Transcript NCLEX Review Course

NCLEX RN Preparation
Program
Cardiovascular Disorders
Module 5, Part 2 of 3
1
Cardiovascular System
Introduction
The heart and the
circulatory
system comprise one
of the most essential
parts of the body.
Failure to function
results in death of
the organism.
Photo Source: National Heart, Lung and Blood Institute (NHLBI)
http://www.nhlbi.nih.gov/health/dci/Diseases/arr/arr_howheartwork.html
2
Gross Structure of the Heart


Layers:
Pericardium





Fibrous
Serous Pericardium
Epicardium
Myocardium
Endocardium
3
Chambers of the Heart



Heart, a muscular organ
divided by a septum into two
halves. Right or venous
chamber and left or arterial
chamber.
Right Chambers
 Right Atrium
 Right Ventricle
Left Chambers
 Left Atrium
 Left Ventricle
4
Coronary Blood Supply
Right Coronary
Artery
 Left Coronary
Artery

Left anterior
descending
 Circumflex

Photo Source: U.S. National Cancer Institute's
Surveillance, Epidemiology and End Results
(SEER) Program
5
Valves of the Heart



Valves are strong membranous openings that provide
one-way flow of blood.
Atrioventricular valves – prevent backflow of blood
from ventricles to atria during systole.
 Tricuspid
 Mitral
Semilunar valves – prevent backflow from the aorta
and pulmonary arteries into the ventricles during
diastole.
 Pulmonic
 Aortic
6
Valves of the Heart
Photo Source: U.S. National Cancer Institute's Surveillance, Epidemiology and End Results (SEER) Program
7
Conduction system


Specialized tissue that allows rapid
transmission of electrical impulses through
the myocardium
Sinoatrial node – main pacemaker of
heart. Normal rhythmic, self-excitatory
impulse is generated.
8
Conduction system
Photo Source: St. Francis
Hospitals & Health Centers,
http://www.stfrancishospitals.o
rg/DesktopDefault.aspx?tabid=
72&Class=Test&pageid=P079
73
9
Gross Structure of Vasculature

Arteries: transport blood under high
pressure to body tissues




Precapillary sphincters
Arteriovenous shunts
Capillaries – exchanging fluid and nutrients
between blood and interstitial space.
Veins: acts as conduits for transport of the
blood from tissues back to heart
10
Physiology of the Heart


Contraction – shortening or increase in
muscle tension. Utilizes chemical energy
to do the work of contraction
Cardiac Muscle Principle:

Frank Starling Law: the greater the heart is
filled during diastole, within physiological
limits, the greater the quantity of blood
pumped into the aorta and pulmonary
artery.
11
Autonomic
Nervous System Control

Cardiac Muscle



Sympathetic (Adrenergic)
Parasympathetic (Cholinergic)
Systemic blood Vessels


Sympathetic – vasoconstriction
Parasympathetic – vasodilation
12
Baroreceptor Reflex
(Pressoreceptors)




Located in the walls of large systemic arteries
Rise in pressure results in baroreceptors
transmitting signals to CNS (Central Nervous
System) to inhibit sympathetic action
Other signals, in turn, sent to circulatory
system to reduce pressure back to normal.
Result: decreased heart rate, vasodilation,
decreased BP.
13
Other Chemical Controls of
Blood Pressure

Kidney



Adrenal cortex - aldosterone
Renin-angiotensin system
Antidiuretic hormone (vasopressin)
14
System Assessment
Evaluate Patient’s History

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Pain
Dyspnea
Cyanosis
Fatigue
Palpitations
Syncope
Hemoptysis


Edema
Condition of
Extremities
15
Evaluate veins and arterial pulses
through inspection/palpation

Veins




Neck veins
Arm and hand veins
Leg and foot veins
Arteries


Central
Peripheral pulses
16
Auscultate lung sounds

Lungs

Listen for bibasilar crackles – if present,
suspect Congestive Heart Failure (CHF)
Photo Source, Wikimedia Commons, Creative Commons,
http://commons.wikimedia.org/wiki/Image:X-ray_lung_consolidation.jpg
17
Auscultate heart sounds


