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Overview of Anatomy and PhysiologyHeartFour-chambered, hollow, muscular organ, not much bigger than a fistLies in the mediastinumLower border is called the apexHeart wall: three layersEpicardium: serous membrane on the outside of the heartMyocardium: constructed of cardiac muscleEndocardium: lines the inner surface of the chambers of the heartFigure 48-1Overview of Anatomy and PhysiologyHeart chambersRight atrium—receives deoxygenated bloodLeft atrium—receives oxygenated bloodRight ventricle—pumps deoxygenated bloodLeft ventricle—pumps oxygenated bloodHeart valvesAtrioventricular valvesTricuspid and bicuspid valvesSemilunar valvesPulmonary and aortic semilunar valvesFigure 48-2Overview of Anatomy and PhysiologyElectrical conduction systemAutomaticityAn inherent ability of the heart muscle tissue to contract in a rhythmic patternIrritabilityThe ability to respond to a stimulusImpulse patternSinoatrial node to AV node to bundle of His to right and left bundle branches to Purkinje fibersFigure 48-3Overview of Anatomy and PhysiologyCardiac cycleA complete heartbeatAtria contract while ventricles relaxVentricles contract while atria relaxSystolePhase of contractionDiastolePhase of relaxationPeriod between contraction of the atria or ventricles during which the blood enters the relaxed chambersFigure 48-4Figure 48-5Overview of Anatomy and PhysiologyBlood vesselsCapillariesTiny blood vessels joining arterioles and venulesArteriesLarge vessels carrying blood away from the heartVeinsVessels that convey blood from the capillaries to the heartCirculationCoronary blood supplyRight and left coronary arteriesBranch off of the aortaEncircle the heart like a crownSupply the myocardium with bloodCoronary veinsReturn the unoxygenated blood to the coronary sinus, then to the right atriumFigure 48-6CirculationSystemic circulationCirculates blood from the left ventricle to all parts of the body and back to the right atriumCarries oxygen and nutritive materials to all body tissues and removes products of metabolismPulmonary circulationCirculates blood from the right ventricle to the lungs and back to the left atrium of the heartCarries deoxygenated blood to the lungs to be reoxygenated and removes the metabolic waste product, carbon dioxideLaboratory and Diagnostic ExaminationsDiagnostic imagingFluoroscopyAngiogramAortogramCardiac catheterization and angiographyElectrocardiographyCardiac monitorsThallium scanningLaboratory tests: CBC, blood cultures, coagulation studies, ESR electrolytes, lipids, arterial blood gases, cardiac markersFigure 48-7Disorders of the Cardiovascular SystemRisk factorsNonmodifiable factorsFamily historyAgeSex (gender)RaceDisorders of the Cardiovascular SystemRisk factors (continued)Modifiable factorsSmokingHyperlipidemiaHypertensionDiabetes mellitusObesitySedentary lifestyleStressOral contraceptivesPsychosocial factorsDisorders of the Cardiovascular SystemCardiac dysrhythmiasAny cardiac rhythm that deviates from normal sinus rhythmSinus tachycardiaSinus bradycardiaSupraventricular tachycardiaAtrial fibrillationAtrioventricular blockPremature ventricular contractionsVentricular tachycardiaVentricular fibrillationDisorders of the Cardiovascular SystemCardiac ArrestThe sudden cessation of cardiac output and circulatory processCause: ventricular tachycardia, ventricular fibrillation, and ventricular asystole Signs and symptoms: abrupt loss of consciousness with no response to stimuli; gasping respirations followed by apnea; absence of pulse and blood pressure; pupil dilation; pallor and cyanosisTreatment: cardiopulmonary resuscitation (CPR) and advanced cardiac life support (ACLS)Disorders of the HeartCoronary atherosclerotic heart diseaseCoronary artery disease (CAD)A variety of conditions that obstruct blood flow in the coronary arteriesAtherosclerosisA common arterial disorder characterized by yellowish plaques of cholesterol, lipids, and cellular debris in the inner layers of the walls of the arteries; the primary cause of atherosclerotic heart disease (ASHD)Figure 48-10Disorders of the HeartAngina pectorisEtiology/pathophysiologyCardiac muscle is deprived of oxygenIncreased workload on the heartClinical manifestations/assessmentPain (usually relieved by rest)DyspneaAnxiety; apprehensionDiaphoresisNauseaDisorders of the HeartAngina pectoris (continued)Medical management/nursing