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On completion of this chapter, the learner will be able to:1. Describe the pathophysiology, clinical manifestations, and
treatment of coronary atherosclerosis.2. Describe the pathophysiology, clinical manifestations, and
treatment of angina pectoris.3. Use the nursing process as a framework for care of patients
with angina pectoris.4. Describe the pathophysiology, clinical manifestations, and
treatment of myocardial infarction.5. Use the nursing process as a framework for care of patients
with myocardial infarction (acute coronary syndrome).6. Describe the nursing care of a patient who has had an invasive
interventional procedure for treatment of coronary artery disease.
7. Describe coronary artery revascularization procedures.8. Describe the nursing care of the patient treated with cardiac
surgery.
Assessment of Cardiovascular Function
− Cardiac output: Amount of blood pumped by each ventricle in liters per minute.
* Normal cardiac output 5L/min in resting.− Stroke volume: Is the amount of blood
ejected per heart beat. * The average stroke volume is about 70 ml. Cardiac output = Stroke volume x Heart beat.
= 70 ml X (60-80) b/min.
Control of stroke volume:
− Stroke volume: Is primarily determined by three factors:
Preload: It’s the degree of stretch of cardiac muscle fibers at end of diastole.
Afterload: The pressure the ventricular myocardium must overcome to eject blood during systole.
Contractility: is a term used to denote the force generating by contracting myocardium under any given condition.
I-Assessment:
1- Health history and clinical manifestation:
* Cardiac Symptoms: - Chest discomfort. -Shortness of breath or Dyspnea. - Edema and weight gain. - Palpitation (dysarrythmias). - Fatigue. - Dizziness and syncope.
I-Assessment:
2- Nutrition and metabolism: Diets that are restricted in sodium,
fat, cholesterol, and calories. 3- Activity and Exercise: If symptoms develop during
exercise, what are nature of exercise.
I-Assessment:4- Physical examination: -The examination, which proceeds logically from head to
toe can be performed in about 10 min. a- General appearance: - The nurse observes the patients level of
consciousness, and thought process as an indication of the hearts ability to
propel oxygen to the brain. b- Inspection of skin: Pallor, cyanosis, Temp, reduce skin turgor,
wounds. c- Blood Pressure. d- Arterial pulses: Pulse rate, rhythm, and volume.
II- Cardiac Auscultation:
Heart Sounds:The normal heart sounds, S1, S2, are
produced primarily by the closing of the heart values.
a- S1= Closure of mitral and tricuspid valves.
b- S2= Closure of aortic and pulmonic valves.
II- Cardiac Auscultation: c- Gallop: S3: Occurring during rapid ventricle filling is impeded
during diastole. e.g MI, CHF. S4: When the ventricle is enlarged or hypertrophied
and therefore resistant to filling. e.g. CAD, aortic stenosis.
Note: S4 heard by bell of stethoscope only, they are heard best at
the apex. d- Murmurs: Are created by the turbulent flow of blood, the
causes turbulence may be a critically narrowed valve or
regurgitation of valves.
III- Diagnostic Evaluation:
1- Laboratory Tests: e.g Cardiac enzyme , blood chemistry (urea, creatinine, serum electrolyte, coagulation studies, lipid profile.) 2- Chest x-ray and fluoroscopy. 3- Cardiac stress test: To detect the ischemia, by increasing the metabolic
demands for oxygen. 4- Echocardiograph: Is non invasive ultrasound test used to examine the size,
shape and motion of cardiac structures. 5- Cardiac Catheterization: Is an invasive diagnostic procedure in which radiopaque arterial and venous catheters are introduced into
selected blood vessels of the right and left sides of the heart.
Normal Components of the EKG Waveform
P waveIndicates atrial depolarization, or contraction of the atrium. Normal duration is not longer than 0.11 seconds (less than 3 small
squares) QRS complexIndicates ventricular depolarization, or contraction of the
ventricles. Normally not longer than .10 seconds in duration T waveIndicates ventricular repolarization ST segmentIndicates early ventricular repolarization PR intervalIndicates AV conduction time Duration time is 0.12 to 0.20 seconds
Management of Patient with Coronary Vascular Disease
Coronary Artery Disease: The most prevalent type of cardiovascular
disease is coronary artery disease (CAD). Coronary Atherosclerosis: Is an abnormal accumulation of lipid , or
fatty substances and fibrous tissue in the vessel wall.