Heart sounds – frequency, pitch, intensity,
duration
Murmurs



Systolic
Diastolic
Pericardial friction rubs
18
Other parameters to assess


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Arterial pressure
Carotid blood vessels for bruit
Palpate and percuss thorax
Evaluate chest x-rays
Assess lung sounds
19
Diagnostic Tests &
Procedures

Laboratory Studies

Cardiac Enzymes

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CK-MB
LDH
Troponin
Myoglobin
BNP


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
Calcium
Phosphorus
Magnesium
BUN
Blood glucose
CBC
Blood coagulation factors
Serum lipids
Electrolytes

K, Na
20
Diagnostic Procedures






Electrocardiogram
Central Venous Monitoring
Cardiac Catheterization
Echocardiography
Angiography
Chest x-rays
21
Acute Coronary Syndromes


Coronary Artery Disease (CAD)
Narrowing or obstruction
of one or more coronary
arteries as a result of
atherosclerosis, an
accumulation of
lipid-containing plaque
in the arteries.
Photo Source: National Heart, Lung and Blood Institute (NHLBI),
http://www.nhlbi.nih.gov/health/dci/Diseases/Cad/CAD_WhatIs.html
22
Pathophysiology





Atherosclerosis - fat deposited in intima of arterial
wall
Inflammatory response begins
Macrophages inflitrate area to ingest lipids, then
die
Smooth muscles cells within the blood vessel
cover the area with fiber and plaque is formed.
If the plaque is thin, the lipid center may grow,
rupture, become a thrombus
23
Myocardial Ischemia /
Angina Pectoris




Decreased oxygen to heart
Exercise-induced chest pain
Unstable angina
Other risk factors
24
Coronary Artery Disease
Myocardial ischemia
CLINICAL MANIFESTATIONS:
 May be asymptomatic unless ischemia occurs
 Chest pains or pressure, may radiate to jaw,
back, shoulder
 Palpitations, weakness
 Dyspnea
 Syncope
 Nausea
 Excessive fatigue
 EKG changes (T wave inversion)
25
Coronary Ischemia/Angina
Silent angina - no
symptoms, but
EKG changes.
Often occurs in
diabetic
patients with CAD.
26
Teaching for Angina




Rest at onset of chest pain
Take one nitroglycerin, repeat 2 more
prn
No relief by 3rd, call 911
Previous angina with particular activity,
take nitroglycerin prior to activity
27
Unstable Angina


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Oxygen: 2-4L nasal cannula
Nitroglycerin
Morphine
Aspirin
Baseline vital signs
12 lead EKG
Monitor for dysrhythmias, heart failure
28
Myocardial Infarction
Photo Source: National Heart, Lung and Blood Institute (NHLBI),
http://www.nhlbi.nih.gov/health/dci/Diseases/Cad/CAD_WhatIs.html
29
MI: Signs and Symptoms



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Pain
Nausea
Impending doom
Diaphoresis
Dyspnea
Dysrhythmias
30
12-lead EKG

Normal
Ischemia
Injury

Acute infarct

Old infarct


31
LABS
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Myoglobin – non specific
Troponin
CK-MB
BNP = CHF
32
Collaborative Management

Immediate assessment


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Vital signs with oxygen saturation
12-lead EKG
Cardiac enzymes
Chest x-ray
Electrolytes – K+ & Mg++
Immediate treatment – “MONA”

Beta blockers?
33
MONA

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Acronym from Advanced Cardiac Life Support
(ACLS) though order is ONMA.
O = Oxygen 2-4 liters per nasal cannula
N = Nitroglycerin (if not already tried outside
hospital); relieves pain
M= Morphine relieves pain, decreases
anxiety, increases venous pooling (to reduce
cardiac workload)
A = Aspirin prevents platelet aggregation at
the site of obstruction
34
Reperfusion Strategies



Thrombolytics
Percutaneous
Transluminal
Coronary
Angioplasty (PTCA)
Stent Procedure
Photo Source: National Heart, Lung and Blood Institute (NHLBI),
http://www.nhlbi.nih.gov/health/dci/Diseases/Cad/CAD_WhatIs.html
35
Post-PCTA Care

