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The Cardiovascular System

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The Cardiovascular System NRS 108-ECC Majuvy L. Sulse RN, MSN, CCRN Lola Oyedele RN, MSN, CTN ANATOMICAL POSITION OF THE HEART Structure and Functions of the Heart ... – PowerPoint PPT presentation

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Title: The Cardiovascular System


1
The Cardiovascular System
  • NRS 108-ECC
  • Majuvy L. Sulse RN, MSN, CCRN
  • Lola Oyedele RN, MSN, CTN

2
ANATOMICAL POSITION OF THE HEART
From Monahan, F. Neighbors, M. (1998).
Medical-surgical nursing Foundations for
clinical practice, ed 2 Philadelphia W.B.
Saunders.
3
Structure and Functions of the Heart
  • Hollow muscular organ encased by pericardium
  • 3 layers- epicardium, myocardium, endocardium
  • 4 chambers divided by septum
  • Consists of valves AV valves Semilunar valves
  • Functions-
  • Circulatory- R L circulation Coronary
  • Conduction- automaticity, excitability,
    conductivity
  • SA node-internodal pathways-AV node-Bundle of
    His-RBBB, LBBB-Purkinje fibers-terminal branches
  • Cardiac cycle-systole (contraction) diastole
    (relaxation/filling)
  • Cardiac output-HR, SV, Preload, Afterload
    Contractility

4
HEART SOUNDS
  • The first heart sound (S1) is heard as the AV
    valves close
  • The second heart sound (S2) is heard when the
    semilunar valves close

5
HEART SOUNDS
  • A fourth heart sound (S4) may be heard on atrial
    systole if resistance to ventricular filling is
    present this is an abnormal finding and the
    causes include cardiac hypertrophy, disease, or
    injury to the ventricular wall
  • A third heart sound (S3) may be heard if
    ventricular wall compliance is decreased and
    structures in the ventricular wall vibrate this
    can occur in conditions such as congestive heart
    failure or valvular regurgitation however, an S3
    heart sound may be normal in individuals younger
    than 30 years of age

6
Normal Deviations associated with aging
  • Chest wall
  • Senile kyphosis
  • Heart
  • Increased incidence of CAD due to atherosclerosis
  • Hypertrophy- higher collagen scarring, elastin
    decreased
  • Decreased CO, increased afterload
  • Valvular rigidity- valve incompetence murmur
  • Decreased control of sympathetic nervous system (
    B adrenergic)- decreased response to stress
  • Blood vessels
  • Arterial stiffening- loss of elastin, thickened
    intima of arteries

7
Cardiac Assessment
  • Physical Examination
  • General appearance
  • Vital signs
  • Inspection
  • Auscultation- heart lungs
  • Palpation
  • Percussion

8
Cardiac Assessment
  • Past health history
  • Risk factors
  • Medications
  • Health perception, concept, management pattern
  • Lifestyle-nutrition, activity, exercise, sleep
    pattern, sexuality
  • Role relationship pattern
  • Coping stress pattern
  • Cultural values

9
Diagnostic Studies
  • CBC
  • RBC, Hgb, Hct, Sed rate
  • Chemistry/Electrolytes
  • Na. K, Ca, Magnesium
  • Lipid profile
  • Triglycerides, HDL-LDL
  • Cardiac enzymes
  • CPK, LDH, Troponin
  • Coagulation studies
  • PT, PTT, INR

10
CBC
  • The red blood cell (RBC) count decreases in
    rheumatic heart disease and infective
    endocarditis and increases in conditions
    characterized by inadequate tissue oxygenation
  • The white blood cell (WBC) count increases in
    infectious and inflammatory diseases of the heart
    and following myocardial infarction (MI) because
    large numbers of WBCs are needed to dispose of
    the necrotic tissue resulting from the infarction
  • An elevated hematocrit can result from vascular
    volume depletion
  • A decrease in hematocrit and hemoglobin can
    indicate anemia

11
Electrolytes
  • SODIUM
  • decreased with the use of diuretic, in heart
    failure- indicating water excess
  • POTASSIUM
  • Hypokalemia causes increased cardiac electrical
    instability, ventricular dysrhythmias, and
    increased risk of digitalis toxicity
  • EKG would show flattening and inversion of the T
    wave, the appearance of a U wave, and sagging of
    the ST segment
  • Hyperkalemia causes asystole and ventricular
    dysrhythmias
  • A low magnesium level can cause ventricular
    tachycardia and fibrillation
  • A high magnesium level can cause muscle weakness,
    hypotension, bradycardia, and a prolonged PR
    interval and wide QRS complex

12
Electrolytes
  • Hypocalcemia can cause ventricular dysrhythmias,
    prolonged QT interval, and cardiac arrest
  • Hypercalcemia can cause a shortened QT interval,
    AV block, tachycardia or bradycardia, digitalis
    hypersensitivity, and cardiac arrest
  • Phosphorus levels should be interpreted with
    calcium levels because the kidneys retain or
    excrete one electrolyte in an inverse
    relationship with the other
  • The BUN is elevated in heart disorders that
    adversely affect renal circulation, such as heart
    failure and cardiogenic shock
  • An acute cardiac episode can elevate the blood
    glucose