interventionsCorrect cardiovascular risk factorsAvoid precipitating factorsPharmacological managementDilate coronary arteries and decrease workload of heartNitroglycerinBeta-adrenergic blocking agentsCalcium channel blockersDisorders of the HeartAngina pectoris (continued)Medical management/nursing interventionsSurgical interventionsCoronary artery bypass graft (CABG)Percutaneous transluminal coronary angioplasty (PTCA)Stent placementDisorders of the HeartMyocardial infarctionEtiology/pathophysiologyOcclusion of a major coronary artery or one of its branches with subsequent necrosis of myocardium Most common cause is atherosclerosisAbility of the cardiac muscle to contract and pump blood is impairedFigure 48-16Disorders of the HeartMyocardial infarction (continued)Clinical manifestations/assessmentAsymptomatic (silent MI)Pain (not relieved by rest, position, or nitroglycerin)NauseaSOB; dizziness; weaknessDiaphoresisPallor—ashen colorSense of impending doomFigure 48-11Disorders of the HeartMyocardial infarction (continued)Medical management/nursing interventionsOxygenFibrinolytic agentsPercutaneous transluminal coronary angioplasty (PTCA)Coronary artery bypass graft surgery Pharmacological managementVasopressors, analgesics, nitrates, beta-adrenergic blockers, calcium channel blockers, antidysrhythmics, diuretics, inotropic agents, diuretics, stool softenersFigure 48-12Figure 48-13Disorders of the HeartHeart failureEtiology/pathophysiologyAbnormal condition characterized by circulatory congestion resulting from the heart’s inability to act as an effective pumpLeft ventricular failureMost commonRight ventricular failureUsually caused by left ventricular failureDisorders of the HeartHeart failure (continued)Clinical manifestations/assessmentDecreased cardiac outputFatigueAnginaAnxiety; restlessnessOliguriaDecreased GI motilityPale, cool skinWeight gainDisorders of the HeartHeart failure (continued)Clinical manifestations/assessment (continued)Left ventricular failurePulmonary congestionDyspneaParoxysmal nocturnal dyspneaCough; frothy, blood-tinged sputumOrthopneaPulmonary cracklesPleural effusion (x-ray)Disorders of the HeartHeart failure (continued)Clinical manifestations/assessment (continued)Right ventricular failureDistended jugular veinsAnorexia, nausea, and abdominal distentionLiver enlargementAscitesEdema in feet, ankles, sacrum; may progress up the legs into thighs, external genitalia, and lower trunkDisorders of the HeartHeart failure (continued)Medical management/nursing interventionsPharmacological managementIncrease cardiac efficiencyDigitalisVasodilatorsACE inhibitors (decrease blood pressure)Bed rest, HOB elevatedOxygenTreat edema and pulmonary congestionMonitor fluid retention (weigh daily; strict I&O)Disorders of the HeartPulmonary edemaEtiology/pathophysiologyAccumulation of fluid in lung tissues and alveoliComplication of congestive heart failure (CHF)Clinical manifestations/assessmentRestlessnessAgitationDisorientationDiaphoresisDyspnea and tachypneaDisorders of the HeartPulmonary edema (continued)Clinical manifestations/assessment (continued)TachycardiaPallor or cyanosisCough—large amounts of blood-tinged, frothy sputumWheezing, cracklesCold extremitiesDisorders of the HeartPulmonary edema (continued)Medical management/nursing interventions Pharmacological managementMorphine sulfateNitroglycerinDiureticsInotropic agents VasodilatorsHigh Fowler’s or orthopneic positionOxygenDisorders of the HeartValvular heart diseaseEtiology/pathophysiologyHeart valves are compromised and do not open and close properlyStenosisInsufficiencyCauses may be:CongenitalRheumatic feverDisorders of the HeartValvular heart disease (continued)Clinical manifestations/assessmentFatigueAnginaOliguriaPale, cool skinWeight gainRestlessnessAbnormal breath soundsEdemaDisorders of the HeartValvular heart disease (continued)Medical management/nursing interventionsPharmacological managementDiureticsDigoxinAntidysrhythmicsRestrict activitiesSodium-restricted dietSurgeryOpen mitral commissurotomyValve replacementDisorders of the HeartRheumatic heart diseaseEtiology/pathophysiologyRheumatic feverInflammatory disease that is a delayed childhood reaction to inadequately treated childhood upper respiratory tract infection of beta-hemolytic streptococciCauses scar tissue in the heartDisorders of the HeartRheumatic heart disease (continued)Clinical manifestations/assessmentElevated