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Instruction: Answer the following questions briefly.

1. Explain the process of pulmonary and systemic circulation. Pathway of blood flow through the heart.

1. Blood enters the right atrium from the superior and inferior venae calvae,

and the coronary sinus.

2. From right atrium, it goes through the tricuspid valve to the right ventricle.

3. From the right ventricle, it goes through the pulmonary semilunar valves to

the pulmonary trunk

4. From the pulmonary trunk it moves into the right and left pulmonary

arteries to the lungs.

5. From the lungs, oxygenated blood is returned to the heart through the

pulmonary veins.

6. From the pulmonary veins, blood flows into the left atrium.

7. From the left atrium, blood flows through the bicuspid (mitral) valve into

the left ventricle.

8. From the left ventricle, it goes through the aortic semilunar valves into the

ascending aorta.

9. Blood is distributed to the rest of the body (systemic circulation) from the

aorta.

2. Explain and enumerate the different classifications of Cardiovascular Disease.

1.Conduction disoders(Dythymias)

- Supraventricular Rhythms

- Ventricular Dysrhythmias

- Atrioventricular Conduction Blocks

- Ventricular Conduction Blocks

2.Myocardial disorders(Coronary Heart Disease)

- Angina pectoris

- Acute Myocardial Infarction

- Sudden Cardiac Death

3.Structural Disorders

- Valvular Hearth Diseases

- Cardiomyopathy

- Infectious Disorder

3. Give the pathophysiology, sign / symptoms and nursing care for the following disorders.

|Inflammatory Heart Disease |Pathophysiology |Sign and Symptoms |Nursing Care |

|Rheumatic Fever/ Rheumatic Heart |-Aschoff bodies, localized areas|-Fever and migratory join |-Nursing care focus: providing |

|Disease |of tissue necrosis surrounded by|pain-initial manifestation. |supportive care and preventing |

| |immune cell, develop in cardiac | |complications. |

| |tissue | |-Teaching to prevent recurrence |

| | | |of RF is extremely important |

|Endocarditis |-inflammation of the endocardium|Fever |-prevention of endocarditis |

| |-relatively uncommon |New onset heart murmurs over |-Education is the key part of |

| |-greatest risk factor:previous |valves affected |prevention |

| |heart damage |Embolic complications | |

| | |Anemia | |

|Myocarditis |-inflammatory process damage the|Flu-like initially |-directed at decreasing |

| |myocardial cell-local or diffuse|Fatigue |myocardial work and maintaining |

| |swelling and damage |Dyspnea and signs of HF if |cardiac output |

| |-infectious agent infiltrate |increases in severity |-both physical and emotional |

| |interstitial tissues-formation |May develop sudden cardiac |rest are indicated,because |

| |of abscesses |death in severe HF |anxiety increased myocardial |

| |-autoimmune injury | |oxygen demand |

| | | |-during acute phase:hemodynamic |

| | | |monitoring and the ECG |

| | | |-frequently assess for |

| | | |manifestations of heart failure |

|Pericarditis |Pericardial damage-release of |Pain over the heart worsening |-early identification and |

| |inflammatory |with movement or breathing |treatment of the disorder can |

| |mediators-vasodilation,hyperemia|deeply(pleuritic pain) |reduce the rick of complications|

| |,and edema:increase capillary |Pericardial friction rub heard|-promptly report a pericardial |

| |permeability-escape of plasma |best over the lower-middle |friction rub or other |

| |proteins and fibrinogens into |left sternal border |manifestations of pericarditis |

| |the pericardial space-influx of |Mild fever |in client with recent |

| |WBC to the site of injury to |Signs of dyspnea if heart |AMU,cardiac surgery,or systemic |

| |destroy the causative |failure occurs |disease associated with a risk |

| |agent-exudate | |pericarditis |

| |formation-inflammatory resolve | | |

| |without long-term effects or may| | |

| |produce scar tissue and adheions| | |

| |between the pericardial | | |

| |layres-restict cardiac function | | |

|Valvular Heart Disease |Pathophysiology |Sign and symptoms |Nusring Care |

|Mitral Stenosis |Physiological changes - Consideration In |* May be asymptomatic; or |HEALTH PROMOTION |

| |Pregnancy |severe impairment depending |Prevent RHD – key element |

| |The most important changes in cardiac |on cardiac output and |in preventing heart valve |

| |function occurs in the first 8 weeks of |pulmonary pressures |disorders |

| |pregnancy with maximum changes at 28 weeks↓ |* Typical earliest |Timely and effective |

