Transcript Chapter 20
CHAPTER 21 Cardiovascular System Function, Assessment, and Therapeutic Measures Aloha Hand, MSN,RN HEART In Mediastinum Pericardial Sac: 3 Layers Fibrous Pericardium Parietal Pericardium Visceral Pericardium (Epicardium) Serous Fluid Between Inner Layers ANTERIOR HEART VIEW FRONTAL HEART VIEW CARDIAC STRUCTURE AND VESSELS Four Chambers Right/Left Atrium, Right/Left Ventricle Cardiac Layers Epicardium, Myocardium, Endocardium CARDIAC STRUCTURE AND VESSELS Coronary Arteries Valves Tricuspid, Pulmonic, Mitral, Aortic BLOOD FLOW Vena Cava » Right Atrium » Tricuspid » Right Ventricle » Pulmonic » Pulmonary Artery » Lungs » Pulmonary Veins » Left Atrium » Mitral » Left Ventricle » Aortic Valve » Aorta CARDIAC CONDUCTION SA Node AV Node Bundle of His Right and Left Bundle Branches Purkinje Fibers CARDIAC OUTPUT Amount of Blood Ejected from the Left Ventricle in 1 Minute Stroke Volume × Heart Rate = CO NERVOUS SYSTEM REGULATION OF HEART HORMONES AND HEART Epinephrine Increases Heart Rate Force of Contraction Cardiac Output Systolic BP HORMONES AND HEART (CONT’D) Aldosterone Regulates Sodium/Potassium Atrial Natriuretic Peptide Excretes Sodium VESSEL STRUCTURE BLOOD PRESSURE Blood Force Against Blood Vessel Walls Normal Systolic 90 to 135 mm Hg Diastolic 60 to 85 mm Hg RENIN-ANGIOTENSINALDOSTERONE MECHANISM PATHWAYS OF CIRCULATION Pulmonary Systemic AGING AND THE CARDIOVASCULAR SYSTEM AGING AND THE CARDIOVASCULAR SYSTEM (CONT’D) Atherosclerosis Arteriosclerosis Blood Pressure Increases Vein Valves More Incompetent Heart Muscle Less Efficient Dysrhythmias Common CARDIOVASCULAR DISEASE Number 1 Killer Lifestyle Smoking Dietary Fat 2 Servings of Fish Weekly Exercise CARDIOVASCULAR DISEASE (CONT’D) Go Red for Women American Heart Association’s nationwide movement to celebrate power women have to band together to wipe out heart disease. Color red and red dress linked with this ability. CARDIOVASCULAR ASSESSMENT Symptoms – WHAT’S UP Health History Past Medical History Medications Family History Health Promotion Methods OBJECTIVE DATA Physical Assessment Vital Signs Diagnostic Studies PHYSICAL ASSESSMENT Inspection Oxygenation, Skin Color Extremities – Hair, Skin, Nails, Edema, Color JVD Capillary Refill Clubbing CLUBBING PHYSICAL ASSESSMENT Palpation Point of Maximum Impulse Extremity Temperature Poikilothermy Edema Homans’ Sign EDEMA HOMANS SIGN PHYSICAL ASSESSMENT Percussion Advanced Practitioner Cardiac Border PHYSICAL ASSESSMENT (CONT’D) Auscultation Heart Sounds S1 S2 S3 S4 PHYSICAL ASSESSMENT (CONT’D) Auscultation Murmurs Pericardial Friction Rub HEART SOUNDS NONINVASIVE DIAGNOSTIC STUDIES Chest X-Ray Cardiac Calcium Scan Shows Areas with Plaque or Calcification Magnetic Resonance Imaging ELECTROCARDIOGRAM Records Cardiac Electrical Activity Signal-Averaged ECG Ambulatory Electrocardiogram Monitoring Risk For Ventricular Dysrhythmias Holter Monitoring Transtelephonic Event Recorders NONINVASIVE DIAGNOSTIC STUDIES (CONT’D) Pressure Measurement BP Readings Along Extremity Tilt Table Test Lying to Standing BP and HR EXERCISE TOLERANCE TESTING Cardiac Stress Test Cardiac Response to Exercise and Increased Oxygen Needs Peripheral Vascular Stress Test Vascular Response to Walking CARDIAC STRESS TEST ECHOCARDIOGRAM Ultrasound Records Motion Heart Structures Valves Heart Size, Shape, Position ECHOCARDIOGRAM Transesophageal Echocardiogram Probe in Esophagus Clearer Picture NPO until Gag Reflex Returns RADIOISOTOPE IMAGING Radioisotopes IV, Gamma Camera Scan Detects Cardiac Ischemia/Damage/Perfusion Thallium Imaging Technetium Pyrophosphate Scan Technetium 99m Sestamibi Blood Pool Imaging Positron Emission Tomography BLOOD FLOW ASSESSMENT Doppler Ultrasound Impaired Blood Flow Reduces Sound Waves Plethysmography Diagnoses Deep Vein Thrombosis/ Pulmonary Emboli/Peripheral Vascular Disease BLOOD FLOW ASSESSMENT (CONT’D) Arterial Stiffness Index Determines Atherosclerosis/Cardiovascular Disease CARDIAC BLOOD STUDIES Homocysteine C-reactive Protein Myeloperoxidase Antigen Cardiac