Anatomy and Physiology

A. Anatomy
1. Layers
a. pericardium: fibrous sac that encloses the heart

b. epicardium: covers surface of heart

c. myocardium: muscular portion of the heart
d. endocardium: lines cardiac chambers and covers surface of heart valves
2. Chambers of heart

a. right atrium: collecting chamber for incoming systemic venous system

b. right ventricle: propels blood into pulmonary system
c. left atrium: collects blood from pulmonary venous system
d. left ventricle: thick-walled, high-pressure pump that propels blood into system the systemic
circulation
Heart valves: membranous openings that allow one way blood flow

a. atrioventricular valves: prevent backflow from ventricles to atria during systole

i.

tricuspid - right heart valve

ii.

mitral - left heart valve (bicuspid)

b. semilunar valves prevent backflow from aorta and pulmonary arteries into ventricles during diastole
i.

pulmonic

ii.

aortic

c. Blood supply to heart

i.

arteries

Cardiovascular: Arteries of the Heart

a. right coronary artery supplies right ventricle and part of left ventricle
b. left coronary artery supplies mostly left ventricle
ii.

veins
a. coronary sinus veins
b. thebesian veins

d. Conduction system

i.

SA (sinoatrial) node - referred to as the "pacemaker" of the heart

ii.

junctional tissue - often referred to as the atrioventricular node (AV node)

iii.

bundle branch Purkinje system

Physiology

1. Function of the heart is the transport of oxygen, carbon dioxide, nutrients and waste products
2. Cardiac cycle - atria and ventricles work in an asynchronous manner

a. systole - phase of contraction during which the ventricles eject blood

b. diastole - the phase of relaxation during which the chambers fill with blood; when the heart pumps,
myocardial layer contracts and relaxes
3. Blood flow
a. deoxygenated blood enters the right atrium through the superior and inferior vena cava
b. enters the right ventricle via the tricuspid valve
c. travels through the pulmonic valve to pulmonary arteries and lungs
d. oxygenated blood returns from lungs through the pulmonary veins into left atrium and enters the left
ventricle via bicuspid (mitral) valve
e. finally, the blood, from the left ventricle, goes through the aortic valve into the aorta and into the
systemic circulation

4.

The vascular system is a continuous network of blood vessels.

a.

5.

the arterial system consists of arteries, arterioles and capillaries and delivers oxygenated blood to
tissues

b.

oxygen, nutrients and metabolic waste are exchanged at the microscopic level

c.

the venous system, veins and venules, returns the blood to the heart

The heart itself is supplied with blood by the left and right coronary arteries

Heart Infections
A. Pericarditis
1. Definition and related terms: inflammation of the pericardial sac

a. due to a bacterial or fungal infection, collagen disease, e.g., systemic lupus erythematosus
(SLE), or as a complication of an acute myocardial infarction
b. there may or may not be pericardial effusion or constrictive pericarditis
c. Dressler's syndrome (also called post myocardial infarction syndrome)
i.

a combination of pericarditis, pericardial effusion and constrictive pericarditis;

etiology is unclear

ii.

occurs several weeks to months after a myocardial infarction

B. Epidemiology
1. may be acute or chronic and may occur at any age
2. pericarditis occurs in up to 15% of persons with a transmural infarction
C. Findings
1. sharp chest pain often relieved by leaning forward
2. pericardial friction rub
Listen
3. dyspnea
4. fever, sweating, chills
5. dysrhythmias
6. pulsus paradoxus
7. client cannot lie flat without pain or dyspnea
D. Diagnostics
1. history and physical exam
2.

serum studies

a. increased
i.

white blood cells

ii.

sedimentation rate

b. positive
i.

blood cultures

ii.

antinuclear antibody (ANA) if due to connective tissue disease

3. EKG changes on 12-lead

4. echocardiography - to determine pericardial effusion or cardiac tamponade, may show pleural
thickening
E. Management
1.

pharmacological
a. antibiotics to treat underlying infection
b. corticosteroids usually reserved for clients with pericarditis due to SLE, or clients who do not
respond to NSAIDs
c. NSAIDS or aspirin for pain, inflammation, and fever control
d. avoid anticoagulants - may increase the possibility of cardiac tamponade from bleeding risk

2. oxygen: to prevent tissue hypoxia

3. surgical
a. emergency pericardiocentesis if cardiac tamponade develops
b. for recurrent constrictive pericarditis, partial pericardiectomy (pericardial window) or total
pericardiectomy
F. Nursing interventions
1. manage pain and anxiety
2. semi-Fowler's or high-Fowler's position
3. the cardio-care six
4. maintain a pericardiocentesis set at the bedside in case of cardiac tamponade
5. observe for pericarditis complications
a. dysrhythmias
b. cardiac tamponade
c. heart failure
6. assess respiratory, cardiovascular, and renal status often
7. rotate IV sites often and observe for findings of infiltration or inflammation at the venipuncture site
(possible complication of long-term IV administration)
8. teach client and family the cardio five
Myocarditis

1. Definition - an inflammatory condition of the myocardium caused by

a. viral infection
b. bacterial infection
c. fungal infection
d. serum sickness
e. rheumatic fever
f.

chemical agent

g. complication of a collagen disease, e.g., SLE

2. Epidemiology
a. may be acute or chronic and may occur at any age
b. usually an acute virus and self-limited, but it may lead to acute heart failure
3. Findings
a. depends on the type of infection, degree of myocardial damage, capacity of myocardium to recover,
and host resistance
b. may be minor or unnoticed, i.e., fatigue and dyspnea, palpitations, occasional precordial discomfort
manifested as a mild chest soreness and persistent fever
c. recent upper-respiratory infection with fever, viral pharyngitis, or tonsillitis
d. cardiac enlargement
e. abnormal heart sounds: murmur, S3 or gallop or friction rub
Listen
f.

possible findings of congestive heart failure such as pulsus alternans, dyspnea, and crackles

g. tachycardia disproportionate to the degree of fever

4. Diagnostic studies
a. EKG for changes and arrhythmias
b.

labs
i.

increases erythrocyte sedimentation rate (ESR)

ii.

increases myocardial enzymes such as:

aspartate aminotransferase (AST)

creatine kinase (CK)

lactic dehydrogenase (LDH)

c. endomyocardial biopsy (EMB)

d. myocardial imaging
5. Management
a.

pharmacological
i.

antibiotics to treat underlying infection

ii.

corticosteroids to decrease inflammation

iii.

analgesics for pain

b. oxygen to prevent tissue hypoxia

6. Nursing interventions and assessments
a. the cardio-care six with modified bedrest and less help with ADLs
b. assess for edema, weigh daily; record intake and output
c. assess cardiovascular status frequently
d. observe for findings of left-sided heart failure, e.g., dyspnea, hypotension and tachycardia
e. check often for changes in cardiac rhythm or conduction; auscultate heart sounds
f.

evaluate arterial blood gas levels as needed to ensure adequate oxygenation

g. client and family teaching

i.

physical activity may be slowly increased to sitting in chair, walking in room, then outdoors

ii.

avoid pregnancy, alcohol, and competitive sports

iii.

immunize against infections

iv.

teach client about anti-infective drugs; stress importance of taking drugs as ordered

v.

teach clients taking digitalis at home to

vi.

check pulse for one full minute before taking the dose, and withhold the drug if heart
rate falls below 60 beats/minute

monitor for findings of digitalis toxicity, e.g., anorexia, nausea, vomiting, blurred
vision, cardiac arrhythmias

teach client to report rapidly beating heart

Endocarditis

1. Definition - inflammation of the endocardium; can involve any portion of the endocardial lining
a. usually infectious
b. usually affects the valves

