Women's hearts are:
Smaller and have smaller cardiac arteries
Cardiac arteries occlude more easily
? resting rate
? stroke volume
? ejection fraction
Women tend to have atypical signs/symptoms of MI:
-Shoulder/upper back pain
-SOB
-Fatigue.
Diagnostic profile for acute MI
Plasma analysis of key cardiac iso-enzymes and other bio-markers:
-CK and CK-MB
-Myoglobin
-Troponin T and I
Cholesterol
-LDL: Normal less than 160mg/dl
-HDL: women: 35-85, men: 35-70
-Triglycerides: Normal100-200 mg/dl.
Brain (B-Type) Natriuretic Profile (BNP)
-Secreted by the ventricular walls in response to an increase in preload or fluid in the ventricles
-Used for diagnosis, monitoring and as a prognostic tool for Heart Failure
-Results are quickly done.
Blood Chemistry Tests related to Cardiovascular System
-Na+
control of fluid volume
-K+
major role in cardiac electrophysiologic function
*Hypokalemia
*Hyperkalemia
-Ca++
*neuromuscular activity and automaticity
*Hypocalemia
*Hypercalemia
-FBS or Hemoglobin A1C
Electrocardiogram (ECG)
-A graphic study of the electrical activity of the myocardium to determine transmission of cardiac impulses through the muscles/conduction tissue.
Exercise Cardiac Stress Test
-Walking on a treadmill - usually 9 to 12 minutes with increases in speed and incline of treadmill every 2 to 3 minutes based upon protocol used
-Exercise bicycle - with increase in resistance at set intervals.
Exercise Cardiac Stress Test Interventions
-Pt. needs to fast for 4 hours before test and avoid stimulants (tobacco, caffeine)
-Some cardiac medications (beta adrenergic blockers) may be held
-Equipment to be used and need to have an IV
-Symptoms to report during testing.
Pharmacologic Cardiac Stress Imaging
-Patients who cannot walk on treadmill or use exercise bike may undergo pharmacologic stress test with imaging
-Vasodilation of coronary arteries with medications mimics the effect of exercise
Cardiac Catheterization
-Insertion of catheter into heart under fluoroscopy, to obtain information about oxygen saturations, structures, performance of valves, assess coronary artery perfusion, and pressure readings within heart chambers
-Inserted into vein for right side of hea
Nursing Responsibility for cardiac catheterization
-Prior to procedure:
*Confirm consent has been signed
*NPO 8-12 hours
*ECG monitoring
*Patent IV line
*Resuscitation equipment on hand
-After procedure:
*Assess site for hematoma, circulation to affected extremity, ECG, HR
*Bed rest for 2-6 hours with leg
Cardiovascular Angiography
-Done via cardiac catheterization
-Dye injected into vessels during catheterization to make them visible on x-ray to check patency, injury, or aneurysms
*Cardiac
*Peripheral (carotid, renal, femoral).
Blood Pressure Classification
Systolic Diastolic
Normal <120 <80
Hypertension <140-159 < 90-99
Non-modifiable Risk Factors: Essential Hypertension
-Family history
-Age
-Gender
-Race & ethnicity
Modifiable Risk Factors: Essential Hypertension
-Obesity
-Sedentary life style
-Alcohol
-Stress
-Smoking
-High sodium diet
-Oral contraceptives
-Decreased Estrogen
-Elevated serum cholesterol
Hypertension Clinical Manifestations
-Usually NO symptoms other than elevated blood pressure
-Symptoms seen related to vascular and organ damage
*Left ventricular hypertrophy
*Heart failure
*Renal failure
*Stroke
- Are seen late and are serious.
Hypertension Assessment and Diagnostic Evaluation
-Retinal examination
-Urinalysis for renal damage
-Blood Chemistry
*Electrolytes
*FBS
*Total and HDL cholesterol levels
*BUN or Creatinine
- 12 lead EKG
-Chest x-ray.
Lifestyle Modifications Hypertension
-Weight reduction.
-Dietary approaches.
-Dietary sodium reduction.
-Physical activity.