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Monitor V/S
Assess distal pulses
Bed rest with limb straight for 6 – 8 hours
Anticoagulants/antiplatelet agents – prevent
thrombus formation
Monitor IV nitroglycerin – prevent coronary
artery spasms
ASA once a day permanently
Assist planning lifestyle modification
36
Acute Myocardial Infarction
Bed rest for 24 to 36 hrs
Pain control
Monitor rhythm
Assess for new murmurs
Monitor potassium, magnesium
Monitor for heart failure
Gradual increase of activities
37
Rehabilitation


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Diet
Progressive exercise
Change modifiable risk factors

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Weight loss
Stress reduction
Lipid-lowering drugs
Anti-hypertensives
Aspirin
38
Coronary Artery Bypass
Graft (CABG)



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Bypass grafts sewn from aorta to below
area of blockage
Fluid overload
Pacemaker?
Bleeding
Atrial fibrillation
39
Nursing Management
Control pain
Early ambulation
Incentive spirometer
Change dressings: watch for infection
Monitor: VS, lungs, heart, weight, I&O,
labs, EKG
40
Complications

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Stroke
Tamponade: pulsus paradoxus
Bleeding
Dysrhythmias
Post-cardiotomy syndrome
41
Cardiac Dysrhythmias

Normal Sinus Rhythm/Regular Sinus Rhythm



Rhythm originates from the SA node
Atrial and ventricular rhythms are regular
Rates are : 60- 100 beats per minute.
42
Cardiac Dysrhythmias

Sinus bradycardia



Atrial and ventricular rates below 60 beats
per minute
Treatment may be necessary if symptomatic
Note: low rates may be normal for some
patients.
43
A-V block: 2nd Degree Mobitz I
44
AV Block: 2nd Degree Mobitz II
45
A-V Block:
rd
3
Degree
46
Supraventricular Tachycardia
47
Atrial Fibrillation
48
Premature Ventricular
Contractions (PVCs)
49
Ventricular Tachycardia
50
Ventricular Fibrillation
51
Defibrillation Options



Paddles
AED
ICD
Photo Source: Wikimedia Commons (Creative Commons),
http://commons.wikimedia.org/wiki/Image:Defibrillator_Monitor.jpg
52
Asystole/PEA
CPR, epinephrine, vasopressin, atropine
Consider 6 H’s, 5 T’s below:
Hypovolemia, Hypoxia, Hydrogen ion
(acidosis), Hypo-/hyperkalemia,
Hypoglycemia, Hypothermia
Toxins, Tamponade (cardiac); Tension
pneumothorax; Thrombosis (coronary
or pulmonary); Trauma
53
Cardiac Pacemaker
Temporary or permanent device that provides
electrical stimulation and maintains the heart
rate when the patient’s intrinsic pacemaker
fails to provide a perfusing rhythm.
54
Pacemakers

Types of Pacemakers




Temporary
Transvenous invasive temporary pacing
Epicardial invasive temporary
Permanent
55
Patient Education


Programmed rate
When to notify MD:
Dizziness, weakness, sudden weight gain of 3-5
pounds overnight, persistent hiccups. Check pulse
daily, report sudden slowing or increasing of pulse.

Signs/symptoms to report:
Fever, redness, swelling, drainage from insertion
site, dizziness, fatigue, shortness of breath, chest
pains, swelling of ankles/legs


Pacemaker identification, medic alert
Measure pulse daily, keep record
56
Patient Education
(continued)
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Wear loose-fitting clothing
Avoid contact sports
Inform all health care providers of pacemaker
Most electrical appliances can be used
without any interference with the functioning
of the pacemaker.
If any unusual feelings occur when near any
electrical devices, move 5 to 10 feet away and
check pulse.
57
Congestive Heart Failure




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Inability of the heart to maintain adequate
circulation to meet the metabolic needs of the
body because of impaired pumping actions.
Cardiac output diminished and peripheral
tissue not adequately perfused
Congestion of the lungs and periphery may
occur.
Classification: Acute and Chronic
Types: Right-sided/left-sided heart failures
58
Congestive Heart Failure

