Unique Introduction ro Cardiovascular Nursing
Studying Cardiovascular nursing is not rocket science. You just need the proper mindset and material in order to excel in this subject.- Aorta & arteries tend to become less distensible
- Heart becomes less responsive to catecholamines
- Maximal exercise heart rate declines
- Decreased rate of diastolic relaxation ( ↑in BP is more pronounced for systolic BP than diastolic BP)
- Note that hypertension is NOT a normal age-related process
- Compensatory mechanism are delayed/insufficient = orthostatic hypotension is common
- Thickness of LV wall may increase with age due to blood vessel changes
http://nursinglectures.blogspot.com - Also known as coronary HEART disease (CHD)
- Describes heart disease caused by impaired coronary blood flow
- Common cause: atherosclerosis
- CAD can cause the following:
- Myocardial Infarction (MI) = heart attack
- Men are more often affected than women
- Approximately 80% who die of CHD are 65+ y/o
http://nursinglectures.blogspot.com - http://nursinglectures.blogspot.com Risk Factors Non-modifiable Modifiable Age, gender, race, heredity Endothelial injury Stress, diet, sedentary living, Smoking, Alcohol, HPN, DM, Obesity, Contraceptive pills, Hyperlipidemia/hypercholesterolemia Desquamation of endothelial lining (peeling off)
- http://nursinglectures.blogspot.com Increased permeability/ adhesion of molecules LDLs & platelets assimilate into the area Plaques begins to form Decreased coronary tissue perfusion Coronary ischemia Decreased myocardial oxygenation ANGINA PECTORIS MYOCARDIAL INFARCTION
- Neck vein distention (jugular vein)
http://nursinglectures.blogspot.com - Heart sounds (presence of S 3 in adults & S 4 )
- Murmurs – audible vibrations of the heart & great vessels produced by turbulent blood flow
- Pericardial friction rub – extra heart sound originating from the pericardial sac
- - may be a sign of inflammation, infection, or infiltration
- - described as a short, high-pitched scratchy sound
http://nursinglectures.blogspot.com - Dyspnea on exertion – may indicate decreased cardiac reserve
- Orthopnea – a symptom of more advanced heart failure
- Paroxysmal nocturnal dyspnea – severe SOB that usually occurs 2-5hrs after onset of sleep
- Chest Pain – may be due to decreased coronary tissue perfusion or compression & irritation of nerve endings
- Edema – increased hydrostatic pressure in venous system causes shifting of plasma resulting to interstitial fluid accumulation
- Syncope – due to decreased cerebral tissue perfusion
http://nursinglectures.blogspot.com - ECG (Electrocardiography) – graphical recording of the heart’s electrical activities; 1 st diagnostic test done when cardiovascular disorder is suspected
- Waves: P wave – atrial depolarization (contraction/stimulation)
- QRS complex – ventricular depolarization (changes are irreversible)
- ST segment – ventricular repolarization (changes are reversible)
- PR interval (time for impulse to travel) = 0.12-0.20s (3-5 squares) √ for AV block
- QRS = 0.10s or (<2squares)>
http://nursinglectures.blogspot.com - absent P wave = atrial fibrillation
- saw-tooth pattern = atrial flutter
- 3rd degree heart block = prolonged PR then progressively prolonged
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- Cardiac Enzymes (Cardiac Markers):
- a. urine = 0 – 2mg/dL (↑within 30mins – 2hrs after MI)
- 2 nd : Troponin* - regulates calcium-mediated contractile process released during MI (Troponin T & I)
- 3 rd : Creatinine kinase (CK) – intracellular enzymes found in muscles converting ATP to ADP
- CK-MB – specific to myocardial tissue (↑within 4-6hrs & decreases to normal within 2-3days)
- 4 th : LDH (specifically LDH 1 - most sensitive indicator of myocardial damage) = 45-90mg/dL - ↑within 3-4 days & remains elevated for 14 days
http://nursinglectures.blogspot.com - Stress Test / Treadmill Test (Treadmill Stress Test) – ECG monitoring during a series of activities of patient on a treadmill
- Purposes: identify ischemic heart disease
- evaluate patients with chest pain
- evaluate effectiveness of therapy
- develop appropriate fitness program