Atheroma: Begins as fatty streaks, lipids that are deposite on the intima of the arterial wall.
Management of Patient with Coronary Vascular Disease
Risk factors for (CAD): Non modifiable risk factors: * Family history. * Increasing age. * Gender. * Race. Modifiable risk factors: * High blood cholesterol. * Obesity. * Smoking. * Stress. * Hypertension. * Diabetes mellitus.
Management of Patient with Coronary Vascular Disease
Angina Pectoris: Is a clinical syndrome usually characterized
by episodes or paroxysm of pain or pressure in the anterior chest, the cause is usually insufficient coronary blood flow.
− Factors those are associated with a typical angina pain:
* Physical exertion. * Exposure to cold. * Eating a heavy meal. * Stress or any emotion- provoking
situation.
Angina: Pathophysiology • Temporary and reversible> partial occlusion,
spasm, or thrombus • Cells deprived of oxygen • Cell membranes release histamines,
kinins,specific enzymes stimulating nerve fibers in cardiac muscle that send pain impulses to CNS
• Pain radiates to upper body • <30 minutes ischemia: adequate
nutrients/oxygen clears waste products • > 30 minutes ischemia: irreversible damage
Angina Types:
• Stable Angina– Most common and predictable; occurs with
predictable amount of activity or stress– Occurs when work of heart is increased by physical
exertion, exposure to cold, stress– Relieved by rest and nitrates
• Prinzmetal’s (variant)– Atypical angina occurs unpredictability; not related
to activity and often at night– Caused by spasm of coronary artery with or without
atherosclerotic lesion
Angina Types:
• Unstable Angina– Occurs with increasing frequency, severity,
duration– Pain is unpredictable and occurs with rest, low
activity, stress– At risk for myocardial infarction
• Silent Angina– Asymptomatic ischemia, thought to very
common with CHD– May occur with activity or mental stress
Angina Pectoris:
Clinical Manifestation: * Chest pain. (Retrosternal pain). * Weakness or numbness in the arms. * Shortness of breath. * Pallor, diaphoresis, dizziness or light –headedness. * Nausea, Vomiting. * Anxiety.
Medical Management:1-Pharmacologic Therapy:a-Nitroglycerine: To decrease workload of the heart, and coronary artery vasodilation. b- Beta-adrenergic blocking agents: Such as propranolol
(Inderal),and atenolol(tenormine).To decrease heart rate, blood pressure and myocardium contractility.c- Calcium channel blocking agents: Such as nipedipia,
verpamil, and diltiazem.To decrease heart rate, decrease workload of heart, and increase coronary artery perfusion.
d-Antiplatlates and anticoagulant medication. * Aspirin prevent platelets aggregation. * Heparin prevents the formation of new blood clots. e-Oxygen administration.
Medical Management:
2- Invasive intervention and surgical management:
a- Percautanouse transluminal coronary angioplasty (PTCA).
b- Coronary artery stent. c- Atherectomy. d- Coronary artery bypass graft. (CABG).
Myocardial Infarction:
Definition: Is a death of heart tissue caused by prolonging ischemia.
- Necrosis of myocardial cells; life‐threatening event– Loss of functional myocardium affects heart’s ability to
maintain effective cardiac output– AMI and other ischemic heart diseases cause majority of
deaths– Majority of AMI deaths occur during initial period post
symptoms: 60% within first hour, 40% prior to hospitalization
MI: Pathophysiology•
Develops from atherosclerotic plaques in coronary arteries
• Occurs when blood flow blocked>prolonged tissue ischemia and irreversible cell damage
• Prolonged ischemia> irreversible damage• Cellular metabolism shifts from aerobic to anaerobic
metabolism producing hydrogen ions and lactic acid• Dysrhythmias and decreased myocardial contractility
cause decreased stroke volume, cardiac output, blood pressure
and tissue perfusion
MI: Pathophysiology• Areas of heart– Particular coronary artery occluded determines
area of damage– The specific infarct site predicts possible
complications and dictates appropriate therapy– Specific artery and affected area of heart • Left anterior descending artery: anterior wall
of left ventricle and part of interventricularseptum
• Left circumflex artery: lateral MI • Right coronary artery: right ventricle, inferior
and posterior infarct • Left main coronary artery: entire left ventricle
Myocardial Infarction: Clinical Manifestation: * Sudden chest pain. * Sweating. * Nausea and vomiting. * Cool, pale. * Anxiety. Diagnostic procedure: * ECG. * Echocardiogram. * Laboratory test. eg. Cardiac enzyme (CPK, LDH,Troponin.)
