chapter 8 care of the patient with a cardiovascular or a peripheral vascular disorder mosby items...

Chapter 8Chapter 8

Care of the Patient with a Cardiovascular or a Peripheral Vascular Disorder

Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.


Key TermsKey Terms

• Aneurysm Hypoexmia• Angina pectoris Intermittent claudication• Arteriosclerosis Ischemia• Atherosclerosis Myocardial infarction (MI)• Bradycardia Occlusion• BNP (B-type natriuretic peptide) Orthopnea• Cardioversion Peripheral• Coronary artery disease (CAD) Pleural Effusion• Defibrillation Polycythemia• Dysrhythmia Pulmonary Edema• Embolus Tachycardia• Endarterectomy• Heart failure


Overview of Anatomy and PhysiologyOverview of Anatomy and Physiology

• Heart Four-chambered, hollow, muscular organ, not much

bigger than a fist Lies in the mediastinum Lower border is called the apex Heart wall: three layers

• Epicardium (pericardium): double, serous membrane on the outside of the heart

• Myocardium: constructed of cardiac muscle

• Endocardium: lines the inner surface of the chambers of the heart


Figure 8-1Figure 8-1

Heart and major blood vessels viewed from front (anterior).

(from Thibodeau, G.A. & Patton, K.T. [2007]. Structure and function of the human body. [13th ed.]. St. Louis: Mosby. )



• Septum (divides right and left halves)

• Heart chambers Right atrium—receives deoxygenated blood Left atrium—receives oxygenated blood Right ventricle—pumps deoxygenated blood Left ventricle—pumps oxygenated blood

• Heart valves Atrioventricular valves

• Tricuspid and bicuspid (mitral) valves Semilunar valves

• Pulmonary and aortic semilunar valvesChordae tendineae



Interior of the heart.

(From Thibodeau, G.A., Patton, K.T. [2007]. Anatomy and physiology. [6th ed.]. St. Louis: Mosby.)



• Electrical conduction system Automaticity

• An inherent ability of the heart muscle tissue to contract in a rhythmic pattern

Irritability• The ability to respond to a stimulus

Impulse pattern• Sinoatrial node to AV node to bundle of His to right and

left bundle branches to Purkinje fibers

* Hormones, ion concentration, and changes in body temperature can effect conduction, rhythm, and coordination of heart beat*



Conduction system of the heart.

(From Thibodeau, G.A., Patton, K.T. [2007]. Anatomy and physiology. [6th ed.]. St. Louis: Mosby.)



• Cardiac cycle A complete heartbeat

• Atria contract while ventricles relax• Ventricles contract while atria relax

Systole• Phase of contraction

Diastole• Phase of relaxation• Period between contraction of the atria or ventricles during

which the blood enters the relaxed chambers

*Lubb-longer and lower pitch

Dubb-shorter and sharper pitch*

*Murmur (swishing) can be normal or abnormal*



Blood flow during systole.

(From Canobbio, M. [1990]. Cardiovascular disorders, Mosby’s clinical nursing series. St. Louis: Mosby.)



Blood flow during diastole.




• Blood vessels Capillaries

• Tiny blood vessels joining arterioles and venules Arteries

• Large vessels carrying blood away from the heart arterioles

Veins• Vessels that convey blood from the capillaries to the

heart venules


CirculationCirculation

• Coronary blood supply Right and left coronary arteries

• Branch off of the aorta

• Encircle the heart like a crown

• Supply the myocardium with blood Coronary veins

• Return the unoxygenated blood to the coronary sinus, then to the right atrium



Arterial coronary circulation (anterior).



