Cardiovascular Disorders - Valencia
Cardiovascular Disorders
Nursing II
Topics
• Hypertension
• Coronary Heart Disease
• Angina
• Stable Myocardial Infarction
• Peripheral Vascular Disease
• Deep Vein Thrombosis
• Raynaud’s Disease
Review
• Identify cultural considerations that impact care for clients with hypertension.
• What role does ethnicity play in the treatment of hypertension?
• What is your teaching plan for a client with hypertension?
Atherosclerosis
• Arteriosclerosis
• Atherosclerosis
Page 778 -783
Pathophysiology
• Etiology unknown
• Theories
• Atherosclerosis development and cardiac complications
Factors Causing Arterial Injury
• Intimal Injury
• Mechanical injury
• Chemical injury
Incidence & Prevalence
• Peripheral Atherosclerosis
• Men vs. Women
Laboratory
• Cholesterol
• < 200 mg/dL
• High density lipoprotein (HDL)
Desirable level > 40 mg/dL
• Low density lipoprotein (LDL)
Desirable level < 100 mg/dL
• Triglycerides
200 mg/dL indicates hypertriglyceridema
• Homocysteine
↑ levels indicates ↑ risk for premature development of PVD and CAD (> 15 µmo/L)
Interventions
• Diet Therapy
• Smoking Cessation
• Exercise
• Drug Therapy
Nursing Care
• Health Promotion - #1 priority
• Teaching
Hypertension
• Blood Pressure
• Tension or pressure exerted by blood against arterial walls
• Hypertension (HTN or HTP)
• Excess pressure in arterial portion of systemic circulation
Page 783 - 793
Types of Hypertension
• Essential HTN
• Secondary HTN
Regulation of Blood Pressure
• Arterial Baroreceptors
• Regulation of Body Fluid Volume
• Renin-Angiotensin- Aldosterone System
• Atrial Natriuretic Peptide
• Epinephrine & Norepinephrine
Incidence/Prevalence
• 50 million Americans, 1 in 4 adults
• ↑ incidence in African Americans
• ↑ incidence in southeastern US
• ↑ mortality with ↑ age
• What is the your greatest concern regarding hypertension?
Assessment
• Manifestations
• Laboratory
• Radiographic
• EKG
Complications of HTN
• Myocardial Infarction
• Brain attack (CVA)
• Peripheral Vascular
Disease
• Renal Failure
• Malignant HTN
Enlarged Left Ventricle
Malignant HTN
• Clinical Manifestations
• Requires immediate treatment
• Treatment goal
Treatment
• Education
• Life Style Modification
Recommendations
Single Drug, once-a-day
• Start with diuretic or beta-blocker
• ACE inhibitor for clients with diabetes or have HF or history of MI
• Considerations for selection
of medication & treatment
• After 1-3 months, if no chg in BP, ↑ dose or substitute for different class of antihypertensive
• After 1 yr of effective control → ↓ dose or # of medications
Antihypertensive Drugs
• Diuretics
• Prevent tubular reabsorption of sodium → water & sodium excretion & ↓ blood volume
• Thiazide (HCTZ)
• Loop (Lasix)
• K+ Sparing
- Spironolactone (Aldactone)
- Eplerenone (Inspra)
• Nursing Implications
Page 788 - 791
• Alpha Adrenergic Blockers
• Block alpha receptors in vascular smooth muscle
• ↓ vasomotor tone & vasoconstriction
• Dozaxicin (Cardura)
• Beta-adrenergic Blocking Agents
• Prevent beta-receptor stimulation in the heart → ↓ HR & C.O.
• Metoprolol (Lopressor, Toprol XL)
• Propanolol (Inderal)
- Not used with hx of asthma or bronchospasm
• Side Effects
• Nursing Implication
• Calcium Channel Blocker
• Inhibit the flow of calcium ions across the cell membrane of vascular tissue & cardiac cells → relaxation of arterial smooth muscle, ↓ PVR through vasodilation
• Diltiazem (Cardizem SR)
• Norvasc
• Cardizem
• Nursing Implications
*No grape fruit juice
• Side Effects
• Effective in older adults & African Americans
• ACE Inhibitors
• Prevent conversion of Angio I to Angio II preventing vasoconstriction & water/Na retention
• Capoten (Captopril)
• Lisinopril (Prinivil, Zestril)
• Nursing Implications
• Side Effects
• Angiotensin II Receptor Antagonists
• Same effect as ACE inhibitor but act by blocking the effect of angio II on receptors
• Losartan (Cozaar)
- Nursing Implication
- Assess for orthostatic hypotension
Vasodilators
• Relax vascular smooth muscle & ↓ PVR
• Loniten, Apresoline,
• Used in combination with diuretic or beta-blocker
• Not used in mgmt of chronic HTN
• Antianginal (Nitrates)
• Nitroglycerin (Nitrostat SL)
• Side Effects
• Nursing Implications
Antilipemic Agents
• HMG-Coal Reeducates Inhibitors (Statins)
• Simvastatin (Zocor)
• Atovastatin (Lipitor)
• Side Effects
• Nursing Implications
Nursing Diagnoses
• Ineffective Health Maintenance
• Risk for Noncompliance
• Imbalanced Nutrition: > body requirements
• Excess Fluid Volume
Home Care
• Take active role in disease management
Angina
and
Coronary Heart Disease
• What layer of the heart is damaged when a person has a heart attack?
