chapter 35
DESCRIPTION
TRANSCRIPT
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Assessment of the Cardiovascular System
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Cardiovascular System: Assessment
Patient history Nutritional history Family history and genetic risk Current health problems:
Pain or discomfort Dyspnea, DOE, orthopnea, PND Fatigue Palpitations Edema Syncope Extremity pain
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Cardiovascular System: Physical Assessment
General appearance Skin Extremities Blood pressure
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Coronary Artery Disease
Includes stable angina and acute coronary syndromes
Ischemia—insufficient oxygen supply to meet the requirements of the myocardium
Infarction—necrosis or cell death that occurs when severe ischemia is prolonged and decreased perfusion causes irreversible damage to tissue
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Nonmodifiable Risk Factors
Age Gender Family history Ethnic background
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Modifiable Risk Factors
Elevated serum cholesterol Cigarette smoking Hypertension Impaired glucose tolerance Obesity Physical inactivity Stress
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Cardiac Catheterization
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Percutaneous Transluminal Coronary Angioplasty (PTCA)
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Percutaneous Transluminal Coronary Angioplasty
Clopidogrel before the procedure IV heparin after the procedure IV or intracoronary nitroglycerine or
diltiazem Long-term therapy, antiplatelet therapy,
beta blocker, ACE inhibitor or ARB
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Other Procedures
Arthrectomy Stents Rheolytic thrombectomy
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Coronary Stents
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CABG
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CABG (Cont’d)
Preoperative care Operative procedures Postoperative care:
Management of F&E balance Management of other complications—
hypotension, hypothermia, hypertension, bleeding, cardiac tamponade, change in level of consciousness
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Coronary Artery Bypass Graft Surgery
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Community-Based Care
Home care management Health teaching Health care resources
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Valvular Heart Disease
Mitral stenosis Mitral regurgitation (insufficiency) Mitral valve prolapse Aortic stenosis Aortic regurgitation (insufficiency)
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Assessment
May become suddenly ill or slowly develop symptoms over many years.
Question patient about attacks of rheumatic fever and infective endocarditis and about possibility of IV drug abuse.
Obtain chest x-ray, echocardiogram, and exercise tolerance test.
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Common Nursing Diagnoses
Decreased Cardiac Output related to altered stroke volume
Impaired Gas Exchange related to ventilation perfusion imbalance
Activity Intolerance related to inability of the heart to meet metabolic demands during activity
Acute Pain related to physiologic injury agent (hypoxia)
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Nonsurgical Management
Nonsurgical management focuses on drug therapy and rest
Drug therapy, including diuretics, beta blockers, digoxin, oxygen, and sometimes nitrates
Prophylactic antibiotic Management of atrial fibrillation Anticoagulant Rest with limited activity
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Surgical Management
Reparative procedures Balloon valvuloplasty Direct, or open, commissurotomy Mitral valve annuloplasty Replacement procedures
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Heart Valves
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Community-Based Care
Home care management Health teaching Health care resources
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Infective Endocarditis
Microbial infection involving the endocardium
Occurs primarily in patients who abuse IV drugs, have had valve replacements, have experienced systemic infections, or have structural cardiac defects
Possible ports of entry—oral cavity, skin rash, lesion, abscess, infections, surgery, or invasive procedures including IV line placement
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Manifestations
Murmur Heart failure Arterial embolization Splenic infarction Neurologic changes Petechiae (pinpoint red spots) Splinter hemorrhages
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Diagnostic Assessment
Blood culture Echocardiography The most reliable criteria for diagnosing
endocarditis include positive blood cultures, a new regurgitant murmur, and evidence of endocardial involvement by echocardiography
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Interventions
Antimicrobials. Anticoagulants are of no value in
preventing embolization from vegetations. Patient’s activities are balanced with
adequate rest.
