care of clients with cardiovascular disorders

7/27/2019 Care of Clients With Cardiovascular Disorders

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LEARNING OBJECTIVES:

1. Discuss the different assessment parameters for cardiacfunctioning.

2. Describe Nursing care of clients undergoing diagnostic tests toassess cardiac functioning.

3. Describe treatment modalities for clients with cardiacdisorders.

4. Explain the basic pathophysiology, clinical manifestations andcollaborative management of cardiac disorders.

5. Design a nursing care plan for clients with cardiac disorders.

6. Discuss about the prevention, management and rehabilitation

factors that optimize health.


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OUTLINE

I. ANATOMY AND PHYSIOLOGY OF THE HEART

II. DIAGNOSTIC TEST: ELECTROCARDIOGRAM

III. CORONARY HEART DISEASESIV. ANGINA PECTORIS

V. MYOCARDIAL INFARCTION

VI. CONGESTIVE HEART FAILUREVII. CARDIAC TAMPONADE

VIII.HYPERTENSION


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ANATOMY AND PHYSIOLOGY OF THE HEART


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ELECTROCARDIOGRAM

A non-invasive procedurethat evaluates theelectrical activity of theheart


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Deflection Waves of ECG

1. P wave - initial wave, demonstrates the depolarization from SA

Node through both ATRIA; the ATRIA contract about 0.1 s after

start of P Wave.

2. QRS complex - next series of deflections, demonstrates the

depolarization of AV node through both ventricles; the ventriclescontract throughout the period of the QRS complex, with a short

delay after the end of atrial contraction; repolarization of atria also

obscured

3. T Wave - repolarization of the ventricles (0.16 s)

4. PR (PQ) Interval - time period from beginning of atrialcontraction to beginning of ventricular contraction (0.16 s)

5. QT Interval - the time of ventricular contraction (about 0.36 s);

from beginning of ventricular depolarization to end of

repolarization.


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CORONARY HEART DISEASES


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A. PRESDISPOSINGFACTORS

1. Sex: male

2. Race: black

3. Smoking

4. Obesity

5. Hyperlipidemia6. Sedentary lifestyle

7. Diabetes Mellitus

8. Hypothyroidism

9. Diet: increased saturatedfats

10. Type A personality

B. SIGNS AND SYMPTOMS

1. Chest pain

2. Dyspnea

3. Tachycardia

4. Palpitations

5. Diaphoresis

C. TREATMENT Percutaneous

Transluminal CoronaryAngioplasty and

Intravascular Stenting


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Percutaneous

Transluminal Coronary

Angioplasty

Mechanical dilation of

the coronary vessel

wall by compresing the

atheromatous plaque. It is recommended for

clients with single-

vessel coronary artery

disease.

Prosthetic

intravascular cylindricstent maintain good

luminal geometry after

ballon deflation and

withdrawal. Intravascular stenting

is done to prevent

restenosis after PTCA.


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CORONARY ARTERIAL BYPASS GRAFT

SURGERY

Greater and lesser

saphenous veins are

commonly used forbypass graftprocedures


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Objectives of CABG

1. Revascularize

myocardium2. To prevent angina

3. Increase survival rate

4. Done to single occludedvessels

5. If there is 2 or more

occluded blood vessels

CABG is done

Nursing Management:

Nitroglycerine is the

drug of choice for reliefof pain from acute

ischemic attacks

Instruct to avoid over

fatigue

Plan regular activity

program


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For Saphenous Vein Site:

Wear support stocking

4-6 week postop Apply pressure

dressing or sand bag

on the site

Keep leg elevated

when sitting

3 Complications of CABG

1. Pneumonia: encourage

to perform deepbreathing,

coughing exercise and use

of incentive spirometer

2. Shock

3. Thrombophlebitis


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ANGINA PECTORIS

DEFINITION:

Transient paroxysmal chest painproduced by insufficient bloodflow to the myocardiumresulting to myocardial

ischemia. Clinical syndrome characterized

by paroxysmal chest pain that isusually relieved by rest ornitroglycerine due to temporarymyocardial ischemia

Types of Angina Pectoris

Stable Angina: pain less than 15minutes, recurrence is lessfrequent.

