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Chapter 32Coronary artery disease (CAD) – a progressive atherosclerotic disorder of the coronary arteries that results in narrowing or complete occlusion of the vessel lumenThe nurse should know that older age, male gender and genetics are nonmodifiable risk factors of CAD, assess for and educate patient on modifiable and contributing risk factors; assess for EKG changes, angina pectoris.Tunica intima – the inner layer of the artery, consisting of endothelial cells, connective tissue, and smooth muscle cellsThe nurse should know that coronary artery disease involves the buildup of plaque that becomes a part of this innermost layer of the coronary arteries; evaluate patient using radionuclide imaging, MRI, intravascular US, or cardiac catheterization.Tunica media – the middle layer of the artery that consists of multiple layers of smooth muscle cells and connective tissue made up of elastic fibers, collagen, and proteoglycansThe nurse should know that in a Stage II Lesion smooth muscle cells from this layer invade the intimal lesion, leading to further buildup of plaque and obstruction of blood flow; evaluate patient using radionuclide imaging, MRI, intravascular US, or cardiac catheterization.Tunica adventitia – the outer layer of the artery consisting of fibrous tissue made of collagen and elastic fibers surrounded by collagen bundlesThe nurse should know that in a normal artery, this outer layer is flexible and allows for diameter changes during vasodilation and constriction.Arteriosclerosis – a condition characterized by thickening, reduced elasticity, and calcification of the arterial wallThe nurse should know that arteriosclerosis of the coronary arteries causes reduced supply of oxygen and nutrients to the myocardium; assess for pain, EKG changes, diaphoresis, pallor; patient at risk for MI.Atherosclerosis – a type of arteriosclerosis in which luminal blood flow is obstructed by buildup of plaque infiltrating the intimal lining of the arterial wallThe nurse should know that atherosclerosis of the coronary arteries results in reduced blood flow to the myocardium; assess for pain, EKG changes, diaphoresis, pallor; patient at risk for MI.Ischemia – tissue hypoxia resulting from imbalance of oxygen supply and demandThe nurse should know that myocardial ischemia is a life-threatening condition that may be caused by CAD; assess for pain, EKG changes, diaphoresis, pallor; treat suspected MI with MONA – morphine, oxygen, nitroglycerin, aspirin.Atheroma – an accumulation of plaque in the inner lining of an arteryThe nurse should know that an atheroma is an accumulation of plaque in the inner lining of an artery which may lead to decreased lumen diameter and decreased elasticity of the artery.Fibrous cap- Connective tissue that covers the lipid core in a stage II lesion.A thin fibrous cap increases the risk of rupture.Know that the stages are determined by maturation levels of lipid core and formation of fibrous capEccentric- With coronary artery stenosis, eccentric lesions occupy part of the vessel wall circumference Once arterial diameter is reduced, symptoms of CAD are expected such as angina. Concentric- W/ coronary artery, concentric lesions occupy the whole circumferenceOnce arterial diameter is reduced, symptoms of CAD are expected such as angina. Thrombus- blood clot that forms in a blood vessel and remains at the site of formation If large enough, can stop blood flow causing tissue ischemia and apoptosis Having a blood disorder (reduced anticoagulation factors, abnormal platelet function, etc) combined with plaque development can increase risk or thrombus formation Myocardial stunning- Temporary dysfunction that occurs in response to artery occlusion of short duration or transient global hypoperfusion during a limited low flow state such as shockEnd result: myocardial muscle temporarily has a limited ability to contract Know this is an adaptive response to chronic coronary occlusionGoal: Establish reperfusion as early as possible to prevent necrosis (clot-dissolving agents)Myocardial hibernation- myocardial tissue actually undergoes cellular structural changes and progressive apoptosis in response to prolonged occlusion Hibernating tissue is thought to recover contractile function fully once perfusion is reestablished Cardiac risk factors- habits, lifestyles, and/or genetic factors that predispose an individual to the development of CADPromote risk factor reduction, such as smoking cessation, BP control, exercise, weight reduction, low fat diets, and pharmacologic therapies that control dyslipidemia Hyperlipidemia- Elevated cholesterol and/or triglyceride levels that permeate the arterial wall, narrowing the lumen and ultimately decrease blood flow to the cardiac muscle.Draw lipid panels after fasting overnight, including no alcohol Hypercholesterolemia- increased cholesterol level in the blood know that this can be inherited as a genetic defect, acquired through diet and lifestyle.Pt teaching: stress risk reduction (lipid screen regularly, diet, exercise, use of lipid-lowering drugs)Cholesterol- steroid molecule produced primarily by the liver that is essential for the formation and maintenance of cell membranes. Serum cholesterol- indicator of risk for CAD levels greater than 250 mg/dl is considered high riskMeasure every 5 years (more often if above ages 55)Low-density lipoprotein- “bad cholesterol”; major cholesterol carrier in the blood Know that oxidized LDL-C cause endothelial damage and aids in development of plaquesPt teaching: dietary control- inquire about food preferences and cultural factors that influence eating habits High-density lipoprotein- “good cholesterol”; consists of heavier lipoproteins that bind to cholesterol, transporting it back to the liver, and may actually remove excess cholesterol from plaque in the arteries.Levels greater than 40-50 mg/dl with no CAD risk factors are desirable Triglycerides- form of fat derived and produced by the body from other sources such as carbohydratesLowering levels to less than 150 mg/dl has become a part of risk preventionReduce factors through exercise, reduce carbohydrate consumptionMetabolic syndrome: having three out of the five following conditions: elevated waist