2. Infection can lead to vegetation or abscess formation with resultant thrombus or embolus
3. Endocarditis can be classified as
a. native valve endocarditis
b. endocarditis in IV drug users
c. prosthetic valve endocarditis
4. Epidemiology
a. with proper treatment, majority of clients recover
b. the prognosis is worse when endocarditis damages valves severely or involves a prosthetic valve
c. infective endocarditis occurs in many clients with previous valvular disorders
d. systemic lupus erythematosus (SLE) often leads to nonbacterial endocarditis
e. in some clients with subacute endocarditis, lesions produce clots that show the findings of splenic,
renal, cerebral or pulmonary infarction, or peripheral vascular occlusion
5. Findings of endocarditis
a. cardiac murmurs in great majority of persons with infective endocarditis
b. fever
c. especially, a murmur that changes suddenly, or a new murmur that develops in the presence of a
fever
d. pericardial friction rub
e. anorexia, abdominal pain
f.

malaise

g. clubbing of fingers
h. neurologic sequelae of embolus
i.

petechiae of the skin (especially on the chest)

j.

splinter hemorrhage under the nails

k. infarction of spleen: pain in the upper left quadrant, radiating to the left shoulder, and abdominal
rigidity
l.

infarction in kidney: hematuria, pyuria, flank pain, and decreased urine output

m. infarction in brain: hemiparesis, aphasia, and other neurologic deficits

n. infarction in lung: cough, pleuritic pain, pleural friction rub, dyspnea and hemoptysis
o. peripheral vascular occlusion: numbness and tingling in an arm, leg, finger, or toe, or signs of
impending peripheral gangrene
6. Diagnostics
a. health history
b.

laboratory data
1. CBC - elevated WBC
2. blood cultures - positive for microbe

3. erythrocyte sedimentation rate (ESR) - elevated

c. chest x-ray to detect heart failure or cardiomegaly
d. transesophageal echocardiogram to detect vegetation and abscesses on valves
e. EKG to detect dysrhythmias
7. Management - clients at risk for prosthetic valves
a.

pharmacological
1. antibiotics - to treat underlying infection (used prophylactically to prevent endocarditis, mitral
valve prolapse)
2. antipyretics - to control fever
3. anticoagulants - to prevent embolization

b. oxygen - to prevent tissue hypoxia

c. surgical - possible valve replacement
8. Nursing interventions
a. the cardio-care six
b. observe for findings of infiltration or inflammation at venipuncture site; rotate sites often
c. client and family teaching
1. explain all procedures in a simple and culturally sensitive manner
2. involve the client and family in scheduling the daily routine activities
3. allow client and family to participate in care
4. teach client relaxation techniques (meditation, visualization, or guided imagery) to cope with
stress, pain, or insomnia
5. explain endocarditis and the need for long-term therapy
6. may need prophylactic antibiotics before dental work and other invasive procedures
7. teach client to report fever, tachycardia, dyspnea and shortness of breath
Rheumatic heart disease (rheumatic endocarditis)

1. Definition and related terms

a. rheumatic heart disease: damage to the heart by one or more episodes of rheumatic fever; pathogen
is group A streptococcus
b. rheumatic endocarditis: damage to the heart, particularly the valves, resulting in valve leakage
(regurgitation) and/or stenosis; to compensate, the heart's chambers enlarge and walls thicken
2. Epidemiology
a. fairly rare in developed countries; more common in developing countries
i.

more common where malnutrition and crowded living are common, in children between ages
5 and 15 years-old

ii.

strikes most often during cool, damp weather

b. could be prevented by finding and treating streptococcal pharyngitis

c. it is unknown how and why group A streptococcal infections cause the lesions called Aschoff bodies

i.

damage depends on site of infection; most often the mitral valve in females and the aortic
valve in males

ii.

malfunction of these valves leads to severe pericarditis, and sometimes pericardial effusion
and fatal heart failure; about 20% die within ten years

3. Findings
a. streptococcal pharyngitis
i.

sudden sore throat

ii.

throat reddened with exudate

iii.

swollen, tender lymph nodes at angle of jaw

iv.

headache and fever to 104 degrees Fahrenheit

b. polyarthritis manifested by warm and swollen joints

c. carditis
d. chorea
e. erythema marginatum (wavy, thin red-line rash on trunk and extremities)
f.

subcutaneous nodules

g. fever to 104 degrees Fahrenheit

h. heart murmurs pericardial friction rub and pericardial rub
Listen
i.
4.

no lab test confirms rheumatic fever, but some support the diagnosis

Diagnostics
a. antistreptolysin O (ASO) titer - increased
b. ESR - increased
c. throat culture - positive for streptococci
d. WBC count - increased
e. RBC parameters - normocytic, normochromic anemia
f.

C-reactive protein (CRP) - positive for streptococci

5. Management
a.

pharmacological
i.

provide analgesics - for pain/inflammation

ii.

oxygen to prevent tissue hypoxia

iii.

give antibiotics steadily to maintain level in blood

b. surgical - commissurotomy, valvuloplasty, prosthetic heart valve

Nursing interventions

a. the cardio-care six

b. help the client with chorea to grasp objects; prevent falls

c. encourage family and friends to spend time with client and fight boredom during the long, tedious
convalescence
d. client and family teaching
i.

explain all tests and treatments

ii.

nutrition

iii.

hygienic practices

iv.

to resume ADLs slowly and schedule rest periods

v.

to report penicillin reaction, e.g., rash, fever, chills

vi.

to report findings of streptococcal infection

sudden sore throat

diffuse throat redness and oropharyngeal exudate

swollen and tender cervical lymph glands

pain on swallowing

temperature of 101 to 104 degrees Fahrenheit

headache

nausea

vii.

keep client away from people with respiratory infections

viii.

explain necessity of long-term antibiotics

ix.

arrange for a visiting nurse if necessary

x.

help the family and client cope with temporary chorea

Valve Disorders
A. Mitral stenosis
1. Definition: mitral valve thickens and gets narrower, blocking blood flow from the left atrium to left
ventricle

2. Epidemiology

a. of clients with mitral stenosis, 2/3 are female

b. most cases of mitral stenosis are caused by rheumatic fever
B. Findings
1. mild - no findings
2. moderate to severe
a. dyspnea on exertion
b. paroxysmal nocturnal dyspnea
c. orthopnea
d. weakness, fatigue, and palpitations
3. peripheral and facial cyanosis in severe cases
4. jugular vein distention
5. with severe pulmonary hypertension or tricuspid stenosis - ascites
6. edema
7. hepatomegaly
8. diastolic thrill at the cardiac apex
9. when client lies on left side, loud S1 or opening snap and a diastolic murmur at the apex
10. crackles in lungs
C. Diagnostic studies
1. history and physical exam
2. EKG - note indications of left atrial enlargement and right ventricle enlargement
3. echocardiogram - for restricted movement of the mitral valves and diastolic turbulence
4. cardiac catheterization
5. chest x-ray
D. Management
1.

antiarrhythmics if needed

2. if medication fails, atrial fibrillation is treated with cardioversion

3.

low-sodium diet - to prevent fluid retention

4. oxygen if needed - to prevent hypoxia

5. surgery - mitral commissurotomy or valvotomy
6.

medications used in severe cases

a. vasodilators (nitroprusside, nitrogylcerin)
b. positive inotropes (dobutamine, dopamine, digoxin)
c. aminophylline (decrease bronchospasm)

E. Nursing interventions and assessment

1. the cardio-care six
2. observe closely for findings of heart failure, pulmonary edema, and reactions to drug therapy
3. if client has had surgery, watch for hypotension, arrhythmias, and thrombus formation
4. monitor the cardio seven
5. client and family teaching
a. explain the need for long-term antibiotic therapy and the need for additional antibiotics before
dental care
b. report early findings of heart failure such as dyspnea or a hacking, nonproductive cough
Mitral insufficiency (or regurgitation)