-Moderation of alcohol consumption.
Medical Management Hypertension
-SBP 140 or less
-DBP 90 or less
Persons with diabetes mellitus or chronic renal disease have a lower goal pressure of 130/80.
Use of Nitroglycerine
-When pain occurs instruct patient to
Stop activities and rest
-Use NTG
*Repeat every 5 minutes if pain is not relieved
*Call 911 if the pain is not relieved in 15 minutes.
Step Care Management of Hypertension
-Step 1
Lifestyle modifications (Diet, exercise)
Acute Coronary Syndrome or Acute Myocardial Infarction
Life threatening condition characterized by the formation of localized necrotic area within the myocardium
Stage 2 HTN without compelling indications
-Continue lifestyle modifications
-Usually on 2-drug combination
-Thiazide diuretic (HCTZ) and ACE-1/ARB/BB/CCB
MI
-Unrelieved ischemia of > 15 minutes causes irreversible damage to the myocardium (necrosis)
-Area of the myocardium is permanently destroyed.
MI Symptoms
-Shortness of breath, indigestion, nausea, anxiety
-Cool, pale and moist skin.
-Symptoms cannot always be distinguished .
MI Pharmacological Therapy
-ASA 162-325 mg
-Nitroglycerin
-Morphine
-Beta-blocker
-Heparin
-ACE inhibitor within 24 hours (acts on BP).
MI Other therapies
-Oxygen
-Bed rest
-Continuous ECG monitoring
-Evaluate for indications for reperfusion therapy
*Percutaneous coronary intervention
*PTCA -Percutaneous Transluminal
*Coronary Angioplasty
*Coronary Artery Stent Placement
*Artherectomy
*Thrombolytic therapy.
ACE inhibitors
-ACE -I (drugs ending in "pril" captopril)
-Inhibit conversion of angiotension I to angiotension II resulting in reduced salt and water retention.
Nursing Implications: ACE
-Hypotension reversed by fluid replacement
-Used with thiazide diuretic and digoxin.
Angiotensin Receptor Blockers (ARB)
-Angiotensin receptor blockers (drugs ending in "sartan" losartan or Cozaar)
-Block the effects of angiotensin II at the receptor site.
-Reduces peripheral resistance.
Nursing Implications: ARB
-Monitor for hyperkalemia.
Aldosterone antagonists (ALDO ANT)
-Methyldopa (Aldomet), clonidine (Catapres)
-Acts on CNS, affecting norepinephrine
Nursing Implications: ALDO ANT
-Rebound htn is common (educate continue taking to avoid rebound)
-SE: dry mouth, drowsiness dizziness, nasal congestion, severe depression, constipation, fatigue, headache, sleepiness.
Beta Blockers
-Drugs ending in "olol" atenolol
-Block the sympathetic nervous system (beta-adrenergic receptors) to slow heart, reduce its pumping force and lower BP.
Nursing Implications Beta Blockers
-Check heart rate (?60) and BP before giving
-May cause mental depression
-Indicated for patients with stable and silent angina
-Avoid sudden discontinuation.
Calcium Channel Blockers
(diltiazem) Cardiazem , (amlodipine) Norvasc
-Inhibits the movement of calcium into the cardiac and smooth muscle cells
-Smooth muscle tone is lost which causes vasodilation in coronary and peripherial arteries.
Calcium Channel Blockers Nursing Implications
-Assess for irregular heart, dizziness or edema
-Do not discontinue suddenly (risk for depression)
-Observe for hypotension.
Percutaneous Coronary Intervention
-Percutaneous transluminal coronary angioplasty (PTCA) is used to open blocked coronary arteries and resolve ischemia
-Balloon, at tip of catheter, is inflated and plaque is pushed against the wall
-Stent may be placed over the balloon and left in place
-
Improve Respiratory Function
-Administer O2 and monitor saturations levels
-T, C, DB
-Prevent fluid overload in lungs
Relieving Pain and Other Signs/Symptoms of Ischemia
-Administration of medications
-Oxygen therapy
-Bed rest with elevation of head and torso.