circumference, elevated triglycerides, reduced HDL-C, elevated BP, elevated fasting glucose (>100 mg/dl)correlated with high risk for CAD and type 2 diabetesmgmt: target each abnormality with modification of corresponding risk factors, especially weight reduction and increased physical activity, use of therapeutic interventions to lower BP, lower serum glucose, and lower serum lipids Angina pectoris: transient chest pain due to myocardial ischemia caused by inadequate supply of oxygen and nutrients to the myocardiumknow that CAD is most common cause of decreased blood to myocardiumclinical manifestations: sudden onset of discomfort in chest, jaw, back or arm aggravated by exertion or emotional stress and relieved with rest or nitroglycerinchest pain is burning, crushing, suffocating, or pt. may feel pressure; pain is not localized to a defined spot women may not experience pain the same way; express pain in less severe terms and often ascribe pain to cause other than cardiac issues Stable angina: less serious angina triggered by a predictable degree of exertion or emotions, and there is a pattern in what brings it on, its duration, its intensity of symptoms, and how to relieve itsubsides by taking away precipitating factor and using SL nitroglycerin Variant/Prinzmetal, or vasospastic angina: occurs when single or multiple sites in major coronary arteries and their large branches experience vasospasm; cause is unknown symptoms are episodic, may last several minutes, and are often associated with exercise and can occur frequently at night Myocardial perfusion imaging (MPI): nuclear imaging technique to detect significant CADIn patients with physical limitations not suitable for standard exercise stress test, imaging combined with basic stress test improve the ability to detect significant CADnurse to know contraindications to stress/exercise test (so imaging is used instead): MI within 2 days, unstable angina, aortic stenosis, symptomatic heart failure, uncontrolled arrhythmias, active endocarditis, uncontrolled HTN Multislice helical CT: tool for visualization of general cardiac structure, the great vessels, and the coronary arteries; allows visualization of fine details of the coronary anatomy such as small branches and aterosclerotic plaques Review pt & family’s understanding of procedure; Provide teaching if necessaryKeep pt NPO prior to procedureMagnetic resonance imaging (MRI): imaging using radiofrequency pulses from a large powerful magnet to disrupt normal spin of certain atoms within the body temporarily. Used to evaluate patients with presumed congential heart diseases, to image heart structures, and enable assessment of myocardial viability provide patient teaching on MRI procedure to reduce anxiety related to lack of knowledgenurse may also administer anti-anxiety medication (claustrophobia) Myocardial viability: info about areas of the myocardium that appear to have normal functioning as well as areas that appear to be dysfunctional and may improve with revascularization (gathered from MRI)know normal v. abnormal scans Cardiac catheterization: commonly performed procedure done using x-ray where catheter is inserted thru a sheath and advanced into the left and/or right side of the heart to provide anatomical and hemodynamic information about the heart and great vesselsNurse to know contraindications to catheterization: severe CHF, severe electrolyte imbalances, bleeding diathesis, serum creatinine > 1.5 mg/dl, poor pt. cooperationPercutaneous coronary intervention (PCI) - catheter-based interventions available for the treatment of CADReview pt & family’s understanding of procedure; Provide teaching if necessaryAsk pt & family about any meds prior to procedureKeep pt NPO prior to procedureAssess ECG Monitor patient closely to ensure a safe environment for the procedureMonitor & assess VS, distal pulses, and painStents - metallic mesh-like structures that are inserted permanently inside the coronary artery, compressing plaque and providing structural support of the vesselReview pt & family’s understanding of procedureAsk pt & family about any meds prior to procedurePost-op: assess distal pulsesAssess CV, vital signs, and ECG to avoid complicationsRestenosis - accumulation of smooth muscle cells at the site of the original procedure that occurs because of the artery’s response to the injury from the PCIRecognize that stents reduce possibilityEnsure pt knows of complication prior to PCIAssess distal pulses frequently Pseudoaneurysm - extravascular cavity communicating w/ femoral artery by a channel or neck at the needle puncture siteMonitor for localized tenderness, palpable & pulsatile mass, & bruitUse doppler imagingMonitor for retroperitoneal hemorrhage or hematoma (potential complication)Monitor for s/sx of infection at access siteDischarge teaching: care of access site, what to do w/ angina or other Sx associated w/ CAD, not stopping medsArteriovenous (AV) fistula - direct communication between the artery & vein that results in a high-velocity jet from the artery into the veinMonitor for bruitMonitor for retroperitoneal hemorrhage or hematoma (potential complication)Use doppler ultrasound to diagnoseMonitor lab valuesDischarge teaching: care of access site, what to do w/ angina or other Sx associated w/ CAD, not stopping medsMonitor for s/sx of infection at access siteDyskinesia - abnormal heart contractility: impaired muscle movementKnow that this is can be a result of poor coronary perfusionassess for any risk factors or s/sx associated with ACSAkinesia - abnormal heart contractility: severe loss or no muscle movementKnow that this is can be a result of poor coronary perfusionassess for any risk factors or s/sx associated with ACSHypokinesia - abnormal heart contractility: hypoactive muscle movement Know that this is can be a result of poor coronary perfusionassess for any risk factors or s/sx associated with ACSAcute coronary syndrome (ACS) - myocardial infarction, myocardial ischemia, and infarction-related complicationsKnow when & how to decrease heart’s workload with oxygen Promote progression of activity as toleratedAdminister appropriate meds (as ordered) - MONAAssess lab tests, evaluate serial ECG, & serum cardiac markers Continuous cardiac monitoring. Encourage pt to inform nurse