13
Cardiac Enzymes
  • CK-MB (CREATINE KINASE, MYOCARDIAL MUSCLE)
  • An elevation in value indicates myocardial damage
  • An elevation occurs within 4 to 6 hours and peaks
    18 to 24 hours following an acute ischemic attack
  • Normal value in conventional units is 0 to 7 U/L
  • LACTIC DEHYDROGENASE (LDH)
  • Elevations in LDH occur 24 hours following
    myocardial infarction and peak in 48 to 72 hours
  • When the serum concentration of LDH1 is higher
    than LDH2, the pattern is indicated as flipped
    signifying myocardial necrosis
  • Normal value in conventional units is 70 to 200
    IU/L

14
Troponins
  • Composed of three proteins cardiac troponin,
    troponin I, and troponin T
  • Troponin I especially has a high affinity for
    myocardial injury it rises within 3 hours and
    persists for up to 7 days
  • Normal values are quite low, with troponin T
    normally ranging from 0.0 to 0.2 ng/ml, and
    troponin I being less than 0.6 ng/ml thus any
    rise can indicate myocardial cell damage
  • MYOGLOBIN LEVEL - an oxygen-binding protein found
    in cardiac and skeletal muscle
  • Level rises within 1 hour after cell death, peaks
    in 4 to 6 hours, and returns to normal within 24
    to 36 hours (and in some clients, even faster)

15
Diagnostic Studies
  • X-ray/Fluoroscopy
  • EKG
  • Holter monitoring
  • Stress test
  • TEE
  • EPS
  • Thallium imaging
  • Muga scan-Multiple gated acquisition image
  • Echo
  • Angiography/ Cardiac catheterization

16
Chest X-ray
  • DESCRIPTION
  • Done to determine the size, silhouette, and
    position of the heart
  • Specific pathological changes are difficult to
    determine via x-ray, but anatomical changes can
    be seen
  • IMPLEMENTATION
  • Prepare the client for x-ray film, explaining the
    purpose and procedure
  • Remove jewelry

17
ECG/EKG
  • DESCRIPTION
  • A common noninvasive diagnostic test that
    evaluates the hearts function by recording
    electrical activity
  • IMPLEMENTATION
  • Determine the clients ability to lie still and
    advise the client to lie still, breathe normally,
    and refrain from talking during the test
  • Reassure the client that an electrical shock will
    not occur
  • Document any cardiac medications the client is
    taking

18
HOLTER MONITORING
  • DESCRIPTION
  • A noninvasive test in which the client wears a
    Holter monitor and an ECG tracing is recorded
    continuously over a period of 24 hours or more
  • It identifies dysrhythmias if they occur and
    evaluates the effectiveness of antidysrhythmics
    or pacemaker therapy
  • IMPLEMENTATION
  • Instruct the client to resume normal daily
    activities and maintain a diary documenting
    activities and any symptoms that may develop

19
ECHOCARDIOGRAM
  • DESCRIPTION
  • A noninvasive procedure based on the principles
    of ultrasound
  • It evaluates structural and functional changes in
    the heart
  • IMPLEMENTATION
  • Determine the clients ability to lie still and
    advise the client to lie still, breathe normally,
    and refrain from talking during the test

20
ECHOCARDIOGRAMPLACEMENT OF LEADS AND TRANSDUCER
21
Stress Test
  • DESCRIPTION
  • A noninvasive test that studies the heart during
    activity and detects and evaluates coronary
    artery disease
  • Treadmill testing is the most commonly used mode
    of stress testing
  • Stress testing may be used in conjunction with
    myocardial radionuclide testing, at which point
    the procedure becomes invasive because a
    radionuclide must be injected
  • A consent form is required if a radionuclide is
    injected

22
EXERCISE TESTING (STRESS TEST)
23
Angiography
  • DESCRIPTION
  • Combines x-ray techniques and a computerized
    subtraction technique with fluoroscopy for
    visualization of the cardiovascular system
  • A contrast medium (dye) is injected
  • PREPROCEDURE
  • Assess the client for allergy to contrast medium
    (dye), iodine, or seafood
  • Obtain consent
  • POSTPROCEDURE
  • Monitor vital signs (VS)
  • Assess injection site for bleeding or discomfort

24
NUCLEAR CARDIOLOGY
  • DESCRIPTION
  • The use of radionuclide techniques and scanning
    in cardiovascular assessment
  • The most common tests include technetium
    pyrophosphate scanning, thallium imaging, and
    multigated cardiac blood pool imaging (MUGA)
  • PREPROCEDURE
  • Obtain consent
  • Inform the client that a small amount of
    radioisotope will be injected, and that the
    radiation exposure and risks are minimal
  • POSTPROCEDURE
  • Assess vital signs (VS)
  • Assess injection site for bleeding or discomfort
  • Inform the client that fatigue may be experienced