Promote adequate tissue perfusion
-Bedrest
-Oxygen therapy.
Valvular Heart Disease
Occurs when valves are compromised and do not open and close properly.
Classification of Valvular Heart Disease
-Stenosed valves
Narrow opening that reduces the flow of blood from one chamber to the next.
-Insufficient (incompetent) valve
Improper closure of valve that allows blood to regurgitate (flow backward) and returns to the chamber it came from.
-Prolapse
St
Nursing Management and Process
-The diagnosis
-Progressive nature of the disease
-Teatment plan
-Signs and symptoms of heart failure
-To report new symptoms or changes in -symptoms to the health care provider
-The need for prophylactic antibiotic therapy before any invasive procedure.
Diuretics
-Loop diuretics
Lasix (furosemide)
-Thiazide diuretics
(hydrochlorothiazide, hydrothiazide)
-Potassium sparing diuretics.
Process for the Patient with Hypertension
Assessment
-Proper measuring of BP at frequent intervals
-Assess apical and peripheral pulse
-Monitor electrolytes and instruct patient on electrolyte replacement therapy if applicable.
Dysrhythmias
Life threatening (Ventricle dysrhytmias)
-Ventricular tachycardia (Flush back)
-Ventricular fibrillation (quiver)
-Asystole (no heart activity)
(Decrease cardiac output and tissue perfusion)
Benign
-Premature atrial contractions (PAC)
-Premature ventricular contractions (PVC) Coffee excess.
Coronary Artery Disease
-There are no symptoms in 80% of patients
-Must be a critical deficit in blood supply to heart in proportion to demands for oxygen and nutrients
-Most common manifestation of myocardial ischemia is acute onset of chest pain.
Coronary Artery Disease symptoms
-Continuum related to location and degree of vessel obstruction
-Angina pectoris
-Myocardial infarction
-Heart failure
-Sudden cardiac death.
Angina Pectoris
Clinical syndrome usually characterized by episodes of pain or pressure in anterior chest, caused by insufficient coronary blood flow.
Angina Precipitating Factors
-Physical exertion
-Temperature extremes
-Eating a heavy meal
-Emotional stress
-Smoking
-Sexual activity.
Types of Angina
-Stable
-Unstable.
Stable Angina
-Infrequent predictable and consistent pain
-Occurs on exertion, by a predictable degree of exercise
-Treatable with rest or nitroglycerides or both.
Unstable Angina
-Triggered by an unpredictable degree of exertion or emotions
-May occur at rest and last longer than stable angina
-Increasing frequency and severity over time that is not relieved by rest and NTG.
Angina Diagnostic Findings
-ECG
Resting
Exercise
-Coronary Angiogram
Remains the gold standard in diagnosing the percentage of blockage in coronary arteries.
Angina Pharmacologic Therapy
-Nitrates
*Dilates vessels, causing decreased peripheral resistance, decreased BP and pooling of blood in the body
-� adrenergic blockers
*Decrease HR, BP and contractility of heart
-Calcium channel blockers
*Act on SA node to slow heart rate and decrease
Endocarditis Nursing Management and Process.
-Diagnosing and treating group A beta-hemolytic streptococcal pharyngitis (common in school-age children) can prevent rheumatic fever and rheumatic heart disease
-Teaching people to recognize and seek medical treatment for streptococcal pharyngitis.
Endocarditis Symptoms
-Fever (intermittent/absent)
-Heart murmur
-Headache
-Small, painful nodules on fingers.
Endocarditis Nursing Management
-Monitor temperature
-Assess heart sounds
-Signs and symptoms of embolization and organ damage.
Myocarditis
-Uncommon infection of the heart muscle caused by viral, bacterial or fungal infection
-Infection causes immune response which damages heart muscles causing dilation of heart and degeneration of heart muscles
-Presenting symptoms are flu-like
-Organism mu
Myocarditis Nursing Management
-Treat infections
-Rest
-Fluids
-Monitor for dysrhythmias (SOB, Skips)
-Monitor for heart failure.