Unstable Angina : pain is morethan 15 mins.,but not less than30 minutes, recurrence is morefrequent and the intensity ofpain increases.

Variant Angina ( PrinzmetalsAngina ): Chest pain is on longer

duration and may occur at rest.Result from coronaryvasospasm.

Angina Decubitus: paroxysmalchest pain that occur when theclient sits or stand.


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A. PRESDISPOSING FACTORS

1. Sex: male

2. Race: black

3. Smoking

4. Obesity5. Hyperlipidemia

6. Sedentary lifestyle


8. Hypertension

9. CAD: Atherosclerosis

10. Thromboangiitis Obliterans

11. Severe Anemia

12. Aortic Insufficiency: heart valvethat fails to open &

close efficiently

13. Hypothyroidism

14. Diet: increased saturated fats


B. PRESIPITATING FACTORS

4 Es of Angina Pectoris

1. Excessive physical exertion: heavyexercises, sexual activity

2. Exposure to cold environment:vasoconstriction

3. Extreme emotional response: fear,anxiety, excitement, strongemotions

4. Excessive intake of foods or heavy

meal.

C. SIGNS AND SYMPTOMS

1. Levines Sign: initial sign thatshows the hand clutching the chest

2. Chest pain: characterized by sharpstabbing pain located at sub sternalusually radiates from neck, back,arms, shoulder and jaw musclesusually relieved by rest or takingnitroglycerine(NTG)

3. Dyspnea


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4.Tachycardia

5. Palpitations

6. Diaphoresis

D. DIAGNOSTICPROCEDURE

1. History taking and physicalexam

2. ECG: may reveals ST

segment depression & T waveinversion during chest pain

3. Stress test / treadmill test:reveal abnormal ECG duringexercise

4. Increase serum lipid levels

5. Serum cholesterol & uricacid is increased

E. MEDICAL MANAGEMENT

1. Drug Therapy: ifcholesterol is elevated

Nitrates: Nitroglycerine(NTG)

Beta-adrenergic blockingagent: Propanolol

Calcium-blocking agent:

nefedipine Ace Inhibitor: Enapril

2. Modification of diet & otherrisk factors

3. Surgery: Coronary arterybypass surgery

4. Percutaneuos TransluminalCoronary Angioplasty (PTCA)


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F. NURSINGINTERVENTIONS

1. Enforce complete bed

rest2. Give prompt painrelievers with nitrates ornarcotic

analgesic as ordered3. Administer medicationsas ordered:

A. Nitroglycerine(NTG):when given in small doseswill act as venodilator, but

in large doses will act asvasodilator

Give 1st dose of NTG:sublingual 3-5 minutes

Give 2nd dose of NTG: ifpain persist after giving1st dose with interval of3-5 minutes

Give 3rd& last dose ofNTG: if pain still persistat 3-5 minutes interval


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NTG Tablets(sublingual)

Keep the drug in a dry place,avoid moisture and exposure to

sunlight as it may inactivate thedrug

Change stock every 6 months

Offer sips of water before givingsublingual nitrates, dryness ofmouth may inhibit drug

absoprtion Relax for 15 minutes after taking

a tablet: to prevent dizziness

Monitor side effects: orthostatichypotension, flushed face.Transient headache & dizziness:

frequent side effect Instruct the client to rise slowly

from sitting position

Assist or supervise inambulation

NTG Nitrol or Transdermal patch

Nitropatch is applied once a day,usually in the morning.

Avoid placing near hairy areas asit may decrease drug absorption

Avoid rotating transdermalpatches as it may decrease drugabsorption

Avoid placing near microwaveovens or during defibrillation asit may lead to burns (mostimportant thing to remember)


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B. Beta-blockers:decreases myocardialoxygen demand by

decreasing heart rate,cardiac output and BP

Propanolol

Metropolol

Pindolol

Atenolol

Assess PR, withhold if

dec.PR Administer with food (

prevent GI upset )

Propanolol: not givento COPD cases: itcauses bronchospasmand

DM cases: it causehypoglycemia

Side Effects: Nauseaand vomiting, mentaldepression and fatigue


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C. Calcium ChannelBlockers: relaxessmooth cardiac

muscle, reducescoronary vasospasm

Amlodipine ( norvasc )

