Management of cardiovascular system

On completion of this chapter, the learner will be able to:1. Describe the pathophysiology, clinical manifestations, and

treatment of coronary atherosclerosis.2. Describe the pathophysiology, clinical manifestations, and

treatment of angina pectoris.3. Use the nursing process as a framework for care of patients

with angina pectoris.4. Describe the pathophysiology, clinical manifestations, and

treatment of myocardial infarction.5. Use the nursing process as a framework for care of patients

with myocardial infarction (acute coronary syndrome).6. Describe the nursing care of a patient who has had an invasive

interventional procedure for treatment of coronary artery disease.

7. Describe coronary artery revascularization procedures.8. Describe the nursing care of the patient treated with cardiac

surgery.

Anatomy of the Heart

Assessment of Cardiovascular Function

− Cardiac output: Amount of blood pumped by each ventricle in liters per minute.

* Normal cardiac output 5L/min in resting.− Stroke volume: Is the amount of blood

ejected per heart beat. * The average stroke volume is about 70 ml. Cardiac output = Stroke volume x Heart beat.

= 70 ml X (60-80) b/min.

Control of stroke volume:

− Stroke volume: Is primarily determined by three factors:

Preload: It’s the degree of stretch of cardiac muscle fibers at end of diastole.

Afterload: The pressure the ventricular myocardium must overcome to eject blood during systole.

Contractility: is a term used to denote the force generating by contracting myocardium under any given condition.

I-Assessment:

1- Health history and clinical manifestation:

* Cardiac Symptoms: - Chest discomfort. -Shortness of breath or Dyspnea. - Edema and weight gain. - Palpitation (dysarrythmias). - Fatigue. - Dizziness and syncope.

I-Assessment:

2- Nutrition and metabolism: Diets that are restricted in sodium,

fat, cholesterol, and calories. 3- Activity and Exercise: If symptoms develop during

exercise, what are nature of exercise.

I-Assessment:4- Physical examination: -The examination, which proceeds logically from head to

toe can be performed in about 10 min. a- General appearance: - The nurse observes the patients level of

consciousness, and thought process as an indication of the hearts ability to

propel oxygen to the brain. b- Inspection of skin: Pallor, cyanosis, Temp, reduce skin turgor,

wounds. c- Blood Pressure. d- Arterial pulses: Pulse rate, rhythm, and volume.

II- Cardiac Auscultation:

Heart Sounds:The normal heart sounds, S1, S2, are

produced primarily by the closing of the heart values.

a- S1= Closure of mitral and tricuspid valves.

b- S2= Closure of aortic and pulmonic valves.

II- Cardiac Auscultation: c- Gallop: S3: Occurring during rapid ventricle filling is impeded

during diastole. e.g MI, CHF. S4: When the ventricle is enlarged or hypertrophied

and therefore resistant to filling. e.g. CAD, aortic stenosis.

Note: S4 heard by bell of stethoscope only, they are heard best at

the apex. d- Murmurs: Are created by the turbulent flow of blood, the

causes turbulence may be a critically narrowed valve or

regurgitation of valves.

III- Diagnostic Evaluation:

1- Laboratory Tests: e.g Cardiac enzyme , blood chemistry (urea, creatinine, serum electrolyte, coagulation studies, lipid profile.) 2- Chest x-ray and fluoroscopy. 3- Cardiac stress test: To detect the ischemia, by increasing the metabolic

demands for oxygen. 4- Echocardiograph: Is non invasive ultrasound test used to examine the size,

shape and motion of cardiac structures. 5- Cardiac Catheterization: Is an invasive diagnostic procedure in which radiopaque arterial and venous catheters are introduced into

selected blood vessels of the right and left sides of the heart.

III- Diagnostic Evaluation:

6-Electro cardiography. (ECG)

Normal Components of the EKG Waveform

Normal Components of the EKG Waveform

P waveIndicates atrial depolarization, or contraction of the atrium. Normal duration is not longer than 0.11 seconds (less than 3 small

squares) QRS complexIndicates ventricular depolarization, or contraction of the

ventricles. Normally not longer than .10 seconds in duration T waveIndicates ventricular repolarization ST segmentIndicates early ventricular repolarization PR intervalIndicates AV conduction time Duration time is 0.12 to 0.20 seconds

Management of Patient with Coronary Vascular Disease

Coronary Artery Disease: The most prevalent type of cardiovascular

disease is coronary artery disease (CAD). Coronary Atherosclerosis: Is an abnormal accumulation of lipid , or

fatty substances and fibrous tissue in the vessel wall.