1. Definition and related terms

a. a damaged mitral valve allows blood from the left ventricle to flow back into the left atrium during
systole
b. to handle the back flow, the atrium enlarges; the left ventricle also enlarges, in part to make up for its
lower output of blood
2. Epidemiology
a. follows birth defects such as transposition of the great arteries

b. in older clients, the mitral annulus may have become calcified

c. cause unknown; may be linked to a degenerative process
d. occurs in 5 to 10% of adults
3. Findings
a. client may be asymptomatic
b. orthopnea, dyspnea, fatigue, weakness, weight loss
c. chest pain and palpitations
d. jugular vein distention

e. peripheral edema
f.

hepatomegaly

4. Diagnostics
a. EKG for arrhythmias and changes of left atrial enlargement
b. echocardiogram - to visualize regurgitant jets and flail chordae/leaflets
c. cardiac catheterization shows regurgitation of blood from left ventricle to left atrium
d. chest x-ray shows cardiomegaly, pulmonary congestion
5. Management
a.

low-sodium diet - to prevent fluid retention

b. oxygen as needed - to prevent tissue hypoxia

c.

antibiotics - to treat infection (prophylactic antibiotics - to prevent infection)

d. surgery - mitral valvuloplasty or valve replacement

6. Nursing interventions and assessment
a. the cardio-care six
b. monitor the cardio seven
c. monitor for left-sided heart failure, pulmonary edema, adverse reactions to drug therapy, and cardiac
dysrhythmias (especially atrial and ventricular fibrillation)
d. if client has surgery, monitor postoperatively for hypotension, arrhythmias and thrombus formation
e. client and family teaching
1. diet restrictions and drugs
2. explain tests and treatments
3. prepare client for long-term antibiotic and follow-up care
4. stress the need for prophylactic antibiotics during dental care
5. teach client and family to report findings of heart failure, i.e., dyspnea and hacking,
nonproductive cough
Tricuspid stenosis

1. Definition: narrowing of the tricuspid valve between right atrium and right ventricle
2. Epidemiology
a. relatively uncommon
b. usually associated with lesions of other valves
c. caused by rheumatic fever
3. Findings
a. dyspnea, fatigue, weakness, syncope
b. peripheral edema

c. jaundice with severe peripheral edema and ascites can mean that tricuspid stenosis has led to right
ventricular failure
d. may appear malnourished
e. distended jugular vein
4. Diagnostics
a. EKG - for arrhythmias
b. echocardiogram - right ventricular dilation and paradoxical septal motion
5. Management: surgery - valvulotomy or valve replacement; valvuloplasty

6. Nursing interventions and assessment

a. the cardio-care six
b. monitor the cardio seven
c. monitor for findings of heart failure, pulmonary edema, and adverse reactions to the drug therapy
d. post valve surgery, monitor client for hypotension, arrhythmias and thrombus formation
e. when client sits, elevate legs to prevent dependent edema
f.

client and family teaching

i.

teach the cardio five

ii.

client must comply with long-term antibiotic and follow up care

iii.

emphasize the need for prophylactic antibiotics during dental care

Tricuspid insufficiency (regurgitation)

1. Definition - tricuspid valve lets blood leak from the right ventricle back into the right atrium
2. Epidemiology
a. results from dilation of the right ventricle and tricuspid valve ring
b. most common in late stages of heart failure from rheumatic or congenital heart disease
3. Findings

a. dyspnea, fatigue, weakness and syncope

b. peripheral edema may cause discomfort
4. Diagnostics - echocardiogram for abnormal valve movement
5. Management: surgical - valve replacement
6. Nursing interventions and assessment
a. the cardio-care six
b. monitor the cardio seven
c. monitor for findings of heart failure, pulmonary edema, and adverse reactions to the drug therapy
d. post-op monitor client for hypotension, arrhythmias and thrombus formation
e. when sitting, client should raise legs to prevent dependent edema
f.

client and family teaching

i.

the cardio five

ii.

emphasize the need for prophylactic antibiotics during dental care

iii.

instruct client to raise legs when sitting - to prevent dependent edema

Pulmonic stenosis

1. Definition - obstructed right ventricular outflow resulting in right ventricular hypertrophy

2. Epidemiology
a. usually congenital, often with other birth defects such as Tetralogy of Fallot

b. rare among the elderly

c. may result from rheumatic fever
3. Findings
a. dyspnea, fatigue, chest pain and syncope
b. peripheral edema may cause discomfort

4. Diagnostics - echocardiogram for abnormal valve or blood movement

5. Management: surgical - replace the valve via balloon and cardiac catheter
6. Nursing interventions
a. same as tricuspid stenosis and tricuspid insufficiency
b. monitor for findings of heart failure, pulmonary edema, and adverse reactions to to the drug therapy
c. post-op: monitor client for hypotension, dysrhythmias and thrombus formation
d. monitor the cardio seven
e. client and family teaching - same as tricuspid stenosis and tricuspid insufficiency
Pulmonic insufficiency (regurgitation)

1. Definition - pulmonary valve fails to close, so that blood flows back into the right ventricle
2. Epidemiology
a. a birth defect, or a result of pulmonary hypertension
b. rarely, result of prolonged use of a pressure-monitoring catheter in the pulmonary artery
3. Findings
a. dyspnea, fatigue, chest pain and syncope
b. peripheral edema may cause discomfort
c. if advanced: jaundice with ascites and peripheral edema
d. possible malnourished appearance
4. Diagnostics - echocardiogram for abnormal blood or valve movement
5. Management
a.

b.

pharmacological
i.

diuretics - to mobilize edematous fluid to reduce pulmonary venous pressure

ii.

anticoagulants - to prevent blood clots

iii.

digitalis - to increase the force or strength of cardiac contractions (inotropic action)

sodium-restricted diet - to control underlying heart disease

c. surgery for severe cases: valvulotomy or valve replacement

6. Nursing interventions and assessment
a. the cardio-care six
b. monitor the cardio seven
c. monitor for findings of heart failure, pulmonary edema, and adverse reactions to drug therapy
d. post-op: monitor client for hypotension, arrhythmias and thrombus formation
e. provide rest periods

f.

when client sits, elevate legs

g. client and family teaching - same as tricuspid stenosis, tricuspid insufficiency, and pulmonic stenosis
i.

the cardio five teaching plan

ii.

client's dentist must give client prophylactic antibiotics to prevent infection

iii.

instruct client to raise legs when sitting to prevent dependent edema

Aortic stenosis

1. Definition - aortic valve stiffens to narrow opening

2. Epidemiology
a. most significant valvular lesion seen among elderly people. It usually leads to left-sided heart failure
b. incidence increases with age
c. occurs in 1% of the population
d. about 80% of these people are male
e. 20% of them die suddenly, around age 60
3. Findings
a. classic triad: dyspnea, syncope, angina (see assessing clients with cardiovascular disorders)
b. fatigue
c. palpitations
d. left-sided heart failure may bring on orthopnea, paroxysmal nocturnal dyspnea, and peripheral
edema
e. systolic murmur that radiates into carotid arteries and the apex of the heart
f.