Nifedipine ( calcibloc )

Diltiazem ( cardizem )

Assess HR and BP

Administer 1 hour

before meal and 2hours after meal (foods delay absorption)

4. Administer oxygeninhalation

5. Place client on semi-tohigh fowlers position

6. Monitor strictly V/S,I&O, status of

cardiopulmonary fuction& ECG tracing

7. Provide decreasesaturated fats sodium and

caffeine


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8. Provide client healthteachings and dischargeplanning

Avoidance of 4 Es Prevent complication

(myocardial infarction)

Instruct client to takemedication beforeindulging into physicalexertion to achieve themaximum therapeuticeffect of drug

Reduce stress & anxiety:relaxation techniques &guided imagery

Avoid overexertion &smoking

Avoid extremes oftemperature

Dress warmly in cold

weather Participate in regular

exercise program

Space exercise periods &allow for rest periods

The importance of followup care

9. Instruct the client to notifythe physician immediately if

pain occurs & persists despiterest & medicationadministration


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MYOCARDIAL INFARCTION

Death of myocardial cells from

inadequate oxygenation, oftencaused by sudden completeblockage of a coronary artery

Characterized by localizedformation of necrosis (tissuedestruction) with subsequent

healing by scar formation &fibrosis

Heart attack

Terminal stage of coronaryartery disease characterized bymalocclusion, necrosis &

scarring.

Types of M.I

Transmural MyocardialInfarction: most dangerous typecharacterized by occlusion ofboth right and left coronaryartery

Subendocardial Myocardial

Infarction: characterized byocclusion of either right or leftcoronary artery

The Most Critical Period FollowingDiagnosis of

Myocardial Infarction 6-8 hoursbecause majority of deathoccurs due to arrhythmia leadingto premature ventricularcontractions (PVC)


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A. PREDISPOSING FACTORS

1. Sex: male

2. Race: black

3. Smoking4. Obesity

5. CAD: Atherosclerotic

6. Thrombus Formation

7. Genetic Predisposition8. Hyperlipidemia

9. Sedentary lifestyle


11. Hypothyroidism

12. Diet: increased saturatedfats


B. SIGNS ANDSYMPTOMS

1. Chest pain

Excruciating visceral,viselike pain with suddenonset located atsubsternal& rarely inprecordial

Usually radiates from neck,back, shoulder, arms, jaw &abdominal muscles(abdominal ischemia):severe crushing

Not usually relieved by restor by nitroglycerine


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2. N/V

3. Dyspnea

4. Increase in bloodpressure & pulse, with

gradual drop in blood

pressure (initial sign)

5. Hyperthermia: elevatedtemp

6. Skin: cool, clammy,

ashen7. Mild restlessness &apprehension

8. Occasional findings:

Pericardial friction rub

Split S1& S2

Rales or Crackles upon

auscultation

S4 or atrial gallop


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DIAGNOSTIC PROCEDURES

1. Cardiac Enzymes

CPK-MB: elevated Creatininephosphokinase(CPK):elevated

Heart only, 12 24 hours Lactic acid

dehydrogenase(LDH): isincreased

Serum glutamic pyruvatetransaminase(SGPT): isincreased

Serum glutamic oxal-acetic

transaminase(SGOT): isincreased

2. Troponin Test: is increased

3. ECG tracing reveals

ST segment elevation

T wave inversion

Widening of QRS complexes:indicates that there isarrhythmia in MI

4. Serum Cholesterol & uric acid:are both increased

5. CBC: increased WBC


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NURSING INTERVENTIONS

Goal: Decrease myocardial oxygendemand

1. Decrease myocardial workload(rest heart)

Establish a patent IV line

Administer narcotic analgesic asordered: Morphine Sulfate IV:

provide pain relief(given IVbecause after an infarction thereis poor peripheral perfusion &because serum enzyme wouldbe affected by IM injection asordered)

Side Effects: RespiratoryDepression

Antidote: Naloxone (Narcan)

Side Effects of NaloxoneToxicity: is tremors

2. Administer oxygen low flow 2-3 L /min: to prevent respiratory arrest or

dyspnea & prevent arrhythmias3. Enforce CBR in semi-fowlersposition without bathroomprivileges(use bedside commode): todecrease cardiac workload