Troponin I and T CARDIAC BLOOD STUDIES Cardiac Enzymes Creatine Kinase Myoglobin Blood Lipids Triglycerides, Cholesterol, Phospholipids INVASIVE STUDIES Angiography Cardiac Catheterization Hemodynamic Monitoring Electrophysiology Study CARDIAC CATHETERIZATION PULMONARY ARTERY CATHETER THERAPEUTIC INTERVENTIONS Exercise: Walking Program, Cardiac Rehab Smoking Cessation Balanced Diet, Weight Loss Oxygen THERAPEUTIC INTERVENTIONS Antiembolism Devices Elastic Stockings Intermittent Pneumatic Compression THERAPEUTIC INTERVENTIONS Medications Cardiac Glycosides Vasodilators Antihypertensives Antidysrhythmics Antianginals THERAPEUTIC INTERVENTIONS (CONT’D) Medications Cont’d Anticoagulants Thrombolytics LIFESTYLE AND CARDIAC CARE Risk Factors Support Groups Sexual Activity CARDIOPULMONARY BYPASS PUMP CARDIOPULMONARY BYPASS PUMP IN USE CARDIAC SURGERY Preparation for Surgery Cardiopulmonary Bypass Video-Assisted Thoracoscope General Procedure for Cardiac Surgery CHAPTER 22 Nursing Care of Patients with Hypertension HYPERTENSION New Guidelines Blood Pressure Taken in Seated Position Normal BP Is Below 120/80 mm Hg Average of 2 or More Readings on Different Dates Highest Reading Determines Category TAKING BLOOD PRESSURE Use Calibrated Instrument Seated Quietly 5 Minutes in Chair (Not on Exam Table) with Feet on Floor, Arm Supported at Heart Level. Use Cuff Bladder Encircling at Least 80 % of Arm. Take 2 BP Measurements. Tell Patients BP Reading CLASSIFICATION OF HYPERTENSION Systolic Diastolic Pre-Hypertension: 120-139 or 80-89 mm Hg Stage 1 Hypertension: 140-159 or 90-99 mm Hg Stage 2 Hypertension: >160 or >100 mm Hg FOLLOW-UP CARE Normal BP: 2 Years Pre-Hypertension: 1 Year Stage 1 Hypertension: 2 Months Stage 2 Hypertension: 1 Month >180/110 mm Hg: Immediate Treatment BLOOD PRESSURE Pressure Exerted by Blood on Walls of Blood Vessels Determined by Cardiac Output, Peripheral Vascular Resistance, Vessel Stretch, Blood Viscosity, Blood Volume PATHOPHYSIOLOGY Primary Hypertension Secondary Hypertension Unknown Cause Known Cause Isolated Systolic Hypertension SBP Over 140 mm Hg HYPERTENSION SIGNS/SYMPTOMS None “Silent Killer” Rare — Headache, Bloody Nose, Anxiety, Dyspnea Target Organ Disease — Damage to Blood Vessels of Heart, Kidney, Brain, Eyes DIAGNOSIS OF HYPERTENSION History Signs and Symptoms Kidney or Heart Disease Medications Blood Pressure Readings DIAGNOSTIC TESTS ECG Blood Glucose Hematocrit Potassium Calcium Lipoprotein, Cholesterol, Triglyceride Levels HYPERTENSION RISK FACTORS Nonmodifiable: Unable to be Changed Modifiable: Changeable NONMODIFIABLE RISK FACTORS Family History of Hypertension Age Ethnicity Diabetes Mellitus MODIFIABLE RISK FACTORS Weight Diet DASH Limit Sodium Limit Caffeine Alcohol Use Exercise Smoking Stress Management HYPERTENSION TREATMENT No/Low Risk Hypertensive BP >140/90 mm Hg over 6 Months Goal of Treatment >140/90 mm Hg >130/80 mm Hg Diabetes/Kidney Disease HYPERTENSION TREATMENT (CONT’D) Lifestyle Changes and Antihypertensive Medications Initial Therapy: Thiazide-type Diuretics MEDICATIONS FOR HYPERTENSION Diuretics Alpha Blockers Beta Blockers Calcium Channel Blockers MEDICATIONS FOR HYPERTENSION Angiotensin-converting Enzyme Inhibitors Central Agents Peripheral Agents Vasodilators COMPLICATIONS OF HYPERTENSION Atherosclerosis Coronary Artery Disease Myocardial Infarction Left Ventricular Hypertrophy Stroke Kidney/Eye Damage HYPERTENSIVE EMERGENCY SBP >180 mm Hg Systolic DBP >120 mm Hg Systolic Risk for/Progression for Target Organ Dysfunction Immediate Gradual Reduction of BP to Protect Target Organs Treatment: Nitroprusside (Nipride) IV HYPERTENSIVE URGENCY Severe BP Elevation Without Target Organ Dysfunction Progression Severe Headaches, Nosebleeds, Shortness of Breath and Severe Anxiety Oral Medication NURSING PROCESS Deficient Knowledge Ineffective Therapeutic Regimen Management PATIENT EDUCATION Lifelong BP control Self-Care Measures Prescribed Medical Regimen NURSING CARE OF PATIENTS WITH VALVULAR, INFLAMMATORY, AND INFECTIOUS CARDIAC OR VENSOUS