EKG - findings of left ventricular hypertrophy

4. Management
a.

pharmacological
1. nitroglycerin to relieve chest pain

2. digitalis - to increase the force or strength of cardiac contractions (inotropic action)

3. diuretics - to mobilize edematous fluid and to reduce pulmonary venous pressure
b.

low-sodium diet - to prevent fluid retention

c. oxygen - to prevent hypoxia

d. surgery - percutaneous balloon valvuloplasty, then valve replacement
5. Nursing interventions and assessment
a. the cardio-care six
b. monitor the cardio seven
c. monitor for findings of heart failure, pulmonary edema, and adverse reactions to the drug therapy
d. post-op: monitor client for hypotension, arrhythmias and clots
e. when client sits, elevate legs to prevent dependent edema
f.

client and family teaching: (same as tricuspid stenosis, tricuspid insufficiency, pulmonic stenosis and
pulmonic insufficiency)
1. the cardio five teaching plan
2. client's dentist must administer prophylactic antibiotics
3. client should elevate legs when sitting

Aortic insufficiency (regurgitation)

1. Definition
a. blood flows back into the left ventricle during diastole overloading the ventricle and causing it to
hypertrophy.
b. extra blood also overloads the left atrium and, eventually, the pulmonary system.
2. Epidemiology
a. by itself, most common among males
b. with mitral valve disease, more common among females
c. may accompany marfan's syndrome, ankylosing spondylitis, syphilis, essential hypertension or a
defect of the ventricular septum
3. Findings

a. uncomfortable awareness of heartbeat

b. palpitations along with a pounding head
c. dyspnea with exertion
d. paroxysmal nocturnal dyspnea, with diaphoresis, orthopnea and cough
e. fatigue and syncope with exertion or emotion
f.

anginal chest pain unrelieved by sublingual nitroglycerin

g. heartbeat that seems to jar the client's entire body

h. client's nail beds appear to be pulsating
i.

if nail tip is pressed, the root will flush and then pale (Quincke's sign)

j.

if left ventricle fails, client may show ankle edema and ascites

k. pulsus bisferiens: a double-beat pulse (palpated over the carotid or brachial arteries)
4. Diagnostics
a. chest x-ray
b. echocardiogram
c. cardiac catherization
5. Management
a.

pharmacological
1. digitalis - increases the heart's contractility (inotropic action)
2. diuretics - to mobilize edematous fluids and to reduce pulmonary venous pressure
3. anticoagulant agents - to prevent blood clots
4. ACE inhibitors - decrease cardiac workload and assist to increase oxygenation

b.

sodium-restricted diet - to prevent fluid retention

c. surgical - valve replacement, however, aortic insufficiency often damages the ventricle before it is
detected

6. Nursing interventions and assessment

a. same as all other valve disorders - the cardio-care six except don't need to elevate head unless
pulmonary problems have begun
b. monitor the cardio seven
c. monitor for signs of heart failure, pulmonary edema, and drug reactions
d. post-op: monitor client for hypotension, arrhythmias and clots
e. client and family teaching
1. same as all other valve disorders - the cardio five teaching plan
2. emphasize the need for prophylactic antibiotics during dental care
3. instruct client to raise legs when sitting

Failures of the Heart Muscle

A. Myocardial infarction (MI)
1. Definition - insufficient oxygen supply kills (causes necrosis of) myocardial tissue; may be sudden or
gradual and total event may take 3 to 6 hours

2. Epidemiology
a. almost equal for men and women
b. client history of smoking, obesity, high cholesterol/low density lipoprotein diet,
physical/emotional stress
c. a common killer in North America and Western Europe
d. mortality

Findings

i.

mortality about 25%; of the sudden deaths from MI, more than half happen within an
hour

ii.

of those who survive the initial MI and recover, up to 10% die within the first year

iii.

factors affecting mortality: age, number of occluded vessels, previous history of MI,
presence of cardiogenic shock

a. classic findings: persistent, crushing substernal chest pain

i.

pain that may radiate to the left arm, jaw, neck and shoulder blades, with a feeling of impending
doom

ii.

pain does not resolve with rest

iii.

some clients report no pain or call it mild indigestion

iv.

more likely in the elderly or clients with diabetes

clues suggesting "silent" MI (acute or sudden): heart failure, change in mental status,
unexplained abdominal pain, dyspnea, fatigue

some clients (especially older women) report only fatigue, nausea or vomiting, shortness of breath,
or flu-like symptoms

b. sudden death
c. within the first hour after an anterior MI, about 25% of clients experience tachycardia or hypertension
d. up to 50% of clients with an inferior MI experience the opposite, i.e., bradycardia or hypotension

4.

Diagnostics
a.

history and physical

b.

EKG - monitor for changes, arrhythmias

c.

serum cardiac markers

i.

isoenzymes - CK-MB isoenzyme: rises 4 to 6 degrees after acute MI; returns to normal in 3
to 4 days

ii.
5.

muscle proteins - Troponin rises quickly but remains elevated for two weeks

Management
a.

cardiac monitoring for arrhythmias

b.

oxygen - to prevent tissue hypoxia

c.

d.

induced hypothermia (target temperature of 32 to 34 degrees Celsius) - initiated as soon as possible

after return of spontaneous circulation
bed rest - to decrease the workload of the heart

e.

pharmacologic agents - to stabilize client

i.

stool softeners - to decrease the workload of the heart caused by straining, which can cause
vagal stimulation producing bradycardia and arrhythmias

ii.

narcotic analgesics - to reduce pain, anxiety and fear and decrease the workload of the heart

iii.

beta-blocking agents - to slow heart rate, decrease contractility, and decrease workload of
heart

iv.

sedatives - to decrease anxiety and fear and to decrease the workload of the heart

v.

antiarrhythmics - only used if serious arrhythmia develops or client is symptomatic with

arrhythmia

vi.

thrombolytic agents - to dissolve the thrombus in the coronary artery and re-perfuse the
myocardium

vii.

nitrates- to decrease pain and decrease preload and afterload while increasing the
myocardial oxygen supply

viii.
f.

g.
h.

i.

anticoagulants - to prevent blood clots

pulmonary artery (Swan-Ganz) catheter to monitor pressure in pulmonary artery (measures

functioning of left ventricle)
intra-aortic balloon counterpulsation may be used for cardiogenic shock
cardiac catheterization may be performed for percutaneous transluminal coronary angioplasty
(PTCA), i.e., stent insertion

surgery - coronary atherectomy or graft of a coronary artery bypass

Therapeutic treatment for MI: " O BATMAN! "

O =Oxygen
B =Beta blocker
A =ASA (aspirin)
T =Thrombolytics (heparin)
M =Morphine
A =ACE (especially for those with heart failure or a lower EF)
N =Nitroglycerin

Nursing interventions

a. the cardio-care six plus monitor the following to prevent heart failure, infections and complications

i.

temperature

ii.

daily weight

iii.

intake and output

iv.

respiratory rate

v.

breath sounds

vi.

blood pressure

vii.

serum enzyme levels

viii.

EKG readings

ix.

peripheral pulses

x.

heart sounds especially S3 and gallop

Listen

b. assess pain and administer analgesics as ordered; record the severity, location, type, and duration of pain
c. do not give intramuscular injections (or CK will be falsely elevated)
d. watch for crackles, cough, tachypnea, and edema, which may predict left ventricle is failing
Listen
e. use anti-embolism stockings to prevent venostasis and thrombophlebitis
f.

assistance with range-of-motion exercises

g. client and family teaching

i.

cardio five teaching plan

ii.

explain the intensive care (or coronary care) unit routine and machinery

iii.

ask dietitian to speak with the client and family to reinforce teaching

iv.

encourage client to join the cardiac rehab exercise program

v.

counsel gradual resumption of sexual activity; taking nitroglycerin before sex may prevent chest pain

vi.

advise the client to report typical or atypical chest pain

vii.

describe post-myocardial infarction syndrome; have client report it to physician

viii.

stress that client must modify high-risk behaviors

h. Heart failure
i.

Definition
a. heart fails to pump enough blood to support the body's functions
b. types of CHF depend on which part of the heart is failing: the left half that pumps to the body
or the right half that pumps to the lungs

ii.

Etiology
a. coronary artery disease
b. myocarditis
c. cardiomyopathy

d. infiltrative disorders, i.e., amyloidosis, tumors, sarcoidosis

e. collagen-vascular disease: systemic lupus erythematosus, scleroderma
f.

dysrhythmias that reduce cardiac filling time

g. disorders that increase cardiac workload: hypertension, valve disease, anemia,

hyperthyroidism
h. cardiac tamponade
iii.