4. Instruct client to avoid forms ofvalsalva maneuver5. Place client on semi fowlersposition

6. Monitor strictly V/S, I&O, ECGtracing & hemodynamic procedures


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7. Perform complete lung /cardiovascular assessment

8. Monitor urinary output & reportoutput of less than 30 ml/ hr:

indicates decrease cardiac output9. Provide a full liquid diet withgradual increase to soft diet:

low in saturated fats, Na & caffeine

10. Maintain quiet environment

11. Administer stool softeners asordered:to facilitate bowel

evacuation & prevent straining

12. Relieve anxiety associated withcoronary care unit(CCU)environment

13. Administer medication asordered:

a. Vasodilators: Nitroglycirine(NTG), Isosorbide Dinitrate, Isodil

(ISD): sublingualb. Anti Arrythmic Agents: Lidocaine(Xylocane), Brithylium

Side Effects: confusion and dizziness

c. Beta-blockers: Propanolol(Inderal)

d. ACE Inhibitors: Captopril(Enalapril)

e. Calcium Antagonist: Nefedipine

f. Thrombolytics / FibrinolyticAgents: Streptokinase, Urokinase,

Tissue Plasminogen ActivatingFactor

(TIPAF)

Side Effects: allergic reaction,urticaria, pruritus

Nursing Intervention: Monitor forbleeding time

i l 14 Provide client health


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g. Anti Coagulant

Heparin

Antidote: Protamine Sulfate

Nursing Intervention:

Check for Partial ThrombinTime (PTT)

Caumadin(Warfarin)

Antidote:Vitamin K

Nursing Intervention: Check forProthrombin Time (PT)

h. Anti Platelet: PASA (Aspirin):Anti thrombotic effect

Side Effects:Tinnitus,

Heartburn, Indigestion / Dyspepsia

Contraindication: Dengue,Peptic Ulcer Disease,

Unknown cause of headache

14. Provide client healthteaching & dischargeplanning concerning:

a. Effects of MI healing process &treatment regimen

b. Medication regimen includingtime name purpose, schedule,dosage, side effects

c. Dietary restrictions: low Na,low cholesterol, avoidance of

caffeined. Encourage client to take 20 30 cc/week of wine,

whisky and brandy:to inducevasodilation

e. Avoidance of modifiable riskfactors


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f. Prevent Complication

Arrhythmia: caused bypremature ventricular

contraction Cardiogenic shock: latesign is oliguria

Left Congestive HeartFailure

Thrombophlebitis:homans sign

Stroke / CVA

Dresslers Syndrome(PostMI Syndrome):client is

resistant topharmacological agents:administer 150,000-450,000 units ofstreptokinase as ordered

g. Importance of participationin a progressive activityprogram

h. Resumption of ADLparticularly sexualintercourse:

is 4-6 weeks post cardiacrehab, post CABG &

instruct to: Make sex as an appetizer

rather than dessert

Instruct client to assume anon weight bearing

position Client can resume sexual

intercourse: if can climbor use the staircase


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B. SIGNS AND SYMPTOMS

1. Pulmonary edema/congestion

Dyspnea, PND (awakening at nightd/t difficulty in breathing), 2-3 pilloworthopnea

Productive cough (blood tinged)

Rales/crackles

Bronchial wheezing

Frothy salivation

2. Pulsus alternans (A unique patternduring which the

amplitude of the pulse changes oralternates in size

with a stable heart rhythm.)This iscommon in

severe left ventricular dysfunction.)3. Anorexia and general body malaise

4. PMI displaced laterally, cardiomegaly

5. S3 (ventricular gallop)

C. DIAGNOSTICS

1. CXR cardiomegaly

2. PAP pulmonary arterial pressure

Measures pressure in right ventricle

Reveals cardiac status

3. PCWP pulmonary capillary wedgepressure

Measures end-systolic and end-

diastolic pressure (elevated) Done through cardiac

catheterization (Swan- Ganz)

4. Echocardiograph reveals enlargedheart chamber

5. ABG analysis reveals elevated PCO2

and decreased PO2 (respiratory acidosis)

hypoxemia and cyanosis

Tracheostomy for severe RIGHT SIDED HEART


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Tracheostomy for severerespiratory distress andlaryngospasm performedat bedside within 10-15minutes

