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Unit 5Nursing Care for Patients

with Cardiovascular Problems

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STRUCTURE OF THE HEART

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Assessment :1. Assess for chest pain, palpitations,

fatigue 2. Habits ( smoking, alcohol intake, use of

drugs, exercise and dietary 3. Hereditary (heart disease, diabetes, high

cholesterol levels, hypertension, stroke, or rheumatic heart disease.)

4. Peripheral circulation( leg cramps, numbness swelling or cyanosis of feet, ankles, or hand.)

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Auscultation:

1. Count heart rate for 1 minute.2. Normal heart sounds ( S1& S2 ).3. Abnormal heart sounds: Rubs: friction sounds heard in heart infections. Murmurs: If available, assess for thrill, which is a

continuous palpable sensation like the purring of a cat.

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Examination:A. Blood pressure:B. Pulse

• Carotid arteries: The carotid arteries supply oxygenated blood to the head and neck.

C. Peripheral Arteries:1. Assess each peripheral artery for elasticity of the

vessel wall, strength, regularity, and equality. 2 . Allen's test: to assess collateral circulation of ulnar

and radial. 3. Tissue Perfusion:

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Difference between Venous and Arterial occlusion Arterial occlusion Venous

occlusioncriteria

Pale; worsened by elevation of extremity. dark red when extremity is lowered

Normal or cyanotic

Color

Cool Normal Temperature

Decreased or absent Normal Pulse

Absent or mild Often marked Edema

Thin, shiny skin; decreased hair growth; thickened nails

Brown pigmentation around ankles

Skin changes

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Cardiac Diagnostic Testing

Serum Enzymes: Enzymes are available in cell of the organs, when the cell is damaged; these Enzymes will release in the serum.

Enzymes are: Creatine phosphokinase (CPK): CPK found in: brain,

heart muscles, and skeletal muscles. CPK normal value is:

Male: less than 99 unit / liter. Female: less than 57 unit / liter

Lactic dehydrogenase (LDH): is available in most tissue. Normal value is less than 115 international unit/L.

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Duration of elevation

Peak time for elevation

Onset of elevation

Normal value

Enzymes

3-4 days 12-24 hours 4-6 hours Male: <99 U/LFemale:<57U/L

CPK

2-3-4 days 12-24 hours 4-6 hours 7 – 10 international unit/L

CPK-MB

hours10-14 days.

hours24-48 L8-12 hours < 115 IU/L LDH

Cardiac enzyme

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1. Chest X-ray2. Echocardiography 3. Doppler Ultrasonography4. Cardiac Catheterization

It is an invasive diagnostic procedure designed to study the anatomical and mechanical aspects of the cardiac function.

Complications- :Cardiac arrest and Dysrhythmias.Acute myocardial infarction.Anaphylactic shock.

Emboli to the lung or brain

Diagnostic procedures

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5. Cardiac Monitoring / ECGEKG Waveform:EKG or ECG is a visual representation of the electrical activity of the heart on a special paper called the EKG paper is a graphic in which horizontal and vertical.

Horizontal: A. 1mm = small box = 0.04 second. B. 5mm = large box= 0.2 second.For 1 minute = 300 large box or 1500 small box.Vertical: 10 mm = 1 mv amplitude Conduction System and EKG Strip.

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ECG strip 1. P wave: contraction of the atrium.2. QRS wave: contraction of the ventricles.3. T wave: relaxation of the ventricles. 4. PR interval: 0.12 seconds.5. ST segment: normally not elevated more

than 1mm or 0.047 second.6. QRS wave: duration: 0.04 – 0.1 second.

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6 .Stress Test/ Exercise tolerance test (ETT) / treadmill test

It can assess the heart’s reaction under physical stress.

During an exercise ST, an EKG is performed while the patient exercises in a controlled manner on a treadmill or stationary bicycle at varied speeds and elevations. During a pharmacological ST, a medication (e.g., dobutamine) is given to the patient, which causes the heart to react as if it were under the physical stress of exercise, though he is actually at rest.

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7 .CORONARY ANGIOGRAMHow it works: This procedure is the gold standard for

viewing the arteries that nourish the heart. Doctors insert a catheter through an artery in the leg and shake it up toward the heart. They then send a special dye through the tube that highlights the arteries under x-rays and exposes any blockages.