DISORDERS Chapter 23 INFLAMMATORY AND INFECTIOUS CARDIAC DISORDERS Rheumatic Carditis Affects Entire Heart Layers of the Heart Endocarditis, Myocarditis, Pericarditis LAYERS OF HEART RHEUMATIC CARDITIS Etiology/Pathophysiology Rheumatic Fever Complication 2–3 Weeks After Autoimmune Reaction to Upper Respiratory BetaHemolytic Streptococci Infection Heart Layers Inflamed RHEUMATIC CARDITIS (CONT’D) Etiology/Pathophysiology Endocardial Vegetations RHEUMATIC CARDITIS (CONT’D) Signs and Symptoms Tachycardia Heart Murmur Pericardial Friction Rub Chest Pain Heart Enlargement RHEUMATIC CARDITIS (CONT’D) Signs and Symptoms ECG Changes Heart Failure RHEUMATIC CARDITIS (CONT’D) Prevention Treat streptococcal infections. After rheumatic fever, lifelong prophylactic antibiotics for dental/invasive procedures to prevent endocarditis. RHEUMATIC CARDITIS (CONT’D) Therapeutic Interventions Antibiotics Analgesics, Aspirin, Corticosteroids Limited Activity Supportive Care RHEUMATIC CARDITIS (CONT’D) Nursing Management History of Infections Vital Signs Heart Failure Symptoms Pain Relief RHEUMATIC CARDITIS (CONT’D) Nursing Management Anxiety Relief Education INFECTIVE ENDOCARDITIS Infection of Endocardium INFECTIVE ENDOCARDITIS (CONT’D) Pathophysiology Invading Organism Attaches to Endocardium Vegetative Lesion Forms Damages Valve Leaflets Emboli/Heart Failure Possible INFECTIVE ENDOCARDITIS ETIOLOGY Entry of Organism into Bloodstream Risk Factors IV Drug Use Immunocompromised Congenital/Valvular Heart Disease Gingival Gum Disease INFECTIVE ENDOCARDITIS Prevention Oral/Dental Care Prophylactic Antibiotics per Criteria INFECTIVE ENDOCARDITIS SIGNS AND SYMPTOMS Fever Murmur Splinter Hemorrhages Petechiae Janeway Lesions Osler’s Nodes PETECHIAE INFECTIVE ENDOCARDITIS (CONT’D) Complications Vegetative Emboli Heart valve Stenosis/Regurgitation Heart Failure INFECTIVE ENDOCARDITIS (CONT’D) Diagnostic Tests Blood Cultures Echocardiography INFECTIVE ENDOCARDITIS (CONT’D) Therapeutic Interventions IV Antimicrobial Drug Rest/Supportive Care Home IV Antimicrobial Therapy Surgical Valve Replacement/Repair INFECTIVE ENDOCARDITIS (CONT’D) Nursing Management Vital Signs/Cardiac Function Report Heart Failure/Emboli Signs Teach Good Hygiene, Oral/Dental Care Report Symptoms: Fever, Chills, Sweats PERICARDITIS Inflammation of Pericardium Acute Chronic PERICARDITIS (CONT’D) Pathophysiology Inflammation of the Pericardium Ventricular Filling Reduced Decreased Cardiac Output and BP PERICARDITIS ETIOLOGY Infections, Lyme Disease Drug Reactions Connective Tissue Disorders Neoplastic Disease Postmyocardial Infarction Renal Disease or Uremia Trauma PERICARDITIS (CONT’D) Signs and Symptoms Chest Pain; Substernal, Radiates, Grating Increases with Deep Inspiration Relieved by Sitting Up/Forward Pericardial Friction Rub Dyspnea PERICARDITIS Signs and Symptoms Low-Grade Fever Cough PERICARDITIS DIAGNOSTIC TESTS ECG Echocardiogram WBC Pericardial Fluid CT Scan MRI PERICARDITIS THERAPEUTIC INTERVENTIONS Pericardiocentsis Treat Cause Antibiotics Hemodialysis Pericardial Window Pericardiectomy PERICARDITIS THERAPEUTIC INTERVENTIONS (CONT’D) Bed Rest NSAIDs PERICARDIOCENTSIS PERICARDITIS Complications Pericardial Effusion Cardiac Tamponade Immediate Pericardiocentesis PERICARDITIS NURSING MANAGEMENT Vital Signs Cardiac Function/Tamponade Signs Pain Relief NSAIDs, Corticosteroids Position of Comfort Education MYOCARDITIS Pathophysiology and Etiology Inflammation of Myocardium Rare Often Follows Virus VENOUS DISORDERS Thrombophlebitis THROMBOPHLEBITIS Clot formation Inflammation Within Vein THROMBOPHLEBITIS (CONT’D) Pathophysiology Clot formation and Inflammation Within Vein Superficial Veins Deep Veins (DVT) Emboli Danger THROMBOPHLEBITIS (CONT’D) Etiology Venous Stasis Reduced Blood Flow Damage to Vein Lining IV Catheters THROMBOPHLEBITIS (CONT’D) Etiology (Cont’d) Increased Blood Coagulation Smoking Oral Contraceptives Estrogen Therapy Hematological Disorders THROMBOPHLEBITIS (CONT’D) Prevention Identify Risk Factors Prevent Dehydration