CirculationCirculation

• Systemic circulation Circulates blood from the left ventricle to all parts of

the body and back to the right atrium Carries oxygen and nutritive materials to all body

tissues and removes products of metabolism

• Pulmonary circulation Circulates blood from the right ventricle to the lungs

and back to the left atrium of the heart Carries deoxygenated blood to the lungs to be

reoxygenated and removes the metabolic waste product, carbon dioxide


Laboratory and Diagnostic ExaminationsLaboratory and Diagnostic Examinations

• Number of diagnostic test available to evaluate cardiovascular function

• Nursing responsibilities Physically prepare patient for test or procedure Explain examination to patient



• Radiographic examination Film record of heart size, shape and position and outline of

shadows Lung congestion also shown (Heart failure)

• Diagnostic imaging Fluoroscopy (action picture radiograh; pacemaker placement,

intracardial catheter (Swan) placement Angiogram-series of radiographs after contrast injected; picture

of circulating process Aortogram-x-ray visual of abdominal aorta and leg arteries

• Cardiac catheterization and angiography Measures heart pressures, ejection fraction, visual of valves,

arteries and structure Sterile procedure; contrast contains iodine; assess circulation

post-operatively (pulses, vitals, EKG, puncture site)



• Electrocardiography (ECG/EKG) Graphic recording of electrical activity of myocardium

• 3 distinct waves (deflections); P, QRS, T

• Contraction-depolarization

• Relaxation-repolarization

• 12 leads Supine, exercise stress, Holter

• Cardiac monitors Similar to EKG; preset alarms; telemetry monitors Monitor wires, battery, connection, gel pads, etc.



Normal ECG deflections.



• Thallium scanning Intracellular ion actively transported into normal cells If cell is ischemic, thallium not picked up Thallium concentrates in tissue with normal blood flow Inadequately perfused areas appear dark on scan (cold spots) Sestamibi in place of thallium diminishes artifact in females Persantine (dipyridamole) given prior to thallium for patients who

cannot tolerate activity

• Echocardiography-high frequency ultrasound EF: normal >60%

• PET (positron emission tomography)-inhaled/injected radioactive substance displaying color coded images related to metabolic function



• Laboratory tests: CBC (rbc, wbc, platetets, H&H)

• High WBC• Low Hgb• High RBC (polycythemia) d/t hypoexmia

blood cultures coagulation studies

• Chronic afib, cardioversion, MI d/t thrombus• PT, INR PTT

ESR-inflammatory infective conditions (MI, endocarditis, rheumatic fever)

Electrolytes; Na, K+, Ca, Mg Lipids; LDL, HDL, VLDL arterial blood gases; PaO2, PaCO2, pH



• cardiac markers Proteins released into blood from necrotic heart muscle after

infarction Cardiac serum enzymes

• CK(creatine kinase • CK-MB (creatine phosphokinase)-gold standard

also found in skeletal muscle Can be elevated from surgery, trauma, diease Not specific for MI Rise within 2-3 hours of injury, peak 24 hours, return to normal

24-40 hours Troponin I

• Myocardial muscle protein released after MI• Not influenced by skeletal muscle injury• Rises 3 hours, peaks 14-18 hours, normal 5-7 days



• B-type Natriuretic Peptide (BNP) Neurohormone secreted by the heart in response to

ventricular expansion Elevated in heart failure; higher the number, more

sever the HF

• Homocysteine Amino acid produced during protein digestion Elevated levels may act as independent risk factor for

heart disease Deficiency in B6, B12, and folate most common cause


Disorders of the Cardiovascular SystemDisorders of the Cardiovascular System

• Major health concern

• Normal aging patterns

• Risk factors Nonmodifiable factors

• Family history

• Age

• Sex (gender)

• Race



• Risk factors (continued) Modifiable factors

• Smoking

• Hyperlipidemia

• Hypertension

• Diabetes mellitus

• Obesity

• Sedentary lifestyle

• Stress

• Oral contraceptives

• Psychosocial factors



• Cardiac dysrhythmias Any cardiac rhythm that deviates from normal sinus

rhythm• Sinus tachycardia

• Sinus bradycardia

• Supraventricular tachycardia

• Atrial fibrillation

• Atrioventricular block

• Premature ventricular contractions

• Ventricular tachycardia

• Ventricular fibrillation



• Cardiac Arrest The sudden cessation of cardiac output and

circulatory process Cause: ventricular tachycardia, ventricular fibrillation,

and ventricular asystole Signs and symptoms: abrupt loss of consciousness

with no response to stimuli; gasping respirations followed by apnea; absence of pulse and blood pressure; pupil dilation; pallor and cyanosis