• What effect will a blood pressure of 85/40 have on the heart?
• What effect does parasymapathetic stimulation have on the heart?
Pathophysiology
• Chest pain causes decreased coronary blood flow
• Ischemia results & cell function altered
• Anaerobic metabolism result
• Only have 30 minutes to
restore perfusion
Page 839 - 847
Coronary Blood Flow
Cardiac Output
• Stroke volume
• Preload
• Afterload
• Contractility
• Heart rate
SV x HR = CO
Page - 680
Types of Coronary Heart Disease
• Chronic ischemic heart disease
• Coronary Syndrome (ACS)
Types of Angina
• Stable
• Silent myocardial ischemia
• Prinzmetal’s Angina
• Unstable Angina
Page 840 - 846
Risk Factors
• Smoking
• Diet
• Exercise
• Hypertension
• Diabetes
Clinical Manifestations
• Chest pain
• Tachycardia
• Pallor
• Dyspnea
• Anxiety
Chest Pain
Angina MI
• Sudden, associated with other factors
• Squeezing, vice like
• Substernal, may radiate to back or arms
• Usually lasts < 15 min
• Relieved with rest, nitrates, or oxygen
• Sudden, without precipitating factors
• Intense, stabbing, vice like pressure, severe
• Substernal, may radiate to back, arms, jaw, neck
• Lasts > 30 min
• Relieved with opioids
Diagnostic Exams
• EKG
• Thallium scan
• Exercise stress test
• Echocardiogram
• Coronary angiography
• Cardiac enzymes
• CBC, CMP, Coagulation studies, lipid profile, cholesterol, C-reactive protein
Medications for CHD
• Lipid/cholesterol lowering agents
• Statins
• Bile acids
• Nicotinic acid
• Fibric Acid
Medications for Angina
• Nitrates
• Treat anginal attacks
• Prevent attacks
• Adverse Effects
Medications for Angina
• Beta Blockers
What is the therapeutic effect of this medication?
What are the nursing implications for a client receiving this medication?
Medications for Angina
• Calcium Channel Blockers
What is the therapeutic effect of this medication?
What are the nursing implications for a client receiving this medication?
Assessment of Chest Pain
• Location
• Character
• Timing
• Precipitating factors
• Intensity
• Aggravating and relieving factors
• Other signs and symptoms
Needed Cardiac Assessment
• Vitals sign
• Cardiac output
• Apical – radial pulse
• Lungs sounds
• Skin
• Peripheral circulation
Nursing Care
• Discuss your teaching plan for this client
• What would be the appropriate nursing care?
Nursing Diagnoses
• Ineffective tissue perfusion
• Activity Intolerance
• Ineffective coping
• Ineffective health maintenance
• Altered sexual patterns
Myocardial Infarction
MI Statistics
• Leading cause of death in the US
• Most deaths occur in the first hour
• 40% of those outside of the hospital
• Usually have CHD prior
• Risk factors are the same for CHD and angina
Pathophysiology
• Interruption of blood flow to the myocardium
• Cellular death and tissue necrosis
• Starts in the subendocardium progress to all layers of the myocardium
• “Stunned” surrounding tissue
Coronary Arteries
Cardiac Cath
Picture of an Ischemic Clot
Signs and Symptoms of MI
• Chest pain
Describe the cardinal chest pain of a MI.
Describe chest pain for a women and elderly clients.
More Signs and Symptoms
Complications of MI
• Dysrhythmias
• Decreased cardiac output
• Cardiogenic shock
• Pericarditis
Diagnostics for MI
• Cardiac Enzymes
• EKG
• CXR
• Echo
• CBC, Coag Studies, CMP
• Stress Test
• Cardiac Cath
• Muga Scan
Cardiac Enzymes
• Troponin
• CPK MB (CK MB)
• LDH isoenzymes
• Myoglobin
• C-Reactive protein
Goals for Treatment
• Relieve chest pain
• Cardiac stability
• Decrease size of infarct
• Decrease workload of the heart
• Prevent complications
Care of an MI Client
• What is the appropriate nursing care for this client?