CVP reveals fluid status;Normal = 4-10cm H2o;right atrium

PAP cardiac status; leftatrium

ALLENS test collateralcirculation

Cardiac Tamponade:pulsus paradoxus,muffled heart sounds,HPN

RIGHT SIDED HEARTFAILURE

A. PREDISPOSING

FACTORS1. Tricuspid valve stenosis

2. COPD

3. Pulmonary embolism

(char by chest pain anddyspnea)

4. Pulmonic stenosis

5. Left sided heart failure


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B SIGNS AND SYMPTOMS C DIAGNOSTICS


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B. SIGNS AND SYMPTOMS(Venous congestion)

1. Jugular vein distention

2. Pitting edema

3. Ascites4. Weight gain

5. Hepatosplenomegaly

6. Jaundice

7. Pruritus/ urticaria8. Esophageal varices

9. Anorexia

10. Generalized body malaise

C. DIAGNOSTICS

1. CXR cardiomegaly

2. CVP measures pressure inright atrium; N = 4-

10cc H2O During CVP: trendelenburg

to prevent pulmo embolismand to promote ventricularfilling

Flat on bed post CVP, checkCVP readings

Hypovolemia fluidchallenge

Hypervolemia diuretics(loop)

3. Echocardiography revealsenlarged heart chamber

Muffled heart soundscardiomyopathy

C i h di


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Cyanotic heart diseases

TOF tet spells cyanosis with

hypoxemia

Tricuspid valve stenosis

Transposition of aorta

Acyanotic

PDA machine-like murmur

DOC: indomethacin SE: corneal

cloudiness

4. Liver enzymes

SGPT up

SGOT up

D. NURSING MANAGEMENT

Goal: increase myocardialcontraction increase CO;

Normal CO is 3-6L/min; N strokevolume is 60-70ml/h2o

1. Administer medications asordered

Cardiac glycosides

Digoxin (N=.5-1.5, tox=2)

Tox: Anorexia, N&V; A: Digibind Digitoxin given if (+) ARF;

metabolized in liver and not inkidneys

Loop diuretics

Lasix IV push, mornings

Bronchodilators

Aminophylline (theophylline)

Tachycardia, palpitations

CNS hyperactivity, agitation


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CARDIAC TAMPONADE

Also known as pericardialtamponade, is an emergencycondition in which fluidaccumulates in the pericardium.

(the sac in which the heart is

enclosed). If the fluid significantly elevates

the pressure on the heart it willprevent the heart's ventriclesfrom filling properly.

This in turn leads to a low stroke

volume. The end result is ineffective

pumping of blood, shock, andoften death.

A. PREDISPOSING FACTORS

1. Chest trauma ( blunt orpenetrating )

2. Myocardial ruptured

3. Cancer

4. Pericarditis

5. Cardiac surgery ( first 24 48hours )

6. Thrombolytic therapy


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CLASSIFICATION OF BP Stage 1 (mild) HPN


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CLASSIFICATION OF BPFOR ADULTS 18 YRSAND OLDER (PHIL.SOCIETY OF HPN)

Optimal o


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A. CLASSIFICATION

Essential / Idiophatic /Primary HPN, accounts

for 90 95% of all casesof HPN, cause isunknown

Secondary HPN, due to

known causes ( Renalfailure, Hypertension )

MalignantHypertension, is severe,

rapidly progressiveelevation in BP thatcauses rapid onset of endorgan complication

Labile HPN,intermittently elevatedBP

Resistant HPN, doesnot respond to usualtreatment

White Coat HPN,

elevation of B onlyduring clinic or hospitalvisits

C SIGNS AND SYMPTOMS


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Hypertensive Crisis,situation that requiresimmediate blood

pressure lowering240mmHg / 120 mmHg

B. RISK FACTORS

1. Family history

2. Age3. High salt intake

4. Low potassium intake

5. Obesity

6. Excess alcoholconsumption

7. Smoking

8. Stress

C. SIGNS AND SYMPTOMS

1. Headache

2. Epistaxis

3. Dizziness4. Tinnitus

5. Unsteadiness

6. Blurred vision

7. Depression8. Nocturia

9. Retinopathy

D TREATMENT Drug therapy


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D. TREATMENTSTRATEGIES

Non-pharmacologic

therapy1. Low salt diet.