of any new s/sxUnstable angina (UA) - transitory syndrome falling between stable angina & MI in which thrombus forms in an area of arterial stenosis but is subsequently fully or partially lysed, or dissolved, by endogenous antithrombotic mechanismsMonitor for onset of new symptomsRecognize that blood markers & ECG will be normalNurses should know when and how to decrease heart’s workload -> Monitor signs for adequate myocardial oxygen supply. Administer & titrate meds to balance O2 supply and demand. Myocardial infarction (MI) - loss of myocytes; myocardial apoptosis as a result of prolonged muscle ischemiaAssess lab tests, evaluate serial ECG, & serum cardiac markersAdminister appropriate drugs (MONA)Monitor signs for adequate myocardial oxygen supply. Administer & titrate meds to balance O2 supply and demand Continuous cardiac monitoring. Encourage pt to inform nurse of any new s/sxIf pt. has a lot of complications & risk factors, use hemodynamic monitoringNSTEMI - Non-ST segment elevation myocardial infarctionAssess lab tests, evaluate serial ECG, & serum cardiac markersMonitor ECG - recognize persistent changes & presence of serum markers can be indicative of serious myocardial injury Encourage pt to inform nurse of any new s/sxSTEMI - myocardial injury associated with ST segment elevation on the ECGAssess lab tests, evaluate serial ECG, & serum cardiac markersIf on thrombolytic therapy, monitor for signs of reperfusion signs: chest pain & ST segment elevationEncourage pt to inform nurse of any new s/sxSudden cardiac death (SCD) - unexpected cardiac arrest that results in death w/i an hour of the onset of symptomsNurse should recognize pt. with CAD are at risk for SCDRecognize S/Sx of MI quicklyMonitor vital signs for changesRecognize not everyone experiencing a MI has chest painTroponins - biochemical markers for cardiac diseaseMonitor for high levels. High levels can indicate MINotify MD if suspected MITroponin T - found in cardiac muscle during periods of cardiac ischemiaMonitor for high levels. High levels can indicate MINotify MD if suspected MITroponin I - found in cardiac muscle during periods of cardiac ischemiaMonitor for high levels. High levels can indicate MI.Notify MD if suspected MICreatine kinase (CK) - enzyme found in high concentrations in the heart & skeletal muscle & in smaller concentrations in the brain (isoforms: CK-MM, CK-BB, CK-MB)Recognize & monitor CK-MB for cardiac ischemia & infarctionMyoglobin - heme-containing, oxygen-binding protein that is exclusive to striated & nonstraited muscleMonitor for muscle damagedo not rely on only this value for heart damage; look at other markers tooMONA - morphine, oxygen, nitroglycerin, and aspirin; protocol for treatment of patients with suspected MIAdminister & titrate drugs per orderMonitor for anginaDischarge teaching: cardiac risk factors, s/sx of MI, how & when to access emergency medical services, & med regimenRemodeling - process of replacing nonviable heart muscle tissue with nonelastic fibrinous collagenNurses should know when and how to decrease heart’s workload -> Monitor signs for adequate myocardial oxygen supply. Administer & titrate meds to balance O2 supply and demand. Continuous cardiac monitoring. Coronary artery bypass grafting (CABG) - surgery used as a treatment for CADNurse should provide post-op care to promote recovery & prevent complications (early mobilization, assess neuro status, OOB to chair POD 1)Receive appropriate report from ORIf extubated, prevent patient from removing the tube themselvesWean patient off of intravenous drips & convert to PO medsChapter 33 Termsallograft valveA valve obtained from human cadaver donations; used primarily to replace the aortic and pulmonic valves. Also called a homograft valve.annuloplastyA surgery done to correct valve regurgitation by repairing the enlarged annulus.*NI: Educate patient that this procedure requires open heart surgery and cardiopulmonary bypass and is done when the valve leaflets are normal, but the valve fails to close due to enlargement.*NI: Elevate HOB, encourage turning, C&DB postop, and change dressings using aseptic technique.annulusThe fibrous ring at the junction of the cardiac valve leaflets and the muscular wall.aortic valve regurgitationIncomplete closure of the aortic valve, which causes blood to regurgitate back into the left ventricle through a valve; results from abnormal valve cusps or aortic root.*NI: Assess for palpitation and diastolic murmur that is heard best at the 2nd?right intercostal space and radiating to the left sternal border.*NI: Look at end of section for more NI.aortic valve stenosisA narrowing of the aortic valve orifice, which results in an obstruction to blood flow from the left ventricle to the aorta during systole.*NI: Assess for dyspnea, angina, exertional syncope, increased pulmonary artery pressure, and harsh crescendo-decrescendo systolic murmur developing due to the valve orifice becoming one-third of its normal size.*NI: Look at end of section for more NI.arrhythmogenic right ventricular cardiomyopathy (ARVC)An electrical disturbance that develops when the muscle tissue in the right ventricle is replaced with fibrous scar and fatty tissues.*NI: Educate patient that the only cure is a heart transplant.*NI: Assess for palpitations, light-headedness, and fatigue, and sudden cardiac death may be the first sign*NI: Right: prominent neck veins, distention of liver, swollen legs; Left: fatigue, SOBautograft valveValve obtained from the patient's own pulmonic valve and pulmonary artery. Also called autologous valve.Beck's triadClassic assessment findings for the patient with cardiac tamponade, consisting of decreased blood pressure, muffled heart sounds, and jugular venous distention.biologic valveValve obtained from other species, most commonly from pigs (porcine valves), although cow valves (bovine) also are used. Also referred to as xenografts.cardiac tamponadeBleeding into the pericardial sac. As the accumulation of blood increases, it compresses the atria and ventricles, decreasing venous return and filling pressure. This leads to decreased cardiac output, myocardial hypoxia, and cardiac failure*NI: Monitor for anxiety, CP (sharp, stabbing, radiating to shoulder, back or abdomen), cyanosis, palpitations, tachypnea, weak or absent pulse*NI: Assess for Beck’s triad*NI: Know that it is worsened by deep breathing or coughingcardiomyopathies (CMPs)Diseases of the myocardial muscle fibers that result in progressive structural and functional abnormalities of the myocardium.