Prophylactic Antiembolism Devices Early Ambulation Range-of-Motion Exercises THROMBOPHLEBITIS (CONT’D) Prevention (Cont’d) Prophylactic Medication Low Molecular Weight Heparin Enoxaparin (Lovenox) Heparin Warfarin (Coumadin) THROMBOPHLEBITIS (CONT’D) Signs and Symptoms None Superficial Veins Redness, Warmth, Swelling, Tenderness THROMBOPHLEBITIS (CONT’D) Signs and Symptoms Deep Veins Leg Usually Swelling, Edema, Pain, Warmth, Tenderness Homans’ Sign in 40% of Cases THROMBOPHLEBITIS (CONT’D) Complications Pulmonary Embolism Life-Threatening Emergency Chronic Venous Insufficiency Varicose Veins Recurrent Deep Vein Thrombosis THROMBOPHLEBITIS (CONT’D) Diagnostic Tests Duplex Ultrasound Impedance Plethysmography Magnetic Resonance Imaging (MRI) Venography D-Dimer and Coagulation Tests THROMBOPHLEBITIS (CONT’D) Therapeutic Interventions Superficial Veins Warm, Moist Heat Analgesics NSAIDs Compression Stockings THROMBOPHLEBITIS (CONT’D) Therapeutic Interventions Deep Veins Low-Molecular Weight Heparin/Heparin Warfarin (Coumadin) Bedrest (Elevate Extremity) Warm, Moist Heat Compression Stocking Therapy THROMBOPHLEBITIS (CONT’D) Therapeutic Interventions Deep Veins Thrombolytic Therapy Thrombectomy Vena Cava Filter VENA CAVA FILTER THROMBOPHLEBITIS (CONT’D) Nursing Diagnoses Acute Pain Impaired Skin Integrity Anxiety Deficient Knowledge NURSING INTERVENTIONS (CONT’D) Identify Risk Factors Monitor Those at Risk for Signs Administer Meds per INR/PT Relieve Pain Monitor for Pulmonary Embolism Educate CARDIAC VALVULAR DISORDERS Mitral Valve Prolapse Mitral Stenosis Mitral Regurgitation Aortic Stenosis Aortic Regurgitation STENOSED, INSUFFICIENT AND NORMAL VALVE TERMS TO KNOW Stenosis Narrowed, Valve Does Not Open Completely Forward Blood Flow Hindered Decreases Cardiac Output TERMS TO KNOW (CONT’D) Regurgitation (Insufficiency) Valve Does Not Close Completely Blood Flow Backs Up MITRAL VALVE PROLAPSE (MVP) PATHOPHYSIOLOGY During ventricular systole, mitral valve flaps normally closed. In mitral valve prolapse one/both flaps bulge into left atrium. If bulging flaps do not fit together, mitral regurgitation occurs. MITRAL VALVE PROLAPSE Etiology Unknown Hereditary Women 20-55 Years of Age MITRAL VALVE PROLAPSE (CONT’D) Signs and Symptoms Often None Anxiety Chest Pain Dysrhythmias Dyspnea MITRAL VALVE PROLAPSE (CONT’D) Signs and Symptoms Fatigue Palpitations MITRAL VALVE PROLAPSE (CONT’D) Diagnostic Tests Murmur Heard 2-D Or Doppler Echocardiogram Coronary Angiogram MITRAL VALVE PROLAPSE (MVP) THERAPEUTIC INTERVENTION None, Unless Symptoms Healthy Lifestyle Avoid Stimulants/Caffeine Stress Management Beta Blockers for Tachycardia Valve Surgery for Severe MVP MVP Complications Dilation of Left Side of Heart Heart Failure Infective Endocarditis Emboli MITRAL STENOSIS Pathophysiology Mitral Valve Thickening/Chordae Tendineae Shortening Narrows Valve Opening Blood Flow Obstructed from Left Atrium Left Atrium Enlarges MITRAL STENOSIS (CONT’D) Pathophysiology (cont’d) Backward Pressure Occurs until Right Ventricle Dilates/Fails Cardiac Output Reduced MITRAL STENOSIS ETIOLOGY Prior Rheumatic Fever Common Congenital Defects Tumors Rheumatoid Arthritis Systemic Lupus Erythematosus Rheumatic Endocarditis MITRAL STENOSIS (CONT’D) Continuous and Progressive MITRAL STENOSIS (CONT’D) Signs and Symptoms None Early Murmur Exertional Dyspnea, Cough, Hemoptysis Fatigue Palpitations MITRAL STENOSIS (CONT’D) Signs and Symptoms (cont’d) Atrial Fibrillation Chest Pain MITRAL STENOSIS (CONT’D) Diagnostic Tests ECG: P-Wave Changes Chest X-Ray: Enlarged Chambers 2-D and Doppler Echocardiography Coronary Angiogram MITRAL STENOSIS (CONT’D) Therapeutic Intervention Prophylactic Antibiotics per Criteria Anticoagulants: Atrial Fibrillation Percutaneous Balloon Valvuloplasty PERCUTANEOUS BALLOON VALVULOPLASTY MITRAL STENOSIS (CONT’D) Surgery Mitral Valve Repair Commissurotomy Annuloplasty Mitral Valve Replacement MITRAL VALVE REPLACEMENT MITRAL STENOSIS Complications Stroke Seizures MITRAL REGURGITATION Pathophysiology Mitral