25
Transesophageal Echocardiogram (TEE)
  • Views internal structures of the heart and major
    vessels by inserting a thin flexible tube with a
    special tip down the throat.
  • Tip of the probe sends out sound waves
    (ultrasound) that echo within the chest wall
    cavity. These echoes are picked up create
    picture of the heart that is displayed on the
    video monitor.
  • Allows the cardiologist to evaluate any
    congenital defects, heart valve disease or if an
    artificial valve is functioning properly,
    presence of clots within the heart
  • A liquid anesthetic is given to the patient to
    gargle. This will numb his throat tongue make
    the probe easier to swallow
  • IV line for sedative to be given
  • VS monitored including pulse oxymetry
  • NPO not to smoke for at least 6 hours prior to
    test

26
Electrophysiology Study (EPS)
  • A catheter is inserted into a vein/artery in the
    groin to allow measurements of the electrical
    activity pathways usually abnormally fast or
    slow heart rhythms.
  • May lead to further treatment as pacemaker, AICD,
    or Ablation

27
CARDIAC CATHETERIZATION
28
Cardiac Catheterization
  • DESCRIPTION
  • Involves insertion of a catheter into the heart
    and surrounding vessels
  • Obtains information about the structure and
    performance of the heart valves and circulatory
    system
  • PREPROCEDURE
  • Document baseline vital signs, and note the
    quality and presence of peripheral pulses for
    postprocedure comparison
  • Inform the client that a local anesthetic will be
    administered prior to catheter insertion
  • Inform the client that he or she may feel
    fatigued because of the need to lie still and
    quiet on a relatively hard table for up to 2
    hours

29
Cardiac Cath
  • POSTPROCEDURE
  • Monitor VS and cardiac rhythm for dysrhythmias at
    least every 30 minutes for 2 hours initially
  • Assess for chest pain, and if dysrhythmias or
    chest pain occur, notify the physician
  • Monitor peripheral pulses and the color, warmth,
    and sensation of the extremity distal to
    insertion site at least every 30 minutes for 2
    hours initially
  • Notify the physician if the client complains of
    numbness and tingling the extremity becomes
    cool, pale or cyanotic or loss of the peripheral
    pulses occurs
  • Monitor the pressure dressing for bleeding or
    hematoma formation
  • Apply a sandbag to the insertion site to provide
    additional pressure if required
  • Monitor for bleeding and if bleeding occurs,
    apply pressure immediately and notify the
    physician

30
Cardiac Cath
  • POSTPROCEDURE
  • Monitor for hematoma, and if a hematoma develops,
    notify the physician
  • Keep extremity extended for 4 to 6 hours, keeping
    the leg straight to prevent arterial occlusion
  • Maintain strict bed rest for 6 to 12 hours,
    however the client may turn from side to side do
    not elevate the head of the bed more than 15
    degrees
  • If the antecubital vessel was used, immobilize
    the arm using an armboard
  • Encourage fluids if not contraindicated to
    promote renal excretion of the dye
  • Monitor for nausea, vomiting, rash, or other
    signs of hypersensitivity to the dye

31
Hemodynamic Studies
  • CVP
  • Swan-ganz catheter
  • Right atrial pressure (RAP)
  • Right ventricular pressure (RVP)
  • Pulmonary artery pressure (PAP)
  • Pulmonary capillary wedge pressure (PCWP)
  • Cardiac output/ cardiac index

32
Hemodynamic Studies
  • DESCRIPTION
  • The CVP is the pressure within the superior vena
    cava and reflects the pressure under which blood
    is returned to the superior vena cava and right
    atrium
  • CVP is measured with a central venous line in the
    superior vena cava or by a balloon flotation
    catheter in the pulmonary artery
  • Normal CVP pressure is 5 to 10 mmHg
  • An elevated CVP measurement indicates an increase
    in blood volume due to sodium and water
    retention, excessive IV fluids, alterations in
    fluid balance, or renal failure
  • A decreased CVP measurement indicates a decrease
    in circulating blood volume, and may be due to
    hemorrhage or severe vasodilation with pooling of
    blood in the extremities that limits venous
    return, and fluid imbalances

33
MEASURING CENTRAL VENOUS PRESSURE
34
Inflammatory Heart Diseases
  • Rheumatic Heart disease
  • Myocarditis
  • Pericarditis
  • Cardiomyopathy

35
Rheumatic Heart Disease
  • Inflammatory disease of the heart involving all
    layers
  • Chronic condition characterized by scarring
    deformity of the heart valves
  • Sequela to B hemolytic strep infection
  • Socio-economic conditions, familial factors
    altered immune response also predisposes
    rheumatic fever
  • Targets joints (polyarthritis), heart (Carditis),
    skin ( Erythema marginatum CNS( Sydenhams
    chorea)
  • Aschoff bodies- nodules from reaction to
    inflammation- scarring of myocardium
  • Attach to valves, attracts platelets fibrin
  • Causes valvular disorders, cardiomegaly heart
    failure

36
Rheumatic Heart Disease
  • Diagnostic studies
  • Throat cultures
  • ASO titer (antistreptolysin O)
  • CRP-Creactive protein
  • ESR WBC
  • Echo-valvular insufficiency thickening
  • Management
  • Bed rest
  • Drug therapy-
  • Antibiotics to fight infection as prophylaxis
    prior to invasive procedure
  • Salicylates cortecosteroids to control fever
    joint manifestations