*NI: Caused by alcohol intake, hypertension, CAD, or may be idiopathiccommissureThe site where cardiac valve leaflets meet each missurotomySurgical procedure used to separate fused heart valve leaflets.constrictive pericarditisOccurs when the pericardial layers adhere to each other as a result of fibrosis of the pericardial sac.*NI: Develops from TB, in people with AIDS, surgery, uremia, or radiationdilated cardiomyopathy (DCM)A disorder of the myocardium characterized by dilation and impaired contraction of one or more ventricles; the most common form of cardiomyopathy.*NI: Conserve patient’s energy and decrease heart’s workload by reduced activity, positioning, and oxygen therapy.*NI: Continuous monitoring for changes in mental status, fluid status, peripheral perfusion, and heart rate and rhythm.Dressler's syndromeCondition characterized by fever, pericarditis, chest pain, and pericardial and pleural effusions. Believed to be an autoimmune response, it occurs in 5% to 15% of patients 1 to 4 weeks after a myocardial infarction.echocardiographyThe noninvasive assessment of the structures and function of the heart and great vessels utilizing high-frequency (ultrasound) sound waves.effusionAbnormal accumulation of fluid.homograft valveSee allograft valve.hypertrophic cardiomyopathy (HCM)A disorder of the sarcomere, the contractile element of the cardiac muscle; characterized by left ventricular and occasionally right ventricular hypertrophy, with greater hypertrophy occurring in the septum. Also referred to as idiopathic hypertrophic subaortic stenosis (IHSS).*NI: Administer beta-adrenergic blocking agents and calcium antagonists as prescribed*NI: Stress the importance of consistent and normal hydration and educate on activities, foods and drinks that cause dehydration*NI: Monitor patient’s hemodynamic status as disease progressesinfective endocarditis (IE)An infection of the cardiac endocardial layer of the heart, which may include one or more heart valves, the mural endocardium, and/or a septal defect; previously known as bacterial endocarditis.*NI: Assess for peripheral manifestations such as splinter hemorrhage, roth’s spots, janeway’s lesions*NI: Assess for new or changing murmurs, embolic events, and skin manifestationsmechanical valveCommercially manufactured heart valve.mitral valve prolapse?(MVP)Occurs when one or more of the valve leaflets bulge or prolapse into the left atrium during systole. This prolapse of the valve results in valve regurgitation.*NI: Assess for sharp stabbing chest pain during rest or periods of stress, panic attacks, chronically cold hands and feet.*NI: Look at end of this section for more interventions. Note: these patient’s have no activity restriction except those necessitated by clinical manifestationsmitral valve regurgitationAn inability of the mitral valve to close due to an abnormality in the structure and function of the valve.*NI: If acute, assess for sudden onset of dyspnea, blowing high-pitched, systolic murmur and thready peripheral pulses.*NI: If chronic, assess for gradual onset of dyspnea, peripheral edema, S3?and pansystolic murmur at the apex radiating to the left axilla.*NI: Look at end of this section for more interventionsmitral valve stenosisOccurs when the mitral valve assumes an abnormal funnel shape due to thickening and shortening of the valve structures as a result of calcification. Contractures develop between the junctions or commissures (leaflets) of the valve. The stenosis narrows the opening of the valve, which obstructs blood flow from the left atrium to the left ventricle.*NI: Assess for dyspnea, orthopnea, afib, and loud first heart sound (S1)*NI: Look at end of this section for more interventions.myocarditisA focal or diffuse inflammation of the myocardium or heart muscle; an uncommon disorder that is frequently associated with pericarditis.*NI: Promote healing by resting the heart by spacing activities and providing pain relief, provide emotional support, and quiet environment.*NI: Educate pt to avoid excessive fatigue and stop all activities immediately when light-headedness, dyspnea, or faintness occurs*NI: Outline specific manifestations of heart and failure and reinforce that the patient must seek medical care if they occurpancarditisInflammation of all three layers of the heart: the endocardium, myocardium, and pericardium.pericardial effusionAn excess buildup of pericardial fluid that is a threat to normal cardiac function. The fluid buildup is the result of an accumulation of infectious exudates or toxins and/or blood.?pericardial friction rubA grating, scraping, squeaking, or crunching sound that is the result of friction between the roughened, inflamed layers of the pericardium.*Auscultate for grating, scraping, or crunching sound over pericardial sac.pericardial windowAn opening in the pericardial sac that allows fluid from effusion and tamponade to drain.pericardiectomyRemoval of the pericardial sac to allow fluid to drain from around the heart.pericarditisInflammation of the pericardial sac due to an inflammatory process in which the two layers of the pericardium become inflamed and roughened, causing fluid to build up*NI: Assess for pericardial friction rub or pericardial effusionpulmonic valve regurgitationThe inability of the pulmonic valve to completely close, causing blood to regurgitate back into the right ventricle.*NI: Assess for high-pitched diastolic blowing murmur along left sternal border, dyspnea, and afib.*NI: Look at end of this section for more interventions.pulmonic valve stenosisA narrowing of the cardiac valve orifice that restricts blood flow due to an inability of the valve to completely open, thus obstructing blood from the right ventricle from flowing into the pulmonary vasculature during systole.*NI: Assess for systolic crescendo-decrescendo murmur heard in 2nd?left intercostal space and tall peaked T waves from atrial hypertrophy.