| |Vascular resistance↓ Blood pressure↑ Heart |manifestation: dyspnea on |treatment of strep throats|

| |rate ↑ Stroke volume ↑ CO↑ Blood volume 30% -|exertion (DOE) |to prevent rheumatic fever|

| |50% |* Cough, hemoptysis, frequent|(sequel to β-hemolytic |

| |The fall in the peripheral resistance is |pulmonary infections |streptococcal infection of|

| |about 20-30% at 21-24 weeks & returns to |(bronchitis, pneumonia), |the pharynx). |

| |normal at term. This fall is due to1. The |paroxysmal nocturnal dyspnea,|Emphasize the importance |

| |trophoblastic erosion of endometrial vessels,|orthopnea, weakness, |of complete the full |

| |the placental bed serves as a large |fatigue, palpitations |prescription of |

| |arteriovenous shunt causing lowered systemic |* Worsen stenosis: right |antibiotics to prevent |

| |vascular resistance2. There is physiological |heart failure, jugular vein |development of resistant |

| |vasodilatation which is believed to be |distension, hepatomegaly, |bacteria. |

| |secondary to endothelial prostacyclin and |ascites, peripheral edema, |Prophylactic antibiotic |

| |circulating progesterone.3 .Anemia decreases |crackles in the lung bases |therapy before invasive |

| |blood viscosity with resultant decrease in |* Severe mitral stenosis: |procedures to prevent |

| |systemic vascular resistance. |cyanosis of the face and |infectious endocarditis |

| | |extremities, chest pain |(important health |

| | |(rare) |promotion measure for |

| | |* Loud S1, split S2, mitral |client with preexisting |

| | |opening snap, diastole |heart disease). |

| | |murmur: low-pitched, | |

| | |rumbling, | |

| | |crescendo-decrescendo, heard | |

| | |best in the apical region; | |

| | |palpable thrill | |

| | |* Atrial dysrhythmias (atrial| |

| | |fibrillation) due to chronic | |

| | |atrial distention | |

| | |* Thrombi formation and | |

| | |subsequently embolize to | |

| | |brain, coronary arteries, | |

| | |kidneys, spleen, and | |

| | |extremities – fatal | |

| | |complications. | |

| | |* Women are asymptomatic | |

| | |until pregnancy (as the heart| |

| | |compensate for increased | |

| | |circulating volume (30% more | |

| | |in pregnancy). | |

|Mitral Regurgitation |?The mitral valve closes incompletely à ‚ |* May be asymptomatic |HEALTH PROMOTION |

| |allowing blood to regurgitate during systole |* Fatigue, weakness, DOE, |Prevent RHD – key element |

| |form L ventricle to L atrium à ƒrising L |orthopnea |in preventing heart valve |

| |atrial pressure à „causes L atrial |* Severe or acute |disorders |

| |hyperthrophy and pulmonary congestion à … |regurgitation: pulmonary |Timely and effective |

| |elevated pulmonary artery pressure à causes |congestion and edema |treatment of strep throats|

| |slight enlargement of the R ventricle. |* Murmur: loud, high-pitched,|to prevent rheumatic fever|

| | |rumbling, and holosystolic |(sequel to β-hemolytic |

| | |(occurring throughout |streptococcal infection of|

| | |systole); accompanied by |the pharynx). |

| | |palpable thrill, heard most |Emphasize the importance |

| | |clearly at the cardiac apex |of complete the full |

| | | |prescription of |

| | | |antibiotics to prevent |

| | | |development of resistant |

| | | |bacteria. |

| | | |Prophylactic antibiotic |

| | | |therapy before invasive |

| | | |procedures to prevent |

| | | |infectious endocarditis |

| | | |(important health |

| | | |promotion measure for |

| | | |client with preexisting |

| | | |heart disease). |

|Mitral Valve Prolapse |?Excess tissue in the valve leaflets and |* Usually asymptomatic |HEALTH PROMOTION |

| |elongated cordae tindienae à ‚impair valve |* Audible midsystolic |Prevent RHD – key element |

| |closure during systoleà ƒsome ventricular |ejection click or murmur; |in preventing heart valve |