Findings

Heart Failure symptoms listed in order of earliest to later findings

Right

Bilateral

Left

Nocturia
Bulging neck veins (JVD)

Fatigue in adults and

decreased play activity in
children

Ankle & foot edema

Tachycardia

Liver enlargement (hepatomegaly

with abdominal pain, anorexia, and
nausea)

Hypotension

Restlessness, irritability,
hostility, agitation, anxiety
Cough (often dry initially)
Weight gain
Shortness of
breath/orthopnea
Tachypnea
Crackles
S3 heart sound
Pulmonary edema
Frothy, sputum (may be
blood-tinged)
Diaphoresis
Cyanosis

4.

5.

Diagnostics - the primary goal is to determine the underlying cause of the heart failure
a.

history and physical exam

b.

chest x-ray to determine heart size and pleural effusions

c.

EKG for changes, arrythmias

d.

echocardiogram to measure valvular abnormalities

e.

nuclear imaging - to determine myocardial contractility, myocardial perfusion, and acute cell injury

f.

hemodynamic monitoring of arterial blood pressure, pulmonary artery pressure, pulmonary artery
wedge pressure and cardiac output

Management - objective is to restore balance between myocardial oxygen supply and demand
a.
b.

c.
6.

oxygen
pharmacological: positive inotropes, e.g., digitalis, vasodilators, nitrates, antihypertensives,
cardiac glycosides, diuretics
intra-aortic balloon counterpulsation, ventricular assist pumping, pacemaker

Nursing interventions
a.

the cardio care six

b.

administer medications as ordered

c.

administer oxygen as ordered - to prevent tissue hypoxia

d.

monitor hemodynamic indicators

e.

monitor for findings of hyponatremia, hypokalemia

f.

restrict fluids and assess for findings of fluid retention

g.

client and family teaching

i.

medications and side effects

ii.

how to conserve energy and thus oxygen

iii.

teach client to report

iv.

weight gain of more than 2 pounds in 24 hours (equals 1 liter) or 5 pounds in 1 week

dyspnea - sudden or progressive with ADLs

decreased exercise tolerance

importance of sodium-restricted diet

Cardiac tamponade

1. Definition: fluid fills pericardial sac and limits cardiac output; a medical emergency

2. Etiology
a. acute pericarditis
b. post-op after cardiac surgery
c. pericardial effusions
d. chest trauma
e. myocardial rupture
f.

aortic dissection

g. anticoagulant therapy
3. Findings: classic triad of findings
a. hypotension with
b. muffled heart sounds with
c. high jugular venous pressure (increased CVP)

4. Diagnostics
5. Management: pericardiocentesis (needle aspiration of pericardial sac)
6. Nursing interventions
a. bed rest with elevated head of bed
b. prepare client for pericardiocentesis
c. provide emotional support
d. prepare for surgery if pericardiocentesis is ineffective

Disorders of the Circulatory System

A. Hypertension
1. Definitions
a. hypertension - systolic blood pressure of 140 mm Hg or greater, diastolic blood pressure of
90 mm Hg or greater, or taking antihypertensive medication
b. chronic hypertension of pregnancy - high blood pressure already present before week 20 of
gestation
c. accelerated hypertension - a hypertensive crisis when blood pressure rises very rapidly
i.

threat of immediate vascular necrosis and target organ damage, particularly to the
heart, kidneys, retina and brain

ii.

blood pressure is usually greater than 180/120 mm Hg or a mean arterial pressure of

more than 150 mm Hg

Etiology and epidemiology

a. essential hypertension: cause unknown.

b. possible risk factors
i.

family history - immediate family, including mother, father, sister, brother

ii.

race - African American, Hispanic, Native American, more susceptible

iii.

stress

iv.

obesity - 20% more than ideal weight

v.

a diet high in sodium or saturated fat

vi.

use of tobacco

vii.

use of hormonal contraceptives

viii.

sedentary life/lack of exercise

ix.

aging process

c. besides hypertension, most individuals have other risk factors for cardiovascular disease (CVD)
d. secondary hypertension may result from
i.

renovascular disease

ii.

renal parenchymal disease

iii.

Cushing's syndrome

iv.

diabetes mellitus

v.

dysfunction of the thyroid, pituitary, or parathyroid

vi.

coarctation of the aorta

vii.

pregnancy

viii.

neurologic disorders

e. Findings

f.

i.

often asymptomatic

ii.

findings reflect the effect of hypertension on organ systems

iii.

occipital headache, blurred vision, dizziness

iv.

weakness, fatigue, and impotence

v.

epistaxis

vi.

nocturia, hematuria

vii.

chest pain, palpitations, and dyspnea, if heart is involved

Diagnostics
i.

based on the average of two or more blood pressure readings, two minutes apart, at each of two or
more visits after an initial screening visit (measuring blood pressure)

ii.

classification of adult hypertension

iii.

hypertension is classified according to its cause:

a. primary or essential hypertension (about 90% of clients)
b. secondary hypertension (results from another disease; about 5% to 10% of clients)
c. pregnancy-induced hypertension (PIH)
d. accelerated hypertension - a hypertensive crisis

5.

Management: initial treatment for prehypertension and uncomplicated stage 1 hypertension is lifestyle
modifications; if life changes fail to decrease the BP to an acceptable level than medication is added
a.
b.

initial treatment for prehypertension and uncomplicated stage 1 hypertension - lifestyle modifications
pharmacological - if life changes fail to decrease the blood pressure to an acceptable level,
medication is added
i.

initial therapy includes one of the following classification of medications: thiazide diuretic,
beta-adrenergic blocking agent, or angiotensin converting enzyme (ACE) inhibitor

ii.

angiotensin-converting enzyme (ACE) inhibitors are the first choice for clients with left-sided
heart failure and diabetics

iii.
c.

antilipemics

goals of treatment: to prevent end organ damage

i.

BP <130/85 mm Hg

ii.

control dyslipidemia, obesity, inactivity

6.

iii.

control diabetes mellitus, if indicated

iv.

increase activity

Nursing interventions - reinforce client and family teaching regarding:

a.
b.

use of self-monitoring blood pressure cuff

the need to record blood pressure readings at least twice weekly in a journal or calendar (for review
by care provider during visits)

c.
d.

a routine or schedule for taking antihypertensive medications

the need to avoid high-sodium antacids and cold or sinus remedies with vasoconstrictors, e.g.,
antihistamines

e.

a diet that is low sodium, cholesterol and saturated fat

f.

when to report extremely high blood pressure readings

g.

lifestyle modifications
i.

optimizing body weight

ii.

drinking alcohol based on current guidelines

iii.

reducing dietary sodium, e.g., 2 gram sodium diet

iv.

participating in regular and moderately intense aerobic activity

v.

avoiding tobacco products

vi.

managing stress trigger and responses to triggers

Complementary and Alternative Medicine

Garlic, ginseng dried root, hawthorn, and snakeroot have been used to treat
hypertension; however, theres not enough research to support the efficacy and safety
of these herbal therapies.

Supplements:

Coenzyme Q10 (CoQ10) supplements may cause small decreases in blood

pressure; low blood levels of CoQ10 have been found in people with
hypertension

Omega-3 fatty acids supplements may lower blood pressure

Amino acid L-arginine diet supplements may temporarily lower blood pressure

Alternative systems of care

Traditional Chinese medicine

Avurveda

Note: Licorice and ephedra should not be used by people with hypertension because
they can increase blood pressure.

