a myocardial infarction and four times as likely to die suddenly. The risk drops sharply within one year after smoking ceases. vi. obesity (waist predominance); [added weight increases the risk of diabetes, hypertension and high cholesterol] vii. sedentary life style 3. Findings: angina TYPES OF ANGINA A. Angina, especially after physical exertion, is the classic symptom of Coronary Artery Disease. B. Angina appears commonly with nausea, vomiting, fainting, sweating, and cool extremities C. Angina may follow excitement, a large meal, or exposure to extreme cold or heat. D. Types of angina 1. Nocturnal angina 2. Angina predictable and relieved by nitroglycerine: stable angina. 3. More frequent and lasting angina: unstable angina. 4. Effort-induced pain that occurs more and more often: crescendo angina 5. Severe angina at rest: Prinzmetal's angina - associated with coronary artery spasm 4. Management a. pharmacology i. nitrates such as nitroglycerin, isosorbide dinitrate (Isordil), or beta-adrenergic neuron-blocking agents ii. oxygen - to prevent hypoxia iii. diuretics and beta-adrenergic blocking agents iv. aspirin - decreases platelet aggregation v. antilipemics - to decrease circulating lipids b. diet: reduce calories, salts, fats, cholesterol c. cardiac catheterization i. after cardiac catheterization and percutaneous transluminal coronary angioplasty (PTCA), maintain heparinization; observe for bleeding systemically at the site, and keep the affected leg straight and immobile for six to 12 hours. ii. check for distal pulses. iii. to counter the diuretic effect of the dye, increase IV fluids and make sure client drinks plenty of fluids. iv. assess potassium level- observe for dysrhythmias v. observe findings of hypotension, bradycardia, diaphoresis, dizziness; give atropine and lay the client flat. d. rotational ablation i. after rotational ablation, monitor the client for chest pain, hypotension, coronary artery spasm and bleeding from the catheter site. ii. provide heparin and antibiotic therapy for 24 to 48 hours or as ordered. e. laser coronary angioplasty f. surgical treatment - coronary artery bypass graft (CABG) CARE OF THE CLIENT UNDERGOING CARDIAC SURGERY WITH CARDIOPULMONARY BYPASS 1. Monitor hemodynamics for lower cardiac output or excess fluid 2. Measure fluid intake and output 3. Monitor specific gravity of urine 4. Monitor ECG (EKG) rate and rhythm 5. Monitor peripheral perfusion 6. Monitor neurological status 7. Administer IV fluids as ordered 8. Administer oxygen as ordered 9. Care of the client on a ventilator 10. Administer medications as ordered 11. Provide comfort measures 12. Limit fluid intake as ordered 13. Weigh client daily 14. Monitor for signs of cardiac tamponade 15. Administer blood and blood products as ordered 16. Provide emotional support 17. Observe incision sites for signs of infection 18. Care of the client with chest tubes 19. Monitor arterial blood gases as ordered 5. Nursing interventions a. help client with ADL (activities of daily living) b. partial bed rest c. reassure client d. assist with turning, deep breathing and coughing exercises e. relieve chest pain by oxygen and medication as ordered f. during angina attacks, monitor bp, heart rate, pain, meds, symptoms; get electrocardiogram g. keep nitroglycerin available for immediate use h. client and family teaching i. risks teach the risk factors for CAD (coronary artery disease) encourage client to lose excess weight; review low-fat, low-cholesterol diet teach smoking cessation teach side effects of drugs for CAD stress - teach stress reduction techniques ii. avoid activities known to cause angina physical activities for two hours after meals very cold and very hot weather alcohol and caffeine drinks diet pills, nasal decongestants, or any remedy that can raise heart rate or blood pressure iii. use nitroglycerin tablets; carry at all times if necessary nitroglycerin patch iv. report angina angina >15 minutes, go to clinic or hospital C. Shock 1. Definition - body cells need more oxygen than blood is supplying. cells and then organs fail. shock has many different causes. It is a medical emergency. 