Treatment: cardiopulmonary resuscitation (CPR) and advanced cardiac life support (ACLS)

• pacemaker


Disorders of the HeartDisorders of the Heart

• Coronary atherosclerotic heart disease Coronary artery disease (CAD)

• A variety of conditions that obstruct blood flow in the coronary arteries

Atherosclerosis• A common arterial disorder characterized by yellowish

plaques of cholesterol, lipids, and cellular debris in the inner layers of the walls of the arteries; the primary cause of atherosclerotic heart disease (ASHD)



Progressive development of coronary atherosclerosis.

(From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2007]. Medical-surgical nursing: assessment and management of clinical problems. [7th ed.]. St. Louis: Mosby.)



• Angina pectoris Etiology/pathophysiology

• Cardiac muscle is deprived of oxygen• Increased workload on the heart

Clinical manifestations/assessment• Pain (usually relieved by rest)• Dyspnea• Anxiety; apprehension• Diaphoresis• Nausea



• Angina pectoris (continued) Medical management/nursing interventions

• Correct cardiovascular risk factors

• Avoid precipitating factors

• Pharmacological management Dilate coronary arteries and decrease workload of heart

o Nitroglycerino Beta-adrenergic blocking agentso Calcium channel blockers



• Angina pectoris (continued) Medical management/nursing interventions

• Surgical interventions Coronary artery bypass graft (CABG) Percutaneous transluminal coronary angioplasty (PTCA) Stent placement



• Myocardial infarction Etiology/pathophysiology

• Occlusion of a major coronary artery or one of its branches with subsequent necrosis of myocardium

• Most common cause is atherosclerosis

• Ability of the cardiac muscle to contract and pump blood is impaired



Four common locations where myocardial infarctions occur.




• Myocardial infarction (continued) Clinical manifestations/assessment

• Asymptomatic (silent MI)

• Pain (not relieved by rest, position, or nitroglycerin)

• Nausea

• SOB; dizziness; weakness

• Diaphoresis

• Pallor—ashen color

• Sense of impending doom



Sites to which ischemic myocardial pain may be referred.




• Myocardial infarction (continued) Medical management/nursing interventions

• Oxygen

• Fibrinolytic agents

• Percutaneous transluminal coronary angioplasty (PTCA)

• Coronary artery bypass graft surgery

• Pharmacological management Vasopressors, analgesics, nitrates, beta-adrenergic

blockers, calcium channel blockers, antidysrhythmics, diuretics, inotropic agents, diuretics, stool softeners



A, Saphenous vein. B, Saphenous aortocoronary artery bypass.

(A, from Urden LD, et al [2006]. Thelan’s critical care nursing: Diagnosis and management. [5th ed.]. St. Louis: Mosby. B, from Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2007]. Medical-surgical nursing: assessment and management of clinical

problems. [7th ed.]. St. Louis: Mosby.)



Coronary artery bypass graft.

(from Monahan, F.D., et al. [2007]. Phipps’ medical-surgical nursing: health and illness perspectives. [8th ed.]. St. Louis: Mosby. )



• Heart failure Etiology/pathophysiology

• Abnormal condition characterized by circulatory congestion resulting from the heart’s inability to act as an effective pump

• Left ventricular failure Most common

• Right ventricular failure Usually caused by left ventricular failure



• Heart failure (continued) Clinical manifestations/assessment

• Decreased cardiac output Fatigue Angina Anxiety; restlessness Oliguria Decreased GI motility Pale, cool skin Weight gain



• Heart failure (continued) Clinical manifestations/assessment (continued)