- Instructions to patient: get adequate sleep prio r to test
- - avoid: caffeinated beverages, tea, alcohol, on the day before until the test day
- - wear comfortable, loose-fitting clothes & rubber-soled shoes on the test day
- - light breakfast on the day of the test
- - inform physician of any unusual sensations during the test
http://nursinglectures.blogspot.com - Pharmacologic Stress Test – use of intravenous injection of pharmacologic vasodilator (dipyridamole, adenosine, or dobutamine) in combination of radionuclide myocardial imaging
- To evaluate presence of significant CHD for patients contraindicated in TST
- Dipyradamole blocks cellular re-absorption of adenosine (endogenous vasodilator) & increases coronary blood flow 3-5x above baseline levels
- If with CHD, the resistance vessels distal to the stenosis already are maximally dilated to maintain normal resting flow, thus, further vasodilatation does not produce increased blood flow
- Dobutamine – used in patients with bronchospastic pulmonary disease
- - increases myocardial O 2 demand by increasing cardiac contractility, HR, & BP
http://nursinglectures.blogspot.com - Cardiac Catheterization – involves passage of flexible catheters into great vessels & heart chambers under local anesthesia
- - lab is equipped for viewing & recording fluoroscopic images & for measuring pressures in the heart & great vessels, cardiac output studies, & for obtaining ABG samples
- - Epinephrine – to counteract possible allergic reactions
- Right heart Catheterization – catheter inserted into peripheral veins (basilic or femoral) then advanced into the right heart
- Left heart Catheterization – catheter inserted retrograde through peripheral artery (brachial or femoral) into the aorta & left heart
- Coronary Angiogram – injection of radiographic contrast medium into the heart so that an outline of moving structures are visualized & filmed
- Coronary Arteriography - injection of radiographic contrast medium into the coronary arteries permits visualization of lesions in these vessels
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- √ for allergies to seafood & iodine
- Explain that warm or flushing sensation may be felt upon administr ation of the dye; “fluttering” sensation may be felt as catheter enters the heart
- Administer sedatives as ordered
- Have the client void prior to transport to cath lab
- Bed rest – upper extremity catheter = until stable v/s, HOB not more than 30 °
- - lower extremity = 24hrs, flat on bed for 6hrs
- Apply pressure (5lb-sand bag) over puncture site & monitor for bleeding
- Monitor v/s q15 for 1 st 2hrs then q1 until stable v/s, esp. peripheral pulses
- Immobilize affected extremity in extension for adequate circulation
- Monitor for color & temperature changes of extremities
- Instruct client to report tingling sensations
http://nursinglectures.blogspot.com - Swan-Ganz Catheterization – to determine & monitor cardiovascular status; inserted via antecubital vein into the right side of the heart & is floated into the pulmonary artery
- 1. CVP – specific to right heart RA = 0-12 RV = 5-12
- Indications: increased CVP = heart failure
- -decreased CVP = hypovolemia
- PAP (pulmonary artery pressure) = 20-30mmHg
- PCWP (pulmonary capillary wedge pressure) = 8-13mmHg (√ for pulmonary edema)
- 3. Specimen collection tube – also used for administering meds
http://nursinglectures.blogspot.com - Echocardiography – uses ultrasound to assess cardiac structure & mobility
- Doppler U/S – to detect blood flow of artery & vein specifically of lower extremities (No smoking 1hr before the test)
- Holter Monitoring – portable 24hr ECG monitoring which attempts to assess activities which precipitate dysrhythmias & its time of the day
- MRI – magnetic fields & radiowaves are used to detect & define abnormalities in tissues (aorta, tumors, cardiomyopathy, pericardiac disease)
- - shows actual beating & blood flow; image over 3 spatial dimensions
- Assess for claustrophobia
- Remove metal items (jewelries, eyeglasses)
- Instruct client to remain still during the entire procedure
- Inform client of the duration (45-60mins)
- CI: clients with pacemakers, prosthetic valves, recently implanted clips or wires