*NI: Look at end of this section for more interventions.pulsus paradoxusA greater-than-10 mmHg drop in systolic blood pressure during inspiration.restrictive cardiomyopathy (RCM)A disorder characterized by endometrial scarring that usually affects one or both ventricles and restricts filling of blood, resulting in systolic dysfunction. The ventricle has normal wall thickness, but the walls are rigid, producing elevated filling pressures and dilated atria.*NI: decrease workload of heart and conserve energy*NI: teach patient to avoid situations that impair venous filling or lower CO*NI: Assess for S3?systolic murmur, syncope, exercise intolerance, signs of pulmonary and systemic congestionsrheumatic feverA pharyngeal infection caused by Lancefield group A beta-hemolytic streptococci. In 3% of the cases it leads to rheumatic heart disease.*NI: Risk factors include poor inner-city neighborhoods, damp weather, crowded living conditions, malnutrition*NI: Be sure to treat pharyngeal infection because if left untreated may result in rheumatic fever.?*NI: Assess for fever, headache, swollen tender joints with small bony protuberances, SOB, elevated WBC.rheumatic heart diseaseAn inflammatory disease of the heart that causes long-term damage, scarring, and malfunction of the heart valves.*NI: Document and report heart failure manifestations and change in murmur volume*NI: Educate patient to decrease myocardial oxygen demand/cardiac workload*NI: Provide emotional support, pain relief and encourage rest*NI: Administer antibiotics as prescribed to eradicate infecting organismstress echocardiographyRefers to the use of echocardiography to detect coronary artery disease.transesophageal echocardiography (TEE)Echocardiogram performed using a miniaturized transducer advanced down the esophagus. Because the esophagus passes directly behind the posterior surface of the heart, TEE affords excellent views of the posterior structures of the heart and great vessels.tricuspid valve regurgitationInability of a heart valve to completely close, resulting in a backflow of blood from the right ventricle to the right atrium.*NI: Increased risk factors include rheumatic heart disease, inferior MI, blunt chest trauma, and IE.*NI: Assess for high-pitched blowing systolic murmur heard over xiphoid process, prominent waves in the neck veins, and tall P waves in normal sinus rhythm.*NI: Look at end of this section for more interventions.tricuspid valve stenosisObstruction of blood flow between the right atrium and the right ventricle due to a narrowed valve orifice.*NI: Low-pitched rumbling diastolic murmur heard over 4th?intercostal space of left sternal border, prominent waves in the neck veins, and tall P waves in normal sinus rhythm.*NI: Occurs w/ rheumatic heart disease, IV drug use, and concurrently w/ mitral stenosis*NI: Look at end of this section for more interventions.valvular regurgitationInability of a heart valve to completely close, resulting in a backflow of blood through the incompetent valve orifice into the previous chamber.*Look at end of section for NI.valvuloplastyA surgical procedure to repair torn or damaged leaflets, chordae tendineae, or papillary muscle.*NI: Educate patient that this procedure is surgically repairing a valve leaflet under general anesthesia and cardiopulmonary bypass.Chapter 34 TermsAscites: an abnormal intraperitoneal accumulation of fluid containing large amounts of protein and electrolytes Nursing: nurse will know ascites is a clinical manifestation of heart failure and will assess for other signs such as, hypotension, rales, tachypnea, confusion, pitting edema etc Biventricular heart failure: global inability of both ventricles of the heart to pump blood effectively. Forward blood is compromised and lead to left and right heart failure symptoms; type of systolic heart failure.S/S: generalized malaise, activity intolerance, poor concentration, elevated neck veins, abd ascites, poor appetite, N&V, pulm congestion, cough, orthopnea, crackles,Nursing: same for all types of heart failure- treat congestion and monitor patients response to therapy by: I&O, daily weight, dysrhythmias, O2 sats, assess neuro; encourage pt to increase level of activity, preform ADLS, admin O2 Cardiomegaly: enlargement of the heart Nursing: this is found in stage B of heart failure- these patients are usually asymptomatic; treatment if a cardiomegaly along with other signs of stage B heart failure are found is admin ACE inhibitors, ARBs and beta blockers to prevent further damage to the myocardium Crackles: common abnormal sound heard on auscultation of the lungs from the movement of fluid or exudate Nursing: crackles may or may not be present in patients with chronic heart failure- crackles are absent in over 80 % of people with elevated filling pressures; usually associated with Left sided heart failure or biventricular heart failure; nurse will recognize this and look for other s/s of heart failure (look above); Diastolic dysfunction: heart failure with preserved LVEF (not under 40 %) – slowing of ventricular relaxation and elevated filling pressures Nursing: nurse will know that this type of heart failure most often effects older women and patients with HTN, diabetes, obesity and A Fib; treatment focuses on controlling HTN, ischemia and ventricular rate when A Fib is present and minimizing congestion Euvolemia: when the body is in a state of equal fluid balance without fluid retention Nursing: A heart failure patient will need to maintain this; we do this by sodium and fluid restriction and diuretics; nurse will teach patient about the importance of compliance to these interventions and educate about the mechanisms of diuretics as well as how to maintain a dry weight Heart failure: a complex and denilitating clinical syndrome caused by cardiac dysfunction, resulting in left ventricular dilation, hypertrophy or both. Nurisng: critical thinking and good judgment skills to assess and recognize subtle and late symptoms; treating congestion and monitoring response to therapy by I&O, daily weights, dysthymias, O2 sats, and neuro status, as well as encouraging increased activity, preforming ADLS, and enhancing pts knowledge of disease, S/S: subtle: edema, cool forearms and legs, crackles (sometimes); abrupt decline: narrowed pulse pressure, altered mentation, hypotension, resting tach, oliguria, tachypnea