Limitations: Because they are invasive angiograms have some risks: catheters can tear artery walls, requiring surgical repair. (In 1% of cases, serious complications including death, may occur.) Afterward, patients need to lie still for four to six hours until the blood vessel in the leg seals.

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DysrhythmiasDysrhythmias or Arrhythmias: is an irregularity in the

rate, rhythm, or conduction of the electrical system of the heart. The dysrhythmia can occur in any part of the conduction system.

Specialized cells in the heart muscle have the ability to generate an electrical impulse. Under certain conditions these cells start sending impulses to other cells in the heart causing irregular beats called ectopic beats.

Causes of dysrhythmias: Coronary artery disease (CAD). Congestive heart failure (CHF). Myocardial infarction (MI). Electrolyte imbalances and drug toxicity.

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Types of Arrhythmias:1. Sinus bradycardia/sinus Tachycardia 2. Atrial flutter3. Atrial Fibrillation4. Premature Atrial Contraction5. SupraVentricular Tachycardia (SVT)6. Premature ventricular contraction7. Ventricular tachycardia8. Ventricular fibrillation9. Ventricular Asystole

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DefinitionsFlutter: Rapid, regular contraction of atria or

ventricle reaching upto 250/300 beats per minute.

Fibrillation: Rapid, random, irregular contraction reaching upto 350-400 beats per

minute .

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Management of Arrythmias1. Cardioversion:is the delivery of a synchronized (coordinated) electrical shock to

change a dysrhythmia to a rhythm Uses: used mainly in ventricular tachycardia (VT) Electrodes are placed to the right of the sternum below the

clavicle and at the apex of the heart. The electrodes are lubricated with a special gel.

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2. Defibrillationis the delivery of an unsynchronized high-energy electrical shock

(up to 360 or more joules) during an emergency situation Note:• Lubricate the electrodes and place them as in cardioversion.• When the electrical shock delivered to the client, everyone

stands clear (avoid touching) of the bed to prevent them from receiving the electrical shock.

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3. Cardiac Pacemaker Therapy: Pacemaker is a high-tension wire, high-

voltage electrical generators used to generate an impulse on the heart.

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Complication: Perforation of the myocardium wall by electrodes

(cardiac tamponade → distended neck vein). Pacemaker malfunction (fails or rapid). Thrombus formation. Infections. Hemorrhage. Lower chest wall and abdominal discomfort

related to impulses for there muscle →spasm.

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Nursing care of patient with pacemaker: Preoperative

1. Assess V/S especially the pulses, mental status, ECG, and other lab and diagnostic test ).

2. Obtain the consent form.3. Recognize that the pacemaker is functioning 4. Provide psychological support and allow client to express his feelings

and answer his question (explanation mostly done by physician).

Postoperative 5. Check the operation site for complication and apply dressing as

ordered.6. Assess V/S especially the pulse (rate, regularity, force)7. Cover the external wires by gauze 8. Ask client to avoid close contact with large electrical motors9. Advice client to inform any health professional referred to them

(Magnetic resonance imagining (MRI) may cause pacemaker malfunction) and air port personnel that he has had a pacemaker.

10. The client should wear a medical identification tag indicating the presence of a pacemaker.

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ATHEROSCLEROSIS Definition: Abnormal accumulation of lipid or fatty substances and fibrous tissues in vessel wall Clinical manifestations:Acute onset chest pain, ECG changes, dysrhythmias & death

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ATHEROSCLEROSIS1. Nonmodifiable

Family history Age Gender race

2. Modifiable High blood cholesterol Smoking Hypertension Diabetes mellitus Obesity Physical inactivity

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PREVENTIONControl cholestrol level, LDL less than normalDietary control decrease fat & increase fiberMedication to decrease serum fat & cholesterolQuit smokingEarly detection & control hypertensionControl DMGender & estrogen levelBehavior pattern

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Acute coronary syndrome

1. Angina pectoris 2. Myocardial infarction (MI)3. Sudden cardiac arrest

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Angina Pectoris (most common types of Coronary Artery Disease): is a condition in which decrease blood and

oxygen supply to the heart muscles related to narrowing of the coronary arteries (Arteriosclerosis).