Atheroma: Begins as fatty streaks, lipids that are deposite on the intima of the arterial wall.

Management of Patient with Coronary Vascular Disease

Risk factors for (CAD): Non modifiable risk factors: * Family history. * Increasing age. * Gender. * Race. Modifiable risk factors: * High blood cholesterol. * Obesity. * Smoking. * Stress. * Hypertension. * Diabetes mellitus.

Management of Patient with Coronary Vascular Disease

Angina Pectoris: Is a clinical syndrome usually characterized

by episodes or paroxysm of pain or pressure in the anterior chest, the cause is usually insufficient coronary blood flow.

− Factors those are associated with a typical angina pain:

* Physical exertion. * Exposure to cold. * Eating a heavy meal. * Stress or any emotion- provoking

situation.

Angina: Pathophysiology • Temporary and reversible> partial occlusion,

spasm, or thrombus • Cells deprived of oxygen • Cell membranes release histamines,

kinins,specific enzymes stimulating nerve fibers in cardiac muscle that send pain impulses to CNS

• Pain radiates to upper body • <30 minutes ischemia: adequate

nutrients/oxygen clears waste products • > 30 minutes ischemia: irreversible damage

Angina Types:

• Stable Angina– Most common and predictable; occurs with

predictable amount of activity or stress– Occurs when work of heart is increased by physical

exertion, exposure to cold, stress– Relieved by rest and nitrates

• Prinzmetal’s (variant)– Atypical angina occurs unpredictability; not related

to activity and often at night– Caused by spasm of coronary artery with or without

atherosclerotic lesion

Angina Types:

• Unstable Angina– Occurs with increasing frequency, severity,

duration– Pain is unpredictable and occurs with rest, low

activity, stress– At risk for myocardial infarction

• Silent Angina– Asymptomatic ischemia, thought to very

common with CHD– May occur with activity or mental stress

Angina Pectoris:

Clinical Manifestation: * Chest pain. (Retrosternal pain). * Weakness or numbness in the arms. * Shortness of breath. * Pallor, diaphoresis, dizziness or light –headedness. * Nausea, Vomiting. * Anxiety.

Medical Management:1-Pharmacologic Therapy:a-Nitroglycerine: To decrease workload of the heart, and coronary artery vasodilation. b- Beta-adrenergic blocking agents: Such as propranolol

(Inderal),and atenolol(tenormine).To decrease heart rate, blood pressure and myocardium contractility.c- Calcium channel blocking agents: Such as nipedipia,

verpamil, and diltiazem.To decrease heart rate, decrease workload of heart, and increase coronary artery perfusion.

d-Antiplatlates and anticoagulant medication. * Aspirin prevent platelets aggregation. * Heparin prevents the formation of new blood clots. e-Oxygen administration.

Medical Management:

2- Invasive intervention and surgical management:

a- Percautanouse transluminal coronary angioplasty (PTCA).

b- Coronary artery stent. c- Atherectomy. d- Coronary artery bypass graft. (CABG).

Myocardial Infarction:

Definition: Is a death of heart tissue caused by prolonging ischemia.

- Necrosis of myocardial cells; life‐threatening event– Loss of functional myocardium affects heart’s ability to

maintain effective cardiac output– AMI and other ischemic heart diseases cause majority of

deaths– Majority of AMI deaths occur during initial period post

symptoms: 60% within first hour, 40% prior to hospitalization

MI: Pathophysiology•

Develops from atherosclerotic plaques in coronary arteries

• Occurs when blood flow blocked>prolonged tissue ischemia and irreversible cell damage

• Prolonged ischemia> irreversible damage• Cellular metabolism shifts from aerobic to anaerobic

metabolism producing hydrogen ions and lactic acid• Dysrhythmias and decreased myocardial contractility

cause decreased stroke volume, cardiac output, blood pressure

and tissue perfusion

MI: Pathophysiology• Areas of heart– Particular coronary artery occluded determines

area of damage– The specific infarct site predicts possible

complications and dictates appropriate therapy– Specific artery and affected area of heart • Left anterior descending artery: anterior wall

of left ventricle and part of interventricularseptum

• Left circumflex artery: lateral MI • Right coronary artery: right ventricle, inferior

and posterior infarct • Left main coronary artery: entire left ventricle

Myocardial Infarction: Clinical Manifestation: * Sudden chest pain. * Sweating. * Nausea and vomiting. * Cool, pale. * Anxiety. Diagnostic procedure: * ECG. * Echocardiogram. * Laboratory test. eg. Cardiac enzyme (CPK, LDH,Troponin.)