Hepatojugular reflex: an increase in jugular venous pressure when pressure is applied over the abdomenNursing: this is suggestive of R sided heart failure, and may be present of volume overload is found in the periphery; assess for other manifestations of heart failureHypertrophy: an increase in the size of an organ caused by an increase in the size of the cells, rather than an increase in the number of cells Nursing Application: hypertrophy of the heart is a part of the neurohormonal response to heart failure, and is a compensatory mechanism; the nurse will recognize that hypertrophy is a sign of heart failure and will assess for other signs of neurohormonal response such as chamber dialation, increased myocardial oxygen consumption, and pulmonary and systemic congestion Left-sided heart failure: impaired pumping of left side of heart which backs the blood up into the pulmonary circulationS/S: fatigue, activity intolerance, SOB, cough, pulmonary congestion, crackles, orthopnea, poor concentrationNursing: determine if the signs/symptoms are associated with heart failure. Rule out other disorders such as neurological. Look for cool arms and legs and signs of poor perfusionLeft Ventricular Ejection Fraction (LVEF): the proportion of blood ejected during each ventricular contraction compared with the total ventricular filling volume. Normal LVEF: 55%-70%Dysfunctional LVEF: below 40% Nursing: nurse will know that a dysfunctional LVEF correlates with systolic dysfunction and will be aware that the heart will be unable to pump blood to sustain metabolic demands and if damage is extensive Left, Right or biventricular HF can occur- watch for symptoms of HF and determine type New York Heart Association Classification System (NYHA): categorizes patients subjective symptoms into 4 classes based on the degree of dyspnea the patient has upon exertionClass 1: no symptomsClass 2: patient has symptoms with ordinary exertionClass 3: patient has symptoms with less than ordinary exertionClass 4: patient has symptoms at restPitting: the indentation that remains for a short time after on skin with edema. Can be measured based on seconds it takes for skin to return to normal, or how deep the indentation of the skin isNursing: nurse will know pitting edema is a clinical manifestation of heart failure and will assess for other signs such as, hypotension, rales, tachypnea, confusion, pitting edema etc Right-sided heart failure: impaired pumping ability of the right side of the heart leading to backup of blood followed by congestion and elevated pressure in systemic veins and capillaries. Most commonly brought on due to left-sided heart failure. S/S: ascites, edema, elevated neck veins, lower extremity swellingNursing: determine if the signs/symptoms are associated with heart failure. Rule out other disorders such as neurological S3: Abnormal third hart sound in the cardiac cycle. May be present with volume overloadS4: Abnormal fourth heart sound in the cardiac cycle. May be heard when pt has significant hypertensionSystolic Dysfunction: left ventricular systolic dysfunction (LVSD) results in volume overload and decreased contractility. The heart is unable to pump enough blood to sustain the body’s metabolic demands and can result in heart failure. Most commonly caused by CAD & HTN. Tachypnea: rapid breathing >20 breaths per minute. Clinical manifestation of heart failureNursing: obtain O2 sat, assess for cyanosis, asses neurological status, place pt on O2 or increase level of O2 flowChapter 35 TermsAneurysm: diseased segment of an artery that becomes thin and dilated because of degenerative changes in the tunic media layer. Interventions/ significance:Mostly abdominal aortic aneurysms (AAA)Localized area of aorta that is weakened due to decreased elastin in the medial layer causing thinning of the vessel wall. Assess for pulsatile abdominal mass near the umbilicus in the lean patient.Auscultation of a bruit can be heard due to the widened and thinned area of the aorta. Report to physician if patient experiences any: restlessness, abdominal pain and tenderness, hypotension, and shock. Ankle-brachial index (ABI): a noninvasive test used to diagnose PAD.Interventions/ significance:ABI tests should be done on those with exertional leg pain or unhealed ulcers, older than 65yrs, those with diabetes, or smokers. Procedure:Take BP of bother arms with Dopple and take the higher reading.Take Dopple and record posterior tibialis and dorsalis pedis pulses and take the BP of these and take the higher of the two. Highest ankle BP/ highest arm BP = ABIABI > 1.0 = normalABI <0.9 = PADABI <0.4 = Severe arterial ischemiaAortic dissection (AD): life threatening condition whereby a tear in the intimal layer of the lumen of the aorta allows blood to flow into the medial layer which serves as a false lumen that may become filled and block or diminish flow through the true lumen. Interventions/ significance:Chronic stress from hypertension appears to play a significant role in the deterioration of the aortic wall. Assess patients for signs of ischemia due to obliteration of blood flow such as stroke, anuria, or extremity ischemia. Patients will typically have syncope or ALOCReport to physician if patient experiences any: restlessness, abdominal pain and tenderness, hypotension, and shock. Nurse should continue to monitor for signs of excessive blood loss such as low H/H, ALOC, pallor, hypovolemia, or shock and report to the physician immediatelyCareful for endoleaks after surgical/medical treatment. Blood pressure (BP): pressure created by the circulating blood through the arteries, veins, and the chambers of the heart. Interventions/ significance:Nurse should assess BP q4h in normal patientsBlood pressure readings are classified into: normal tension, prehypertension, stage 1 hypertension, and stage 2 hypertension. 