Clinical manifestations

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Weight gain, I & 0, edema, if severe: ascites
Crackles in lungs (especially bibasilar)
Dyspnea, orthopnea, urinary frequency, murmurs
(if valve problem)
S3 heart sound - sign heart beginning to fail & increased
blood volume remains in heart after each beat
BNP lab test - the higher the number, the worse the CHF
is. Can monitor severity of CHF, improvement due to
treatment regimen, timely diagnosing of CHF
Jugular vein distension, LOC, pulse oximetry.
59
CHF: Collaborative Mgmt


Vasodilators: Nitrates
Positive inotropes: increase contraction

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Digoxin (Lanoxin)
Beta blockers (though some 
contractility & are contraindicated)
ACE inhibitors
Diuretics
60
CHF: Nursing Management

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Elevate head of bed
Give oxygen
Decrease oxygen demand
Exacerbation? Identify precipitating factors
Teach: low-salt diet, medications and their
rationale, weigh daily, exercise but pace
activities. Wait 90 min. after meals to exercise.
Avoid extremes in weather when exercising.
61
Cardiac Valve Disorders
Mitral stenosis
Mitral prolapse
Aortic stenosis
Aortic regurgitation
Photo Source: National Heart, Lung and Blood Institute (NHLBI),
http://www.nhlbi.nih.gov/health/dci/Diseases/Cad/CAD_WhatIs.html
62
Cardiac Valve Disorders

Clinical Manifestations:
 Heart murmur
 Left ventricular hypertrophy seen on EKG
63
Congestive Heart Failure
Photo Source: Lippincott, Williams, &
Wilkins Connection Image Bank,
http://connection.lww.com/products/sm
eltzer9e/imagebank.asp
Congestive Heart Failure

Collaborative Management


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
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Digoxin (inotropic)
Diuretics (lasix, aldactone)
Coreg - beta blocker shown to improve
cardiac function in CHF patient
Ace inhibitor - shown to improve cardiac
function in CHF patient
Oxygen, cardiac rehab
65
CHF Management (continued)




Treat heart failure if present
Atrial fibrillation?
Antibiotic prophylaxis
Weigh daily
66
Pericarditis


Inflammation of pericardial sac. Can be
caused by viral infection, complicaton
after cardiac surgery 10 days to 2
months, or after MI
Idiopathic cause, or disorder of
connective tissue (lupus), cancer,
radiation therapy, etc
67
Pericarditis: Manifestations




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
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Chest pain on inspiration, worse when patient
leans forward, lying down or turning
Pericardial friction rub
Symptoms of right-sided heart failure
Mild fever, elevated WBC, ESR
Atrial fibrillation common
12 lead EKG may have elevation in ALL leads
Can worsen to cardiac tamponade
68
Pericarditis

Collaborative Management


NSAIDs or corticosteroids
Pericardiocentesis or surgical pericardial
window
69
Pericarditis: Nursing Mgmt




Position for comfort
Monitor for cardiac tamponade (fluid between
heart and pericardial sac) that causes heart to
be compressed inside the sac leading to
decreased blood pressure and shock, distant
heart sounds
Teach: gradual increases of activity
Teach: avoid aspirin, anticoagulants
70
Infective Endocarditis



Valves infected, spreads to endothelium
Leaflets deform, leak
High risk: elderly, prosthetic valves, IV
drug abusers, immunosuppressed
71
Manifestations

Slow onset



Flu-like symptoms, anorexia, weight loss, joint
& back pain, fever, splinter hemorrhages
undernails, petechiae, murmur, headache?
Major complication: embolus
Diagnosis: blood culture, echocardiogram
72
Management



IV antimicrobials based on cultures
Teach prevention
Monitor: sepsis, new murmur, stroke,
meningitis, CHF
73
Hypertension

Pathophysiology




90-95% unknown cause
5-10% secondary causes
Some genetic tendency, obesity, stress,
excess sodium intake
Prolonged hypertension eventually damages
blood vessels, heart (LVH) and kidneys,
eyes, brain.
74
Hypertension

Clinical manifestations



Usually asymptomatic “silent killer”
Some report headache, especially early morning
Risk factors

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Family history
Age
Diabetes
Obesity
Heavy alcohol
High sodium intake
75
Hypertension

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Goals: reduce BP. Goal: 120/80
Ask for S/S indicative of HTN
Obtain BP on both arms
Family history, weight, dietary patterns
Identify medication therapy
Assess cardiac, neuro, renal, diagnostic
and lab studies.
76
Hypertension