37
Pericarditis
  • DESCRIPTION
  • An acute or chronic inflammation of the
    pericardium
  • Chronic pericarditis, a chronic inflammatory
    thickening of the pericardium, constricts the
    heart causing compression
  • The pericardial sac becomes inflamed
  • Can result in loss of pericardial elasticity or
    an accumulation of fluid within the sac
  • Heart failure or cardiac tamponade may result

38
PERICARDITIS
  • ASSESSMENT
  • Precordial pain in the anterior chest that
    radiates to the left side of the neck, shoulder,
    or back
  • Pain that is aggravated by breathing
    (particularly inspiration), coughing, and
    swallowing
  • Pain is worse when in the supine position and may
    be relieved by leaning forward
  • Pericardial friction rub (scratchy, high-pitched
    sound) heard on auscultation, produced by the
    rubbing of the inflamed pericardial
    layers-hallmark finding
  • Fever and chills
  • Fatigue and malaise
  • Elevated WBC count
  • ECG changes- key diagnostic clues
  • Signs of right-sided heart failure in clients
    with chronic constrictive pericarditis

39
Pericarditis
  • IMPLEMENTATION
  • Assess the nature of the pain anxiety
  • Position the client side-lying, high-Fowlers, or
    upright and leaning forward
  • Administer analgesics, (nonsteroidal
    antiinflammatory drugs (NSAIDs), or
    corticosteroids for pain as prescribed
  • Avoid the administration of aspirin and
    anticoagulants because they increase the risk of
    tamponade
  • Auscultate for a pericardial friction rub
  • Evaluate the blood culture report
  • Administer antibiotics for bacterial infection as
    prescribed
  • Administer diuretics and digoxin (Lanoxin) as
    prescribed to the client with chronic
    constrictive pericarditis
  • Assist with pericardiocentesis if prescribed

40
Pericardiocentesis
41
Myocarditis
  • DESCRIPTION
  • An acute or chronic inflammation of the
    myocardium due to pericarditis, systemic
    infection, or allergic response
  • ASSESSMENT
  • Fever
  • Pericardial friction rub
  • A gallop rhythm
  • A murmur that sounds like fluid passing an
    obstruction
  • Pulsus alterans
  • Signs of heart failure
  • Fatigue
  • Dyspnea, tachycardia, chest pain

42
Myocarditis
  • IMPLEMENTATION
  • Assist the client to a position of comfort as
    sitting up and leaning forward
  • Administer analgesics, salicylates, NSAIDs as
    prescribed, to reduce fever and pain
  • Administer oxygen as prescribed
  • Provide adequate rest periods
  • Limit activities to avoid overexertion and to
    decrease the workload of the heart
  • Administer digoxin (Lanoxin) as prescribed and
    monitor for signs of digoxin toxicity
  • Administer antidysrhythmics as prescribed
  • Administer antibiotics as prescribed to treat the
    causative organism
  • Monitor for complications, which can include
    thrombus, heart failure, or cardiomyopathy

43
ENDOCARDITIS
  • DESCRIPTION
  • An inflammation of the inner lining of the heart
    and valves
  • Occurs primarily in clients who are IV drug
    abusers, have had valve replacements, or have
    mitral valve prolapse or other structural defects
  • Ports of entry for the infecting organism include
    the oral cavity (especially if the client had a
    dental procedure in the previous 3 to 6 months),
    cutaneous invasion, infections, or by invasive
    procedures or surgery

44
BACTERIAL INFECTIVE ENDOCARDITIS
45
Endocarditis
  • ASSESSMENT
  • Fever- 90 of patients
  • Anorexia
  • Weight loss
  • Fatigue
  • Cardiac murmurs noted in 80 of cases
  • Heart failure
  • Embolic complications from vegetation fragments
    traveling through the circulation
  • Petechiae
  • Splinter hemorrhages in the nail beds
  • Oslers nodes (reddish tender lesions) on the
    pads of the fingers, hands, and toes
  • Janeways lesions (nontender hemorrhagic lesions)
    on the fingers, toes, nose, or earlobes
  • Roth spots- hemmorhaging retinal lesions
  • Splenomegaly
  • Clubbing of the fingers

46
OSLERS NODES
47
JANEWAY LESION
48
CLUBBING
49
ENDOCARDITIS
  • IMPLEMENTATION
  • Provide adequate rest balanced with activity to
    prevent thrombus formation
  • Monitor cardiovascular status
  • Monitor for signs of heart failure
  • Monitor for pulmonary emboli as evidenced by
    pleuritic chest pain, dyspnea, and cough
  • Assess skin, mucous membranes, and conjunctiva
    for petechiae
  • Assess nail beds for splinter hemorrhages
  • Assess for Oslers nodes on the pads of the
    fingers, hands, and toes
  • Assess for Janeways lesions on the fingers,
    toes, nose, or earlobes

50
Endocarditis
  • CLIENT EDUCATION
  • Signs and symptoms of complications and to notify
    the physician if they occur
  • Importance of good oral hygiene
  • Brush teeth twice daily with a soft toothbrush
    followed by oral rinses
  • Avoid irrigation devices, electric toothbrushes,
    and flossing, because these activities can cause
    the gums to bleed, allowing bacteria to enter the
    mucous membranes and bloodstream
  • Inform the client of the importance of
    prophylactic antibiotics prior to any invasive
    procedure and the importance of informing all
    health care professionals of his or her disease