Pericarditis
-Inflammation of the pericardium (membranous sac that surrounds heart)
-Has multiple causes : bacteria, virus, fungus, parasites, renal failure, MI, chest trauma.
Pericarditis Symptoms
-Creaky or scratchy friction rub heard most clearly at the left lower sternal border
-Chest pain that becomes worse when the patient takes a deep breath or lie down
-May be relieved when patient leans forward and/or is in sitting position.
Pericarditis Nursing Management
-Assess and treat pain
-Bed rest to promote healing
-Elevate HOB and lean forward to decrease pain and dyspnea
-Education and reassurance that the pain is not a heart attack
-Monitor for heart failure.
Right Sided Heart Failure
-Blood backs up into the systemic circulation.
-Fluid accumulates behind the chambers that fail first.
-Congestion occurs in the liver, gastrointestinal tract and periphery (arms and legs).
Right Side Heart Failure Clinical Manifestation
-Pronounced jugular neck vein (JVD).
-Pitting edema (Peripheral/Perineal/sacral).
-Ascitis (Pain).
-Hepatomegaly.
-Weight gain. (2-3 lbs in 1 day or 5 lb in 1 week)
-Increase urine output.
-Frequent nocturnal urination.
Left Sided Heart Failure
-Blood backs up into the pulmonary system causing pulmonary congestion or fluid in the lungs.
-Cardiac output is decreased which means less blood enters the systemic circulation
-The body than does not receive oxygen and nutrients.
Left Sided Heart Failure Clinical Manifestation
-Pulmonary congestion/edema
*Dyspnea
*Orthopnea
*PND paroxysmal nocturnal dyspnea
*Cough that is dry at first but than becomes moist over time and is sometimes blood tinged
*Crackles (Dry cough).
Left Sided Heart Failure Clinical Manifestation (2)
-Decreased cardiac output
*Decreased oxygen saturation
*Cerebral hypoxia/ Confusion
*Oliguria (decreased urine output)
*Weak pulses
*Fatigue and weakness
-Clinical Manifestations of Heart Failure may not be detected until the disease is advanced
Heart Failure Diagnostic
-B-type natriuretic peptide (BNP) is key indicator of Heart Failure
-Low pulse oximetry readings <90%
-X-ray may reveal fluid infiltrates.
ACE inhibitors
-Promote vasodilatation and diuresis decreasing blood volume, resulting in a decrease in the heart's workload
-May be the first medication prescribed
-Monitor patient for hyperkalemia and hypotension.
Beta-blockers
-Reduces stimulation and slows the heart
-Side effects may include dizziness, hypotension and bradycardia.
-Hold them if Bp is >60 Bpm
Digitalis: digoxin (Lanoxin)
-Increases force of myocardial contraction and slows conduction through AV node
-CO is increased and body is better perfused.
-Small therapeutic window.
Therapies Heart Failure
-Nutritional Therapy
*Low-sodium (2-3 g/day) diet
*Avoid excessive fluid intake
-Oxygen therapy
*May become necessary as heart failure progresses
*Based on patient SpO2.
Heart Failure Nursing Planning and Interventions
-Promoting Activity Tolerance
*Goal should be for patient to engage in 30-45 minutes of physical activity per day
*Choice of exercise needs to consider other medical conditions
*Enroll in rehabilitation program.
Heart Failure Nursing Planning and Interventions (2)
-Managing Fluid Volume
*Administer medications
*Assess fluid balance (I & O/Weigh patient daily/Dependent edema [gravity based])
Auscultate lung sound for crackles)
*Determine the degree of jugular venous distention
*Monitor apical pulse for rate, rhythm
Report immediately to the physician or clinic
-Weight gain of more than or equal to 2-3 lbs in 1 day or 5 lb in 1 week
-Loss of appetite
-Unusual shortness of breath with activity
-Swelling of ankles, feet or abdomen
-Persistent cough
-Development of restless sleep; increase in the number of pillows
Atherosclerosis
Accumulation of lipids, calcium, blood components, and fibrous tissue on the intima of large and medium-sized arteries.