Pain Control
• Nitroglycerin (NTG)
• Morpine Sulfate (MS)
Other Medications
• Aspirin and antiplatelets medications
• Plavix
• Anticoagulants
• Heparin or Lovenox
• Thrombolytics
• Antidysrhythmics
• Beta blockers
• Lopressor
• ACE inhibitors
• Captopril
• Stool softeners
• Antianxiety medications
NANDAs
• Acute pain R/T
• Decreased cardiac output R/T
• Ineffective tissue perfusion R/T
• Ineffective coping R/T
• Fear R/T
Preparing for Discharge
• Cardiac rehab
What would be an appropriate teaching plan for this client?
Peripheral Vascular Disease
Incidence of PVD
• Usually over age 60
• Men more than women
• Black women more than
white women
Review
• What is the function and structure of an artery?
• What is the function and structure of a vein?
Peripheral Vascular Disease
• Disorders that alter the natural flow of blood through the arteries and veins of peripheral circulation
• Affects lower and upper extremities
• Peripheral artery disease (PAD)
Pathophysiology
• PAD
• Chronic condition
• Partial or total arterial occlusion
• Arterial Obstruction
Pain Assessment
• Intermittent Claudication
• Rest Pain
Clinical Manifestations
Physical Assessment
• Palpate pulses
Arterial Ulcers
• Arterial ulcers
Diagnostic Assessment
• Arteriography
• Segmental systolic BP measurements
• Exercise tolerance testing
• Plethysmography
• Doppler ultrasound
• Duplex doppler
Venous Stasis Ulcer
Interventions
• Non-invasive
• Smoking cessation
• Exercise
• Positioning
• Vasodilation promotion
• Drug therapy
• ASA
• Trental
• Plavix
• Invasive
• Percutaneous Transluminal angioplasty (PTA)
• Laser-assisted angioplasty
• Atherectomy
• Endarterectomy
Surgical Intervention
• Revascularization
• Bypass graft
• Autologous saphenous vein
• Gortex or Dacron graft
• Preoperative Care
• Mark peripheral pulses for baseline
Surgical Intervention
• Postoperative Care
• Assess for graft patency
Treatment of Graft Occlusion
• Notify surgeon immediately
• Emergency thrombolectomy
• Local thrombolytic therapy
• Platelet inhibitor infusion (Reo-pro)
• Compartment Syndrome
Goals for Care
• How would you promote graft patency?
Home Care for PVD
• Follow foot care instructions
• Quit Smoking
• Maintain dietary restrictions
• Exercise
• Avoid exposure to extreme cold or heat
• Avoid constrictive clothing
Acute Peripheral Arterial Occlusion
• Emboli originating from heart
• Severe pain below occlusion
• Cool or cold extremity, pulseless, mottled
• Six “P’s” of ischemia
Interventions
• Immediate intervention
• Anticoagulant therapy
• Surgical thrombolectomy or embolectomy
• Post-operative care
Deep Vein Thrombosis (DVT)
Deep Vein Thrombosis
• Thrombophlebitis
Definition
• All Refer Health - Deep Venous Thrombosis, Ileofemoral - Deep Venous Thrombosis Pictures & Images (Blood Clot in the Legs, DVT)
• Deep vein thrombosis
• ↑ risk for pulmonary embolism
• Stasis of blood flow, endothelial injury &/or hypercoagulability
• Risk factors
Diagnostics
For DVT
• Doppler flow study
• Venogram
• MRI
• D- Dimer
• Coagulation studies
• Physical exam
Signs and Symptoms
of DVT
• Asymptomatic
• Calf or groin tenderness & pain
• Sudden onset of unilateral swelling
• Pain upon dorsiflexion (Homan’s sign) not recommended
• Warmth & edema at site
Interventions
• Non-surgical
• Rest
• Anticoagulants
• Heparin
• Lovenox
• Coumadin
• Thrombolytic therapy
• T-PA
• Platelet Inhibitors
• Reo-pro
• Surgical
• Prevent Pulmonary Embolis
• Inferior Vena Caval Interruption
• “Umbrella”
• Greenfield filter
• Ligation or External Clips
• Abdominal Laparotomy
Home Care
• Anticoagulant teaching
Raynaud’s Phenomenon
• Raynaud’s Disease
- A primary vasospastic disease
- small arteries & arterioles
- cause unknown
- exaggerated response of vasomotor
controls to cold & emotion
Raynaud’s cont.
• Symptoms
- affect digits of hands bilaterally (most often)
- color changes occur in sequence
(pallor, cyanosis & red)
Cont.
• Initially
- numbness & sensation of cold
- red phase (throbbing & paresthesia)
• Long-term
- may develop atrophy of skin & subc tissue, brittle nails & skin ulcerations or gangrene
Cont.
• Management
- Maintain warmth in the extremities.
- Avoid cold materials & prolonged exposure to cold environments.
- Avoid use of tobacco.
Cont.
• Treatment
- vasodilator drugs
- calcium channel blockers
- sympathectomy (not always successful)
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