Valve Incomplete Closure Backflow of Blood to Left Atrium Left Atrium Dilates, Extra Volume to Left Ventricle Left Ventricle Dilates from Extra Volume, Eventually May Fail MITRAL REGURGITATION (CONT’D) Etiology Rheumatic Heart Disease (Most) Endocarditis Congenital Defects Chordae Tendineae Dysfunction MVP MITRAL REGURGITATION (CONT’D) Signs and Symptoms None Early Murmur Dyspnea, Cough, Hemoptysis Fatigue Palpitations MITRAL REGURGITATION (CONT’D) Signs And Symptoms (cont’d) Atrial Fibrillation Chest Pain MITRAL REGURGITATION (CONT’D) Diagnostic Tests ECG: P-Wave Changes Chest X-Ray: Enlarged Chambers 2-D and Doppler Echocardiography Coronary Angiogram MITRAL REGURGITATION (CONT’D) Therapeutic Intervention None, Unless Symptoms Prophylactic Antibiotics per Criteria ACE Inhibitors Anticoagulants: Atrial Fibrillation Mitral Valve Repair/Replacement AORTIC STENOSIS Pathophysiology Aortic Valve Narrowed Left Ventricle Contracts More Forcefully Left Ventricle Hypertrophies Decreased Cardiac Output Eventual Heart Failure AORTIC STENOSIS (CONT’D) Etiology Congenital Defects Rheumatic Heart Disease Calcification with Aging AORTIC STENOSIS (CONT’D) Signs And Symptoms None Early Angina Murmur Syncope Orthopnea Dyspnea on Exertion Fatigue Pulmonary Edema AORTIC STENOSIS (CONT’D) Diagnostic Tests ECG Chest X-Ray: Enlarged Left Ventricle 2-D and Doppler Echocardiography Serial Echocardiography Cardiac Catheterization AORTIC STENOSIS (CONT’D) Therapeutic Intervention Surgery Aortic Valve Replacement Valvotomy (Young Adults) Treat Heart Failure Symptoms Prophylactic Antibiotics per Criteria AORTIC REGURGITATION PATHOPHYSIOLOGY Aortic Valve Does Not Close Left Ventricle’s Volume Increases Left Ventricle Dilates Left Ventricle Fails Decreased Cardiac Output Pulmonary Edema AORTIC REGURGITATION Etiology Rheumatic Heart Disease (Most) Congenital Defects Syphilis Endocarditis Severe Hypertension AORTIC REGURGITATION (CONT’D) Etiology (cont’d) Rheumatoid Arthritis Aortic Dissection AORTIC REGURGITATION (CONT’D) Signs and Symptoms None Early Exertional Dyspnea, Fatigue Corrigan’s Pulse: Palpated Pulse Forceful, Quickly Collapses Widened Pulse Pressure Angina At Night AORTIC REGURGITATION (CONT’D) Diagnostic Tests ECG Chest X-Ray 2-D and Doppler Echocardiography Coronary Angiogram AORTIC REGURGITATION (CONT’D) Therapeutic Intervention Vasodilator Prophylactic Antibiotic Therapy Surgical Valve Replacement NURSING PROCESS: VALVULAR DISORDERS Nursing Assessment History Vital Signs Signs andSymptoms NURSING DIAGNOSES Pain Decreased Cardiac Output Activity Intolerance Excess Fluid Volume Ineffective Therapeutic Regimen Management PLANNING Pain Management Relieves Pain Maintain Vital Signs/Oxygen Saturation Maintain Desired Activities Maintain Clear Lung Sounds Understand Disease/Treatment NURSING INTERVENTIONS Pain Relief Rating Scale NTG Pace Activities NURSING INTERVENTIONS (CONT’D) Normal Cardiac Function Vital Signs Intake and Output Daily Weights Sodium Restriction Smoking Cessation Medications as Ordered NURSING INTERVENTIONS (CONT’D) Improve Quality of Life Assist ADLs Rest Periods Energy Conservation NURSING INTERVENTIONS (CONT’D) Maintain Fluid Volume Daily Weights Assess for Edema Intake/Output Diuretics as Ordered Monitor Potassium Levels NURSING INTERVENTIONS (CONT’D) Education Medications Anticoagulants Monthly INR/PT Tests Medic Alert Identification NURSING INTERVENTIONS (CONT’D) Education (cont’d) Include Caregivers for Elderly Endocarditis Prevention - Prophylactic Antibiotics EVALUATION Reports Satisfactory Pain Relief Vital Signs Normal/No Heart Failure Signs Reports Reduced Fatigue, Task Completion Remains Free of Edema, Maintains Weight, Clear Lung Sounds EVALUATION Verbalizes Understanding of Teaching/with No Symptom Recurrence CARDIAC VALVULAR SURGERY Traditional Open Cardiac Surgery with Cardiopulmonary Bypass CARDIAC VALVULAR SURGERY (CONT’D) Exploring Less Invasive Options Transseptal Stitch Repair and Coronary Sinus Tucking Mini Thoracotomy Robotic Devices HEART VALVE REPAIRS Stenosed