30 minutes before and 30 minutes after administration of blood pressure medicationsBP is an indicator of peripheral vascular resistance Blood pressures below 90/50 and above 160/90 are disconcerning readings. Take blood pressure in different orthostatic positions to assess for orthostatic hypotension.Wait at least 3 minutes between blood pressure readings to get accurate results. Avoid taking blood pressure on arms with IV’s and/or dialysis grafts in place. DASH diet: low in sodium, saturated fat, cholesterol, and total fat. Interventions/ significance:Having a patient on a DASH diet has been proven to lower blood pressure by lowering sodium intake and lowering fat intake which reduces risk of hyperlipidemia. Encourage for patients with stage 1 or stage 2 hypertension along with lifestyle changes and exercise. Deep venous thrombosis: clot that forms in the deep veinsInterventions/ significance:Promote ambulation to prevent venous stasis.Elevate LE as tolerated to promote venous return and discourage venous stasis. Apply TEDs or SCDs if on bed rest to provide external compression to promote venous return. Perform Homan’s sign to assess for presence of DVTDiastolic blood pressure: reflexts cardiax relaxation; thus it is the minimum pressure in the arteries that occurs prior to the next cycle of ventricular contraction.Intervention/ significance:Increased diastolic pressure is a better indicator of the stage of hypertension.Diastolic blood pressure is also a good indicator of blood volume (increased blood volume = increased pressure in arteries when ventricles are relaxed) Much like systolic, diastolic pressure also rises when there is more resistance in the arteries such as a narrow lumen. Embolectomy: mechanical removal of a clot.Interventions/ significance:Continually monitor and follow up with patient following embolectomy to assess for reformation of blood clots. Carefully monitor for VTE or PE in case a piece of the clot was not removed and dislodged and got into circulation. Endoleaks: continued leaking of blood into aneurysmal sac after an endovascular stent graft repair.Interventions/ significance:Nurse should continually be assessing client’s condition note for any changes in health status. Nurse should continue to monitor for signs of excessive blood loss such as low H/H, ALOC, pallor, hypovolemia, or shock and report to the physician immediatelyHypertension: average blood pressure that is higher than the accepted norm over a period of time consisting of two or more consecutive office visits.Interventions/ significance:Nurse should be able to determine the stage of hypertension that the patient is in: prehypertension, normal tension, stage 1 hypertension, and stage 2 hypertension. Nurse should administer antihypertensives as ordered.Take BP 30 min before and 30 min follow up when giving antihypertensives. Treatment depends on patient’s stage of hypertension: Diet & Exercise (DASH diet) Weight controlStress ReductionAlcohol ConsumptionMedicationsCollaborate with clinical dietitians, fitness/ exercise leaders, and the pharmacist when devising a plan of care for the patient with hypertension.Hypertensive crisis: rare and sometimes fatal occurrence in which there is a sudden onset of DBP between 120-130mmHg. Interventions/ significance:Clinical Manifestations:Target organ vascular damageStructural organ changesAcute vascular damageCatecholamines released and RAA activatedUnstable anginaPulmonary edemaMIEclampsiaStrokeManagement:Bring BP down within 1hr without dropping too low Administer titratable IV meds such as labetalol, nicardipine, nitroglycerin, or nitroprusside. Hypertensive encephalopathy: very dangerous state of multifocal cerebral ischemia due to severely acute or subacute elevated blood pressure. Interventions/ significance:Requires immediate and urgent treatment. U6/8Bring BP down within 1hr without dropping too low Administer titratable IV meds such as labetalol, nicardipine, nitroglycerin, or nitroprusside. Intermittent claudication (IC): exercise-induced leg pain.Interventions/ significance:IC is caused by atherosclerosis or lesions in the vasculature proximal to the sensation of pain. A pain in the calf is typically caused by stenosis or occlusion in the femoral or popliteal arteries.Assessment of IC would include that exercise-induced pain is relieved when at rest due to a decrease in metabolic demand. Pain is a result of hypoperfusion to the leg muscles being hypoperfused therefore they must resort to anaerobic metabolism resulting in lactic acid production Pain even at rest is a sign of severe ischemia and should be reported immediately. Patient’s more comfortable with legs in a dependent position because gravity enhances arterial circulation. Lymphangitis: acute inflammation of the lymphatic channels most commonly cause by an infection in one of the extremities. Interventions/ significance:Assess for enlarged and tender lymph nodes to determine site of infection. Administer antibiotics, analgesics, and anti-inflammatory agents as ordered. Most commonly associated with a streptococcal infection of the skin. Lymphedema: swelling due to obstruction of the lymphatic system. Interventions/ significance:Presented as bilateral or diffuse edema, which may occur in the lower extremities.Should not be confused with DVT due to the bilateral edema while DVT is unilateral edema. Paresthesia: abnormal sensation such as pricking, tingling, or numbnessInterventions/ significance:Can be associated with problems with arterial blood flow causing a lack of O2 supply to peripheral tissues causing “tingling or numbness”.Continually assess abnormal sensation to determine whether it is a vascular problem or a nerve problem. Peripheral arterial disease (PAD): “vascular disease caused primary by atherosclerosis and thromboembolic pathophysiological processes that alter the normal structure of the aorta, its visceral branches, and the arteries of the lower extremities.” Interventions/ significance:PAD increases with ageRisk factors: smoking, diabetes, hyperlipidemia, hypertension, elevated C-reactive protein, and elevated homocystein levels. Clinical Manifestations:Intermittent claudicationPoor hair growthCool skinResting limb painParesthsiaPoor healing of sores or ulcers Management:Antiplatelet therapy with aspirinEndovascular repair for endoluminal damageAngioplasty, stenting, and radiation therapyMajority of PAD patients also have coronary artery disease Obtain health history of: smoking, hyperlipidemia, diabetes, activity level, and any pertinent family history.Skin color in various orthostatic positions:Pallor when elevated, deep red when in dependent position. PAD is a lifelong disease so patient education is extremely