Arteriosclerosis is a narrowing and hardening of the arteries due to fatty deposit

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Types of angina:1. Unstable angina: occurs at rest or with minimal exertion

and is not relieved with nitroglycerin. Client is at risk for myocardial infarction and sudden death.

2. Stable angina: occurs with physical exertion, emotional stress, smoking, exposure to extreme cold, and heavy meals.

S&S of angina:1. Squeezing pain under the sternum, which radiates to

the Lt or Rt shoulder, jaw, or ear. 2. Shortness of breath with increased respiratory rate3. Physical or mental fatigue and dizziness.4. Changes in sleep patterns and mental alertness.

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Risk factors of angina:1. Hereditary factors.2. Hypertension. 3. Diabetes mellitus.4. Obesity.5. Sedentary life-styles.6. High LDL level.Diagnoses by:

Stress test: the heart is placed under stress through increasing physical activity on a treadmill or exercise bicycle. The increased oxygen demand of the body puts an extraload on the heart causing electrocardiogram changes and sometimes pain.

Coronary arteriogram: shows narrowing or occlusion of the vessels of the heart.

Reviewing the client's history and lifestyle. Laboratory tests: Cholesterol, low-density lipoprotein (LDL), and high-

density lipoprotein (HDL) levels.

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Management of angina:A. Medical: Goal is to increase the blood supply to the

affected area by: Pharmacological Vasodilators: such as nitroglycerin Analgesic medication. Beta-adrenergic blockers and calcium channel blockers slow

the heart rate and decrease the oxygen demand of the heart. Calcium channel blockers dilate vessels and decrease

spasms of the coronary vessels. D. Diet and Activity:1. low-fat, low-cholesterol, salt-restricted diet. 2. Bed rest may be need in the first time and then moderate

exercise was allowed.

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2. B. Surgical1-Percutaneous trans luminal coronary angioplasty

(PTCA): the atherosclerotic matter is pressed against the wall of the coronary vessels to improve circulation.

Complications: Occlusion of the vessel because of a vascular spasm or vessel rupture.

2. Intracoronary stent. 3. Atherectomy cutter shaves the plaque away from the

artery wall.4. Coronary Artery Bypass Graft (CABG) surgery is

performed by grafting a vein or artery from aorta to the blood vessel after occlusion.

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Percutaneous transluminal coronary angioplasty (PTCA)

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Coronary artery bypass graft (CABG)

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ATHERECTOMY

Rotational Atherectomy

Directional Coronary

Atherectomy

Extraction Atherectomy

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Nursing care:

1. Ask client to describe the pain (type, radiation, onset, duration, and precipitating factors) frequently.

2. Assess vital signs 3. Observe the client on an EKG monitor and observed for any

dysrhythmias.4. Give medication as ordered and monitor client's response.5. Administer oxygen.6. Teach the client to avoid situations that may produce angina

(stressful situations, sleep in a warm room, eat smaller meals)7. Inform the client to carry nitroglycerin at all times.8. Observe for side effect of nitroglycerin: (orthostatic

hypotension and headache).

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Myocardial Infarction (MI)Myocardial infarction (MI) is caused by an obstruction in a coronary artery

resulting in necrosis (death) to the tissues. MI is the leading cause of sudden death in men and women.

Cause: Atherosclerotic plaque Thrombus Embolism.

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Non modifiable risk factor 1. Age2. Gender3. Family history

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Modifiable risk factor

1. Elevated serum lipids2. Hypertension3. Cigarette smoking4. Obesity5. Stress/anxiety

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Clinical manifestation:A. with symptoms: Chest heaviness or tightness that progresses to a severe

gripping pain (not relieved by rest or nitroglycerin) in the lower sternal area. Upper abdominal pain.

Shortness of breath. Diaphoretic. Anxious. Nausea and vomiting. Fatigue. Skin will be pale and then turn cyanotic. Confusion.B. without symptoms: general symptoms:

Fatigue. Frequent hiccups.

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Complications: 1. Heart failure. 2. Stroke.3. Cardiogenic shock.4. Thrombosis.Diagnosis by:

1. Clinical symptoms2. Electrocardiogram (ECG): elevation of ST segment and inversion

of T wave. 3. Cardiac enzymes.

LDH. CPK. Cardiac tropinin I: protein found in cardiac cells. When cardiac cells are

damaged, this protein is released resulting in elevated levels (<0.6 mg) for 7 days.