51
Cardiomyopathty
  • Categories
  • Congestive-Dilated
  • Hypertrophic
  • Restrictive
  • Risk factors
  • Cardiotonic agents-cocaine, alcohol
  • HTN
  • CAD
  • Valvular disorder
  • Pregnancy

52
Cardiomyopathy
  • Diagnostics-History and PE, Echo, CXR, ECG,
    Cardiac Cath, Nuclear imaging studies
  • Nursing diagnosis interventions
  • Decreased cardiac output R/T alterations in
    structure function
  • Activity intolerance
  • Provide rest
  • On going monitoring
  • Diet drug therapy
  • Therapy
  • Palliative
  • Curative- Digitalis, diuretics, anticoagulants,
    antiarrythmics, Betablockers, inotropes, ace
    inhibitors
  • Cardiac transplant

53
VALVULAR HEART DISEASE
  • DESCRIPTION
  • Occurs when the heart valves cannot fully open
    (stenosis) or close completely (insufficiency or
    regurgitation)
  • Prevents efficient blood flow through the heart

54
TYPES OF VALVULAR HEART DISEASE
  • MITRAL, TRICUSPID, AORTIC, PULMONIC
  • STENOSIS- Valvular tissue thickens and narrows
    the valve opening, impedes blood flow from one
    chamber to another
  • INSUFFICIENCY/REGURGITATION- Valve is incompetent
    and prevents complete valve closure, BLOOD FLOWS
    BACK TO CHAMBER
  • VALVE PROLAPSE-Valve leaflets protrude into the
    left atrium during systole

55
Mitral Valve Disease
  • Mitral valve stenosis
  • Obstruction to blood flow causing Increased
    pressure to eject blood low CO
  • L atrial hypertrophy, pulmonary congestion R
    ventricular hypertrophy
  • Manifestations
  • Diastolic murmur-best heard at apex with bell
  • Dyspnea, orthopnea R/T pulmonary congestion
    reduced lung compliance
  • Management
  • Diuretics, digitalis, anticoagulation

56
Mitral Valve Regurgitation
  • Incomplete closure of valve- CO
  • L atrial hypertrophy, pulmonary congestion, R
    ventricular hypertrophy
  • Manifestations fatigue, weakness,dyspnea
  • Complications-Atrial fibrillation emboli
  • Management- diuretics, digitalis,
    beta-blockers,anticoagulation
  • Mitral valve prolapse regurgitation

57
Aortic Valve Disease
  • Aortic stenosis
  • Maybe congenital or acquired (secondary to RH)
  • Narrowed outlet CO pressure L ventricles
  • Pulmonary HTN from increased LV pressure LA
    filling pressures
  • Preload is important to open valve-No NTG
  • Manifestations
  • Systolic crescendo-decrescendo murmur ending
    before S2
  • Chest pain on exertion
  • Dyspnea from pulmonary edema
  • Complications
  • Dysrhythmias

58
  • Aortic Regurgitation-backflow-LV-hypertrophy-incre
    ase ventricular force-high SBP
  • Manifestations-
  • Acute-abrupt onset of dyspnea, chest pain-shock
  • Chronic-
  • Corrigans pulse- abrupt distension during systole
    quick collapse on diastole
  • Austin Flint murmur- low frequency diastolic
    rumble

59
EFFECTS OF AORTIC REGURGITATION
60
Tricuspid Pulmonic Valve Disease
  • R side of heart
  • Stenosis regurgitation pathology
  • Manifestations are R/T R venticular dysfunction/
    R sided heart failure
  • Management related to R sided failure

61
VALVULAR HEART DISEASE REPAIR PROCEDURES
  • BALLOON VALVULOPLASTY
  • An invasive, nonsurgical procedure
  • The passage of a balloon catheter from the
    femoral vein through the atrial septum to the
    mitral valve, or through the femoral artery to
    the aortic valve
  • The balloon is inflated to enlarge the orifice
  • Institute precautions for arterial puncture if
    appropriate
  • Monitor for bleeding from the catheter insertion
    site
  • Monitor for signs of systemic emboli
  • Monitor for signs of a regurgitant valve by
    monitoring cardiac rhythm, heart sounds, and
    cardiac output

62
Valvular Repair Procedures
  • MITRAL ANNULOPLASTY
  • Tightening and suturing the malfunctioning valve
    annulus to eliminate or markedly reduce
    regurgitation
  • COMMISSUROTOMY/VALVOTOMY
  • Accomplished with cardiopulmonary bypass during
    open heart surgery
  • The valve is visualized, thrombi are removed from
    the atria, fused leaflets are incised and calcium
    is debrided from the leaflets, thus widening the
    orifice
  • MECHANICAL PROSTHETIC VALVES
  • Prosthetic valves are very durable but can fail
  • Thromboembolism is a problem following the valve
    replacement and lifetime anticoagulant therapy is
    required
  • BIOPROSTHETIC VALVES
  • Biological grafts are xenografts (valves from
    other species), porcine valves (pig), bovine
    valves (cow), or homografts (human cadavers)
  • There is little risk of clot formation
    therefore, long-term anticoagulation is not
    indicated