http://nursinglectures.blogspot.com - http://nursinglectures.blogspot.com CHD Chronic Ischemic Heart Disease Acute Coronary Syndrome Stable Angina Variant Angina Silent Myocardial Ischemia Non ST-segment Elevation MI (Unstable Angina) ST-segment Elevation MI
- Ischemia – suppressed blood flow
- Occurs when blood supply is inadequate to meet the heart’s metabolic demands
- Symptomatic paroxysmal chest pain or pressure sensation associated with transient ischemia
http://nursinglectures.blogspot.com - http://nursinglectures.blogspot.com Causes: Atherosclerosis, HPN, DM, Buerger’s Disease, Polycythemia Vera, Aortic regurgitation Reduced coronary tissue perfusion Decreased myocardial oxygenation Anaerobic metabolism Increased lactic acid production (lactic acidosis) Chest pain
- Stable angina – the common initial manifestation of a heart disease
- Common cause: atherosclerosis (although those with advance atherosclerosis do not develop angina)
- Pain is precipitated by increased work demands of the heart (i.e.. physical exertion, exposure to cold, & emotional stress)
- Pain location: precordial or substernal chest area
- con stricting, squeezing, or suffocating sensation
- Usua lly steady, increasing in intensity only at the onset & end of attack
- May radiate to left shoulder, arm, jaw, or other chest areas
- Relie ved by rest (preferably sitting or standing with support) or by use of NTG
http://nursinglectures.blogspot.com - Variant/Vasospastic Angina (Prinzmetal Angina)
- 1 st described by Prinzmetal & Associates in 1659
- Cause: spasm of coronary arteries (vasospasm) due to coronary artery stenosis
- Mechanism is uncertain (may be from hyperactive sympathetic responses, mishandling defects of calcium in smooth vascular muscles, reduced prostaglandin I 2 production)
- Pain Characteristics: occurs during rest or with minimal exercise
- - commonly follows a cyclic or regular pattern of occurrence (i.e.. Same time each day usually at early hours)
- If client is for cardiac cath, Ergonovine (nonspecific vasoconstrictor) may be administered to evoke anginal attack & demonstrate the presence & location of spasm
http://nursinglectures.blogspot.com - Nocturnal Angina - frequently occurs nocturnally (may be associated with REM stage of sleep)
- Angina Decubitus – paroxysmal chest pain occurs when client sits or stands up
- Post-infarction Angina – occurs after MI when residual ischemia may cause episodes of angina
http://nursinglectures.blogspot.com - Dx: detailed pain history, ECG, TST, angiogram may be used to confirm & describe type of angina
- Tx: directed towards MI prevention
- Lifestyle modification (individualized regular exercise program, smoking cess a tion)
- PTCA (percutaneous transluminal coronary angioplasty) may be indicated if with severe artery occlusion
http://nursinglectures.blogspot.com - Nitroglycerin (NTGs) – vasodilators:
- patch (Deponit, Transderm-NTG)
- Calcium channel blockers:
- Nifedipine (Calcibloc, Adalat)
- Lipid lowering agents –statins:
http://nursinglectures.blogspot.com - Class I – angina occurs with strenuous, rapid, or prolonged exertion at work or recreation
- Class II – angina occurs on walking or going up the stairs rapidly or after meals, walking uphill, walking more than 2 blocks on the level or going more than 1 flight of ordinary stairs at normal pace, under emotional stress, or in cold
- Class III – angina occurs on walking 1-2 blocks on the level or going 1 flight of ordinary stairs at normal pace
- Class IV – angina occurs even at rest
http://nursinglectures.blogspot.com - Diet instructions (low salt, low fat, low cholesterol , high fiber); avoid animal fats
- E.g.. White meat – chicken w/o skin, fish
- Stop smoking & avoid alcohol
- Activity restrictions are placed within client’s limitations
- NTGs – max of 3doses at 5-min intervals
- Stinging sensation under the tongue for SL is normal
- Advise clients to always carry 3 tablets
- Store meds in cool, dry place, air-tight amber bottles & change stocks every 6months
- Inform clients that headache, dizziness, flushed face are common side effects.
- Do not discontinue the drug.