| |blood regurgitates into the L atrium |high pitched last systolic |disorders |

| | |murmur |Timely and effective |

| | |* Most common symptom – |treatment of strep throats|

| | |atypical chest pain: left |to prevent rheumatic fever|

| | |sided or substernal, |(sequel to β-hemolytic |

| | |frequently related to |streptococcal infection of|

| | |fatigue, not exertion |the pharynx). |

| | |* Tachydysrhythmias causing |Emphasize the importance |

| | |palpitations, |of complete the full |

| | |lightheadedness, |prescription of |

| | |syncope |antibiotics to prevent |

| | |* Progressive worsening: |development of resistant |

| | |leads to heart failure, |bacteria. |

| | |embolization may |Prophylactic antibiotic |

| | |cause transient ischemic |therapy before invasive |

| | |attacks (TIAs) |procedures to prevent |

| | | |infectious endocarditis |

| | | |(important health |

| | | |promotion measure for |

| | | |client with preexisting |

| | | |heart disease). |

|Aortic Stenosis |?The narrowed aortic valve orifice à |* Asymptomatic for many years|HEALTH PROMOTION |

| |‚decreased the L ventricular ejection |(50 to 70 years of age) |Prevent RHD – key element |

| |fraction during systole à ƒL ventricle |* Classic manifestations: [L |in preventing heart valve |

| |hypertrophies à „ incomplete emptying of the |ventricular failure] DOE, |disorders |

| |L atrium à … causes backward pressure through|angina pectoris (66% of the |Timely and effective |

| |pulmonary veins and pulmonary HTN à† causes R|patients), narrow pulse |treatment of strep throats|

| |ventricular strain |pressure (30 mmHg or less) |to prevent rheumatic fever|

| | |* Increased LAP and PAWP |(sequel to β-hemolytic |

| | |* Harsh systolic murmur in |streptococcal infection of|

| | |2nd ICS to the right of the |the pharynx). |

| | |sternum |Emphasize the importance |

| | |* Palpable thrill |of complete the full |

| | |* S3 and S4 heart sounds – |prescription of |

| | |indicating heart failure |antibiotics to prevent |

| | | |development of resistant |

| | | |bacteria. |

| | | |Prophylactic antibiotic |

| | | |therapy before invasive |

| | | |procedures to prevent |

| | | |infectious endocarditis |

| | | |(important health |

| | | |promotion measure for |

| | | |client with preexisting |

| | | |heart disease). |

|Aortic Regurgitation |?aortic valve cusps widen and fail to close |* Asymptomatic for many years|HEALTH PROMOTION |

| |during diastole à ‚blood regurgitates from |even when severe. |Prevent RHD – key element |

| |the aorta into the L ventricle à ƒincreasing |* Persistent palpitation (esp|in preventing heart valve |

| |L ventricular volume and decreasing cardiac |when in recumbent, visible |disorders |

| |output à „L ventricle dilates and |throbbing pulse in the |Timely and effective |

| |hypertrophies in response to the increase in |arteries of the neck |treatment of strep throats|

| |blood volume and workload. |* Musset’s sign: head bobbing|to prevent rheumatic fever|

| | |and shake the whole body by |(sequel to β-hemolytic |

| | |the force of contraction in |streptococcal infection of|

| | |time with the pulse |the pharynx). |

| | |* Dizziness, exercise |Emphasize the importance |

| | |intolerance |of complete the full |

| | |* Common signs: fatigue, DOE,|prescription of |

| | |orthopnea, PND |antibiotics to prevent |

| | |* Anginal pain occur at night|development of resistant |

| | |and may not respond to |bacteria. |

| | |conventional therapy |Prophylactic antibiotic |

| | |* Murmur: heard during |therapy before invasive |

| | |diastole, “blowing”, |procedures to prevent |

| | |high-pitched (heard best at |infectious endocarditis |

| | |3rd left ICS), palpable |(important health |

| | |thrill, ventricular heave, S3|promotion measure for |

| | |and S4 |client with preexisting |

| | |* Displaced apical impulse to|heart disease). |

| | |the left | |

| | |* ŒWater hammer pulse | |

| | |(arterial pressure waveform | |

| | |has a rapid upstroke and | |

| | |quickly collapsing | |

| | |downstroke), ?widened pulse | |

| | |pressure, Ž Quinke’s sign | |

| | |(visible pulsation in the | |

| | |nail bed), ?Corrigan’s sign | |

| | |(visible carotid pulsation), | |

| | |? Musset’s sign, ‘ Early | |

| | |diastolic murmur | |

|Tricuspid Stenosis |Tricuspid stenosis results from alterations |* Obstructs blood flow from |HEALTH PROMOTION |

| |in the structure of the tricuspid valve that |the R atrium to the R |Prevent RHD – key element |