63
Porcine Aortic valve
Mechanical Valves
Valve replacement procedures
64
CLIENT INSTRUCTIONS FOLLOWING VALVE REPLACEMENT
  • Adequate rest is important and fatigue is usual
  • Need for anticoagulant therapy if a mechanical
    prosthetic valve was inserted
  • Hazards related to anticoagulant therapy and to
    notify the physician if bleeding or excessive
    bruising occurs
  • Importance of good oral hygiene to reduce the
    risk of infective endocarditis
  • Heavy lifting (greater than 10 pounds) is to be
    avoided and to exercise caution when in an
    automobile to prevent injury to the sternal
    incision
  • If a prosthetic valve was inserted, a soft,
    audible clicking sound may be heard
  • Importance of prophylactic antibiotics prior to
    any invasive procedure and the importance of
    informing all health care professionals of the
    valvular disease history
  • Obtain and wear a Medic Alert bracelet

65
Coronary Artery Disease
  • Pathology-focal deposits of cholesterol lipids
    within the intimal wall of the artery-causes
    decrease in lumen size--decreased blood flow
    (ischemia to tissues major organs- may lead to
    emboli formation

66
CAD
  • Causes decreased perfusion of myocardial tissue
    and inadequate myocardial oxygen supply
  • Leads to hypertension, angina, dysrhythmias,
    myocardial infarction, heart failure, and death
  • Collateral circulation, more than one artery
    supplying a muscle with blood, is normally
    present in the coronary arteries, especially in
    older persons
  • The development of collateral circulation takes
    time and develops when chronic ischemia occurs to
    meet the metabolic demands therefore, an
    occlusion of a coronary artery in a younger
    individual is more likely to be lethal than in an
    older individual
  • Symptoms occur when the coronary artery is
    occluded to the point that inadequate blood
    supply to the muscle occurs, causing ischemia
  • Coronary artery narrowing is significant if the
    lumen diameter of the left main artery is reduced
    at least 50, or if any major branch is reduced
    at least 75
  • The goal of treatment is to alter the
    atherosclerotic progression

67
Coronary Artery Disease
  • Risk factors-
  • Modifiable-smoking, obesity, stress, physical
    immobility, hyperlipidemia, DM, type-A
    personality
  • Non-modifiable- age, gender, ethnicity, genetic
    inheritance
  • Clinical manifestations- asymptomatic until acute
    decrease in blood flow to heart develops
  • Diagnostic studies-
  • Cholesterol, lipid profile, EKG, coronary
    arteriogram, CT scan
  • Medical management
  • Treat cause control modifiable risk factors
  • Restore blood supply
  • Drug therapy
  • Complications
  • Angina, MI, stroke

68
SURGICAL PROCEDURES
  • PTCA to compress the plaque against the walls of
    the artery and dilate the vessel
  • Laser angioplasty to vaporize the plaque
  • Atherectomy to remove the plaque from the artery
  • Vascular stent to prevent the artery from closing
    and to prevent restenosis
  • Coronary artery bypass graft to improve blood
    flow to the myocardial tissue that is at risk for
    ischemia or infarction due to the occluded artery

69
Myocardial Infarction (MI)
  • Injury to myocardium from sudden restriction of
    blood flow to the heart.
  • Etiology/ Pathophysiology
  • Main cause is CAD-build up of atherosclerotic
    plaque in coronary arteries restricting blood
    flow to the heart.
  • Risk factors age, gender, family history,
    diabetes ethnicity
  • Smoking, obesity, stress, elevated cholesterol
    HTN
  • Coronary aretry blood flow is blocked-thrombus
    formation or persistent vasospasm-deprivation of
    oxygen-persistent ischemia may rapidly lead to
    tissue death.
  • Angina pectoris- chest pain from restricted blood
    flow

70
ANGINA
  • DESCRIPTION
  • Chest pain resulting from myocardial ischemia
    caused by inadequate myocardial blood and oxygen
    supply
  • Caused by an imbalance between oxygen supply and
    demand
  • Causes include obstruction of coronary blood flow
    due to atherosclerosis, coronary artery spasm,
    and conditions increasing myocardial oxygen
    consumption

71
Angina
  • STABLE ANGINA
  • Also called exertional angina
  • Occurs with exertion or emotional stress, and is
    relieved with rest or nitroglycerin
  • It usually has a stable pattern of onset,
    duration, severity, and relieving factors
  • UNSTABLE ANGINA
  • Also called preinfarction angina
  • Occurs with an unpredictable degree of exertion
    or emotion and increases in occurrence, duration,
    and severity over time
  • Pain may not be relieved with nitroglycerin

72
Angina
  • VARIANT ANGINA
  • Also called Prinzmetals or vasospastic angina
  • Results from coronary artery spasm and is similar
    to classic angina but lasts longer
  • May occur at rest
  • Attacks may be associated with ST segment
    elevation noted on the ECG
  • INTRACTABLE ANGINA
  • A chronic, incapacitating angina that is
    unresponsive to interventions
  • POSTINFARCTION ANGINA
  • Occurs after an MI, when residual ischemia may
    cause episodes of angina