Malignant Hypertension

1. Definition: a sudden and rapid development of extremely high blood pressure; systolic is greater than 180
mm Hg and the diastolic is higher than 120 mm Hg

2. Etiology: the most common cause is suddenly when client stops taking antihypertensive medication
3. Findings: headache, confusion, blurred vision, restlessness, motor sensory deficits
4. Management
a. goal: to reduce blood pressure by no more than 25% within minutes to one hour, then toward
160/100 within 2 to 6 hours; must avoid rapidly dropping blood pressure because this could cause
ischemia to body systems
b.

pharmacological
i.

sodium nitroprusside

ii.

nitroglycerin

5. Nursing interventions
a. monitor for end organ damage
b. monitor urine output; assess level of consciousness
c.

monitor BUN, creatinine, arterial blood gases, urinalysis

d. continuous cardiac monitoring

e. vital signs every 5 to 30 minutes (while titrating medication)
Coronary artery disease (CAD)

1. Definition - fatty deposits in coronary arteries (atheroma or plaque) narrow the artery (by 75% or more) and
cut flow of blood and oxygen to the heart muscle

2. Epidemiology and etiology

a. CAD is epidemic in the western world
b. more than 30% of men age 60 or older show signs of CAD on autopsy
c. most common cause: Atherosclerosis
d. risk factors:
i.

over 40 white male

ii.

family history of CAD

iii.

high blood pressure

iv.

high cholesterol

v.

smokers are twice as likely to have a myocardial infarction and four times as likely to die
suddenly; the risk drops sharply within one year after smoking cessation

vi.

obesity, particularly waist circumference; added weight increases the risk of diabetes,
hypertension and high cholesterol

vii.

sedentary life style

3. Findings: angina
4. Diagnostics
a.

serum elevations
i.

homocysteine levels

ii.

C-reactive protein

iii.

LDH cholesterol

iv.

triglycerides

b. cardiac catherization
Management

a.

pharmacological
i.

nitrates such as nitroglycerin, isosorbide dinitrate (Isordil), or beta-adrenergic neuron-blocking

agents

ii.

diuretics and beta-adrenergic blocking agents

iii.

antiplatelet agents (aspirin [81 mg daily]) - reduces platelet aggregation and decreases platelet
aggregation

iv.

antilipemics- to decrease circulating lipids

b. oxygen - to prevent hypoxia

c.

diet: reduce calories, salts, fats, cholesterol

d. cardiac catheterization

e. rotational ablation

f.

laser coronary angioplasty

g. surgical treatment - cardiovascular bypass graft surgery (CABG)

Nursing interventions

a. help client with ADL (activities of daily living)

b. partial bed rest
c. reassure client
d. assist with turning, deep breathing and coughing exercises
e. relieve chest pain by oxygen and medication as ordered
f.

during angina attacks, monitor blood pressure, heart rate, pain, medications, symptoms; get
electrocardiogram

g. keep nitroglycerin available for immediate use

h. post cardiac catheterization and percutaneous transluminal coronary angioplasty
i.

maintain heparinization

ii.

observe for bleeding systemically at the site

iii.

keep the affected leg straight and immobile for 6 to 12 hours

i.

j.

iv.

check for distal pulses

v.

to counter the diuretic effect of the dye, increase IV fluids and make sure client drinks plenty of fluids

vi.

assess potassium level and observe for dysrhythmias

vii.

observe findings of hypotension, bradycardia, diaphoresis, dizziness; give atropine and lay the client
flat

post rotational ablation

i.

monitor the client for chest pain, hypotension, coronary artery spasm and bleeding from the catheter
site

ii.

provide heparin and antibiotic therapy for 24 to 48 hours or as ordered

client and family teaching

i.

risks

ii.

teach the risk factors for coronary artery disease (CAD)

encourage client to lose excess weight; review low-fat, low-cholesterol diet

teach smoking cessation

teach side effects of drugs for CAD

stress - teach stress reduction techniques

avoid

iii.

activities known to cause angina

physical activities for two hours after meals

very cold and very hot weather

alcohol and caffeine drinks

diet pills, nasal decongestants, or any remedy that can raise heart rate or blood pressure

nitroglycerin tablets and carry at all times

if necessary nitroglycerin patch

use

iv.

report

angina

go to clinic or hospital when angina lasts more than 15 minutes

Shock

1. Definition - a clinical syndrome marked by inadequate perfusion and oxygenation of cells, tissues and
organs.
2. Four physiologic components for homeostatic regulation - if one or more of these components malfunctions
shock may follow
a. adequate cardiac output
b. uncompromised vascular system
c. adequate blood volume

d. ability of tissue to extract and use oxygen

3. Major categories or types of shock
a. cardiogenic (pump failure)
b. obstructive (mechanical interference with ventricular filling or ventricular emptying)
c. distributive (vasogenic)
i.

septic

ii.

anaphylactic

d. hypovolemic (intravascular volume loss)

Findings: progression of shock (you will note there are many terms used to describe the stages of shock)

a. stage I - reversible, compensatory, initial, "warm"

i.

characterized by decreased cardiac output and perfusion; anaerobic metabolism begins

(development of lactic acidosis)

ii.

compensatory mechanisms (neural, chemical, and hormonal) act to maintain perfusion

iii.

neural compensation

baroreceptors in carotid sinus aortic arch activate sympathetic nervous system (NS),
which contracts blood vessels so that skin cools

sympathetic NS stimulates heart, so tachycardia sets in; it cuts blood flow to kidneys
and gastrointestinal system and dilates pupils

hormonal compensation

decreased blood flow to kidneys releases angiotensin, which constricts vessels and
increases BP

angiotensin stimulates the secretion of aldosterone; aldosterone makes kidneys

retain sodium, which increases serum osmolality, which in turn stimulates antidiuretic
hormone (ADH)

ADH causes water retention

increased sodium and water retention results in increased BP, decreased urine
volume and increased urine specific gravity

anterior pituitary is stimulated to secrete adrenocorticotropic hormone (ACTH); ACTH

acts on adrenal cortex to increase secretion of glucocorticoids, which increase serum
glucose

chemical compensation

decreased pulmonary blood flow causes hypoxemia

hypoxemia is sensed by chemoreceptors that increase rate and depth of respirations,

which results in respiratory alkalosis

clinical findings at this stage are vague because of compensatory mechanisms

anxiety, restlessness

tachypnea

skin cool and clammy

thirst

pupils dilated

slight tachycardia

weak or normal peripheral pulses

decreased bowel sounds

normal to decreased urine output

concentrated urine

b. progressive stage of shock - compensatory mechanisms can no longer maintain perfusion

i.

severe hypoperfusion

ii.

massive cell death

iii.

organs begin to fail

iv.

severe lactic acidosis and metabolic acidosis

v.

findings of progressive stage of shock

consciousness - LOC depressed

lungs - tachypnea with hypoventilation and adventitious lung sounds (crackles and wheezes)

cardiovascular

decreased cardiac output and decreased BP with systolic below 90 mm Hg

narrowing pulse pressure

tachycardia and irregular pulse

weak and thready peripheral pulses

elimination

urine volume below 20 mL/hour

dilute urine osmolality

absent bowel sounds

c. refractory stage - shock irreversible

i.

death from multi-organ dysfunction syndrome (MODS)

ii.

findings of refractory stage of shock

cardiac failure

respiratory failure

renal shutdown

liver dysfunction

loss of consciousness

d. Diagnostics - bedside data collection based on etiology of shock

e. Management - objective is to correct underlying cause and prevent progression

i.

many treatments listed are used for all shock syndromes, e.g., vasopressors, positive inotropic
support, oxygen therapy (intubation), fluid replacement

ii.

cardiogenic shock

iii.