Collaborative Management


Medications: diuretics, beta blockers, ACE
inhibitors, angiotensin receptor blockers,
calcium channel blockers, alpha blockers
Monitor and routine follow-up with EKG,
lipid lower agents if needed
77
Hypertension

Nursing Management



TEACH: weight loss, stress management,
rationale for medications prescribed & their
importance. Low-sodium, low-fat, lowcholesterol diet. Stop smoking. Limit caffeine,
alcohol. Teach how to modify risk factors.
Monitor for target-organ problems. Teach
potential problems if hypertension untreated.
Many people undiagnosed. Promote screening
for early detection.
78
Classification
Category
Normal
Systolic
<120 mmHg
Diastolic
<80 mmHg
Pre-HTN
120-139 or
80-89
Stage 1
140-159 or
90-99
Stage 2
≥ 160 or
≥ 100
79
Hypertensive Crisis…
Assessment







Diastolic pressure > 120 mm Hg.
Headache
Drowsiness
Confusion
Changes in LOC
Tachycardia and tachypnea
Dyspnea/cyanosis/seizure
80
Hypertensive Crisis: Mgmt

Lower BP slowly






IV nitrates (nitroglycerin)
Nitroprusside (Nipride)
Enalapril (Vasotec)
Beta blockers
Diuretics
Monitor rhythm, vital signs
81
Peripheral Vascular Disease
(PVD)

Pathophysiology




Generalized atherosclerosis (plaque
development) or arteriosclerosis (hardening
of the arteries)
Narrowing of lumen, obstruction by
thrombosis
Bifurcation or branch areas higher risk of
blockage.
If have PVD, at risk of having CAD as well
82
Peripheral Arterial Disease




Stage I:
Stage II:
Stage III:
Stage IV:
Asymptomatic
Claudication
Rest pain
Necrosis
83
PVD: Management







Medications
Control hypertension
Angioplasty, bypasses
Exercises
Position
Vasodilation
Avoid vasoconstriction
84
Arterial Bypass



Monitor for graft occlusion
Promote graft patency
Monitor for compartment syndrome
85
Peripheral Venous
Insufficiency




Stasis dermatitis lower legs
Edema
Ulcers over malleoli
Anterior leg ulcers if arterial flow
impaired
86
Peripheral Vascular Disease






Compression stockings
Sequential compression pump
Manage ulcers
Elevate legs
Avoid prolonged sitting or standing
No compression of legs
87
Abdominal Aortic Aneurysm
Localized dilatation of the wall of the abdominal
aorta caused by congenital weakness, trauma,
disease, atherosclerosis



Risk factors: smoking, hypertension
Progressive weakening and enlarging of area
of vessel
If a tear develops - medical emergency
(rupture)
88
Aortic Aneurysms

Goal of treatment:
limit progression of
the condition by
modifying risk
factors, controlling
BP, recognizing
symptoms early, and
preventing rupture
Photo Source: National Heart, Lung and Blood Institute (NHLBI),
http://www.nhlbi.nih.gov/health/dci/Diseases/Cad/CAD_WhatIs.html
89
Abdominal Aortic Aneurysm

Clinical Manifestations:




Can palpate enlarged aorta, possible
bruit ausculated
If rupture, sudden pain in back or
abdomen
If tearing, pain in abdominal area or
back; can be slowly progressive
If rupture-hemorrhage, shock, death
unless emergent surgical intervention
90
Manage Abdominal
Aneurysm

Non-surgical:




Modify risk factors
Monitor BP
Regular exams for size, pulsation
Report: chest/back pain, SOB, Difficulty
swallowing, hoarseness
91
Thoracic Aortic Aneurysm






Pain: neck, shoulders, lower back
or abdomen
Syncope
Dyspnea
Tachycardia
Cyanosis
Weakness
92
Manage Thoracic Aneurysm





Monitor V/S
Assess for pain – abdominal or back
pains.
Check peripheral pulses, including
temperature and color
Observe for signs of rupture
Note tenderness/distention of abdomen
93
Photo Acknowledgement:
All unmarked photos and clip art
contained in this module
were obtained from the
2003 Microsoft Office Clip Art
Gallery.
94