Medical Management:
The goal of medical management is to minimize myocardial damage, preserve myocardial function and prevent complication.
a- Emergent PTCA or stent. b- Pharmacological therapy.e.g
thrombolytics: the purpose is to dissolve and lyses the thrombus in coronary artery. (Reperfusion)
e.g. TPA (Tissue plasminogen activate), Streptokinase.
c- Analgesic. d- Oxygen administration.
Myocardial Infarction:
Nursing intervention: * Relieving chest pain.
* Improving respiratory function. * Promoting adequate tissueperfusion. * Reducing anxiety. * Managing and monitoring potential complication.
Management of Patients With Complications FromHeart Disease
LEARNING OBJECTIVESOn completion of this chapter, the learner will be able to: 1. Describe the management of patients with chronic heart
failure. 2. Use the nursing process as a framework for care of patients
with heart failure. 3. Describe the management of patients with acute heart
failure. 4. Develop teaching plans for patients with heart failure. 5. Describe the management of patients with cardiogenic
shock. 6. Describe the management of patients with thromboembolic
episodes, pericardial effusion and cardiac tamponade, and myocardial rupture.
7. Demonstrate the techniques of cardiopulmonary resuscitation.
Cardiac Failure: Congestive heart failure :( CHF)
Referred to as a cardiac failure, is the inability of the heart to pump sufficient blood to meet the needs of the tissue for
oxygen and nutrient. - The term “congestive heart failure” is most commonly
used when referring to Lt- sided and right-sided heart
failure. - Cardiac failure commonly occurs with disorders of
cardiac muscle that result in decrease contractile properties of
the heart, lead to decrease myocardial contractility include. Myocardial dysfunction (especially from coronary atherosclerosis), arterial hypertension, and valvular dysfunction.
Left –Sided Cardiac failure:
Pulmonary congestion occurs when the left ventricle cannot pump the blood out of the chamber. This increase pressure in the left ventricle and decrease the blood flow from the left atrium. The pressure in the left atrium increase, which decrease the blood flow coming from the pulmonary vessels. The result increase in pressure in the pulmonary circulation forces fluid into the pulmonary tissue and alveoli.
Sings & Symptoms: * Dyspnea on exertion. * Pulmonary Crackles. * Orthopnea. * Restlessness and anxiety. * Cough. * Tachycardia.
Right sided heart failure:
The right side of the heart cannot eject blood, and thus can not accommodate all the blood that normally returns to it from the venous circulation.
Sings & Symptoms; * Edema of the lower extremities. * Wight gain. * Hepatomegally (enlargement of the liver). * Distended neck vein. * Ascites (an accumulation of fluid in the peritoneal cavity). * Anorexia and nausea. * Nocturia. * Weakness. * Pitting edema.
HemodynamicMonitoring
• Intra-arterial pressure (art line; a line) Direct and continuous monitoring of systolic, diastolic, mean arterial pressure; arterial blood sampling• Central venous pressure (CVP) Measures blood volume/venous return; reflects right heart filling pressures• Pulmonary artery pressure (PA; Swan-Ganzcatheter) Evaluate left ventricular and overall cardiac function
Medical Management:
The basic objectives in treating patients with congestive heart failure are the following:
* Reducing the workload on the heart. * Increasing the force and efficiency of myocardial
contraction. Pharmacological Therapy: a-ACE (Angiotinsin converted enzyme)
inhibitors: ACE inhibitors promote vasodilation and diuresis
by decreasing afterload and preload, they decrease the work load of the heart.
b-Diuretic Therapy. c-Digitalis. The most commonly prescribed forms of
digitalis for patients with CHF are digoxin (lanoxine) and digotoxin.