• Left ventricular failure Pulmonary congestion

o Dyspneao Paroxysmal nocturnal dyspneao Cough; frothy, blood-tinged sputumo Orthopneao Pulmonary crackleso Pleural effusion (x-ray)



• Heart failure (continued) Clinical manifestations/assessment (continued)

• Right ventricular failure Distended jugular veins Anorexia, nausea, and abdominal distention Liver enlargement Ascites Edema in feet, ankles, sacrum; may progress up the legs

into thighs, external genitalia, and lower trunk



• Heart failure (continued) Medical management/nursing interventions

• Pharmacological management Increase cardiac efficiency

o Digitaliso Vasodilatorso ACE inhibitors (decrease blood pressure)

• Bed rest, HOB elevated

• Oxygen

• Treat edema and pulmonary congestion

• Monitor fluid retention (weigh daily; strict I&O)



• Pulmonary edema Etiology/pathophysiology

• Accumulation of fluid in lung tissues and alveoli

• Complication of congestive heart failure (CHF) Clinical manifestations/assessment

• Restlessness

• Agitation

• Disorientation

• Diaphoresis

• Dyspnea and tachypnea



• Pulmonary edema (continued) Clinical manifestations/assessment (continued)

• Tachycardia

• Pallor or cyanosis

• Cough—large amounts of blood-tinged, frothy sputum

• Wheezing, crackles

• Cold extremities



• Pulmonary edema (continued) Medical management/nursing interventions

• Pharmacological management Morphine sulfate Nitroglycerin Diuretics Inotropic agents Vasodilators

• High Fowler’s or orthopneic position

• Oxygen



• Valvular heart disease Etiology/pathophysiology

• Heart valves are compromised and do not open and close properly

Stenosis Insufficiency

• Causes may be: Congenital Rheumatic fever



• Valvular heart disease (continued) Clinical manifestations/assessment

• Fatigue

• Angina

• Oliguria

• Pale, cool skin

• Weight gain

• Restlessness

• Abnormal breath sounds

• Edema



• Valvular heart disease (continued) Medical management/nursing interventions

• Pharmacological management Diuretics Digoxin Antidysrhythmics

• Restrict activities

• Sodium-restricted diet

• Surgery Open mitral commissurotomy Valve replacement



• Rheumatic heart disease Etiology/pathophysiology

• Rheumatic fever Inflammatory disease that is a delayed childhood reaction

to inadequately treated childhood upper respiratory tract infection of beta-hemolytic streptococci

Causes scar tissue in the heart



• Rheumatic heart disease (continued) Clinical manifestations/assessment

• Elevated temperature

• Elevated heart rate

• Epistaxis

• Anemia

• Joint pain and stiffness

• Nodules on the joints

• Specific to valve affected

• Heart murmur



• Rheumatic heart disease (continued) Medical management/nursing interventions

• Pharmacological management NSAIDs

• Prevention Treat infections rapidly and completely

• Bed rest• Application of heat• Dietary recommendations

Well-balanced diet Supplement with vitamins B and C

• Encourage fluids• Commissurotomy or valve replacement



• Pericarditis Etiology/pathophysiology

• Inflammation of the membranous sac surrounding the heart

• May be acute or chronic

• Bacterial, viral, or fungal

• Noninfectious conditions Azotemia, MI, neoplasms, scleroderma, trauma, systemic

lupus erythematosus (SLE), radiation, drugs



• Pericarditis (continued) Clinical manifestations/assessment

• Debilitating pain

• Dyspnea

• Fever

• Chills

• Diaphoresis

• Leukocytosis

• Pericardial friction rub

• Pericardial effusion



• Pericarditis (continued) Medical management/nursing interventions

• Pharmacological management Analgesics Salicylates Antibiotics Anti-inflammatory agents Corticosteroids