2. Five types of shock: a. cardiogenic b. septic c. neurogenic d. anaphylactic e. hypovolemic Types of shock are classified according to etiology: CHANS Cardiogenic - ventricle loses pumping power and cardiac output becomes inadequate Hypovolemic - excessive blood loss Anaphylactic - severe allergic reaction inappropriately dilates the veins to pool blood Neurogenic - sympathetic NS inappropriately dilates the veins to pool blood Septic shock - systemic infection causes excessive capillary permeability with excess intravascular volume loss 3. Findings: progression of shock a. initial stage: i. decreased cardiac output and perfusion ii. cellular function interrupted iii. anaerobic metabolism increases iv. no clinical symptoms at this stage b. compensatory stage: neural, chemical, and hormonal mechanisms act to restore perfusion. i. neural compensation: pressoreceptors in aorta activate sympathetic nervous system (NS), which contracts blood vessels so that skin cools; sympathetic NS stimulates heart, so tachycardia sets in; it cuts blood flow to kidneys and gastrointestinal system, and dilates pupils. ii. Hormonal compensation: decreased blood flow to kidneys releases angiotensin, which constricts vessels and increases BP; Angiotensin stimulates the secretion of aldosterone. Aldosterone makes kidneys retain sodium, which increases serum osmolality, which in turn stimulates antidiuretic hormone; ADH causes water retention. increased sodium and water retention results in increased BP, decreased urine volume and increased urine specific gravity. anterior pituitary is stimulated to secrete Adrenocorticotropic hormone , and ACTH acts on adrenal cortex to increase secretion of glucocorticoids, which increase serum glucose. iii. chemical compensation: decreased pulmonary blood flow causes hypoxemia; hypoxemia is sensed by chemoreceptors that increase rate and depth of respirations, which results in respiratory alkalosis iv. findings of compensatory stage of shock altered L.O.C. tachypnea anxiety, restlessness skin cool and clammy diaphoresis thirst pupils dilated tachycardia weak peripheral pulses decreased bowel sounds decreased urine output concentrated urine c. progressive stage of shock - compensatory mechanisms can no longer maintain perfusion. i. severe hypoperfusion ii. massive cell death iii. organs begin to fail iv. findings of progressive stage of shock consciousness - L.O.C. severely depressed lungs -hypoventilation, moist crackles cardiovascular - decreased BP: systolic below 90 mm mg, narrowing pulse pressure, tachycardia, irregular pulse, peripheral pulses weak, thready elimination - urine volume below 20 cc/hour, urine osmolality dilute, absent bowel sounds d. refractory stage: shock irreversible: death from multi- system organ failure is evident i. findings of refractory stage of shock cardiac failure respiratory failure renal shutdown liver dysfunction loss of consciousness ii. diagnostics FLUID FACTORS IN DIAGNOSIS OF SHOCK 1. Hematocrit: decreased except in hypovolemic where it is increased 2. Serum osmolality: decreased in hypervolemia, increased in hypovolemia 3. Urine osmolality: decreased in hypervolemia, increased in hypovolemia 4. Urine Specific gravity: decreased in hypervolemia, increased in hypovolemia 5. Sodium level: decreased in hypervolemia; increased in hypovolemia iii. management - objective: to correct underlying cause and prevent progression cardiogenic shock o pharmacologic treatments (see emergency cardiac drugs) positive inotropic agents: increase myocardial contractility and improve systolic ejection: dobutamine (Dobutrex), amrinone lactate (Inocor) EMERGENCY CARDIAC DRUGS vasodilators: improve heart's pumping action by reducing its Oxygen workload: nitroglycerin Morphine sulfate (Corobid), nitroprusside Diuretics sodium (Nipride), (Usually Aminophylline limited to clients with failing Dopamine hydrochloride ventricular function) Digoxin vasopressors: increase Lidocaine peripheral vascular resistance Epinephrine and elevate blood pressure: Sodium bicarbonate norepinephrine (Levophed), Atropine dopamine hydrochloride Procainamide (Intropin) Bretylium oxygen therapy Verapamil o surgical treatments Isoproterenol intra-aortic balloon Sodium nitroprusside counterpulsation Magnesium left and right ventricular assist Adenosine pumping Diltiazem heart transplant Propranolol Esmolol