important. Peripheral vascular resistance: the resistance to the flow of blood as determined by the vascular musculature and the diameter of the blood vessels.Interventions/significance:Deficiencies in the musculature of the ventricles and their ability to withstand the pressure of ventricular contraction affect the peripheral vascular resistance. The artery’s elasticity affects the ability of the peripheral vessels resistance to the force of blood by ventricular contraction. Peripheral vascular resistance can be controlled by neural regulation in response to arterial baroreceptors.Peripheral vascular resistance can also be affected by chemoreceptors, regulation of fluid volume, and humoral regulation. PrehypertensionInterventions/ significance:Treatment depends on patient’s stage of hypertension: Diet & Exercise (DASH diet) Weight controlStress ReductionAlcohol ConsumptionMedicationsCollaborate with clinical dietitians, fitness/ exercise leaders, and the pharmacist when devising a plan of care for the patient with hypertension.Pulmonary embolism: presence of a thrombus or blood clot in the pulmonary vessels that obstructs blood flow and impedes gas exchange.Interventions/ significance:Assess patients lung soundsHave patient C & DB and provide O2 therapy to maintain oxygenation. Assess patients PaCO2 levels to determine oxygenation and gas exchange.Assess patients PaO2/ FiO2 ratio to determine oxygenation and gas exchange.Get a CT scan, MRI or US to determine presence of a PE. Pulse pressure: pulse pressure is the difference between the systolic and the diastolicInterventions/ significance:It represents the force in mmHg that the heart generates with each contraction. Elevated pulse pressure could indicate stiffness of major arteries, aortic regurgitation, or a arteriovenous malformation. Antihypertensives may increase pulse pressure, while ACE inhibitors can lower pulse pressure. Chronic high pulse pressure increases the risk for heart disease. Raynaud’s disease (RD): arterial vasospastic disorder caused by emotional distress or coldTransient spasm of arteries and arterioles, which result in decreased blood flow to affected extremity. Associated with RA, scleroderma, SLE, leukemia, or polycythemia rubra vera.Associated with occupational or environmental conditions: cold exposure, repetitive trauma, or excessive vibration injury. Management:Avoid known stressors (cold, emotional stress)Assess characteristics of RD attacks such as pain, numbness, color changes, and frequency of attacks. Get history of patient medications that may trigger spasms. Stress managementPatient education extremely important since there is no cure. Stage 1 hypertension: BP of 140-159 systolic, 90-99 diastolic on multiple office visitsInterventions/ significance:Treatment depends on patient’s stage of hypertension: Diet & Exercise (DASH diet) Weight controlStress ReductionAlcohol ConsumptionMedicationsCollaborate with clinical dietitians, fitness/ exercise leaders, and the pharmacist when devising a plan of care for the patient with hypertension.Stage 2 hypertension: BP of 160+ systolic, 100+ diastolic on multiple office visitsInterventions/ significance:Treatment depends on patient’s stage of hypertension: Diet & Exercise (DASH diet) Weight controlStress ReductionAlcohol ConsumptionMedicationsCollaborate with clinical dietitians, fitness/ exercise leaders, and the pharmacist when devising a plan of care for the patient with hypertension.Sympathectomy: removal of sympathetic ganglia.Interventions/ significance:Can be done for patients with severe Raynaud’s Disease symptoms. Interrupts SNS stimulation in the affected vessels to prevent the vasospasms. Systolic blood pressure: maximum pressure in the aorta and major arteries. Interventions/ significance:Systolic blood pressure is more indicative of vascular disease SBP typically increases with age as arteries become more stiff causing more resistance therefore increasing the pressure in the aorta and arteries. A person with elevated systolic, but normal diastolic can benefit from treatment immensely. Thoracic outlet syndrome: rare disorder in which there is a compression of the nerves and arteries in the thoracic outlet (between the thorax and clavicle)Interventions/ significance:To assess for thoracic outlet syndrome an elevated arm stress test (EAST) can be done.Patient place both arms in 90-degree abduction and externally rotate for 3 minutes.Positive test occurs when there is a reproduction of exacerbated symptoms. Treatment options are mostly directed towards nonsurgical interventions such as:Collaboration with physical therapyPain management (NSAIDS)Moist heatMassageUnna’s boot: rigid bandage that is used to treat venous ulcers which also prevent edema while promoting healing and is worn for several days at a time. This is a type of compression therapy which doesn’t impede in ADL’s very much.Should still assess for signs of DVT. Typically used for patient’s who are able to walk around and move on their own and NOT for patients who are confined to bedrest or wheelchairs. Varicose veins: dilated, tortous veins that occur in the lower extremities as a result of incompetence of valves of the deep and superficial venous system, which leads to valve reflux. Interventions/ significance:Risk factors include constipation/ low fiber-diet, smoking, hypertension, pregnancy, and injury. Nurse can perform Tredelenburg test to assess the competency of the valves in the superficial and deep veins of the lower extremities. Venous thromboembolism (VTE): two conditions: DVT and pulmonary embolism.Interventions/ significance:Assess for signs of PEProvide anticoagulation medications as orderedPromote use of SCDs and TEDs to prevent DVT from ever occurring. Promote ambulation to prevent venous stasis.Elevate LE as tolerated to promote venous return and discourage venous stasis. Perform Homan’s sign to assess for presence of DVTVirchow’s triad: venous stasis, damage of the endothelium, and hypercoagulability.Interventions/ significance:The triad represents the three factors that are associated with DVT formation. If any of these factors increase, then the patient will be at an increased risk for the formation of a DVT. ................
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