pharmacologic treatments

positive inotropic agents: increase myocardial contractility and improve systolic

ejection, e.g., dobutamine (Dobutrex), amrinone lactate (Inocor)

vasodilators: improve heart's pumping action by reducing its workload;

e.g., nitroglycerin (Corobid), nitroprusside sodium (Nipride); usually limited to clients
with failing ventricular function

vasopressors: increase peripheral vascular resistance and elevate blood pressure,

e.g., norepinephrine (Levophed), DOPamine hydrochloride (Intropin)

oxygen therapy - titrated based on ABG analysis and respiratory effort

supportive treatments

intra-aortic balloon pump (counterpulsation)

left and right ventricular assist pumping

hypovolemic shock: rapid fluid replacement therapy to replace lost volume

iv.

crystalloids- 2/3 moves out of vascular space, e.g. normal saline or ringers lactate

colloids (not for sepsis or burn) 1/3 to 1/2 moves out of vascular space, e.g. dextran, blood,
hetastarch, FFP, albumin

hemoglobin based oxygen carriers, e.g. PolyHeme, Hemopure, Hemolink

blood products: whole blood (autotransfusion an option if they go to surgery/chest tube)

anaphylactic shock

epinephrine (adrenalin)

antihistamines

aminophylline (Truphylline)

v.

neurogenic: depends on causative agent

vi.

septic shock

fluid replacement

antiinfective agents based on culture results

improve cardiac output with positive inotropes and vasopressors

Nursing interventions for shock: the cardio-care six except

a. do not elevate or lower head: maintain complete bed rest in flat position or with legs slightly raised to
increase venous return (modified trendelenburg)
b. bed rest
c. turn patient every two hours as tolerated

d. keep client warm

e. administer parenteral therapy, medications
f.

monitor mean hemodynamic indicators as ordered

g. blood plasma expanders or packed cells if hematocrit and hemoglobin low

Dysrhythmias and Lesser Vascular Disorders

A. Dysrhythmias
1. Definition: disturbance in heart rate or rhythm
2. Types of dysrhythmia
a. supraventricular: sinus, atrial, and junctional
i.

sinus tachycardia

ii.

sinus bradycardia

iii.

sinus arrhythmia

iv.

premature atrial complexes

v.

atrial tachycardia

vi.

atrial flutter

vii.

atrial fibrillation

viii.

premature junctional complex

ix.

junctional tachycardia

b. ventricular
i.

premature ventricular contraction

ii.

ventricular tachycardia

iii.

ventricular fibrillation

iv.

asystole

v.

atrioventricular block

vi.

first degree A-V block

vii.

second degree A-V block Mobitz one (type one)

viii.

second degree A-V block Mobitz two (type two)

ix.

third degree A-V block

Nursing interventions - always check your client for symptoms of an arrythmia (the number and degree of findings
will often dictate the treatment)

a. supraventricular dysrhythmias
i.

asymptomatic - no nursing interventions indicated

ii.

symptomatic

vagal stimulation

administer medications as ordered (slow rate of administration)

adenosine (Adenocard)

calcium channel blockers

beta blockers

procedures

cardioversion

ablation

provide emotional support

teach client

about medications and side effects

to decrease stimulant use, i.e., caffeine, nicotine

to control reactions to stress

to reduce alcohol intake

about importance of sleep

b. ventricular dysrhythmias
i.

administer medications as ordered

ii.

monitor hemodynamic indicators as ordered

iii.

administer oxygen as ordered

iv.

provide a restful environment

v.

prepare the client for cardioversion

vi.

initiate cardiopulmonary resuscitation as indicated

vii.

provide emotional support

viii.

teach client

medications and side effects

importance of wearing MedicAlert identification

c. atrio-ventricular (AV) conduction disturbances

i.

asymptomatic: no nursing interventions indicated

ii.

symptomatic

administer medications as ordered

prepare client for pacemaker insertion

care of the client undergoing surgery

provide emotional support

provide a restful environment

Aneurysms

1. Definition: dilation of an artery due to a weakness in the arterial wall

2. Etiology - atherosclerosis
3. Types
a. four types of aneurysms
i.

saccular: out-pouching of one wall in a circumscribed area

ii.

fusiform: involves complete circumference of artery

iii.

dissecting: accumulation of blood separating the layers of the arterial wall

iv.

pseudoaneurysm: tear of the full thickness of the arterial wall, leading to a collection of blood
contained in the connective tissue

b. common locations
i.

location one: abdominal aortic aneurysm

findings of abdominal aortic aneurysm

usually asymptomatic

vague abdominal or back pain

tenderness on palpation

hypotension

diminished pulses in lower extremities

commonest site: just below renal arteries and above iliac arteries

diagnostics - arteriography

management - surgical repair

nursing interventions

postop care of client

after surgery, watch for back pain, a sign of retroperitoneal hemorrhage

ii.

monitor perfusion

provide comfort measures

provide emotional support

teach client - to avoid prolonged sitting and lifting of heavy objects

location two: thoracic aortic aneurysm

findings of thoracic aortic aneurysm

may be asymptomatic

vague chest pain

dyspnea

distended neck veins

diagnostics - arteriography

management - surgical repair

nursing interventions

care of the client undergoing surgery

postop care of client

Arterial occlusive disease

1. Definition: insufficient blood supply in the arteries, usually in legs; may be acute or chronic

2. Acute arterial occlusive disease

a. etiology
i.

embolism, thrombosis, and trauma

ii.

femoral artery most often affected

b. findings
i.

pain in affected limb

ii.

cyanosis in affected limb

iii.

paresthesia in affected limb

iv.

if untreated, gangrene

c. management
i.

anticoagulants

ii.

IV heparin

iii.

surgical treatment

embolectomy

bypass of affected artery

amputation of limb

percutaneous transluminal coronary angioplasty

Chronic arterial occlusive disease

a. etiology
i.

arteriosclerosis obliterans, aneurysms, hypercoagulability states, tobacco use

ii.

slow, progressive arteriosclerotic changes give collateral circulation a chance to form

iii.

collateral circulation cannot give tissues enough oxygen; result is hypoperfusion

iv.

hypoperfusion leads to ischemia

v.

usually affects legs

b. findings
i.

intermittent claudication indicates mild to moderate obstruction

ii.

pain at rest indicates severe obstruction

iii.

affected limb will show

iv.

edema

paresthesia

weak pulses

skin: waxy, hairless, cool, pale, cyanotic

in men, impotence

c. management
i.

physical activity

ii.

diet

iii.

smoking cessation

iv.

pharmacologic

anticoagulants - to prevent blood clots

v.

vasodilators

antiplatelet drugs - to prevent platelet aggregation

pentoxifylline (Trental): increases blood flow by thinning blood

surgical treatment

endarterectomy

femoral-popliteal bypass

sympathectomy

amputation of affected limb for gangrene

laser coronary angioplasty

peripheral angioplasty

Both acute and chronic arterial occlusive disease

a. nursing interventions
i.

administer medications as ordered

ii.

monitor peripheral pulses and blanch test

iii.

provide comfort measures

iv.

help client develop an exercise program

v.

postop care of client

vi.

provide foot care

b. teach client
i.

to change positions frequently

ii.

to avoid crossing legs

iii.

to avoid any constrictive clothing on legs

iv.

to avoid trauma to lower extremities

v.

foot care

vi.

to place legs in dependent position to increase blood flow

Raynaud's phenomenon (arteriopastic disease)

1. Definition
a. episodic vasospasm of the small cutaneous arteries that results in intermittent pallor or cyanosis of
the skin - usually affects the fingers bilaterally, but occasionally affects the toes, nose, or tongue that
result in intermittent pallor or cyanosis of the skin
b. the process involves a severe constriction of cutaneous vessels followed by vessel dilation and then
a reactive hyperemia (blue, white, red)
2. Etiology
a. unknown
b. frequently occurs in women

c. may be triggered by stress, cold

3. Findings
4. Diagnostics
a. clinical pattern
b. digital plethysmography
c. peripheral arteriography
5. Management
a.

pharmacologic agents
i.

calcium channel blockers: nifedipine (Procardia), diltiazem (Cardiazem)

ii.