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Surgical Management
Removing the infected valve Repairing or removing congenital shunts Repairing injured valves and chordae
tendineae Draining abscesses in the heart or
elsewhere
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Peripheral Arterial Disease
Disorders that alter the natural flow of blood through the arteries and veins of the peripheral circulation
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Lower Extremity Arterial Disease
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Physical Assessment
Intermittent claudication Pain that occurs even while at rest;
numbness and burning
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Physical Assessment (Cont’d)
Hair loss and dry, scaly, pale or mottled skin and thickened toenails
Severe arterial disease—extremity is cold and gray-blue or darkened; pallor may occur with extremity elevation; dependent rubor; and/or muscle atrophy
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Diagnostic Assessments
Imaging assessment
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Nonsurgical Management
Exercise Positioning Promoting vasodilation Drug therapy Percutaneous transluminal angioplasty Laser-assisted angioplasty Atherectomy
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Surgical Management
Aortoiliac and aortofemoral bypass surgery
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Axillofemoral Bypass Graft
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Surgical Management
Preoperative Intraoperative
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Surgical Management (Cont’d)
Postoperative care: Assessment for graft occlusion Promotion of graft patency Treatment of graft occlusion Monitoring for compartment syndrome Assessment for infection
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Acute Peripheral Arterial Occlusion
Embolus—the most common cause of occlusions, although local thrombus may be the cause
Assessment—pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia
Drug therapy Surgical therapy Nursing care
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Aneurysms of Central Arteries
Aneurysm—a permanent localized dilation of an artery, enlarging the artery to twice its normal diameter
Fusiform aneurysm Saccular aneurysm Dissecting aneurysm (aortic dissection) Abdominal aortic aneurysm Thoracic aortic aneurysm
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Arterial Aneurysms
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Assessment of Abdominal Aortic Aneurysm (AAA)
Pain related to AAA is usually steady with a gnawing quality, is unaffected by movement, and may last for hours or days.
Pain is in the abdomen, flank, or back. Abdominal mass is pulsatile. Rupture is the most frequent complication
and is life threatening.
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Assessment of Thoracic Aortic Aneurysm
Assess for back pain and manifestation of compression of the aneurysm on adjacent structures.
Assess for shortness of breath, hoarseness, and difficulty swallowing.
Occasionally a mass may be visible above the suprasternal notch.
Sudden excruciating back or chest pain is symptomatic of thoracic rupture.
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Diagnostic Assessment
X-ray “eggshell” appearance CT Aortic arteriography Ultrasonography
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Nonsurgical Management
Monitor the growth of the aneurysm. Maintain BP at a normal level to decrease
the risk of rupture.
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Abdominal Aortic Aneurysm Resection
Preoperative care Operative procedure Postoperative care:
Monitor vital signs Assess for complications Assess for signs of graft occlusion or rupture
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Thoracic Aortic Aneurysm Repair
Preoperative care Operative procedure Postoperative care assessments:
Vital signs Complications Sensation and motion in extremities Respiratory distress Cardiac dysrhythmias
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Endovascular Repair of Abdominal Aortic Aneurysm
Patients selected for endovascular repair are generally at high risk for major abdominal surgery
Various designs Benefits of endovascular repair Complications of endovascular repair
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Aneurysms of the Peripheral Arteries
Femoral and popliteal aneurysms Symptoms—limb ischemia, diminished or
absent pulses, cool to cold skin, and pain Treatment—surgery Postoperative care—monitor for pain
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Aortic Dissection
May be caused by a sudden tear in the aortic intima, opening the way for blood to enter the aortic wall
Pain described as tearing, ripping, and stabbing
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Aortic Dissection (Cont’d)
Emergency care goals include: Elimination of pain Reduction of blood pressure Decrease in the velocity of left ventricular
ejection Nonsurgical treatment Surgical treatment
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Venous Thromboembolism
Thrombus—a blood clot Thrombophlebitis Deep vein thrombosis (DVT) Pulmonary embolism Virchow’s triad Phlebitis
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Assessment
Calf or groin tenderness or pain Sudden onset of unilateral swelling of the
leg Checking Homans’ sign—not advised Localized edema Venous flow studies—venous duplex
ultrasonography MRI D-dimer
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Nonsurgical Management
Rest, drug therapy, preventive measures Drug therapy includes:
Unfractionated heparin therapy Low–molecular weight heparin Warfarin therapy Thrombolytic therapy
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Surgical Management
Thrombectomy Inferior vena caval interruption Ligation or external clips
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Shock
Widespread abnormal cellular metabolism that occurs when the human need for oxygenation and tissue perfusion is not met to the level needed to maintain cell function.
“Whole-body” response. Shock is a “syndrome.” Any problem that impairs oxygen delivery to
tissues and organs can start the syndrome of shock and lead to a life-threatening emergency.
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Classification of Shock by Origin of the Problem
Hypovolemic Cardiogenic Vasogenic Septic
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Hypovolemic Shock
Occurs when low circulating blood volume causes a mean arterial pressure decrease; the body’s oxygen need is not met
Commonly caused by hemorrhage (external or internal) and dehydration
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Health Promotion and Maintenance
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Physical Assessment/Clinical Manifestations
Cardiovascular changes Pulse Blood pressure Oxygen saturation Skin changes Respiratory changes Renal and urinary changes Central nervous system changes Musculoskeletal changes
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Assessment
Psychosocial assessment Laboratory tests
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Nonsurgical Management
Goals of shock management are to maintain tissue oxygenation, increase vascular volume to normal range, and support compensatory mechanisms
Oxygen therapy IV therapy Drug therapy