Valve Repair Commissurotomy Balloon Valvotomy Insufficent Valve Repair Annuloplasty HEART VALVE REPLACEMENT Mechanical Durable Creates Turbulent Blood Flow Lifelong Anticoagulation Used For Younger Adults MECHANICAL HEART VALVES HEART VALVE REPLACEMENT Biological Types Porcine (Pig) Bovine (Cow) Allografts (Human) Cultural Considerations HEART VALVE REPLACEMENT (CONT’D) Biological Not as Durable as Mechanical Valves No Lifelong Anticoagulation Used For Older Adults VALVE REPLACEMENT COMPLICATIONS Biological Valves Degenerative Changes Calcification VALVE REPLACEMENT COMPLICATIONS (CONT’D) Mechanical Valves INR/PT Monitoring for Bleeding Risk Thrombus/Embolism Formation Anemia Endocarditis NURSING PROCESS: CARDIAC SURGERY PREPARATION Data Collection Circulatory Status Pain Control Needs Diagnostic Tests Typing And Crossmatching of Blood Needed PREOPERATIVE VASCULAR NURSING DIAGNOSES Acute or Chronic Pain Anxiety Deficient Knowledge CARDIAC SURGERY PREPARATION Teaching Pain Management Endotracheal Tube/Ventilator Communicating Chest Tubes Coughing/Deep Breathing CARDIAC SURGERY PREPARATION (CONT’D) Teaching IV Lines Urinary Catheter CARDIAC SURGERY PREPARATION (CONT’D) Preoperative Medications Antiseptic Scrub Showers NPO POSTOPERATIVE CARDIAC SURGERY NURSING DIAGNOSES Pain Ineffective Airway Clearance Impaired Gas Exchange Decreased Cardiac Output Risk for Infection Deficient Knowledge POSTOPERATIVE CARDIAC SURGERY NURSING CARE Pain/Provide Relief Vital Signs, ECG ABGs Intake and Output Lung Sounds Incision POSTOPERATIVE CARDIAC SURGERY NURSING CARE (CONT’D) Promote Lung Expansion Cough and Deep Breathe Turn Ambulate POSTOPERATIVE CARDIAC SURGERY NURSING CARE (CONT’D) Prevent Infection Hand Hygiene Cleanse Stethoscope Sterile Technique Monitor Temperature POSTOPERATIVE CARDIAC SURGERY NURSING CARE (CONT’D) Teaching Pain Management Medications Activity Follow-up Monitoring/Care CHAPTER 24 Nursing Care of Patients with Occlusive Cardiovascular Disorders ARTERIOSCLEROSIS Artery/Arteriole Walls Thicken Harden Lose Elasticity ATHEROSCLEROSIS ATHEROSCLEROSIS (CONT’D) Type of Arteriosclerosis Plaque Formation in Arterial Wall Childhood Onset ATHEROSCLEROSIS (CONT’D) Non-modifiable Risk Factors Age Gender Ethnicity Genetic Predisposition for Hyperlipidemia ATHEROSCLEROSIS (CONT’D) Modifiable Risk Factors Diabetes Mellitus Hypertension Smoking Obesity Sedentary Lifestyle Increased Serum Homocysteine ATHEROSCLEROSIS (CONT’D) Modifiable Risk Factors (cont’d) Increased Serum Iron Levels Infection Depression Hyperlipidemia Elevated Apolipoprotein B Excessive Alcohol Intake ATHEROSCLEROSIS (CONT’D) Diagnostic Tests for Increased CVD Cholesterol Elevated Increases Risk Low-density Lipoproteins (LDL) Increased risk High-density Lipoproteins (HDL) Protective ATHEROSCLEROSIS (CONT’D) Diagnostic Tests (cont’d) Lp(a) Cholesterol Elevated Increases Risk Apolipoprotein B > Apolipoprotein A Increased Risk Triglycerides Increased Risk ATHEROSCLEROSIS (CONT’D) Diagnostic Tests (cont’d) C-reactive Protein Inflammation in C.A. Shows Increased Risk Elevated Leukocyte Count in Women Increased Risk ATHEROSCLEROSIS (CONT’D) Therapeutic Interventions Low-fat Diet Avoid Smoking Exercise Lipid-lowering Agents CORONARY ARTERY DISEASE (CAD) Obstruction of Coronary Artery Blood Flow Typically from Atherosclerosis Contributes to Angina Myocardial Infarction Sudden Death CAD PREVENTION Modify Risk Factors Low-cholesterol Diet Lipid-lowering Agents Low Dose Aspirin ANGINA PECTORIS Symptom of Ischemia Chest Pain Causes: CAD, Vasospasm, Valvular Heart Disease, Hypertension, Heart Failure TYPES OF ANGINA Stable Angina Arteries Cannot Increase Blood to Heart Increased Activity Usually Stops with Rest/Vasodilator During TYPES OF ANGINA (CONT’D) Variant Angina (Prinzmetal’s Angina) Longer Duration Can Occur at Rest Often Same Time Each Day Coronary Artery Spasm Cause Serious ANGINA SIGNS AND SYMPTOMS Pain Heaviness, Tightness, Viselike, Crushing Pain in Chest Center In the Morning Radiation ANGINA SIGNS AND SYMPTOMS (CONT’D) Pale