Cardiac myoglobin: blood levels elevate within an hour of an MI, peak in 4 to12 hours, and return to normal in 18 hours.

Radioactive isotope scan.

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Management: Medical: Aim of management:

1. Reduce oxygen demands.2. Increase oxygen supply to the myocardium.3. Relieve pain.4. Improve tissue perfusion.5. Prevent complications.

A.Medical management:1. Oxygen administration.2. Complete bed rest.3. Analgesia.4. Coronary artery vasodilators (Nitrates).5. Decrease stress and anxiety.B. Surgical:6. PTCA (balloon compression).7. CABG.

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CABG

Harvested vessels are connected to the blocked arteries. Several medical centers are now offering minimally invasive coronary artery surgery. Less invasive technique for 1 or 2 clogged arteries.

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C. Pharmacological1. Morphine sulfate.2. Nitrates.3. Sedatives.4. Thrombolytic therapy: streptokinase (Streptase)

and Activase. These medications may cause bleeding.

5. Heparin therapy inhibits further clotting. 6. Aspirin or ticlopidine (Ticlid) is given to prevent

vasoconstriction and platelet aggregation.D. Diet: liquid diet is progressed to a regular low-fat,

low-cholesterol, low-salt diet (small frequent feedings).

E. Activity: physical, mental, and emotional rest.

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Nursing care:1. Assess pain, vital signs (peripheral pulses), skin changes,

breath sounds, mental status, and EKG rhythm strips. 2. Administer medication.3. Observe for complication and side effect of medication4. Provide all care for client while is in complete bed rest.5. Prevent visits.6. Provide oxygen.7. Provide a quiet, calm environment.8. Reassurance and provide of psychological support.9. Monitor I&O.

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Heart Failure (HF) or Congestive Heart Failure (CHF)

Heart Failure is the inability of the heart muscle to contract well to eject blood for the body parts. The muscles are hypertrophied (increases muscle mass) and ventricles are enlarged.Types of heart failure :

1. Left-sided heart failure Pulmonary edema2. Right-sided heart failure. Peripheral edemaCauses:

1. Coronary artery disease.2. MI and other cardiac diseases.

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Heart Failure

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Clinical manifestations OF Left Ventricular Failure

Signs and Symptoms:•Tachycardia (early sign)Exertional and nocturnal dyspneaOrthopneaDry Cough with frothy sputumNocturiaCrackles in the lungs→ Pulmonary EdemaS3 and S4 heart sounds ↑HR (early sign)Fatigue Mental Confusion

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Right Ventricular FailureTachycardia (early sign)By itself usually from pulmonary diseaseMost often occur 2nd-ary to Left Heart FailureAscites, GI Disorders (nausea), abd. painLiver and Spleen engorgementJVDDependent bilateral pitting edemaWeight GainMurmursAnxietyAnorexiaNocturiaFatigue

Jugular Vein Distention (JVD)

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Diagnosis:1. Chest x-ray: visualize the ventricles and check for evidence

of lung congestion. 2. EKG. 3. Arterial blood gases.4. Oxygen saturation.Management:A. MedicalGoals for treating CHF:5. Improve circulation to the coronary arteries6. Decrease the workload of the left ventricle. Intervention:

1. Use medication.2. Administer oxygen.3. Keep client in bed rest.

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B. Pharmacological1. Diuretics. 2. Digitalis preparation to increase the strength and contractility of the heart

muscle. 3. Vasodilators such as nitroglycerin are given to dilate the veins → blood

will stay in the peripheral vessels and decrease blood return to the right side of the heart→ decreasing the workload on the heart.

4. ACE (angiotensin-converting enzyme inhibitors; Capoten): to reduce blood pressure and peripheral arterial resistance and improve cardiac output.

5. Morphine: to control pain and decrease anxiety.C. Diet: Fluid intake may be limited and the client is generally on a low-

sodium diet.D. Activity: Activity may range from complete bed rest to allowances of some

activity according to the client condition.

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E. Surgical: 1. Intra-aortic balloon pump.2. Ventricular assist device (VAD).3. A cardiomyoplasty.