Medical Management:

The goal of medical management is to minimize myocardial damage, preserve myocardial function and prevent complication.

a- Emergent PTCA or stent. b- Pharmacological therapy.e.g

thrombolytics: the purpose is to dissolve and lyses the thrombus in coronary artery. (Reperfusion)

e.g. TPA (Tissue plasminogen activate), Streptokinase.

c- Analgesic. d- Oxygen administration.

Myocardial Infarction:

Nursing intervention: * Relieving chest pain.

* Improving respiratory function. * Promoting adequate tissueperfusion. * Reducing anxiety. * Managing and monitoring potential complication.

Management of Patients With Complications FromHeart Disease

LEARNING OBJECTIVESOn completion of this chapter, the learner will be able to: 1. Describe the management of patients with chronic heart

failure. 2. Use the nursing process as a framework for care of patients

with heart failure. 3. Describe the management of patients with acute heart

failure. 4. Develop teaching plans for patients with heart failure. 5. Describe the management of patients with cardiogenic

shock. 6. Describe the management of patients with thromboembolic

episodes, pericardial effusion and cardiac tamponade, and myocardial rupture.

7. Demonstrate the techniques of cardiopulmonary resuscitation.

Cardiac Failure: Congestive heart failure :( CHF)

Referred to as a cardiac failure, is the inability of the heart to pump sufficient blood to meet the needs of the tissue for

oxygen and nutrient. - The term “congestive heart failure” is most commonly

used when referring to Lt- sided and right-sided heart

failure. - Cardiac failure commonly occurs with disorders of

cardiac muscle that result in decrease contractile properties of

the heart, lead to decrease myocardial contractility include. Myocardial dysfunction (especially from coronary atherosclerosis), arterial hypertension, and valvular dysfunction.

Left –Sided Cardiac failure:

Pulmonary congestion occurs when the left ventricle cannot pump the blood out of the chamber. This increase pressure in the left ventricle and decrease the blood flow from the left atrium. The pressure in the left atrium increase, which decrease the blood flow coming from the pulmonary vessels. The result increase in pressure in the pulmonary circulation forces fluid into the pulmonary tissue and alveoli.

Sings & Symptoms: * Dyspnea on exertion. * Pulmonary Crackles. * Orthopnea. * Restlessness and anxiety. * Cough. * Tachycardia.

Right sided heart failure:

The right side of the heart cannot eject blood, and thus can not accommodate all the blood that normally returns to it from the venous circulation.

Sings & Symptoms; * Edema of the lower extremities. * Wight gain. * Hepatomegally (enlargement of the liver). * Distended neck vein. * Ascites (an accumulation of fluid in the peritoneal cavity). * Anorexia and nausea. * Nocturia. * Weakness. * Pitting edema.

Heart Failure Diagnostics:

• Electrolytes.• UA, BUN, creatinine• LFTs• ABGs• ECG• Echocardiography

HemodynamicMonitoring

• Intra-arterial pressure (art line; a line) Direct and continuous monitoring of systolic, diastolic, mean arterial pressure; arterial blood sampling• Central venous pressure (CVP) Measures blood volume/venous return; reflects right heart filling pressures• Pulmonary artery pressure (PA; Swan-Ganzcatheter) Evaluate left ventricular and overall cardiac function

Medical Management:

The basic objectives in treating patients with congestive heart failure are the following:

* Reducing the workload on the heart. * Increasing the force and efficiency of myocardial

contraction. Pharmacological Therapy: a-ACE (Angiotinsin converted enzyme)

inhibitors: ACE inhibitors promote vasodilation and diuresis

by decreasing afterload and preload, they decrease the work load of the heart.

b-Diuretic Therapy. c-Digitalis. The most commonly prescribed forms of

digitalis for patients with CHF are digoxin (lanoxine) and digotoxin.