Diaphoretic Dyspneic FEMALE ANGINA SIGNS AND SYMPTOMS Chest Pain, Jaw Pain, Heartburn Atypical Symptoms Describe Less Severe Pain Fatigue Nausea Breathlessness DIAGNOSTIC TESTS ECG Exercise ECG (Stress Test) Graded Exercise Testing Stress Echocardiography Chemical Stress Testing Radioisotope Imaging Coronary Angiography THERAPEUTIC INTERVENTIONS Weight Reduction Low-fat, Low-cholesterol Diet Stress Reduction Medications THERAPEUTIC INTERVENTIONS (CONT’D) Vasodilators Calcium Channel Blockers Nitroglycerin (NTG) Diltiazem, Amlodipine Beta blockers Propranolol, Metoprolol, Atenolol THERAPEUTIC INTERVENTIONS (CONT’D) ACEI Statins Captopril, Lisinopril, Ramipril, Enalapril Atorvastatin, Fluvastatin, Lovastatin, Pravastatin, Simvastatin, Rosuvastin Antiplatelets Aspirin, Clopridogrel (Plavix) NURSING CARE Acute Pain Interventions Oxygen Vital Signs Sublingual NTG Remain with Patient Emotional Support ACUTE CORONARY SYNDROMES Caused by Lack of Oxygen to Heart Muscle Conditions Unstable Angina Myocardial Infarction UNSTABLE ANGINA Worsening CAD Rest Does Not Relieve Can Occur at Rest Increasing Frequency Risk for Cardiac Damage/Death MYOCARDIAL INFARCTION (MI) Death of Heart Muscle Pathophysiology Coronary Artery Blockage Decreased Cardiac Blood Supply Types Non-ST Segment Elevation Myocardial Infarction ST Segment Elevation Myocardial Infarction MYOCARDIAL INFARCTION (MI) (CONT’D) SILENT ISCHEMIA Myocardial Ischemia Without Chest Pain SUDDEN CARDIAC DEATH Cardiac Arrest Triggered by Lethal Ventricular Dysrhythmias or Asystole from an Abrupt Occlusion of a Coronary Artery SIGNS AND SYMPTOMS Crushing, Viselike Pain Radiates to Arm/Shoulder/Neck/Jaw Shortness of Breath Restlessness Dizziness, Fainting Nausea Sweating SIGNS AND SYMPTOMS (CONT’D) Atypical – Women/Older Adult Absence of Classic Pain Dyspnea Fatigue Anxiety Chest Cramping, Epigastric or Abdominal Pain SIGNS AND SYMPTOMS (CONT’D) Atypical – Women/Older Adult (cont’d) Restlessness Falling OLDER ADULTS AND MI Report Shortness of Breath, Fatigue, Fast/Slow Heartbeats, Chest Discomfort Silent MI Collateral Circulation TIMELY MEDICAL CARE “Act in Time to Heart Attack Signs” Call 9-1-1 (or Local Emergency Number) www.nhlbi.nih.gov/actintime/ National Heart Attack Alert Program “60 Minutes to Treatment” www.nhlbi.nih.gov/about/nhaap WOMEN AND MI Leading Cause of Death African American Women at Higher Risk Higher Mortality Rate, More Complications Than Men Prodromal Symptoms the Month Before MI Unusual Fatigue, Sleep Disturbances, Dyspnea WOMEN AND MI (CONT’D) Delay Treatment Less Aggressive Treatment Given DIAGNOSTIC TESTS Consider Patient History Serial ECG Cardiac Troponin I or T Myoglobin CK-MB C-reactive Protein Magnesium ECG CHANGES WITH MI PRE-HOSPITAL CARE “Time is Muscle” Chew One Uncoated Adult Aspirin Call 911 in 5 Minutes for Unrelieved Chest Pain Do Not Drive Self EMERGENCY PERCUTANEOUS CORONARY INTERVENTION Mission: Lifeline www.americanheart.org/ Door-to-Balloon Time: 90 Minutes www.d2balliance.org/ THERAPEUTIC INTERVENTIONS Oxygen Aspirin Morphine Sulfate Thrombolytics Vasodilators Nitrates Beta Blockers Antidysrhythmic INVASIVE PROCEDURES PCI Balloon Angioplasty Coronary Artery Stents PCI: BALLOON ANGIOPLASTY CORONARY ARTERY STENT THERAPEUTIC INTERVENTIONS (CONT’D) Bedrest/Bedside Commode Intra-aortic Balloon Pump Glucose Control Daily Weight Low-sodium Clear Liquids Low-fat, Low-cholesterol, Low-sodium Diet THERAPEUTIC INTERVENTIONS (CONT’D) No Caffeine Fluid Restriction Weight Loss Smoking Cessation THERAPEUTIC INTERVENTIONS (CONT’D) Fab Four Cardiac Drugs Antiplatelets Statins ACEIs Beta Blockers MYOCARDIAL REVASCULARIZATION Coronary Artery Bypass Graft Coronary Artery Occlusions Bypassed with Vein/Artery Grafts Increases Blood Flow/Oxygen to Myocardium MIDCAB Thoracoscope No Cardiopulmonary Bypass Small Incisions Two Coronary Arteries Maximum PORT-ACCESS CORONARY ARTERY BYPASS Combines Peripheral Cardiopulmonary Bypass (CPB) with Minimally Invasive Heart Access NURSING CARE Monitor Vital Signs Report Symptoms