• Oxygen

• IV fluids

• Surgery: pericardial window, pericardial tap



• Endocarditis Etiology/pathophysiology

• Infection or inflammation of the inner membranous lining of the heart

Clinical manifestations/assessment• Influenza-like symptoms

• Petechiae on the conjunctiva, mouth, and legs

• Anemia

• Splinter hemorrhages under nails

• Weight loss

• Heart murmur



• Endocarditis (continued) Medical management/nursing interventions

• Bed rest

• Antibiotics IV for 1 to 2 months

• Prophylactic antibiotics for “high-risk” patients

• Surgical repair of diseased valves or valve replacement



• Myocarditis Etiology/pathophysiology

• Inflammation of the myocardium

• Rheumatic heart disease

• Viral, bacterial, or fungal infection

• Endocarditis

• Pericarditis



• Myocarditis (continued) Medical management/nursing interventions

• Bed rest

• Oxygen

• Antibiotics; anti-inflammatory agents

• Assessment and correction of dysrhythmias Clinical manifestations/assessment

• Vary according to site of infection

• Cardiac enlargement

• Murmur; gallop; tachycardia



• Cardiomyopathy Etiology/pathophysiology

• A group of heart muscle diseases that primarily affects the structural or functional ability of the myocardium

• Not associated with CAD, hypertension, vascular disease, or pulmonary disease

• Primary—unknown cause

• Secondary—infective, metabolic, nutritional, alcohol, peripartum, drugs, radiation, SLE, rheumatoid arthritis



• Cardiomyopathy (continued) Clinical manifestations/assessment

• Angina

• Syncope

• Fatigue

• Dyspnea on exertion

• Severe exercise intolerance

• Signs and symptoms of left- and right-sided CHF



• Cardiomyopathy (continued) Medical management/nursing interventions

• Pharmacological management Diuretics ACE inhibitors Beta-adrenergic blocking agents

• Treat underlying cause

• Internal defibrillator

• Cardiac transplant


• Arterial assessment PATCHES

• P = Pulses

• A = Appearance

• T = Temperature

• C = Capillary refill

• H = Hardness

• E = Edema

• S = Sensation

Disorders of the Peripheral Vascular System Disorders of the Peripheral Vascular System


• Venous assessment First symptom is usually edema Dark pigmentation Dryness and scaling Ulcerations Pain, aching, and cramping

• Usually relieved by rest or elevation



• Diagnostic tests Noninvasive procedures

• Treadmill test

• Plethysmography

• Digital subtraction angiography (DSA)

• Doppler ultrasound Invasive procedures

• Phlebography or venography

• 125I-fibrinogen uptake test

• Angiography



• Arteriosclerosis Thickening, loss of elasticity, and calcification of

arterial walls, resulting in decreased blood supply

• Atherosclerosis Narrowing of the artery due to yellowish plaques of

cholesterol, lipids, and cellular debris in the inner layers of the walls of large- and medium-sized arteries

A type of arteriosclerosis



• Hypertension Etiology/pathophysiology

• A sustained elevated systolic blood pressure greater than 140 mm Hg and/or a sustained elevated diastolic blood pressure greater than 90 mm Hg.

• Vasoconstriction (increases blood pressure )

• Essential (primary) hypertension 90% to 95% of all diagnosed cases

• Secondary hypertension Attributed to an identifiable medical diagnosis



• Hypertension (continued) Clinical manifestations/assessment

• Headache; blurred vision

• Epistaxis

• Angina Medical management/nursing interventions

• Pharmacological management Antihypertensive medications; diuretics

• Dietary recommendations Weight control, reduction of saturated fats, and low

sodium

• No smoking

Disorders of the Peripheral Vascular System Disorders of the Peripheral Vascular System Disorders of the Peripheral Vascular System Disorders of the Peripheral Vascular System


• Arteriosclerosis obliterans Etiology/pathophysiology

• Narrowing or occlusion of the blood vessel with plaque formation—little or no blood flow to the affected extremity