hypovolemic shock: rapid fluid replacement Amiodarone therapy to replace lost volume Calcium chloride anaphylactic shock: o epinephrine (adrenalin) o antihistamines o aminophylline (truphylline) neurogenic: depends on causative agent septic: antibiotic therapy EMERGENCY CARDIAC DRUGS Positive inotropic agents: increase myocardial contractility and improve systolic ejection: dobutamine dopamine hydrochloride amrinone epinephrineMp norepinephrine Vasodilators: improve heart's pumping action by reducing its workload: nitroglycerin nitroprusside morphine furosemide (Usually limited to clients with failing ventricular function) Vasopressors: increase peripheral vascular resistance and elevate blood pressure: norepinephrine phenylephrine epinephrine dopamine hydrochloride Oxygen therapy iv. nursing interventions for shock: the cardio-care six except do not elevate or lower head: maintain complete bed rest in flat position or with legs slightly raised to increase venous return do not move client; no commode keep client warm administer parenteral therapy, drugs, and O2 as ordered monitor mean hemodynamic indicators as ordered blood plasma expanders or packed cells VI. Dysrhythmias and Lesser Vascular Disorders A. Dysrhythmias 1. Definition: disturbance in heart rate or rhythm 2. Types of dysrhythmia a. supraventricular: sinus, atrial, and junctional i. sinus tachycardia ii. sinus bradycardia iii. sinus arrhythmia iv. premature atrial complexes v. atrial tachycardia vi. atrial flutter vii. atrial fibrillation viii. premature junctional complex ix. junctional tachycardia b. ventricular i. premature ventricular contraction ii. ventricular tachycardia iii. ventricular fibrillation iv. asystole v. atrioventricular block vi. first degree A-V block (no treatment) vii. second degree A-V block (no treatment) viii. third degree A-V block 3. Nursing interventions a. supraventricular dysrhythmias i. asymptomatic - no nursing interventions indicated ii. symptomatic administer medications as ordered (see pharmacologic interventions for dysrhythmias) provide emotional support teach client o medications and side effects o to wear dysrhythmia identification jewelry b. ventricular dysrhythmias i. administer medications as ordered ii. monitor EKG iii. monitor hemodynamic indicators as ordered iv. administer oxygen as ordered v. provide a restful environment vi. prepare the client for cardioversion vii. initiate cardiopulmonary resuscitation as indicated viii. provide emotional support ix. teach client medications and side effects importance of dysrhythmia identification jewelry c. atrio-ventricular (AV) conduction disturbances i. asymptomatic: no nursing interventions indicated ii. symptomatic administer medications as ordered prepare client for pacemaker insertion care of the client undergoing surgery provide emotional support provide a restful environment PACEMAKERS 1. A battery-powered device that provides electric stimulation for: a. atrial pacing b. pacing c. atrioventricular sequential and physiologic pacing 2. Pacemakers can be set to a. sense the person's intrinsic rhythm and pace only if intrinsic rate declines below rate set on pacemaker b. pace at a preset rate, regardless of person's rhythm (asynchronous) c. overdrive and suppress the underlying rhythm in tachyarrhythmia d. provide increased rate in bradycardias 3. Indications for pacing a. symptomatic bradyarrhythmia b. symptomatic tachyarrhythmia c. asystole d. prophylaxis in persons with high-risk bradycardia e. diagnosis of dysrhythmias during electrophysiologic testing 4. Types of pacemakers a. temporary pacemaker b. endocardial ( transvenous ) pacemakers c. transcutaneous (external) pacemakers d. epicardial (applied during cardiac surgery) e. permanent pacemakers 5. Complications of pacemakers a. infection b. perforation c. pneumothorax d. hemothorax e. dysrhythmias f. thrombosis B. Aneurysms 1. Definition, four types, two locations a. dilation of an artery due to a weakness in the arterial wall b. four types of aneurysms i. saccular: outpouching of one wall in a circumscribed area ii. fusiform: involves complete circumference of artery iii. dissecting: accumulation of blood separating the layers of the arterial wall iv. pseudoaneurysm: tear of the full