- The medication increases the force of myocardial contraction and slows conduction through the AVnode. d- Dobutamine (dobutrex): It stimulates the beta1-adrenergic receptor, and its major action to increase cardiac contractility. e- Other Medication. e.g Anticoagulant, Beta-adrenergic

blockers (propranolol,atenolol)

Aneurysm:

Is an abnormal widening or ballooning of apportion of a blood vessel, the blood vessel wall becomes weaker in this location.

Causes and Risks: * Aneurysms are either congenital or acquired. * Hypertension. * Atherosclerosis disease. * Pregnency, associated with formation and or rupture of splenic artery aneurysms. Signs & Symptoms: * Swelling with a pulsatile (throbbing) mass at site of aneurysms are often seen. * In case of rupture, hypotesion, high heart rate and light headedness are seen; the risk of death from rupture is high.

Aneurysm:

Sings and Tests: * Physical Examination. * Ultrasound Examination. * CT-scan. (Abdomen).

Treatment: * Surgical excision is generally

recommended.

Management of Patients With Structural, Infectious, and Inflammatory Cardiac Disorders

On completion of this chapter, the learner will be able to:1. Define valvular disorders of the heart and describe the

pathophysiology, clinical manifestations, and management of patients

with mitral and aortic disorders.2. Describe types of cardiac valve repair and replacement

procedures used to treat valvular problems and the care needed by patients who undergo these procedures.

3. Describe the pathophysiology, clinical manifestations, and management of patients with cardiomyopathies.

4. Describe the pathophysiology, clinical manifestations, and management of patients with infections of the heart.

5. Describe the rationale for prophylactic antibiotic therapy for patients with mitral valve prolapse, valvular heart disease, rheumatic endocarditis, infective endocarditis, and myocarditis.

Infectious Disease of the Heart:

Rheumatic Endocarditic: − It is results directly from rheumatic fever caused by group A Streptococcal infection. − The disease affects all bony joint, producing polyarthritis; the heart is also a target organ and is where the most serious damage occurs. − Rheumatic endocarditis are not infectious in origin rather they represent reaction occurring in response to hemolytic

streptococci, Leukocytes accumulate in the affected tissue and

forms nodules, which are replaced by scars, gradually thicker than normal and preventing them from closing completely result in leakage, a condition called valvular regurgitation. − The most common site of valvular regurgitation is the mitral valve.

Rheumatic Endocarditic:

Prevention and Treatment: − Early and adequate treatment of streptococcal

infections. − Long term antibiotic therapy is the treatment of

choice. − Penicillin administered parentally remains the

medication of choice.

Infectious Disease of the Heart:

II- Myocarditis: Is an inflammation process involving the myocardium. − Myocarditis can cause heart dilatation, thrombi on the heart wall. Medical Management: − Antibiotic Therapy (penicillin). − Same used for congestive heart failure.III- Pericarditis: Refers to an inflammation of the pericardium, the membrane sac enveloping the heart. Clinical Manifestation: − Sever pain may be felt beneath the clavicle and in the neck and left scapular region. Pericardial pain is aggravated by breathing. Medical Management: − Antibiotic therapy. − Analgesic and NSAID. e.g indomethacin(indocin).

Regurgitation: blood flow backward through the valve. (valve do not close completely).

Prolapse: stretching the valve leaflet into the atrium during systole.

Stenosis: narrowing or obstruction of a cardiac valve’s orifice.

Medical Management : *Valvuloplasty

*Comissurotomy *Valve replacement

•VALVUALR HEART DISEASE

Cardiomyopathies

Is a heart muscle disease associated with cardiac dysfunction. Dilated cardiomyopathy (dilation of the

ventricles) Hypertrophic cardiomyopathy (increase

in size and mass of heart muscle) Restrictive cardiomyopathy (diastolic

dysfunction caused by rigid ventricular walls)

Medical Management

Heart transplantation Mechanical assistive devices

Assessment and Management of PatientsWith Hypertension

LEARNING OBJECTIVES ●On completion of this chapter, the learner will be able to:1. Define blood pressure and identify risk factors for

hypertension.2. Explain the difference between normal blood pressure

and hypertension and discuss the significance of hypertension.