alpha-adrenergic blocking agents: prazosin (Minipress)

iii.

vasodilators

b. surgery
i.

sympathectomy in advanced stages

ii.

amputation of fingers showing gangrene

6. Nursing interventions
a. administer medications as ordered
b. care of the client undergoing surgery
c. teach client
i.

to manage stress

ii.

to stop smoking, avoid caffeine

iii.

to avoid temperature extremes

iv.

how to protect self from the cold

v.

medications and their side effects

Thromboangiitis obliterans (Buerger's disease)

1. Definition: blocking of the medium and small arteries, usually in the legs and feet
2. Etiology
a. affects men more than women
b. 25 to 40 age group who smoke
c. the disease only occurs in smokers
3. Findings
a. intermittent claudication
b. numbness and tingling of toes
c. weak or absent peripheral pulses
d. ischemic ulcerations may occur

e. can lead to gangrene

4. Diagnostics - angiography
Varicose veins

1. Definition: dilation of superficial veins of the legs and feet

2. Etiology
a. usually found in greater saphenous vein (leg)
b. incompetent valves (incompetence, valvular) in the superficial veins
c. increased pressure in veins causing them to distend
d. risk factors: standing for long periods, pregnancy
3. Findings
a. pain after period of standing
b. foot and ankle swelling at end of day
c. distended leg veins
4. Diagnostics - venography
5. Management
a. objective - to reduce pain and halt underlying condition
b. medical - sclerotherapy (injection of sclerosing agent that causes vein thrombosis)
c. surgical - vein ligation (vein stripping)
6. Nursing interventions
a. care of the client undergoing surgery
b. post-operative care includes
i.

application of elastic stocking or bandages

ii.

elevation of leg

c. teach client
i.

not to cross legs

ii.

to elevate legs as much as possible

iii.

to avoid prolonged sitting or standing

iv.

avoid anything that impedes venous return

v.

overweight clients should lose weight

Thrombophlebitis

1. Definition: a thrombus (clot) accompanied by the inflammation of the wall of a superficial blood vessel

2. Etiology
a. trauma
b. intravenous catheters
c. prolonged immobility
d. IV drug use
3. Findings
a. redness
b. swelling
c. tenderness
d. warmth
4. Diagnostics
a. history and physical
b. ultrasonography
c. plethysmography
5. Management
a. bed rest, with elastic stockings
b. elevation of affected extremity
c.

anticoagulants - to prevent clot formation

d.

analgesics - to control discomfort

6. Nursing interventions
a. keep leg elevated
b. monitor
i.

for findings of pulmonary embolism, i.e., sudden pain, cyanosis, hemoptysis, shock

ii.

vital signs, including peripheral pulses

iii.

for findings of vascular impairment, i.e., pallor, cyanosis, coolness

c. administer analgesics as ordered

d. client teaching
i.

avoid tight or constricting clothing

ii.

stop cigarette smoking

iii.

avoid maintaining one position for long periods

Deep venous thrombosis

1. Definition: clot formation in a deep vein (upper or lower extremity)

2. Etiology and risk:
a. Virchow's triad, e.g., hypercoagulability, hemodynamic changes (stasis, burbulence), endothelial
injury/dysfunction
b. immobilization
c. sepsis
d. hematological disorders and clotting disorders
e. malignancies
f.

congestive heart failure

g. myocardial infarction
h. obesity
i.

pregnancy

j.

fractures

k. venipuncture
l.

surgeries, i.e., orthopedic, neurologic, urologic and gynecologic

m. risk of pulmonary embolus

3. Findings unilateral edema of extremity
4. Diagnostics - venography
5. Management
a. objective: to eliminate the clot and prevent complications
b. bed rest

c.

pharmacological
i.

anticoagulant therapy - to prevent new clots

ii.

thrombolytic therapy - to dissolve thrombus

d. compression stockings
e. surgery - thrombectomy
6. Nursing interventions
a. monitor for findings of pulmonary embolus
b. maintain bed rest
c. administer medications as ordered
d.

monitor drug therapy (aPTT for heparin, PT/INR for warfarin) and know therapeutic levels

e. observe for evidences of bleeding, i.e., bruises, nosebleeds, bleeding gums, blood in urine or stool
f.

teach client
i.

medications and side effects

ii.

to avoid prolonged immobility

iii.

to maintain adequate fluid intake

Venous stasis ulcers

1. Definition: skin and subcutaneous ulcers usually found on legs, ankles or feet (often is a chronic symptom
for clients with chronic venous insufficiency)
2. Etiology
a. chronic venous insufficiency
b. venous stasis is caused by incompetent valves in either perforating veins or in deep veins
c. pressure of blood pooling causes capillaries to leak
d. ulcer begins as small, inflamed, tender area
e. any trauma causes tissue to break or it may break spontaneously
f.

site: pretibial and medial supramalleolar areas of the ankle

3. Findings
a. open skin lesion with irregular border
b. skin around ulcer usually brown and leathery
c. pain in affected area
4. Diagnostics - history and physical exam of site
5. Management
a. objective: to correct venous hypertension and both prevent and correct ulceration
b. local wound care
c.

antibiotics and analgesics as indicated

d. surgery
1. debridement
2. skin grafting
3. removal of veins with incompetent valves
6. Nursing interventions
a. keep legs elevated, with feet above level of heart at all times
b. compression dressings (e.g. elastic bandages)
c. cleanse and dress ulcer as ordered
d. administer drugs as ordered
e. teach client
1. to report any signs of inflammation immediately
2. to avoid trauma to affected limb
3. to provide skin care
4. to apply elastic bandages

Points to Remember

Cardiovascular disease is the leading cause of death among Americans.

Measure blood pressure correctly

give client 5 minutes rest, with 2 to 3 minutes between checks

take blood pressure while client is lying, sitting, and standing

ask client if s/he has recently smoked, drank a beverage containing caffeine or was emotionally
upset; if s/he answers yes to any of the questions, repeat blood pressure in 30 minutes

use the correct size BP cuff

ensure the client's arm is supported and does not have legs crossed

Rarely, the heart may lie on the right side instead of the left (this is called dextrocardia ).

Valves control the direction of the blood flow through the heart; flow is unidirectional.

When the atria contract, the atrioventricular valves swing open, allowing the blood to flow down into the
ventricles.

When the ventricles contract the valves snap shut preventing blood from flowing back up into the atria;
semilunar valves open allowing blood to eject during ventricular contraction.

If the SA node fails to generate an impulse, the AV node takes over, generating a slower rate. If the AV node
fails to generate an impulse, the Bundle of His takes over, generating an even slower rate. If the Bundle of
His fails to generate an impulse, the Purkinje fibers take over and generate an even slower rate.

More Points to Remember

Damaged areas of the heart may also stimulate contractions and produce arrhythmias.

Rapid, short-term control of blood pressure is achieved by cardiac and vascular reflexes that are initiated by
stretch receptors (baroreceptors) in the walls of the carotid sinus and the aortic arch.

Many clients with angina or who have experienced a heart attack benefit from involvement in a structured
cardiac rehabilitation program to assist clients to increase their activity level in a monitored environment.

Current research suggests that cardiovascular changes once related aging can now be attributed to lifestyle
and personal habits.

The elderly are less able to physically adapt to stressful physical and emotional conditions, because their
hearts do three things less quickly:

the myocardium contracts less easily

the left ventricle ejects blood less quickly

the heart is slower to conduct the impulse for a heartbeat

Because different enzymes are released into the blood at varying periods after a myocardial infarction, it is
important to evaluate enzyme levels in relation to the onset of the physical symptoms, e.g., chest pain.

Clients who are in postoperative recovery, on bed rest, obese, taking hormonal contraceptives or had knee
or hip surgery should be monitored closely for the development of thrombophlebitis.