73
MI-Coronary Circulation
  • LAD-L ventricular muscle
  • L circumflex-posterior wall of LV, SA node (39),
    AV node )(12), LV muscle
  • RCA-R ventricle
  • Inferior portion of L Ventricle, SA node (59),
    AV node (88)

74
MI
  • Inferior Wall-Lead ll, lll, AVF
  • Lateral Wall-I, AVL, V5, V6
  • Anterior Wall- V1-V4

ST elevation
T wave inversion
75
MI
  • ASSESSMENT PAIN
  • Can develop slowly or quickly
  • Usually described as mild or moderate pain
  • Substernal, crushing, squeezing pain
  • May radiate to the shoulders, arms, jaw, neck,
    back
  • Usually lasts less than 5 minutes however, can
    last up to 15 to 20 minutes
  • Dyspnea
  • Pallor
  • Sweating
  • Palpitations and tachycardia
  • Dizziness and faintness
  • Hypertension
  • Digestive disturbances

76
Treatment of MI
  • The goal of treatment is to provide relief of an
    acute attack, correct the imbalance between
    myocardial oxygen supply and demand, prevent the
    progression of the disease and further attacks to
    reduce the risk of MI
  • Assess pain
  • Provide bed rest
  • Administer oxygen at 3 L via nasal cannula as
    prescribed
  • Administer nitroglycerin as prescribed to dilate
    the coronary arteries, reduce the oxygen
    requirements of the myocardium, and relieve the
    chest pain
  • Obtain a 12-lead ECG
  • Assess hemodynamic status
  • Provide continuous cardiac monitoring

77
Treatment for MI
  • MEDICATIONS
  • Nitroglycerine
  • Morphine Sulfate
  • Anticoagulant or Antiplatelet or thrombolytic
    therapy may be prescribed to inhibit platelet
    aggregation and reduce the risk of developing an
    acute MI
  • Betablockers post MI
  • Antidysrhythmic drugs
  • SURGICAL PROCEDURES
  • Same procedures performed to treat CAD( PTCA,
    CABG)
  • Client Education
  • Cardiac rehabilitation
  • Lifestyle change
  • Medication regimen
  • Bleeding precautions

78
Diagnostics for MI
  • ECG
  • Normal during rest, with ST depression or
    elevation and/or T wave inversion during an
    episode of pain
  • STRESS TEST
  • Chest pain or changes in the ECG or vital signs
    during testing may indicate ischemia
  • CARDIAC ENZYMES
  • Normal findings in angina, elevated in MI
  • CARDIAC CATHETERIZATION
  • Provides a definitive diagnosis

79
(No Transcript)
80
ARTERIAL AND VENOUS DISORDERS
81
HYPERTENSION
  • DESCRIPTION
  • Persistent elevation of the systolic blood
    pressure above 140 mmHg and the diastolic blood
    pressure above 90 mmHg
  • Most significant predictor of developing coronary
    artery disease and a major risk factor for
    coronary, cerebral, renal, and peripheral
    vascular disease
  • The disease is initially asymptomatic

82
HYPERTENSION
  • DESCRIPTION
  • The goals of treatment include to reduce the
    blood pressure and to prevent or lessen the
    extent of organ damage
  • Nonpharmacological approaches, such as lifestyle
    changes, may be initially prescribed and if the
    BP cannot be decreased after a reasonable time
    period (1 to 3 months), then the client may
    require pharmacological treatment

83
HYPERTENSION ORGAN INVOLVEMENT
  • EYES
  • Visual changes
  • BRAIN
  • Cerebrovascular accident (CVA)
  • CARDIOVASCULAR SYSTEM
  • Congestive heart failure (CHF), hypertensive
    crisis
  • KIDNEYS
  • Renal failure

84
HYPERTENSIVE RETINOPATHY
From Michelson JB, Friedlaender MH (1996) The eye
in clinical medicine. London Times Mirror
International Publishers.
85
HYPERTROPHY OF THE LEFT VENTRICLE IN HYPERTENSION
From Cotran RS, Kumar V, Collins T Robbins
pathologic basis of disease, ed. 6, Philadelphia,
1999, W.B. Saunders.
86
HYPERTENSION
  • TYPES
  • Primary or essential
  • Secondary

87
PRIMARY OR ESSENTIAL HYPERTENSION
  • DESCRIPTION
  • No known etiology
  • RISK FACTORS
  • Aging
  • Family history
  • Black race with higher prevalence in males
  • Obesity
  • Smoking
  • Stress

88
SECONDARY HYPERTENSION
  • DESCRIPTION
  • Occurs as a result of other disorders or
    conditions
  • Treatment depends on the cause and the organs
    involved
  • PRECIPITATING CONDITIONS
  • Cardiovascular disorders
  • Renal disorders
  • Endocrine system disorders
  • Pregnancy
  • Medications

89
HYPERTENSION
  • ASSESSMENT
  • May be asymptomatic
  • Headache
  • Visual disturbances
  • Dizziness
  • Chest pain
  • Tinnitus
  • Flushed face
  • Epistaxis