temperatureElevated heart rateEpistaxisAnemiaJoint pain and stiffnessNodules on the jointsSpecific to valve affectedHeart murmurDisorders of the HeartRheumatic heart disease (continued)Medical management/nursing interventionsPharmacological managementNSAIDsPreventionTreat infections rapidly and completelyBed restApplication of heatDietary recommendationsWell-balanced diet Supplement with vitamins B and CEncourage fluidsCommissurotomy or valve replacementDisorders of the HeartPericarditisEtiology/pathophysiologyInflammation of the membranous sac surrounding the heartMay be acute or chronicBacterial, viral, or fungalNoninfectious conditionsAzotemia, MI, neoplasms, scleroderma, trauma, systemic lupus erythematosus (SLE), radiation, drugsDisorders of the HeartPericarditis (continued)Clinical manifestations/assessmentDebilitating painDyspneaFeverChillsDiaphoresisLeukocytosisPericardial friction rubPericardial effusionDisorders of the HeartPericarditis (continued)Medical management/nursing interventionsPharmacological managementAnalgesicsSalicylatesAntibioticsAnti-inflammatory agents CorticosteroidsOxygenIV fluidsSurgery: pericardial window, pericardial tapDisorders of the HeartEndocarditisEtiology/pathophysiologyInfection or inflammation of the inner membranous lining of the heartClinical manifestations/assessmentInfluenza-like symptomsPetechiae on the conjunctiva, mouth, and legsAnemiaSplinter hemorrhages under nailsWeight lossHeart murmurDisorders of the HeartEndocarditis (continued)Medical management/nursing interventionsBed restAntibioticsIV for 1 to 2 monthsProphylactic antibiotics for “high-risk” patientsSurgical repair of diseased valves or valve replacementDisorders of the HeartMyocarditisEtiology/pathophysiologyInflammation of the myocardiumRheumatic heart diseaseViral, bacterial, or fungal infectionEndocarditisPericarditisDisorders of the HeartMyocarditis (continued)Medical management/nursing interventionsBed restOxygenAntibiotics; anti-inflammatory agentsAssessment and correction of dysrhythmiasClinical manifestations/assessmentVary according to site of infectionCardiac enlargementMurmur; gallop; tachycardiaDisorders of the HeartCardiomyopathyEtiology/pathophysiology A group of heart muscle diseases that primarily affects the structural or functional ability of the myocardiumNot associated with CAD, hypertension, vascular disease, or pulmonary diseasePrimary—unknown causeSecondary—infective, metabolic, nutritional, alcohol, peripartum, drugs, radiation, SLE, rheumatoid arthritisDisorders of the HeartCardiomyopathy (continued)Clinical manifestations/assessmentAnginaSyncopeFatigueDyspnea on exertionSevere exercise intoleranceSigns and symptoms of left- and right-sided CHFDisorders of the HeartCardiomyopathy (continued)Medical management/nursing interventionsPharmacological managementDiureticsACE inhibitorsBeta-adrenergic blocking agentsTreat underlying causeInternal defibrillatorCardiac transplantDisorders of the Peripheral Vascular System Arterial assessmentPATCHESP = Pulses A = AppearanceT = TemperatureC = Capillary refillH = HardnessE = EdemaS = SensationVenous assessmentFirst symptom is usually edemaDark pigmentationDryness and scalingUlcerationsPain, aching, and crampingUsually relieved by rest or elevationDiagnostic testsNoninvasive proceduresTreadmill testPlethysmographyDigital subtraction angiography (DSA)Doppler ultrasoundInvasive proceduresPhlebography or venography125I-fibrinogen uptake testAngiographyArteriosclerosisThickening, loss of elasticity, and calcification of arterial walls, resulting in decreased blood supplyAtherosclerosisNarrowing of the artery due to yellowish plaques of cholesterol, lipids, and cellular debris in the inner layers of the walls of large- and medium-sized arteriesA type of arteriosclerosisHypertensionEtiology/pathophysiologyA sustained elevated systolic blood pressure greater than 140 mm Hg and/or a sustained elevated diastolic blood pressure greater than 90 mm Hg.Vasoconstriction (increases blood pressure )Essential (primary) hypertension90% to 95% of all diagnosed casesSecondary hypertensionAttributed to an identifiable medical diagnosisHypertension (continued)Clinical manifestations/assessmentHeadache; blurred visionEpistaxisAnginaMedical management/nursing interventions Pharmacological managementAntihypertensive medications; diureticsDietary recommendationsWeight control, reduction