- For patches, rotate skin sites usually on chest wall
- Instruct on evaluation of effectiveness based on pain relief
- Propanolols causes bronchospasm & hypoglycemia, do not administer to asthmatic & diabetic clients
- Heparin – monitor bleeding tendencies (avoid punctu res , use of soft-bristled toot hbrush ); monitor PTT levels; use d for 2wks max; do not massage if via SC; have protamine sulfate available
- Coumadin – monitor for bleeding & PT; always have vit K readily available (avoid green leafy veggies)
http://nursinglectures.blogspot.com - Unstab le Angina/Non ST-Segment Elevation MI – a clinical syndro me of myocardial ischemia
- Causes: atherosclerotic plaque disruption or significant CHD, cocaine use (risk factor)
- Defining guidelines: (3 presentations)
- Symptoms at rest (usually prolonged, i.e.. >20mins)
- New onset exertional angina (increased in severity of at least 1 class – to at least class III) in <2months>
- Recent acceleration of angina to at least class III in <2months>
- Dx: based on pain severity & presenting sympto ms , ECG findings & serum cardiac markers
- When chest pain has been unremitting for >20mins, possibility of ST-Segment Elevation MI is usually considered
http://nursinglectures.blogspot.com - ST-Segment Elevation MI (Heart Attack)
- Characterized by ischemic death of myocardial tis sue associated with atherosclerotic disease of coro nar y arteries
- Area of infarction is determined by the affected coronary artery & its distribution of blood flow (right coronary artery, left anterior descending artery, left circumflex artery)
- Dx: based on presenting S/Sx, serum markers, & ECG (changes may not be present immediately after symptoms except dysrhythmias; PVCs/premature ventricular contractions are common after MI)
- Typical ECG changes: ST-segment elevation, Q wave prolongation, T wave inversion
http://nursinglectures.blogspot.com - chest pain – severe crushing, constricting, “someone sitting on my chest”
- - substernal radiating to left arm, neck or jaw
- - prolonged (>35mins) & not relieved by rest
- Shortness of breath, profuse perspiration
- Feeling of impending doom
- Complications: death (usually within 1 hr of onset)
- Heart fail ure & cardiogenic shock – profound LV failure from massive MI resulting to low cardiac output
- Thromboe mboli – leads to immobility & impaired cardiac function contributi ng to blood stasis in veins
- Ventricul ar aneurysms – decreases pumping efficiency of heart & increase s work of LV
http://nursinglectures.blogspot.com - Causes: atherosclerotic heart disease, thrombosis/embolism, shock &/or hemorrhage, direct trauma Myocardial ischemia ↑ cellular hypoxia ↓ myocardial O 2 supply ↓ myocardial contractility ↓ cardiac output ↓ arterial pressure Stimulation of sympathetic receptors ↑ peripheral vasoconstriction ↑ myocardial contractility ↑ afterload ↑ myocardial O 2 demand ↑ HR ↑ diastolic filling ↓ myocardial tissue perfusion http://nursinglectures.blogspot.com
- http://nursinglectures.blogspot.com Time after Onset Type of Injury & Gross Tissue Changes 0-0.5hrs Reversible injury 1-2hrs Onset of irreversible injury 4-12hrs Beginning of coagulation necrosis 18-24hrs Continued necrosis; gross pallor of infected tissue 1-3days Total necrosis; onset of acute inflammatory process 3-7days Infarcted area becomes soft with a yellow-brown center & hyperemic edges 7-10days Minimally soft & yellow with vascularized edges; scar tissue generation begins (fibroplastic activity) 8 th week Complete scar tissue replacement
- - O 2 therapy via nasal prongs
- - adequate analgesia ( M orphine via IV – also has vasodilator property)
- -sublingual N TG (unless contraindicated; IV may be given to limit infarction size & most effective if given within 4hrs of onset)
- Thrombolytic Therapy – best results occur if initiated within 60-90mins of onset (Streptokinase & Urokinase – promote conversion of plasminogen to plasmin)
- Anti-arrhythmics: lidocaine, atropine, propano lol
- Anticoagulants & antiplatelets: ASA, heparin
http://nursinglectures.blogspot.com - Coronary stent implantation
- Coronary Artery Bypass Graft (CABG) – no response to medical treatment & PTCA
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- Promote oxygenation & tissue perfusion (place client on semi-fowler’s, O 2 via nasal cannula, monitor v/s changes, remind client on his activity limitations & restrictions)
- Monitor the ff perimeters: v/s, ECG, rate & rhythm of pulse, effects of ADLs on cardiac status
- Diet: low salt, low cholesterol, low calories, avoid alcohol & smoking
- Take prescribe meds at regular basis
- Resume sexual activity after 4-6wks from discharge or when client can go up 2 flights of stairs without difficulty
- Assume less tiring position (non-MI partner takes active role).