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Intra-Aortic Balloon Pump Procedure :

Catheter is inserted into femoral arteryAdvanced into descending AortaBalloon inflates during DiastoleBalloon deflates during Systole

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Ventricular Assist Devices(VAD)

Purpose: Provides longer term support for a decompensated heart

Assist or replace the action of the ventricleMay be implanted or external

Indications :Ventricular failure associated with an MI

Waiting for a donor or artificial heart

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Nursing care:1. A daily weight and strict intake and output are

necessary to assess fluid retention. 2. Restrict fluid and provide diet as ordered3. Provide bed rest.4. Elevate the head of the bed to 45°. 5. Administer medication as prescribed.6. Provide oxygen.

Continue

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7.Monitor the electrolytes: potassium and sodium level.

8.Take the apical pulse before giving a digitalis preparation (If the heart rate is below 60, withhold the medication and notify the physician).

9. Assess of peripheral pulses and capillary refill: check the level of circulation to the extremities.

10. Assessment for edema in extremities and abdomen.

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Inflammatory Disorders of the Heart

1. Infective endocarditis.2. Myocarditis.3. Pericarditis.Other Disorders4. Valvular heart disease. 5. Rheumatic heart disease.

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Rheumatic Heart Disease: Is inflammation on the heart which results as a complication of rheumatic fever and is linked to group "A beta-hemolytic streptococcus" following an upper respiratory infection (mainly pharyngitis).Symptoms of rheumatic fever :

1. Mild fever2. Polyarthritis3. Carditis.4. Chorea (abnormal movement in hands).5. Rash.

Once the person is affected with rheumatic fever, he is more susceptible to having it again.

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Sites of inflammation on the heart:1. Three heart layers: endocardium, myocardium, and epicardium.2. Mitral valve (stenosis: thickening and stenosis).

Management:Types of management:

1. Antibiotics.2. Anti-inflammatory agents3. Corticosteroids4. Strict bed rest. Main goal of treatment:5. Treat the inflammation.6. Prevent cardiac complications.7. Prevent the recurrence of the disease.

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Infective EndocarditisIt is an inflammation or infection (bacteria, fungi, or virus) of the inside lining of the heart, particularly the heart valves→ scar tissue on the valves → become hard, weak,

and do not close properly .Symptoms of endocarditis:

1. Symptoms of a systemic infection. 2. Tachycardia, pallor, and diaphoresis. 3. Dyspnea, peripheral edema, and pulmonary congestion.

Management of Infective endocarditis:1. Surgical repair or replacement of a valve is done in severe

cases. 2. Pharmacological:Antibiotics such as penicillin1 V,

vancomycin, and gentamycin sulfate.3. Activity: he client is placed on bed rest.

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Myocarditis:It is the inflammation of the myocardium of the heart.

diagnosis of myocarditis can be confirmed with an endomyocardial biopsy.

Management1. Medical: Oxygen is administered as needed.2. Pharmacological:

1. Digitalis preparations are given to try to prevent congestive heart failure.

2. Antibiotics.3. Anti-inflammatory agents: to reduce the inflammation. 4. Activity: bed rest on semi-Fowler's position

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Pericarditis:is the inflammation of the membranous sac surrounding the heart mainly by

virus, bacteria, fungal, and parasites or idiopathic (meaning no known cause).

Symptoms:

Severe precordial pain (anterior surface of the chest over the heart). Pericardial friction rubs (noisy sound heard when 2 layers of the pericardial

surfaces are rubbing during heart contraction. Cardiac tamponade (excess fluid in pericardial space) may develop.

Management:

1. Pericardiocentesis: aspiration the excess fluid from the pericardial sac. 2. Pharmacological

Antipyretics, analgesics, anti-inflammatory agents, and antibiotics. Digitalis and diuretics

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Nursing care for Inflammatory Disorders of the Heart patient:

1. Administer medication and monitor for their action and side effect.

2. Encourage bed rest.3. Administer oxygen.4. Assist in procedure and preparing for procedural treatment

and surgery.5. Monitor vital signs.6. Monitor EKG for dysrhythmias.7. Put client in a comfortable position.