2. Weight reduction.

3. Exercise.

4. Cessation of smoking.5. Decreased alcoholconsumption.

6. Psychological methods:Relaxation / meditation.

7. Dietary decrease insaturated fat.

Drug therapy

Stepped Care

Progressive addition of

drugs to a regimen,starting with one, usuallya diuretic, and adding, ina stepwise fashion, asympatholytic,

vasodilator, andsometimes an ACEinhibitor.

Monotherapy

Advantageous because

of its simplicity, betterpatient compliance, andrelatively low incidenceof toxicity.


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CATEGORIES OF

ANTI-HYPERTENSIVEDRUGS

Drugs that alter sodiumand water balanceDiuretics.

Loop diuretics

Thiazides Spironolactone and

Triamterene

Drugs that altersympathetic nervoussystem function

Sympatholytic drugs.

Centrally-actingsympatholytics

Clonidine

Guanabenz Guanfacine

Methyldopa

Peripherally-acting

sympatholytics Guanadrel

Guanethidine

Reserpine


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a blockers


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a-blockers

Doxazosin

Prazosin

b-blockers Acebutolol - Labetalol

Atenolol - Metoprolol

Betaxolol - Nadolol

Bisoprolol - Penbutolol Carteolol - Pindolol

Carvedilol - Propranolol

Esmolol - Timolol

Vasodilators

Direct vasodilators

Diazoxide - Hydralazine

Minoxidil - Nitroprusside

Fenoldopam

Calcium channel blockers

Amlodipine - Nifedipine

Diltiazem - Nimodipine

Felodipine - Nisoldipine

Isradipine - Nitrendipine

Manidipine - Nicardipine

Lacidipine - Verapamil

Lercanidipine -Gallopamil


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AGENTS THAT BLOCK THE DRUGS FOR HYPERTENSIVE


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AGENTS THAT BLOCK THEPRODUCTION OR

ACTION OF ANGIOTENSIN

ACE inhibitors

Benazepril - Moexipril Captopril - Quinapril

Enalapril - Perindopril

Fosinopril - Ramipril

Lisinopril - Trandolapril

AT1-receptor blockers

Irbesartan - Losartan

Telmisartan - Valsartan

Candesartan - Eprosartan

DRUGS FOR HYPERTENSIVEEMERGENCIES OR

CRISES

Trimethaphan

o 1 mg/ml IV infusion; titrate; instantaneous onset

Sodium nitroprusside

o 5-10 mg/L IV infusion; titrate;

instantaneous onset

Diazoxide o 300-600 mg Rapid IV push;

instantaneous onset

Nifedipine

o 10-20 mg Sublingual or

chewed; onset within 5-30 min.

Labetalol

o 20-80 mg IV at 10-minuteintervals (max.dose:

300mg); immediate onset

E NURSING 2. Teaching about


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E. NURSINGINTERVENTIONS

1. Patient Teaching and

Counselling Teaching about HPN and

its risk factors

Stress therapy

Low NA and lowsaturated fat

Avoid stimulants (caffeine, alcohol,smoking )

Regular pattern ofexercise

Weight reduction ifobese

gmedication

The most common sideeffects of diuretics are

potassium depletion andorthostatic hypotension.

The most common sideeffect of the differentantihypertensive drugs isorthostatic hypotension.

Take anti hypertensivemedications at regularbasis

Assume sitting or lyingposition for few minutes


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Avoid very warm bathP ti N li


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Avoid very warm bath

Avoid prolonged sittingand standing

Avoid alcoholic beverages

Avoid tyramine richfoods ( proteins ) asfollows: ( this may causehypertensive crisis )

Aged cheese Liver

Beer

Wine

Chocolate

Pickles

Sausages

Soy sauce

3. Preventing Non-compliance

Inform the client thatabsence of symptoms

does not indicate control ofBP

Advise the client againstabrupt withdrawal of

medication, rebound

hypertension may occur. Device ways to facilitate

remembering of

taking medications


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care of clients with cardiovascular disorders

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