Incisional Care PATIENT EDUCATION Disease Information Medications Diet Activity Rehabilitation CARDIAC REHABILITATION Optimizes Functioning Begins in Hospital Protocols Specify Activities Outpatient Program After Discharge PERIPHERAL VASCULAR DISEASE Arterial Venous ARTERIAL THROMBOSIS/EMBOLISM Arterial Blood Clot Can Become Embolus ARTERIAL THROMBOSIS/EMBOLISM (CONT’D) Six Ps Pain Pulselessness Paralysis Pallor Paresthesia Poikilothermia ARTERIAL THROMBOSIS/EMBOLISM (CONT’D) Therapeutic Interventions Anticoagulants Thrombolytics Thrombectomy Embolectomy PERIPHERAL ARTERIAL DISEASE Pathophysiology Chronic, Progressive Arterial Narrowing Reduced Blood Supply Ischemia Develops SIGNS AND SYMPTOMS Intermittent Claudication Cool Skin Reddish-purple When Dependent Pale When Elevated Diminished/Absent Pulses DIAGNOSTIC TESTS Ankle-brachial Index Doppler Ultrasound MRI Arteriography THERAPEUTIC INTERVENTIONS Low-fat, Low-cholesterol, Low-calorie Diet Medications Lipid-lowering Agents Pentoxifylline (Trental) Thrombolytics THERAPEUTIC INTERVENTIONS (CONT’D) Invasive Therapies Percutaneous Transluminal Angioplasty (PTA) Atherectomy Stents Aortic-femoral Bypass AORTIC-FEMORAL BYPASS RAYNAUD’S DISEASE Vasoconstriction with Cold/Stress Causing Ischemia Mainly Affects Hands Phases: Blanching, Pain, Reddening Therapeutic Intervention: Keep Warm, Avoid Vasoconstriction, Take Vasodilators RAYNAUD’S DISEASE (CONT’D) Nursing Care: Education BUERGER’S DISEASE Recurring Inflammation of Small and Medium Arteries and Veins of Hands/Feet Vasospasms, Ischemia, Gangrene Cause is Unknown Heavy Cigarette Smoking Contributes BUERGER’S DISEASE (CONT’D) Signs and Symptoms Intermittent Claudication Six Ps Lower Extremities Red or Cyanotic in Dependent Position BUERGER’S DISEASE (CONT’D) Therapeutic Interventions Smoking Cessation Calcium Channel Blockers Skin Assessment ANEURYSMS Dilation at Weakened Area of Artery Cause Unknown Abdominal Aorta Most Common TYPES OF ANEURYSMS (CONT’D) SIGNS AND SYMPTOMS None Early Back/Flank Pain Classic Pulsating Abdominal Mass Rupture Severe, Sudden Back, Flank, or Abdominal Pain Shock DIAGNOSTIC TESTS CT Scan Abdominal Ultrasound Aortography THERAPEUTIC INTERVENTIONS Control Hypertension Bypass Graft Open Endovascular NURSING CARE Education Medication Avoid Lifting Reduce Stress Postoperative Care VARICOSE VEINS Elongated, Tortuous, Dilated Veins Cause is Unknown Hereditary Varicosities Primary Secondary VARICOSE VEINS (CONT’D) Contributing Factors Prolonged Standing Pregnancy Obesity VARICOSE VEINS (CONT’D) Signs and Symptoms Disfigurement of Lower Extremity Dull Pain Edema Ulceration VARICOSE VEINS (CONT’D) Therapeutic Interventions Reduce Contributing Factors Compression Stockings Injection Sclerotherapy Radiofrequency Ablation Laser Surgical Intervention VENOUS INSUFFICIENCY Damaged/Aging Valves Cause Pooling of Blood in Lower Extremities Chronic VENOUS STASIS ULCERS Result of Chronic Venous Insufficiency Leg/Foot: Edema; Brownish Discoloration; Hardened, Leathery Skin Stasis Ulcers at Ankle Patient’s Quality of Life Affected THERAPEUTIC INTERVENTIONS Goal: Decrease Edema/Heal Ulcerations Compression Wraps Bedrest with Elevation of Legs Avoid Prolonged Standing/Sitting Walk Skin Ulcers: Unna Boot, Skin Grafts NURSING INTERVENTIONS Wound Care Emotional Support EMBOLECTOMY AND THROMBECTOMY Restores Blood Flow and Oxygenation Can Be Surgical Emergency VASCULAR BYPASSES AND GRAFTS Bypass: Graft Anastomosed to Artery Above and Below Occlusion Graft Repair: Diseased Area of Blood Vessel Replaced with Graft VASCULAR BYPASSES AND GRAFTS (CONT’D) Video-assisted Aortofemoral Bypass ENDARTERECTOMY Arteriosclerotic Plaques Dissected Carotid Artery Common ANGIOPLASTY Open Plaque-blocked Arteries Balloon or Laser STENTS Support to the Artery Walls to Keep Them Open COMPLICATIONS OF VASCULAR SURGERIES Bleeding and Hemorrhage Re-occlusion Hematoma Neurological Dysfunction Volume Deficit POSTOPERATIVE THERAPEUTIC INTERVENTIONS Neurological Checks Neurovascular Checks Incision Care Fluid Status