| |precipitate inadequate excursion of the valve|ventricle |in preventing heart valve |

| |leaflets. The most common etiology is |* Usually results from RHD; |disorders |

| |rheumatic fever, and tricuspid valve |mitral stenosis |Timely and effective |

| |involvement occurs universally with mitral |* Manifestations are related |treatment of strep throats|

| |and aortic valve involvement. With rheumatic |to systemic congestion and |to prevent rheumatic fever|

| |tricuspid stenosis, the valve leaflets become|right-sided heart failure |(sequel to β-hemolytic |

| |thickened and sclerotic as the chordae |* Murmur: low-pitched, |streptococcal infection of|

| |tendineae become shortened. The restricted |rumbling diastolic clearly |the pharynx). |

| |valve opening hampers blood flow into the |heard in the 4th ICS at the L|Emphasize the importance |

| |right ventricle and, subsequently, to the |sternal border or over the |of complete the full |

| |pulmonary vasculature. Right atrial |xiphoid process |prescription of |

| |enlargement is observed as a consequence. The| |antibiotics to prevent |

| |obstructed venous return results in hepatic | |development of resistant |

| |enlargement, decreased pulmonary blood flow, | |bacteria. |

| |and peripheral edema. Other rare causes of | |Prophylactic antibiotic |

| |tricuspid stenosis include carcinoid | |therapy before invasive |

| |syndrome, endocarditis, endomyocardial | |procedures to prevent |

| |fibrosis, systemic lupus erythematosus, and | |infectious endocarditis |

| |congenital tricuspid atresia | |(important health |

| |In the rare instances of congenital tricuspid| |promotion measure for |

| |stenosis, the valve leaflets may manifest | |client with preexisting |

| |various forms of deformity, which can include| |heart disease). |

| |deformed leaflets, deformed chordae, and | | |

| |displacement of the entire valve apparatus. | | |

| |Other cardiac anomalies are usually present. | | |

|Tricuspid Regurgitation |The pathophysiology of tricuspid |* Blood flow back into the |HEALTH PROMOTION |

| |regurgitation focuses on the structural |right atrium during systole |Prevent RHD – key element |

| |incompetence of the valve. The incompetence |* Usually occurs secondary to|in preventing heart valve |

| |can result from primary structural |R ventricular dilation |disorders |

| |abnormalities of the leaflets and chordae or,|* Stretching distorts the |Timely and effective |

| |more often, be secondary to myocardial |valve and its supporting |treatment of strep throats|

| |dysfunction and dilatation. [1] |structures |to prevent rheumatic fever|

| |Tricuspid valve insufficiency due to leaflet |* RHD, infective |(sequel to β-hemolytic |

| |abnormalities may be secondary to |endocarditis, inferior MI, |streptococcal infection of|

| |endocarditis or rheumatic heart disease. When|trauma |the pharynx). |

| |due to the latter, it generally occurs in |* Manifestations are related |Emphasize the importance |

| |combination with tricuspid stenosis. Ebstein |to right-sided heart failure;|of complete the full |

| |anomaly is the most common congenital form of|common atrial fibrillation |prescription of |

| |tricuspid regurgitation. |(atrial distention) |antibiotics to prevent |

| |Inspiration increases the severity of |* Murmur: high-pitched, |development of resistant |

| |tricuspid regurgitation. Inspiration induces |blowing systolic murmur heard|bacteria. |

| |widening of the RV, which enlarges the |over the tricuspid or xiphoid|Prophylactic antibiotic |

| |tricuspid valve annulus and thus increases |area. |therapy before invasive |

| |the effective regurgitant orifice area | |procedures to prevent |

| |Chronically, tricuspid regurgitation leads to| |infectious endocarditis |

| |RV volume overload, which results in | |(important health |

| |right-sided congestive heart failure (CHF). | |promotion measure for |

| |This manifests as hepatic congestion, | |client with preexisting |

| |peripheral edema, and ascites. | |heart disease). |

|Pulmonic Stenosis |Clinically significant narrowing of a valve |* Blood flow from the R |HEALTH PROMOTION |

| |or a blood vessel increases pressure proximal|ventricle into the pulmonary |Prevent RHD – key element |

| |to the obstruction. This pressure gradient is|system |in preventing heart valve |

| |necessary to maintain flow across the |* Congenital; RHD, cancer |disorders |

| |stenotic site. In pulmonic stenosis, |* Manifestations are related |Timely and effective |

| |hypertrophy of the right ventricle ensues and|to right-sided heart failure |treatment of strep throats|