- Perform sexual activity in a cool, familiar place.
- Take prescribed NTG before sexual activity
- Refrain from sexual activity after a large meal or during a tiring day.
- Moderation should be observed if palpitations, dizziness or dyspnea is observed
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- Also known as Thromboangiitis obliterans
- Usually a disease of heavy cigarette smoker/tobacco user men, 25-40y/o
- Inflammatory arterial disorder that causes thrombus formation often extends to adjacent veins & nerves
- Affects medium-sized arteries (usually plantar & digital vessels in the foot or lower legs)
- unknown pathogenesis but it had been suggested that:
- tobacco may trigger an immune response or
- unmask a clotting defect;
- -> these 2 can incite an inflammatory reaction of the vessel wall
http://nursinglectures.blogspot.com - Pain – predominant symptom; R/T distal arterial i schemia
- Intermittent claudication in the arch of foot & digits
- Increased sensitivity to cold (due to impaired circulation
- Absent/diminished peripheral pulses
- Color changes in extremity (cyanotic on dependent position; digits may turn reddish blue)
- Thick malformed nails (chronic ischemia)
- Disease progression ulcerate tissues & gangrenous changes may arise; may necessitate amputation
http://nursinglectures.blogspot.com - Diagnostic methods – those that assess blood flow (Doppler ultrasound & MRI)
- Tx: mandatory to stop smoking or using tobacco
- Meds to increase blood flow to extremities
- Surgery (surgical sympathectomy)
http://nursinglectures.blogspot.com - Mechanism: intensive vasospasm of arteries & arterioles in the fi ngers
- Usually affects young women
- Precipitated by exposure to cold & strong emotions
- Raynaud’s phenomenon – associated with previous injury (i.e.. Frostbite, occupation al trauma associated with use of heavy vibr ating tools, collagen diseases, neuro d/o, chro nic arterial occlusive d/o)
http://nursinglectures.blogspot.com - Period of ischemia (ischemia due to vasospasm)
- change in skin color = pallor to cyanotic
- 1 st noticed at the fingertips later moving to distal phalanges
- Sensory perception changes (numbness & tingling)
- Period of hyperemia – intense redness
- Note: although all of the fingers are affected symmetrically, only 1-2digits may be involved
- Severe cases: arthritis may arise (due to nutritional impairment)
- Thickening of the skin of fingertips
- Ulceration & superficial gangrene of fingers (rare occasions)
http://nursinglectures.blogspot.com - Dx: initial = based on Hx of vasospastic attacks
- Immersion of hand in cold water to initiate attack aids in the Dx
- Doppler flow velocimetry – used to quantify blood flow during temperature changes
- Serial Computed thermography (finger skin temp) – for diagnosing the extent of disease
- Tx: directed towards eliminating factors causing vasospasm & protecting fingers from injury during ischemic attacks
- PRIORITIES: Abstinence in smoking & protection from cold
- Avoidance of emotional stress (anxiety & stress may precipitate vascular spasm)
- Meds: avoid vasoconstrictors (i.e.. Decongestants)
- -Calcium channel blockers (Diltiazem, Nifedip ine , Nicardipine) – decrease episodes of attacks
http://nursinglectures.blogspot.com - Hx of symptoms (pain, esp. chest pain; palpitations; dyspnea)
- ineffective tissue perfusion (cardio pulmonary)
- Anxiety due to fear of death (clients with MI or An gina)
- Relief of pain & symptoms
- Prevention of further cardiac damage
- Decrease client’s anxiety
- Health teachings (meds, activities, diet, exercise, etc)
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