cardiovascular disturbances

8/6/2019 Cardiovascular Disturbances

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Disturbances in Gas Transport


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DISTURBANCES IN GAS TRANSPORT

The Heart Propels oxygenated blood into arterial

system located in the center of the thorax , in the

middle of mediastinum occupies the spacebetween the lungs and rest on diaphragm


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weighs 300g ( 10.60z)

weight and sizeinfluenced by age,gender body wt.,extent of physical exercise and conditioning,

disease


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normal HR 60-80 ejects 70 ml of blood/beat by each ventricle 5L/min output per day (2000 gal/day) Layers

The heart is enclosed by

pericardium


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Layers of Pericardiuma. Visceral Pericardium(Inner)b. Parietal Pericardium (Outer)c. Pericardial Sac (20ml but can hold 30-50ml

of fluid)

Layers of the HeartA. Epicardium (outer)B. Myocardium, the thick muscular middle

layerC. Endocardium, the inner layer


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Upper chamber (left andright atrium), arereceiver chamber of the blood

Lower chamber ( left andright ventricle), are thehearts pumpingchamber

Chambers of the Heart


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Valves of the heart


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CARDIOPULMONARY CIRCULATION


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CONDUCTION SYSTEM


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ELECTRICAL CONDUCTION

Consist of:SA node (Sinoatrial), initiate the electrical impulses thatcause the atria and ventricles to contract thats why its

called as pacemaker of the heart Normally it produces between 60-100

impulses/min, the average is72impulses/min

Initiate impulses faster in response tosympathetic nervous system stimulation andslow impulses in response toparasympathetic stimulation


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AV node , coordinates the incoming electrical impulsesfrom atria and delayes the impulse about hundredthsof a seconds allowing time for atria to contract.

Bundle of His , to the right and left bundle branch.

Purkinje Fibers , the terminal point in the conductionsystem. The point at which the myocardial cells arestimulated causing ventricular contraction.


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Cardiac Cycle One cardiac cycle=to one complete

heartbeatCardiac Output

The amount of blood ejected from a ventricleper minute

4.0 8.0 L/min normal COStroke Volume

the total amount of blood ejected from aventricle with each beat

70ml normal SV Has major influence on CO


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Control of Stroke Volume

1. PRELOAD Degree of stretch of cardiac muscle

fibers at the end of diastole SV is directly R/T preload Frank Starling LAW states that the

greater the stretch the stronger the

degree of contraction


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Greater the stretch

Strong Contraction

Produce Large SV

Increase CO


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2. AFTERLOAD the amount of pressure required by the left

ventricle to open the aortic valve during systoleto eject blood

SV is inversely R/T afterload

3. CONTRACTILITY force generated by contracting myocardium under

any given condition

Cardiac Output is computed by:CO = SV x HR


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ASSESSMENT

A. Nursing HistoryI. HISTORY

A)Biographic age, gender,status,occupation

B)Demographic data ethnic background &cultural consideration

C)Current health organize the history andreveals the sequence of events that lead to client

seek helpD)CHIEF COMPLAINT


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B. Clinical Manifestation

1. CHEST PAIN (OLDCARR) O onset ( gradual) L location (Retrosternal that radiates bilaterally across the chest into the arms,left greater than right to the neck and jaw

D duration (


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C characteristic Strange feeling

Dull, heavy pressure Burning, crushing, constricting, squeezing Crescendo( gradually increasing) pattern at onset

A - associated symptoms Dyspnea

Nausea and vomiting Palpitations Diaphoresis Syncope Fatigue for several week (common in women)


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A aggravating factor Exertion Eating a heavy meal

Excitement Extreme temperature Exercise

R relieving factor Rest Vasodilator Oxygen


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2. Palpitation (means to throb) Sensation of rapid, skipping hear beat Ask about the use of the ff:

Over the counter drug Decongestant Caffeine intake Hx of thyroid disease

3. Cyanosis Bluish discoloration of mucous

membrane or skin caused by hgblevel or blood perfusion


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2 Forms

A. Peripheral Cyanosis Result of blood flow to the areas of the body caused by

cutaneous vasoconstriction or CO Lips, earlobes, nailbeds

B. Central Cyanosis Result of arterial oxygen saturation caused by impaired

pulmonary function (reduced Oxygen inspiration &/or inability tooxygenate blood in the lungs)

Causes:

Advance pulmonary edema R-L shunting within the heart


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4. Syncope Fainting caused reduce CO resulting to

inadequate circulation Most are of cardiac origin

Dysrhythmias Vasovagal Neurocardiogenic (postural

hypotension)


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Other causes: Medications Valvular disorder (aortic stenosis)

5. Dyspnea Defined as shortness of breath or labored breathing Sudden onset of dyspnea may occur with:

Fever Pneumonia pneumothorax,emboli,obstruction

Chronic dyspnea may occur in: Anxiety Depression Left ventricular failure


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Pulmonary disease (Asthma) Obesity

Dyspnea with wheezing: L ventricular failure Bronchial constriction

Forms Exertional

cardiac related occur during mild-modexercise activity


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Orthopnea Result from i ncrease pressure in the lungs when the person is

lying flat Paroxysmal nocturnal dyspnea

Caused by L-ventricular heart failure 2-4 after the person goesto bed

6. Fatigue Complaints of fatigue should be considered as warning sign of

impending cardiac event Manifestation low cardiac output

7. Edema Excess accumulation of fluid in the tissues Anasarca generalized edema associated with nephrotic

syndrome, HF, cirrhosis


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Peripheral Edema particular areas for examination are thedependents parts of the (feet , ankleslegs and sacrum)

Non pitting peripheral edema is causedby gravity flow or interruption of venous return to the heart as a resultof constricting clothing or pressure onthe veins of LE


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Pitting Edema

Degree of pit +1 slight indention (30% accumulation of

interstitial fluid) +2 deeper pit after pressing (4mm)

+3 deep pit (6mm) +4 deep pit (8mm), frank swelling Brawny edema

Fluid could no longer be displaced

2excessive accumulation of ISF No pitting Tissue is firmed and hard Skin surface is shiny, warm and moist


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Physical examination

A. General appearance Consider the ff:

Does the client lies quietly, restless Can lie flat or upright Facial expression Manifestations LOC

B. Vital signs BP

Assess for postural hypotension (lying ,sitting & standing)


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Orthostatic changes:a) decrease of 10-15 mmHg systolic and 10 mmHg

diastolicb) Increase in HR 10-20%

Pulse Assess for pulse deficit Quality

Refers to the its palpated volume (bounding,thready, absent)

Rhythm Pattern of pulsation There should be similar pauses between them


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Respiratory Rate

Character Easy, labored, dyspneic, deep shallow Use of accessory muscle

C. Skin Warm dry skin Cold clammy Cyanosis and pallor

D. Edema


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E. Weight Can indicate edema

2 lb weight gain means of additional liter of fluid in the body Should weigh at same time, same clothing, scale each day

F. Jugular veins A general estimate of venous return can be obtained by

observation of the neck vein Normal

distended neck vein in supine position Collapsed in a 45 degrees angle

If jugular vein distention is present, assess the pressure bymeasuring from the highest point of visible distention to the

sternal angle 3 cm is elevated indicates venous pressure cause by RHF,

Regurgitation


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Jugular vein distention


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Physical Examination

S1 first heart sound heard due to closure of

AV valves loudest at the apex

S2 second heart sound due to closure of

semilunar valves loudest at the base


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S3 or Ventricular Gallop 3rd heart sound. Normal in children

S4 or Atrial Gallop

4th

heart sound normal in childrenbut is associated w/ systemic or pulmonary HPN, MI, and other cardiac disease