Clinical manifestations/assessment• Pain—intermittent claudication

• Pulselessness

• Pallor

• Paresthesia

• Paralysis



• Arteriosclerosis obliterans (continued) Medical management/nursing interventions

• Anticoagulants

• Fibrinolytics

• Surgery Embolectomy Endarterectomy Arterial bypass Percutaneous transluminal angioplasty Amputation



• Arterial embolism Etiology/pathophysiology

• Blood clots in the arterial bloodstream

• May originate in the heart

• Foreign substances Clinical manifestations/assessment

• Pain

• Absent distal pulses

• Pale, cool, and numb extremity

• Necrosis



• Arterial embolism (continued) Medical management/nursing interventions

• Pharmacological management Anticoagulants Fibrinolytics

• Endarterectomy

• Embolectomy



• Arterial aneurysm Etiology/pathophysiology

• Enlarged, dilated portion of an artery

• Causes: arteriosclerosis; trauma; congenital Clinical manifestations/assessment

• Asymptomatic

• Large pulsating mass

• Pain, if large enough to press on other structures




Types of aneurysms. A, Fusiform. B, Saccular.

C, Dissecting.



• Arterial aneurysm (continued) Medical management/nursing interventions

• Assess for signs and symptoms of rupture, thrombi, ischemia

• Control hypertension

• Surgery Ligation Grafts



• Thromboangitis obliterans (Buerger’s disease) Etiology/pathophysiology

• Occlusive vascular condition in which the small and medium-sized arteries become inflamed and thrombotic

Clinical manifestations/assessment• Pain; sensitivity to cold

• Skin cold and pale

• Ulcerations on feet or hands; gangrene

• Superficial thrombophlebitis



• Thromboangitis obliterans (Buerger’s disease) (continued) Medical management/nursing interventions

• No smoking

• Exercise to develop collateral circulation

• Surgery Amputation of gangrenous fingers and toes Sympathectomy



• Raynaud’s disease Etiology/pathophysiology

• Intermittent arterial spasms

• Primarily affects fingers, toes, ears, and nose

• Exposure to cold or emotional stress Clinical manifestations/assessment

• Chronically cold hands and feet

• Pallor, coldness, numbness, cyanosis, and pain during spasms; erythema following a spasm

• Ulcerations on the fingers and toes



• Raynaud’s disease (continued) Medical management/nursing interventions

• Pharmacological management Vasodilators Calcium antagonists Muscle relaxants

• Surgery: sympathectomy

• No smoking

• Avoid exposure to cold

• Amputation for gangrene



• Thrombophlebitis Etiology/pathophysiology

• Inflammation of a vein in conjunction with the formation of a thrombus

• Risk factors: venous stasis, hypercoagulability, trauma of a blood vessel, immobilization after surgery

Clinical manifestations/assessment• Pain

• Edema

• Positive Homans’ sign

• Erythema, warmth, and tenderness along the vein




Deep vein thrombophlebitis.

(From Kamal, A., Brockelhurst, J.C. [1991]. Color atlas of geriatric medicine. [3rd ed.]. St. Louis: Mosby-Year Book —Europe.)


• Thrombophlebitis (continued) Medical management/nursing interventions

• Superficial Pharmacological management

o NSAIDs Bed rest Moist heat Elevate extremity



• Thrombophlebitis (continued) Medical management/nursing interventions

• Deep Pharmacological management

o Anticoagulantso Fibrinolytics

Bed rest Elevate extremity Antiembolism stockings Surgery: thrombectomy; vena cava umbrella (Greenfield

filter)



• Varicose veins Etiology/pathophysiology

• Tortuous, dilated vein with incompetent valves Clinical manifestations/assessment

• Dark, raised, tortuous veins

• Fatigue; dull aches

• Cramping of the muscles

• Heaviness or pressure of extremity

• Edema, pain, changes in skin color, and ulcerations with venous stasis



• Varicose veins (continued) Medical management/nursing interventions

• Elastic stockings

• Rest

• Elevate legs

• Sclerotherapy

• Surgery Vein ligation and stripping



• Venous stasis ulcers Etiology/pathophysiology

• Ulcerations of the legs from chronic deep vein insufficiency and stasis of blood in the venous system of the legs

