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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