of saturated fats, and low sodiumNo smokingArteriosclerosis obliteransEtiology/pathophysiologyNarrowing or occlusion of the blood vessel with plaque formation—little or no blood flow to the affected extremityClinical manifestations/assessmentPain—intermittent claudicationPulselessnessPallorParesthesiaParalysisArteriosclerosis obliterans (continued)Medical management/nursing interventionsAnticoagulantsFibrinolyticsSurgeryEmbolectomyEndarterectomyArterial bypassPercutaneous transluminal angioplastyAmputationArterial embolismEtiology/pathophysiologyBlood clots in the arterial bloodstreamMay originate in the heartForeign substancesClinical manifestations/assessmentPainAbsent distal pulsesPale, cool, and numb extremityNecrosisArterial embolism (continued)Medical management/nursing interventionsPharmacological managementAnticoagulantsFibrinolyticsEndarterectomyEmbolectomyArterial aneurysmEtiology/pathophysiologyEnlarged, dilated portion of an arteryCauses: arteriosclerosis; trauma; congenitalClinical manifestations/assessmentAsymptomatic Large pulsating massPain, if large enough to press on other structuresFigure 48-20Arterial aneurysm (continued)Medical management/nursing interventions Assess for signs and symptoms of rupture, thrombi, ischemiaControl hypertensionSurgeryLigationGraftsThromboangitis obliterans (Buerger’s disease)Etiology/pathophysiologyOcclusive vascular condition in which the small and medium-sized arteries become inflamed and thromboticClinical manifestations/assessmentPain; sensitivity to coldSkin cold and paleUlcerations on feet or hands; gangreneSuperficial thrombophlebitisThromboangitis obliterans (Buerger’s disease) (continued)Medical management/nursing interventionsNo smokingExercise to develop collateral circulationSurgeryAmputation of gangrenous fingers and toesSympathectomyRaynaud’s diseaseEtiology/pathophysiologyIntermittent arterial spasmsPrimarily affects fingers, toes, ears, and noseExposure to cold or emotional stressClinical manifestations/assessmentChronically cold hands and feetPallor, coldness, numbness, cyanosis, and pain during spasms; erythema following a spasmUlcerations on the fingers and toesRaynaud’s disease (continued)Medical management/nursing interventionsPharmacological managementVasodilatorsCalcium antagonistsMuscle relaxantsSurgery: sympathectomyNo smokingAvoid exposure to coldAmputation for gangreneThrombophlebitisEtiology/pathophysiologyInflammation of a vein in conjunction with the formation of a thrombusRisk factors: venous stasis, hypercoagulability, trauma of a blood vessel, immobilization after surgeryClinical manifestations/assessmentPainEdemaPositive Homans’ signErythema, warmth, and tenderness along the veinFigure 48-23Thrombophlebitis (continued)Medical management/nursing interventionsSuperficialPharmacological managementNSAIDsBed restMoist heatElevate extremityThrombophlebitis (continued)Medical management/nursing interventionsDeepPharmacological managementAnticoagulantsFibrinolyticsBed restElevate extremity Antiembolism stockingsSurgery: thrombectomy; vena cava umbrella (Greenfield filter)Varicose veinsEtiology/pathophysiologyTortuous, dilated vein with incompetent valvesClinical manifestations/assessmentDark, raised, tortuous veinsFatigue; dull achesCramping of the musclesHeaviness or pressure of extremityEdema, pain, changes in skin color, and ulcerations with venous stasisVaricose veins (continued)Medical management/nursing interventionsElastic stockingsRestElevate legsSclerotherapySurgeryVein ligation and strippingVenous stasis ulcersEtiology/pathophysiologyUlcerations of the legs from chronic deep vein insufficiency and stasis of blood in the venous system of the legsOpen necrotic lesion due to an inadequate supply of oxygen-rich blood to the tissueCausesVaricose veins, burns, trauma, sickle cell anemia, diabetes mellitus, neurogenic disorders, and hereditary factorsVenous stasis ulcers (continued)Clinical manifestations/assessmentPainUlceration with dark pigmentationEdemaMedical management/nursing interventions Diet: increased protein; vitamins A and C and zincDebridement of necrotic tissueAntibioticsUnna bootFigure 48-17Nursing ProcessNursing diagnosesActivity intoleranceAnxietyDecreased cardiac outputIneffective coronary tissue perfusionFluid volume excessImpaired gas exchangeKnowledge, deficientPain ................
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