| |maintains this forward flow. The magnitude of|* Murmur: harsh, systolic |to prevent rheumatic fever|

| |right ventricular pressure and the pressure |crescendo-decrescendo heard |(sequel to β-hemolytic |

| |gradient across the pulmonary valve are |in the pulmonic area, 2nd L |streptococcal infection of|

| |generally proportional to the degree of |ICS |the pharynx). |

| |obstruction. Under usual circumstances, | |Emphasize the importance |

| |proportional right ventricular hypertrophy | |of complete the full |

| |maintains normal pulmonary blood flow. If the| |prescription of |

| |normal output is not maintained, right-sided | |antibiotics to prevent |

| |heart failure ensues. This occurs in neonates| |development of resistant |

| |with critical pulmonary stenosis and in | |bacteria. |

| |patients with severe obstruction that occurs | |Prophylactic antibiotic |

| |in childhood or adulthood. | |therapy before invasive |

| |Changes in the geometry of the left ventricle| |procedures to prevent |

| |and decreased left ventricular function can | |infectious endocarditis |

| |also occur. [10, 11]The changes are | |(important health |

| |proportional to the degree of right | |promotion measure for |

| |ventricular hypertrophy; however, they revert| |client with preexisting |

| |to normal after obstruction of the right | |heart disease). |

| |ventricular outflow tract is relieved. | | |

| |With increasing right ventricular | | |

| |hypertrophy, right ventricular compliance | | |

| |decreases with a resultant increase in | | |

| |end-diastolic pressure and with prominent a | | |

| |waves in the right atrium. As right atrial | | |

| |pressure rises, a right-to-left shunt may | | |

| |occur if the foramen ovale is patent or if an| | |

| |atrial septal defect is present; this change | | |

| |results in systemic arterial desaturation and| | |

| |clinically discernible cyanosis. This | | |

| |shunting may occur even without measurable | | |

| |elevation of right atrial pressure and is | | |

| |attributable to decreased right ventricular | | |

| |compliance  Such a right-to-left shunt can | | |

| |also occur in patients with an underdeveloped| | |

| |(hypoplastic) right ventricle | | |

|Pulmonic Regurgitation |(pulmonary) regurgitation (PR) is |* Incomplete valve closure |HEALTH PROMOTION |

| |incompetency of the pulmonic valve causing |allows blood flow back into |Prevent RHD – key element |

| |blood flow from the pulmonary artery into the|the right ventricle during |in preventing heart valve |

| |right ventricle during diastole. ... PR is |diastole, decreasing blood |disorders |

| |usually asymptomatic. |flow to the pulmonary circuit|Timely and effective |

| | |* Manifestations are related |treatment of strep throats|

| | |to right-sided heart failure |to prevent rheumatic fever|

| | |* Murmur: high-pitched, |(sequel to β-hemolytic |

| | |decrescendo, blowing, heard |streptococcal infection of|

| | |at left sternal border during|the pharynx). |

| | |diastole |Emphasize the importance |

| | | |of complete the full |

| | | |prescription of |

| | | |antibiotics to prevent |

| | | |development of resistant |

| | | |bacteria. |

| | | |Prophylactic antibiotic |

| | | |therapy before invasive |

| | | |procedures to prevent |

| | | |infectious endocarditis |

| | | |(important health |

| | | |promotion measure for |

| | | |client with preexisting |

| | | |heart disease). |

|Cardiomyopathy |Disorders that affect the heart |With the exception of treating|dilated and restrictive |

| |muscle itself affecting both |an underlying cause, little |cadriomyopathies: similar to |

| |systolic and diastolic functions.|can be done to treat either |client with heart failure |

| |Primary cardiomyopathy: |dilated or restrictive |hypertrophic cardiomyopathy: |

| |idiopathic |cardiomyopathies; focus on |similar to client with |

| |Secondary cardiomyopathy: result |managing heart failure and |myocardial infarction |

| |of the other process such as |treating dysrhythmias. | |

| |ischemia, infectious disease, |Hypertrophic cardiomyopathy | |

| |exposure to toxins, connective |treatment focuses on reducing | |

| |tissue disorders, metabolic |contractility and preventing | |

| |disorders, or nutritional |sudden cardiac death. | |

| |deficiencies. |Restrict strenuous physical | |

| |Mortality: higher in older |exertion, dietary and sodium | |

| |adults, men, and African |restrictions | |

| |Americans (AHA, 2001). | | |

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