3. Describe the treatment approach for hypertension, including lifestyle changes and medication therapy.

4. Use the nursing process as a framework for care of the patient with hypertension.

5. Describe the necessity for immediate treatment of hypertensive

crisis.

Hypertension

It is a systolic blood pressure greater than 140 mmHg and a diastolic pressure 90 mmHg based on average two or more readings

Types Primary Hypertension (essential hypertension):

high blood pressure of unidentified cause Secondary Hypertension: high blood pressure

from an identified cause

Identifiable causes of hypertension

Sleep apnea Drug induced or related causes Chronic kidney disease Primary aldosteronism Vascular disease Thyroid disease

Clinical manifestation

Often no signs and symptoms Late signs are retinal hemorrhages,

arteriolar narrowing, cotton-wool spots, papilledema

Pathological changes include coronary artery disease, kidney damage, and cerebrovascular involvement

Lifestyle modification to manage Hypertension

Weight reduction Dietary sodium reduction Physical activity Moderation of alcohol consumption

Medical Management

Goal is to achieve BP 140/90 mm Hg. or lower

Pharmacologic therapy includes: diuretics, beta-blockers, or both

Hypertensive Crises

Hypertensive Emergency- BP must be lowered immediately to prevent damage to target organs. E.g. MI, ICH, Aortic aneurysm

Hypertensive Urgency- BP must be lowered within a few hours.

Vascular Disorders and Problems of Peripheral Circulation

Pump failure Alterations in blood and lymphatic vessels

Circulatory insufficiency of the extremities

Health history and clinical manifestations

Intermittent claudication Rubor, loss of hair, dry skin, ulcerations, and edema

Pulses

Diagnostic Evaluation

Doppler Ultrasound Flow Studies Exercise Testing Computed Tomography and

Angiography Magnetic Resonance

Angiography Angiography

Arterial disorders

Arteriosclerosis: hardening of arteries Atherosclerosis

Management Prevention by dietary modifications and

exercise to reduce lipid levels Medications Surgical management Radiologic interventions

Peripheral Arterial Occlusive Disease

Legs are most frequently affected Hallmark symptom is intermittent

claudication Pharmacologic therapy is to increase RBC

flexibility, reduce blood viscosity, inhibit platelet aggregation, inhibit smooth muscle cell proliferation, and increase vasodilation

Surgical management includes vascular grafting or endarterectomy

Arterial Embolism and Arterial Thrombosis

Acute vascular occlusion may be caused by trauma or result of invasive interventions

Arterial emboli most often caused by atrial fibrillation, MI, or other heart dysfunction

Medical management is anticoagulation Surgical management is emergency

embolectomy

Venous Disorders

I- Varicose Veins: Are abnormally dilated, tortuous, superficial veins

caused by incompetent venous valves. - In normal veins, valves in the veins keep blood

moving forward toward the heart. With varicose veins, the valves do not function properly, allowing blood to remain in vein. - This process usually occurs in lower extremities

(saphenous veins, it can occur else where in the body. e.g. esophageal varices.

I- Varicose Veins:

Causes: * Prolong standing. * A hereditary weakness of vein wall. * Increasing the pressure within abdomen. Clinical Manifestation: * Dull aches. * Muscle cramps. * Increase muscle fatigue. * Ankle edema.Medical Management: * Surgery for varicose vein.

Venous Disorders

II- Chronic Venous Insufficiency: Is a condition in which the veins do not

efficiently return blood from the lower limbs back to the heart.

- Venous insufficiently involves one or more veins. - The valves in the vein usually channel the flow of blood toward the heart .When these are damaged, the blood leaks and pools in the legs and feet.

Chronic Venous Insufficiency:

- Clinical Manifestation: * Edema. * Alterd pigmentation. * Pain. * Stasis dermatitis. - Medical and Nursing Management: * Elevating the legs. * Walking should be encouraged. * Compression of the legs with elastic

pressure stocking.

Venous DisordersIII- Thrombophlebitis: Is vein inflammation related to a blood clot. Causes: * Local irritation. e.g. IV line. * Infection in or near vein. Clinical Manifestation: * Tenderness over the vein. * Pain in the part of the body affected. * Skin redness. Medical Management: * Analgesic. * Anticoagulants. * Non steroidal anti-inflammatory drugs (NSADs). * Antibiotics.