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AUSCULTATORY AREAS

APE TO MAN


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DIAGNOSTIC TEST

A. Laboratory Test SERUM ENZYMES

1.Troponin, an enzyme in myocardial contractile

& is present only in myocardialtissue

more specific to cardiac injury for diagnosis of MI w/an uncertaintime frame

returns to normal after 2 weeks


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2.Creatine kinase (CK) formerly creatinephospokinase

(CK-MB) cardiac muscle

(CK-MM) muscles(CK-BB) Brain

Elevation indicates injury Returns to normal after 2-3 days


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3.Lactate Dehydrogenase (LDH) Is found in many body tissues Useful in delayed diagnosis of MI Elevated w/in 24-72 hours after MI Returns to normal after 2 weeks


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SERUM LIPID Plasma lipids are composed mainly of

cholesterol, triglycerides, phospholipids

and free fatty acids All are insoluble in water and require a

carrier for transport

PROTEIN are carrier of plasma lipid thatswhy they are known as LIPOPROTEIN


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4 MAJOR CLASSES : Chylomicrons Very low density lipoproteins (VLDL) Low density lipoproteins( LDL) High Density Lipoproteins (HDL)

A. High Density Lipoprotein Transport cholesterol away from tissues

to liver excretion Total cholesterol ratio should be at least

5:1 with an optimal ratio range from 3.5:1NV = >60 mg/dl


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B. Low Density Lipoprotein

They transport cholesterol into peripheraltissues NV =


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Echocardiography (2D Echo) Uses ultrasound waves to assess cardiac

structure and mobility noninvasively Conditions detected by echocardiography

Abnormal pericardial fluid

Valvular disorders including prostheticsvalves Ventricular aneurysm Congenital heart defects Cardiac tumors Cardiac chamber size SV & CO

ECHOCARDIOGRAPHY


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ECHOCARDIOGRAPHY


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You will be asked to remove clothing above the waist

EKG patches will be placed on your chest. You will be lying on your back or left side. A doctor or technician will apply gel, which feels cold, to your chest and a transducer will be placed over the heart area. Heart structures will be examined by changing the direction othe transducer. The sound waves cause no discomfort. You may hear a "whooshing" sound, timed with your heartbeat. This is the blood movement near the transducer. An EKG will be recording the electrical activity of your heart

which will help the doctor interpret your test. When the test is completed the gel can be wiped off easily.Considerations An echo takes about 45 minutes.

2D ECHO (2 Di i E h di h )


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2D ECHO (2 Dimension Echocardiography)

Transesophageal Echocardiography


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Transesophageal Echocardiography

Involves passing of a tube with a smalltransducer internally from the mouthto the esophagus

Images of the posterior heart and itsinternal structures are obtained ( this provides superior views that are not possible using the conventional

technique


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Transesophageal

echocardiographyultrasound transducermounted on the tip of adirectable gastroscope-like tube about 12mm indiameter.

Using topical mouthanesthesia and a littlesedative

most individuals canswallow the probewithout difficulty.Because

Nsg intervention:


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Can be performed at the bedside w/o contrastdye with the patient under conscious sedation

NPO 4-6 hours Cardiac rhythm, V/S and O2 sat are monitred Caution the client to avoid eating or drinking until

sensation and gag reflex return which may takeone hour or longer after removal of the tubecontaining the transducer( bec the throat is

anesthesized locally) Remain client in upright or side-lying position

position to support ventilation

Nsg intervention:

ELECTROCARDIOGRAPHY


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ELECTROCARDIOGRAPHY

Is the graphic recording of the electricalcurrent generated by the heart muscle

Helpful in identifying cardiacdysrhythmias and detectingmyocardial damage

Forms: Standard 12 Lead ECG


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Ambulatory ECG/Holter Monitoring, is the recording of an ambulatory

clients cardiac rate and rhythmover 28-48 hours as the clientperforms daily activities

Exercise-Induced Stress Testing to evaluate how the heart functions

during exercise


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The activity of the heart is assessed with anECG monitor while the patient walks on atreadmill ,pedals a stationary bicycle, or climbsup and down stairs