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Valvular Heart Disease

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Understanding TermsStenosis = Constriction or narrowing of orifice

Regurgitation = Retrograde or backflow of the flow of blood from one chamber back into another

Prolapse = valve leaflets billow back or buckle back into the atrium

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Mitral StenosisMitral valve becomes narrow and constricted

Causes : -↑ L. Atrial pressure and volumeMost are due to Rheumatic Heart disease

Symptoms: murmur at 5th Inter Costal Space (ICS) , Extended dyspnea and fatigue

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Mitral Valve ProlapseValve billows back into L. Atrium

Cause is unknownHeard as a murmur

Can be familial due to connective tissue disorder

Most people asymptomatic, benignMost common valve disorder

May lead to Mitral Valve RegurgitationDiagnosed by ECHO

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Mitral RegurgitationRetrograde blood flow from L. Ventricle to

L. AtriumEtiology R/T: MI, Rheumatic heart disease,

MVPSymptoms R/T acute or chronic murmur

Heard best at 5th ICSMay feel a thrill

More common in women than men

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Aortic StenosisBlood flow restricted from L. Ventricle to

AortaResults in LVH, & ↑myocardial oxygen

consumption Causes: congenital, Rheumatic Fever,

atherosclerosisSymptoms - ↓ S1 or S2 sound

MurmurS4

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Aortic RegurgitationRetrograde blood flow from the Ascending

Aorta into L. VentricleResults in: L. Ventricle dilation & LVH,

leading to ↓contractility of the heartmurmurSoft S1, S3 or S4Causes: Congenital, Rheumatic Heart DiseaseMay have Orthopnea, Exertional dyspnea,

paroxysmal nocturnal dyspnea

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Tricuspid Valve DiseaseStenosis & RegurgitationTricuspid Stenosis is uncommon

R. Atrium enlargement & ↑systemic venous pressure

Tricuspid RegurgitationVolume overload in R. Atrium and Ventricle

occursCauses: R. Ventricular dysfunction, or

pulmonary HTN

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Diagnosing Valve DiseaseHistory and Physical ExamEchocardiographyCardiac CatheterizationECG

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Collaborative Care for Valvular Disease

Ask about history of Rheumatic Heart DiseaseUse of antibiotic prophylaxisDigitalisDiureticsAnticoagulation (ASA, Coumadin)Surgical repair or replacement

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REPAIR PROCEDURESBalloon valvuloplasty:- A balloon catheter is passed

thru the femoral vein to enlarde the valvular orifice.Mitral Annuloplasty:- Tightening and suturing the

malfunctioning valve annulus to eliminate or greatly reduce regurgitation

Commissurotomy / valvotomy:- The valve is visualised, thrombi removed from the atria, fused

leaflets incised and calcium is removed to widen the orifice thru open heart surgery

VALVE REPLACEMENT ProceduresMechanical prosthetic vavesBioprosthetic valves

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Shock It is a condition of profound hemodynamic and

metabolic disturbance characterized by inadequate tissue perfusion and inadequate circulation to the vital organs.

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Emergency care Signs and symptoms

cause Type

Replace fluids Increased HR; hypotension; cold, clammy skin; thirst

Hemorrhage, burns or fluid loss

Hypovolemic

Initiate drug therapy for myocardial infarction; replace fluids; possible emergency coronary bypass surgery

Increased HR; hypotension; cold, clammy skin

MI, HF Cardiogenic

Locate source of infection, treat with broad-spectrum antibiotic; replace fluids.

Hot, dry, flushed skin; hypotension; increased heart rate

infection Toxic

Manage ABCs; administer epinephrine (Adrenalin);

Throat edema with increasing difficulty breathing; hypo- tension; increased heart rate

Medications, insect bites or stings, foods

Anaphylactic

Replace fluids, administer drugs to increase blood pressure and heart rate

Slow HR and hypotension

Spinal cord injury. Neurogenic

Types of shock

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Management:A. Medical1. Initiate resuscitation: maintenance of the ABCs

(Airway, Breathing, and Circulation). 2. Stop active bleeding. 3. Blood can be administered.4. Identify and treat the underlying cause of shock

(after the client is stabilized).B. Pharmacological:5. Administration of oxygen. 6. Insertion of two large intravenous (IV) lines; fluids

may be administered. 7. Administration of epinephrine, ( to improve

circulation).

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Nursing care:

1. Maintenance of the ABCs (airway, breathing, circulation). 2. Administration of oxygen. 3. Stop active bleeding.4. Evaluate vital signs.5. Initiate and maintain fluid replacement with two large IV

access lines.6. Administer medication.7. Administer blood as ordered.8. Evaluate client for paleness, diaphoretic, and clammy skin.9. Monitor intake and output.10. The client should be asked to describe any pain with

regard to intensity, location, and duration.