90
HYPERTENSION
  • IMPLEMENTATION GOALS
  • To reduce the blood pressure
  • To prevent or lessen the extent of organ damage

91
HYPERTENSION
  • IMPLEMENTATION
  • Question the client regarding the signs and
    symptoms indicative of hypertension
  • Obtain the blood pressure (BP) two or more times
    on both arms with the client supine and standing
    compare the BP with prior documentation
  • Determine family history of hypertension
  • Identify current medication therapy
  • Obtain weight
  • Evaluate dietary patterns and sodium intake

92
HYPERTENSION
  • IMPLEMENTATION
  • Assess for visual changes or retinal damage
  • Assess for cardiovascular changes, such as
    distended neck veins, increased heart rate,
    dysrhythmias
  • Evaluate chest x-ray for heart enlargement
  • Assess neurological system
  • Evaluate renal function
  • Evaluate results of diagnostic and laboratory
    studies

93
HYPERTENSION
  • NONPHARMACOLOGICAL
  • Weight reduction, if necessary, or maintenance of
    ideal weight
  • Dietary sodium restriction to 2 g daily as
    prescribed
  • Moderate intake of alcohol and caffeine-containing
    products
  • Initiation of a regular exercise program

94
HYPERTENSION
  • NONPHARMACOLOGICAL
  • Avoidance of smoking
  • Relaxation techniques and biofeedback therapy
  • Elimination of unnecessary medications that may
    contribute to the hypertension

95
HYPERTENSION STEPPED CARE APPROACH
  • DESCRIPTION
  • If a pharmacological approach to treating
    hypertension is required, a single medication is
    prescribed and monitored for its effectiveness
  • Medications are added to the treatment regimen
    until the BP is controlled
  • Refer to the module entitled Cardiovascular
    Medications, for information regarding
    medications to treat hypertension

96
HYPERTENSION STEPPED CARE APPROACH
  • STEP 1
  • A single medication is prescribed, which may be a
    diuretic, beta blocker, calcium channel blocker,
    or angiotensin-converting enzyme (ACE) inhibitor
  • STEP 2
  • Step 1 therapy is evaluated after 1 to 3 months
  • If the response is not adequate, compliance is
    evaluated
  • The medication may be increased or a new
    medication is prescribed, or a second medication
    is added to the treatment plan

97
HYPERTENSION STEPPED CARE APPROACH
  • STEP 3
  • Compliance is evaluated
  • Further evaluation of Step 2
  • If a therapeutic response is not adequate, a
    second medication is substituted or a third
    medication is added to the treatment plan
  • STEP 4
  • Compliance is evaluated
  • Careful assessment of factors limiting the
    antihypertensive response is done
  • A third or fourth medication may be added to the
    treatment plan

98
HYPERTENSION CLIENT EDUCATION
  • Importance of compliance with the treatment plan
  • The disease process, explaining that symptoms
    usually do not develop until organs have suffered
    damage
  • Planning a regular exercise program, avoiding
    heavy weight lifting and isometric exercises
  • Importance of beginning the exercise program
    gradually
  • Express feelings about daily stress
  • Identify ways to reduce stress

99
HYPERTENSION CLIENT EDUCATION
  • Relaxation techniques
  • Incorporate relaxation techniques into the daily
    living pattern
  • Technique for monitoring blood pressure
  • Maintain a diary of blood pressure readings
  • Importance of lifelong medication and the need
    for follow-up treatment
  • Dietary restriction, which may include sodium,
    fat, calories, and cholesterol

100
HYPERTENSION CLIENT EDUCATION
  • How to shop and prepare low-sodium meals
  • List of products that contain sodium
  • Read labels of products to determine sodium
    content focusing on substance listed as sodium,
    NaCl, and MSG
  • Bake, roast, or boil foods, avoid salt in
    preparation of foods, and avoid using salt at the
    table
  • Fresh foods are best to consume and to avoid
    canned foods

101
HYPERTENSION CLIENT EDUCATION
  • The action, side effects, and scheduling of
    medications
  • If uncomfortable side effects occur, to contact
    the physician and not to stop the medication
  • Avoid over-the-counter medication
  • Importance of follow-up care

102
HYPERTENSIVE CRISIS
  • DESCRIPTION
  • Any clinical condition requiring immediate
    reduction in blood pressure
  • An acute and life-threatening condition
  • The accelerated hypertension requires emergency
    treatment, since target organ damage (brain,
    heart, kidneys, retina of the eye) can occur
    quickly
  • Death can be caused by stroke, renal failure, or
    cardiac disease

103
HYPERTENSIVE CRISIS
  • ASSESSMENT
  • A diastolic pressure above 120 mmHg
  • Headache
  • Drowsiness
  • Confusion
  • Changes in neurological status
  • Tachycardia and tachypnea
  • Dyspnea
  • Cyanosis
  • Seizures

104
HYPERTENSIVE CRISIS
  • IMPLEMENTATION
  • Maintain a patent airway
  • Administer IV antihypertensive medications as
    prescribed
  • Monitor vital signs assessing BP every 5 minutes
  • Assess for hypotension during the administration
    of antihypertensives
  • Place the client in a supine position if
    hypotension occurs
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