Preparation Consent Light meal 1-2 hours before the test No caffeine, alcohol, smoking Wear comfortable clothing

During the Procedure


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During the Procedure

Nursing Responsibility: Obtain baseline BP and ECG

tracing

Instruct client to report onset of chest pain, dizziness, leg crampsor weakness

The stress test is aborted if theclient develop severe dyspnea,elevated BP, confusion or dysrhythmias

After the procedure:


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After the procedure:

Nursing Responsibility Continue to monitor ECG and BP until client to

baseline and is symptom free

Drug-Induced Stress TestingDrugs maybe used to stress the

heart for client w/sedentarylifestyles or those w/physicaldisability such as severe arthritis,that interferes w/exercise testing

Cardiac Catheterization


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Cardiac Catheterization

Valuable diagnostic tool for obtaining detailedinformation about the structure of the cardiacchambers, valves and coronary arteries

Indication Confirmation of suspected heart disease Determination of the location and severity of

heart disease Preoperative assessment whether cardiac

surgery is indicated Evaluate ventricular function

Evaluation of the effect of medical treatment


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Evaluation of the effect of medical treatmentmodalities performance of specialized

cardiac interventions such as internalpacemaker


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Nursing Responsibility b4 test:


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g p y

1.Foods and fluids are withheld, if the testis late in the day, clear liquid mealmaybe permitted

2.Allergies must be identified (iodine,shellfish, radiographic dye)

3.IV fluids to maintain hydration

4.a sedative is administered before thetest

5.assess peripheral pulses before the test

During the procedure:


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g p instruct the client that a warm

sensation is felt when dye is injected(Left-sided catheterization)

Instruct client to report if any chestdiscomfort, nausea or difficulty inbreathing

after removing the catheter applypressure dressing to prevent

bleeding

After the procedure


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p

1.Keeping the extremities straight for severalhours and avoiding movement are important.Monitor for bleeding and infection

2.Monitor BP and pulse frequently 15 minutes x 1hour then every 30 min x 3 hours

3.Check the dressing at the insertion site todetect for bleeding

4.Palpate pulse in various location and checked thecolor and temp of the extremeties to confirm that bloodis circulating well.

5. Monitor I & O . Drink large volume of fluid to relieve thirst


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fluid to relieve thirst.

Hemodynamic MonitoringA Is used to assess the volume and

pressure of blood in the heart andvascular system by means of surgicallyinserted catheter

Such monitoring is used to:1.Assess cardiac function and circulatory

status2.Adjust fluid infusion rates

Methods:


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1.Central Venous Pressure CVP measurements reflects the

pressure in the R atrium and

provide information regardingchanges in right ventricular pressure

Used to monitor blood volume andthe adequacy of venous return tothe right side of the heart


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NV vary w/different equipment ;however a range of 5-15 cmH20 isacceptable

Low (Falling) indicate inadequate bloodvolume

High (rising) usually secondary to LNVvary w/different equipment ; however a

range of 5-15 cmH20 is acceptable.-sided heart failure

2 Pulmonary Artery Pressure


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2.Pulmonary Artery Pressure

3.Pulmonary Capillary Wedge Pressures A balloon- tipped catheter (Swan-Ganz) maybe

introduced into the pulmonary artery to obtainessential information regarding L ventricular function

Normal reading of PAEDP 4-12 mmHg.Elevation results fr increased peripheralvascular resistance

Normal reading of PCWP- 4-12mmHg.(>25mmHg indicate pulmonary edema

Intra-arterial Pressure Monitoring


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Method in obtaining BP in critically ill patients Method in obtaining BP in critically ill patients Beneficial for clients whose BP

measurement are unreliable such as thosew/ low COBeneficial for clients whose BPmeasurement are unreliable such as thosew/ low CO


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If Radial artery is chosen as site blood flowto the hand should be evaluated w/ AllensTest

cardiovascular disturbances

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