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VASCULAR DISORDERS

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HypertensionHypertension (HTN): known as high blood pressure. A systolic blood pressure above 140 or a diastolic pressure above 90 is indicative of hypertension.

Cause: the cause of HTN is unknown but there are many Risk factors

e.g:.1. Family history of hypertension.2. Smoking.3. Hyperlipidemia.4. Obesity and lack of exercise.5. Diabetes mellitus.6. Low education and low socioeconomic status.

Classification of HTN:1. Primary hypertension: the cause is unknown2. Secondary hypertension: is due to another condition within the body such

as renal diseases and Arteriosclerosis disease.

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Classification of hypertension DBPMM of HG

SBPMM of HG

Bp classification

And <80 <120 Normal

80-89 120-139 Prehypertentsion

90-99 140-159 Stage 1 HTN

≥100 ≥160 Stage 2HTN

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Complications of HTN:1. cerebral vascular accident (stroke)2. myocardial infarction3. congestive heart failure4. Renal failure.

Sings and symptoms: The hypertensive client may not be experiencing any symptoms

or may complain of the following symptoms:1. Headache.2. Blurred vision.3. Fatigue.

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Management:A. Medical: Main goal is to keep blood pressure within normal limits. 1. The first step (3-6 months) is to encourage the client to change the diet and

lifestyle. If the BP still remains high (>140/90) →the second step.2. The second step (2 months) adding a diuretic or a beta blocker to the client's care

regimen. 3. Trying another drug, or adding a second antihypertensive drug from another class

of drugs.4. The last step would be implemented by adding a second or third antihypertensive

drug.B. Pharmacological:5. Diuretics (increase the renal excretion of sodium and water).6. Beta-adrenergic blocking agents are given to block the epinephrine and

norepinephrine receptor sites: Inderal.7. Alpha-receptor blockers: cardura.8. Angiotensin-converting enzyme (ACE) inhibitors: Capoten.9. Calcium channel blockers: isoptin.10. Direct vasodilators: hydrolazine hydrochloride (Apresoline).C. Diet: Low fat, low-cholesterol, and low-sodium diet (6 grams sodium chloride). D.Activity: A regular aerobic exercise (Walking and swimming) regimen (30 to 45

minutes 3 to 5 times / week) assists in lowering blood pressure

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Nursing care:1. Assess BP accurately and repeat blood

pressure (if it is high) after 15 minutes later and compared to previous readings. Report any abnormal readings.

2. Assess height and weight. 3. Assess life-styles. 4. Educate client about dietary and lifestyle

changes.5. Assess for complication.

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Disorders of Peripheral ArteriesAcute arterial occlusion:Causes:

External compression. Thrombosis (blood clots) or embolus (foreign mass such as air, fat, and

cancerous cell).

Signs and symptoms ( 5 Ps):1. Pain (intermittent caludication): relived by rest.2. parastheasia or Numbness or burning sensation (more at

night) and worsen progressively. 3. Pulselesness: Weak or absent peripheral pulses. Compare

between 2 legs. If pulse is deep Doppler flowmeter may be used.

4. Pallor.5. Paralysis.

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Treatment:Aim of treatment:1. Prevent enlargement of clots 2. Prevent other clots formation.3. Prevent transmission to the vital organs.Types of treatment:

Thrombolytic therapy. Anticoagulant to prevent new cases. Bypass surgery.

Nursing responsibility:

4. Identify persons at risk and early detection by frequent assessment of the circulation (establish baseline assessment of the pulses, skin color, and temperature) and report abnormal findings to the physician.

5. Observe for complication.6. Administer medication.7. Provide skin care because client may be in bed rest.8. Monitor client for signs of bleeding

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Deep vein thrombosis (DVT): DVT is the formation of a blood clot (thrombus) inside

a blood vessel. Causes:

Injury to the inner lining of a blood vessel Blood disorders that result in thickened blood and an

increased tendency toward clotting. Restricted blood flow, caused by such problems as

obesity. Atherosclerosis.

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DVT → Thrombophlebitis (swelling and inflammation where the clot develops in the vein).