thickness of the arterial wall, leading to a collection of blood contained in the connective tissue c. two locations: abdominal aorta and thoracic aorta i. location one: abdominal aortic aneurysm findings of abdominal aortic aneurysm o usually asymptomatic o vague abdominal or back pain o tenderness on palpation o hypotension o diminished pulses in lower extremities o commonest site: just below renal arteries and above iliac arteries ii. treatment - surgical repair iii. nursing interventions care of the client undergoing surgery after surgery, watch for back pain, a sign of retroperitoneal hemorrhage monitor perfusion provide comfort measures provide emotional support teach client - to avoid prolonged sitting and lifting of heavy objects d. location two: thoracic aortic aneurysm i. findings of thoracic aortic aneurysm may be asymptomatic vague chest pain dyspnea distended neck veins ii. management - surgical repair iii. nursing interventions care of the client undergoing surgery care of the client undergoing cardiac surgery 2. Etiology - atherosclerosis CARE OF THE CLIENT UNDERGOING CARDIAC SURGERY WITH CARDIOPULMONARY BYPASS 1. Monitor hemodynamics for lower cardiac output or excess fluid 2. Measure fluid intake and output 3. Monitor specific gravity of urine 4. Monitor ECG (EKG) rate and rhythm 5. Monitor peripheral perfusion 6. Monitor neurological status 7. Administer IV fluids as ordered 8. Administer oxygen as ordered 9. Care of the client on a ventilator 10. Administer medications as ordered 11. Provide comfort measures 12. Limit fluid intake as ordered 13. Weigh client daily 14. Monitor for signs of cardiac tamponade 15. Administer blood and blood products as ordered 16. Provide emotional support 17. Observe incision sites for signs of infection 18. Care of the client with chest tubes 19. Monitor arterial blood gases as ordered C. Arterial occlusive disease 1. Definition: insufficient blood supply in the arteries; usually in legs. may be acute or chronic. 2. Acute arterial occlusive disease a. etiology i. embolism, thrombosis, and trauma ii. femoral artery most often affected b. findings i. pain in affected limb ii. cyanosis in affected limb iii. paresthesia in affected limb iv. if untreated, gangrene c. management i. pharmacology : anticoagulants CARE OF CLIENTS TAKING ORAL ANTICOAGULANTS 1. Medicate same time every day 2. Wear medical identification jewelry: wearer takes anticoagulants 3. Use a soft toothbrush 4. Do not use a straight razor; use an electric razor 5. Avoid alcohol 6. Report any signs of bleeding, red or black bowel movements, headaches, rashes, red or pink-tinged urine, sputum 7. Avoid trauma 8. Monitor levels of the anticoagulant in the blood ii. surgical treatment embolectomy bypass of affected artery amputation of limb percutaneous transluminal coronary angioplasty 3. Chronic arterial occlusive disease a. etiology i. arteriosclerosis obliterans, aneurysms, hypercoagulability states, tobacco use ii. slow, progressive arteriosclerotic changes give collateral circulation a chance to form iii. collateral circulation cannot give tissues enough oxygen; result is hypoperfusion iv. hypoperfusion leads to ischemia v. usually affects legs b. findings i. intermittent claudication indicates mild to moderate obstruction ii. pain at rest indicates severe obstruction iii. affected limb will show edema paresthesia weak or absent pulses skin: waxy, hairless, cool, pale, cyanotic iv. in men, impotence c. management i. pharmacologic anticoagulants - to prevent blood clots vasodilators antiplatelet drugs - to prevent platelet aggregation pentoxifylline (Trental): increases blood flow by thinning blood ii. surgical treatment endarterectomy femoral-popliteal bypass sympathectomy amputation of affected limb for gangrene laser coronary angioplasty (LTA) peripheral angioplasty 4. Both acute and chronic arterial occlusive disease a. nursing interventions i. administer medications as ordered ii. monitor peripheral pulses and blanch test iii. provide comfort measures iv. help client develop an exercise program v. care of the client undergoing surgery vi. provide foot care vii. teach client to change positions frequently to avoid crossing legs to avoid any constrictive clothing on legs to avoid trauma to lower extremities foot care to place legs in dependent position to increase blood flow D. Raynaud's phenomenon (arteriopastic disease) 1. Definition: disorder of small cutaneous arteries causing vasospasm. usually affects the fingers bilaterally. 