- The medication increases the force of myocardial contraction and slows conduction through the AVnode. d- Dobutamine (dobutrex): It stimulates the beta1-adrenergic receptor, and its major action to increase cardiac contractility. e- Other Medication. e.g Anticoagulant, Beta-adrenergic
blockers (propranolol,atenolol)
Aneurysm:
Is an abnormal widening or ballooning of apportion of a blood vessel, the blood vessel wall becomes weaker in this location.
Causes and Risks: * Aneurysms are either congenital or acquired. * Hypertension. * Atherosclerosis disease. * Pregnency, associated with formation and or rupture of splenic artery aneurysms. Signs & Symptoms: * Swelling with a pulsatile (throbbing) mass at site of aneurysms are often seen. * In case of rupture, hypotesion, high heart rate and light headedness are seen; the risk of death from rupture is high.
Aneurysm:
Sings and Tests: * Physical Examination. * Ultrasound Examination. * CT-scan. (Abdomen).
Treatment: * Surgical excision is generally
recommended.
Management of Patients With Structural, Infectious, and Inflammatory Cardiac Disorders
On completion of this chapter, the learner will be able to:1. Define valvular disorders of the heart and describe the
pathophysiology, clinical manifestations, and management of patients
with mitral and aortic disorders.2. Describe types of cardiac valve repair and replacement
procedures used to treat valvular problems and the care needed by patients who undergo these procedures.
3. Describe the pathophysiology, clinical manifestations, and management of patients with cardiomyopathies.
4. Describe the pathophysiology, clinical manifestations, and management of patients with infections of the heart.
5. Describe the rationale for prophylactic antibiotic therapy for patients with mitral valve prolapse, valvular heart disease, rheumatic endocarditis, infective endocarditis, and myocarditis.
Infectious Disease of the Heart:
Rheumatic Endocarditic: − It is results directly from rheumatic fever caused by group A Streptococcal infection. − The disease affects all bony joint, producing polyarthritis; the heart is also a target organ and is where the most serious damage occurs. − Rheumatic endocarditis are not infectious in origin rather they represent reaction occurring in response to hemolytic
streptococci, Leukocytes accumulate in the affected tissue and
forms nodules, which are replaced by scars, gradually thicker than normal and preventing them from closing completely result in leakage, a condition called valvular regurgitation. − The most common site of valvular regurgitation is the mitral valve.
Rheumatic Endocarditic:
Prevention and Treatment: − Early and adequate treatment of streptococcal
infections. − Long term antibiotic therapy is the treatment of
choice. − Penicillin administered parentally remains the
medication of choice.
Infectious Disease of the Heart:
II- Myocarditis: Is an inflammation process involving the myocardium. − Myocarditis can cause heart dilatation, thrombi on the heart wall. Medical Management: − Antibiotic Therapy (penicillin). − Same used for congestive heart failure.III- Pericarditis: Refers to an inflammation of the pericardium, the membrane sac enveloping the heart. Clinical Manifestation: − Sever pain may be felt beneath the clavicle and in the neck and left scapular region. Pericardial pain is aggravated by breathing. Medical Management: − Antibiotic therapy. − Analgesic and NSAID. e.g indomethacin(indocin).
Regurgitation: blood flow backward through the valve. (valve do not close completely).
Prolapse: stretching the valve leaflet into the atrium during systole.
Stenosis: narrowing or obstruction of a cardiac valve’s orifice.
Medical Management : *Valvuloplasty
*Comissurotomy *Valve replacement
•VALVUALR HEART DISEASE
Cardiomyopathies
Is a heart muscle disease associated with cardiac dysfunction. Dilated cardiomyopathy (dilation of the
ventricles) Hypertrophic cardiomyopathy (increase
in size and mass of heart muscle) Restrictive cardiomyopathy (diastolic
dysfunction caused by rigid ventricular walls)
Assessment and Management of PatientsWith Hypertension
LEARNING OBJECTIVES ●On completion of this chapter, the learner will be able to:1. Define blood pressure and identify risk factors for
hypertension.2. Explain the difference between normal blood pressure
and hypertension and discuss the significance of hypertension.