Treatment:1. Administration of anticoagulants and thrombolytic

drugs.2. Surgical techniques for removing particularly

threatening clots.

An important nursing intervention is to assess the improvement of the condition and the early signs

of complication (movement of the clots to the brain, lung, or the heart).

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Chronic peripheral vascular problems Varicose Vein: mean is dilated and tortuous (unstraight) vein.Causes:1. Increased resistance to its forward movement (upright

position, compression, long standing, obesity, and pregnancy) →valve become incompetent and may be damaged→ blood stasis.

2. Hereditary weak vein.Signs and symptoms:

1. Dilated, tortuous vein, and discolored vein area (blue color).2. Local edema → necrosis.3. Cramp pain.4. Heavy feeling of affected tissue.5. Swelling of the ankles and ulcerations on the skin.

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Dilated, tortuous vein, and discolored vein area (blue color).

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Common sites:1. Legs (most commonly) →venous thromboses.2. Anus (hemorrhoids)3. Esophagus4. Testes in males (varicocele)

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Treatment: Applying elastic stocking. Avoid conditions that increase the resistance to movement of blood in to the

vein. Sclerosing agent. Surgical: ligation under general anesthesia.

Nursing care:1. Assess for adequate circulation (color, temp, sensation, capillary refill).2. Inspect site of surgery for bleeding, infection, and make a dressing as ordered.3. Apply elastic stocking.4. Elevate leg.5. Encourage mobilization in the first day of operation.

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Aneurysms is a localized dilation of an artery's medial layer. Causes of aneurysms:1. Atherosclerosis and HTN. 2. Hereditary: lack of elastin in the arterial wall.3. Congenital conditions.4. Acquired: trauma to the vessel wall, infection and/or inflammation, and

syphilis.

Symptoms of an aneurysm: Aneurysms are often asymptomatic until they start leaking or pressing on other structures.

Rupture of an aneurysm is an emergency. Signs of rupture:

1. Hypotension, tachycardia, pallor, cool and clammy skin. 2. Intense abdominal, back, or groin pain.3. Diaphoresis and loss of consciousness.

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Diagnoses: may be discovered by X-ray and ultrasound done for other conditions.1. Doppler ultrasound.2. Cardiac catheterization. 3. Angiogram.4. CT scan.

Main types:A. Abdominal Aortic Aneurysm (AAA): Signs:

5. Abdominal, back, or flank pain.6. The client may feel a pulse in the abdomen when in a supine position. 7. Tender pulsating mass may be palpated slightly left of the umbilicus.

B. Thoracic Aorta Aneurysm (TAA):

8. Thoracic aneurysm may press on surrounding structures causing dull upper back pain or deep, scattered chest pain.

9. Pressure on the trachea and bronchus may cause dyspnea, coughing, wheezing, and hoarseness.

10. The client experiences dysphagia from pressure on the esophagus.

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Management of the Aneurysm:A. Medical

Control of the hypertension. Monitor Aneurysms for enlargement & for Thrombi formation.

B. SurgicalReplacement of the aorta by grafting with a saphenous vein or a synthetic vein.

1. Administer blood (4 to 8 units) before surgery.2. Nasogastric tube may be inserted: to decrease pressure on the aneurysm repair site

and incision. 3. After surgery, the client kept with mechanical ventilator assistance in breathing.Complications of surgery: Myocardial infarctions &Strokes. Renal damage. Occlusion of the Vessels below the repaired aneurysm.C. Pharmacological1. Inderal: to decrease the pressure of the blood coming from the heart to the affected

vessel. 2. Antihypertensive medications and diuretics. 3. Analgesics.D. Activity: avoid any activity that increases blood pressure

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Nursing care:1. Palpate abdomen for a pulsating mass or other parts

of the body according to the site of aneurysm. 2. Check vital signs. 3. Assess capillary refill.4. Take antihypertensive medication regularly .5. Monitor for symptoms of vessel occlusion (pain,

paleness, cyanosis, and coldness).Continue

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6. Check the operative site and under the client's body frequently for hemorrhage.

7. Measure the abdomen for increasing abdominal girth (internal bleeding).

8. Assess for edema which could indicate fluid overload or a vessel occlusion.

9. Measure output to make sure the client has at least 25 to 30 cc of urine/ h.

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Thank you