2. Etiology a. unknown b. frequently occurs in women c. may be triggered by stress, cold 3. Findings – signs of arterial insufficiency in the etremities 4. Management a. pharmacologic agents b. antihypertensive agents: reserpine (Serpasil) c. alpha-adrenergic blocking agents: phenoxybenzamine (Dibenzyline), tolazoline (Piscoline) d. vasodilators e. surgery i. sympathectomy in advanced stages ii. amputation of fingers showing gangrene 5. Nursing interventions a. administer medications as ordered b. care of the client undergoing surgery c. teach client i. to manage stress ii. to stop smoking, avoid caffeine iii. to avoid temperature extremes iv. protection from cold v. medications and their side effects E. Thromboangiitis obliterans (Buerger's disease) 1. Definition: blocking of the medium and small arteries, usually in the legs and feet. 2. Etiology a. affects men more than women b. 25 to 40 age group who smoke c. the disease only occurs in smokers 3. Findings – signs of arterial insufficiency in the etremities a. intermittent claudication b. numbness and tingling of toes c. weak or absent peripheral pulses d. ischemic ulcerations may occur e. can lead to gangrene 4. Management a. smoking cessation b. other treatment, see arterial occlusive disease c. analgesics d. surgery in late stages, amputation 5. Nursing interventions a. assist client with smoking cessation b. see nursing interventions for arterial occlusive disease: i. administer medications as ordered ii. monitor peripheral pulses and blanch test iii. provide comfort measures iv. help client to develop an exercise program v. care of the client undergoing surgery vi. provide foot care vii. teach client how stopping smoking can relieve symptoms F. Varicose veins 1. Definition: dilation of superficial veins of the legs and feet. 2. Etiology a. usually found in greater saphenous vein (leg) b. incompetent valves (incompetence, vavular) in the superficial veins c. increased pressure in veins causing them to distend d. risk factors: standing for long periods, pregnancy 3. Findings – signs of venous insufficiency in the extremities a. pain after period of standing b. foot and ankle swelling at end of day c. distended leg veins 4. Management a. objective: to reduce pain and halt underlying condition b. medical: sclerotherapy (injection of sclerosing agent that causes vein thrombosis) c. surgical: vein ligation (Vein stripping) 5. Nursing interventions a. care of the client undergoing surgery b. post-operative care includes i. application of elastic stocking or bandages ii. elevation of leg c. teach client i. not to cross legs ii. to elevate legs as much as possible iii. to avoid prolonged sitting or standing iv. avoid anything that impedes venous return v. overweight clients should lose weight G. Thrombophlebitis 1. Definition: A clot inflames the wall of a superficial blood vessel. 2. Etiology a. trauma b. intravenous catheters c. prolonged immobility d. IV drug use 3. Findings a. redness b. swelling c. tenderness d. warmth 4. Management a. bed rest, with elastic stockings b. elevation of affected extremity c. anticoagulants - to prevent clot formation d. analgesics - to control discomfort 5. Nursing interventions a. keep leg elevated b. monitor i. for findings of pulmonary embolism (sudden pain, cyanosis, hemoptysis, shock) ii. vital signs, including peripheral pulses iii. for findings of vascular impairment (pallor, cyanosis, coolness) c. administer analgesics as ordered d. client teaching i. avoid tight or constricting clothing ii. stop cigarette smoking iii. avoid maintaining one position for long periods H. Deep venous thrombosis 1. Definition: clotting in a deep vein 2. Etiology and risk a. immobilization b. sepsis c. hematological disorders and clotting disorders d. malignancies e. congestive heart failure f. myocardial infarction g. obesity h. pregnancy i. fractures j. venipuncture k. surgeries: orthopedic, neurologic, urologic and gynecologic l. risk of pulmonary embolus 3. Findings - unilateral edema of extremity, signs of venoue insufficiency in the extremities 4. Management a. objective: to eliminate the clot and prevent complications b. bed rest c. anticoagulant therapy - to prevent new clots d. thrombolytic therapy - to dissolve thrombus e. compression stockings f. surgery - thrombectomy 5. Nursing interventions a. monitor for findings of pulmonary embolus b. maintain bed rest c. administer medications as ordered d. teach client i. medications and side effects ii. to avoid prolonged immobility iii. to maintain adequate fluid intake I. Venous stasis ulcers 1. Definition: chronic skin and subcutaneous ulcers usually found on legs, ankles or feet. 2. Etiology a. chronic venous insufficiency b. incompetent valves (vavular, incompetence) in perforating veins or deep veins cause venous stasis c. pressure of blood pooling causes capillaries to leak d. ulcer begins as small, inflamed, tender area e. any trauma causes tissue to break or it may break spontaneously f. site: pretibial and medial supramalleolar areas of ankle 3. Findings – signs of venous insufficiency in the extremities a. open skin lesion with irregular border b. skin around ulcer usually brown and leathery c. pain in affected area 4. Management a. objective: to correct venous hypertension and both prevent and correct ulceration b. local wound care c. antibiotics and analgesics as indicated d. surgery i. debridement ii. skin grafting iii. removal of veins with incompetent valves 5. Nursing interventions a. keep legs elevated, with feet above level of heart at all times b. apply elastic bandages as ordered c. cleanse and dress ulcer as ordered d. administer drugs as ordered e. teach client i. to report any signs of inflammation immediately ii. to avoid trauma to affected limb iii. to provide skin care iv. to apply elastic bandages Points to Remember Cardiovascular disease is the leading cause of death among Americans. Take blood pressures correctly give client 5 minutes rest. take blood pressure while client is lying, sitting, and standing. ask client if he/she has recently smoked, drank a beverage containing caffeine or was emotionally upset. If so, repeat blood pressure in 30 minutes. Rarely, the heart may lie on the right side instead of the left, this is called Dextrocardia. Valves control the direction of the blood flow through the heart. Flow is unidirectional. When the atria contract, the atrioventricular valves swing open, allowing the blood to flow down into the ventricles. When the ventricles contract the valves snap shut preventing blood from flowing back up into the atria. Semilunar valves open allowing blood to eject during ventricular contraction. If the SA node fails to generate an impulse, the AV node takes over, generating a slower rate. If the AV node fails to generate an impulse, the Bundle of His takes over, generating an even slower rate. If the Bundle of His fails to generate an impulse, the Purkinje fibers take over and generate an even slower rate. Damaged areas of the heart may also stimulate contractions and produce arrhythmias. Rapid, short-term control of blood pressure is achieved by cardiac and vascular reflexes that are initiated by stretch receptors (baroreceptors) in the walls of the carotid sinus and the aortic arch. Many clients with angina or MIs benefit from involvement in a structured cardiac rehabilitation program to assist clients to increase their activity level in a monitored environment. Current research suggests that life style and personal habits are closely related to cardiac changes once attributed to aging. The elderly are less able to physically adapt to stressful physical and emotional conditions, because their hearts do three things less quickly: the myocardium contracts less easily, the left ventricle ejects blood less quickly, and the heart is slower to conduct the impulse for a heartbeat. Because different enzymes are released into the blood at varying periods after a myocardial infarction, it is important to evaluate enzyme levels in relation to the onset of the physical symptoms such as chest pain. Clients who are in postoperative recovery, on bed rest, obese, taking hormonal contraceptives or had knee or hip surgery should be monitored closely for thrombophlebitis.