Atherosclerosis Risk Factors
-Modifiable
*Nicotine
*Diet
*Hypertension
*Diabetes
*Obesity
*Stress
*Sedentary lifestyle
*C-reactive protein
Peripheral Vascular Disorders Symptoms
Depends on the organ or tissue affected
-Intermittent claudication - hallmark
Aching/cramping that occurs with same degree of exercise or activity and relieved with rest
-Pain at rest.
Arteriosclerosis Prevention and Medical Management
-Modification of Risk Factors
-Lower cholesterol
*Diet
*Medications
-Maintain normal blood pressure
-Smoking cessation
-Increasing activity
-Manage diabetes
-Surgery to clear occlusion in artery.
Arteriosclerosis Nursing Diagnosis
-Ineffective or altered peripheral tissue perfusion r/t compromised circulation
-Chronic pain r/t impaired ability of peripheral vessels to supply tissues with oxygen
-Risk for Impaired Skin Integrity r/t decreased peripheral circulation
-Deficient knowle
Arteriosclerosis Nursing interventions
-Improving Peripheral Arterial Circulation
*Position of extremity
*Exercise
-Promoting Vasodilation and Preventing *Vascular Compression
*Smoking cessation.
*Warm blanket to abdomen.
*Avoid cold temperatures.
*Adequate loose fitting clothing.
Arteriosclerosis Nursing interventions (2)
-Relieving Pain
*Analgesic administration
*Slow increase in exercise and formation of collateral circulation
-Maintaining Tissue Integrity
*Avoid trauma to area
*Sturdy, well fitting foot wear.
*Careful examination and care of feet.
*Good nutrition for ce
Arteriosclerosis Medical Management
-Avoid particular stimuli
*Cold
*Tobacco
*Stress
-Pharmacologic
*Calcium channel blocker (nifedipine: low dose vasodilator)
Buerger's Disease:
-Recurring inflammatory process of small and intermediate vessels
-Most often occurs in men ages 20-35
-Generally in lower extremities.
Raynaud's Disease
-Intermittent arterial vaso-occlusion, usually of the fingertips or toes
-Brought on by trigger such as cold or stress
-Often occurs in young women.
-White hands.
Venous Thrombosis Causes
-Endothelial damage (Surgery)
-Venous stasis (rest)
-Altered or hyper-coagulation (surgery, hepatic diseases, Birth control pills)
Thrombosis Clinical Manifestations
-Edema and swelling.
-Warm skin and erythema.
-Tenderness.
-Homans is an unreliable sign.
Pulmonary Embolism Symptom
-SOB
Venous Stasis
-Results from obstruction of venous valves in legs or a reflux of blood through the valves.
Chronic Venous Stasis
Clinical Manifestations.
-Edema
-Altered pigmentation in gaiter area
-Pain
-Stasis dermatitis
-Skin is dry, cracked, itches and can easily become infected.
Reduce venous stasis and prevent ulcerations
-Avoid prolong standing, sitting or crossing the legs
-Elevation of legs above the heart
-Sleep with the foot of the bed elevated
-Use of elastic compression stockings
Arterial Ulcers
-Typically small, circular and deep
-On tips of toes or in the web spaces between the toes
-Gangrene of toe results from trauma to area
-Pain is described as intermittent claudication.
-No Edema (not enough blood)
Venous Ulcers
-Feet and ankles are edematous
-Ulcerations are in area of the medial or lateral malleolus
-Typically are large, superficial and highly exudative
-Superficial (Not Deep)
Varicose Veins
-Abnormally dilated, tortuous, superficial veins caused by incompetent venous valves
-Impaired blood return due to incompetent valves
-Seen more frequently in women and in people whose occupations require prolonged standing.
Varicose Veins Clinical Manifestations
-Dull aches, muscle cramps, increased muscle fatigue, ankle edema and heaviness of the legs
-Cause of chronic venous insufficiency
-More susceptible to injury and infections.
Varicose Veins Nursing Process
-Instruct patient to avoid standing for extended periods of time
-Elevate legs when seated
-Compression stocking should be worn
-Weight reduction
-Exercise
Weight reduction, if factor