3. Describe the treatment approach for hypertension, including lifestyle changes and medication therapy.
4. Use the nursing process as a framework for care of the patient with hypertension.
5. Describe the necessity for immediate treatment of hypertensive
crisis.
Hypertension
It is a systolic blood pressure greater than 140 mmHg and a diastolic pressure 90 mmHg based on average two or more readings
Types Primary Hypertension (essential hypertension):
high blood pressure of unidentified cause Secondary Hypertension: high blood pressure
from an identified cause
Identifiable causes of hypertension
Sleep apnea Drug induced or related causes Chronic kidney disease Primary aldosteronism Vascular disease Thyroid disease
Clinical manifestation
Often no signs and symptoms Late signs are retinal hemorrhages,
arteriolar narrowing, cotton-wool spots, papilledema
Pathological changes include coronary artery disease, kidney damage, and cerebrovascular involvement
Lifestyle modification to manage Hypertension
Weight reduction Dietary sodium reduction Physical activity Moderation of alcohol consumption
Medical Management
Goal is to achieve BP 140/90 mm Hg. or lower
Pharmacologic therapy includes: diuretics, beta-blockers, or both
Hypertensive Crises
Hypertensive Emergency- BP must be lowered immediately to prevent damage to target organs. E.g. MI, ICH, Aortic aneurysm
Hypertensive Urgency- BP must be lowered within a few hours.
Vascular Disorders and Problems of Peripheral Circulation
Pump failure Alterations in blood and lymphatic vessels
Circulatory insufficiency of the extremities
Health history and clinical manifestations
Intermittent claudication Rubor, loss of hair, dry skin, ulcerations, and edema
Pulses
Diagnostic Evaluation
Doppler Ultrasound Flow Studies Exercise Testing Computed Tomography and
Angiography Magnetic Resonance
Angiography Angiography
Arterial disorders
Arteriosclerosis: hardening of arteries Atherosclerosis
Management Prevention by dietary modifications and
exercise to reduce lipid levels Medications Surgical management Radiologic interventions
Peripheral Arterial Occlusive Disease
Legs are most frequently affected Hallmark symptom is intermittent
claudication Pharmacologic therapy is to increase RBC
flexibility, reduce blood viscosity, inhibit platelet aggregation, inhibit smooth muscle cell proliferation, and increase vasodilation
Surgical management includes vascular grafting or endarterectomy
Arterial Embolism and Arterial Thrombosis
Acute vascular occlusion may be caused by trauma or result of invasive interventions
Arterial emboli most often caused by atrial fibrillation, MI, or other heart dysfunction
Medical management is anticoagulation Surgical management is emergency
embolectomy
Venous Disorders
I- Varicose Veins: Are abnormally dilated, tortuous, superficial veins
caused by incompetent venous valves. - In normal veins, valves in the veins keep blood
moving forward toward the heart. With varicose veins, the valves do not function properly, allowing blood to remain in vein. - This process usually occurs in lower extremities
(saphenous veins, it can occur else where in the body. e.g. esophageal varices.
I- Varicose Veins:
Causes: * Prolong standing. * A hereditary weakness of vein wall. * Increasing the pressure within abdomen. Clinical Manifestation: * Dull aches. * Muscle cramps. * Increase muscle fatigue. * Ankle edema.Medical Management: * Surgery for varicose vein.
Venous Disorders
II- Chronic Venous Insufficiency: Is a condition in which the veins do not
efficiently return blood from the lower limbs back to the heart.
- Venous insufficiently involves one or more veins. - The valves in the vein usually channel the flow of blood toward the heart .When these are damaged, the blood leaks and pools in the legs and feet.
Chronic Venous Insufficiency:
- Clinical Manifestation: * Edema. * Alterd pigmentation. * Pain. * Stasis dermatitis. - Medical and Nursing Management: * Elevating the legs. * Walking should be encouraged. * Compression of the legs with elastic
pressure stocking.
Venous DisordersIII- Thrombophlebitis: Is vein inflammation related to a blood clot. Causes: * Local irritation. e.g. IV line. * Infection in or near vein. Clinical Manifestation: * Tenderness over the vein. * Pain in the part of the body affected. * Skin redness. Medical Management: * Analgesic. * Anticoagulants. * Non steroidal anti-inflammatory drugs (NSADs). * Antibiotics.