• Open necrotic lesion due to an inadequate supply of oxygen-rich blood to the tissue

• Causes Varicose veins, burns, trauma, sickle cell anemia,

diabetes mellitus, neurogenic disorders, and hereditary factors



• Venous stasis ulcers (continued) Clinical manifestations/assessment

• Pain

• Ulceration with dark pigmentation

• Edema Medical management/nursing interventions

• Diet: increased protein; vitamins A and C and zinc

• Debridement of necrotic tissue

• Antibiotics

• Unna boot




Scale for pitting edema depth.



• Nursing diagnoses Activity intolerance Anxiety Decreased cardiac output Ineffective coronary tissue perfusion Fluid volume excess Impaired gas exchange Knowledge, deficient Pain

Nursing ProcessNursing Process

Chapter 15

Cardiovascular and Renal Medications

Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 91

Chapter 15

Lesson 15.1

92Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Learning Objectives

Identify the approved way to give different forms of antianginal therapy

Discuss the uses and general actions of cardiac drugs used to treat dysrhythmias

Describe the common treatment for various types of lipoprotein disorders


Cardiovascular System: Major Arteries


Question 1

Arteries move blood from the heart to tissues using smaller branches called:

1. Arterioles.2. Bronchioles.3. Nerves.4. Venules.


Cardiovascular System: Major Veins


Urinary System


Antianginals and Peripheral Vasodilators

Antianginals Nitrates: “Universal Vasodilators”

Directly cause vascular smooth muscle to relax in arterial and venous circulation

Decrease myocardial oxygen use Increase collateral-vessel circulation to the heart

Calcium Channel Blockers Dilate coronary arteries and arterioles Reduce response of electrical conduction system


Question 2

Which are the best drugs for treating coronary artery disease?

1. Beta blockers2. Calcium channel blockers3. Diuretics4. Nitrates


Main Components of Microcirculation


Antianginals and Peripheral Vasodilators (cont.)

Action and Uses Nitrates

Acute and chronic anginal attacks Reduce the workload of the heart

Peripheral Vasodilators Relax the smooth muscles of peripheral arterial

vessels to increase peripheral circulation Used to treat leg pain caused by vasoconstriction


Site of Action of Peripheral Vasodilators


Antianginals and Peripheral Vasodilators (cont.)

Adverse Reactions Nitrates: Flushing, postural hypotension,

tachycardia, confusion, dizziness, fainting, headache, lightheadedness, vertigo, weakness, drug rash, localized pruritus, skin lesions, eye and mouth edema, local burning in mouth, nausea and vomiting

Peripheral Vasodilators: Headache, weakness, tachycardia, flushing, postural hypotension, dysrhythmias, confusion, severe rash, nervousness, tingling, and sweating


Antidysrhythmics

Four Classes Class I: disopyramide, procainamide, quinidine

Lengthen the refractory period Decrease cardiac excitability

Class II: acebutolol, esmolol, propranolol Reduce sympathetic excitation (reduce loading)

Class III: amiodarone Lengthen the time it takes for one cell to fire and recover

Class IV: verapamil Blocks calcium entry into the myocardium, prolongs resting

phase


Conduction System of the Heart


Antidysrhythmics (cont.)

Action and Uses Quinidine and Procainamide

Treat rapid and irregular dysrhythmias by decreasing the excitability of myocardial cells

Bretylium Slows conduction rate in the ventricles, slows

norepinephrine release in the myocardium Disopyramide

Slows the depolarization of cardiac cells


Antidysrhythmics (cont.)

Lidocaine Increases the strength of electrical impulses

Adenosine Stops the heart for several seconds to allow it to

convert to normal sinus rhythm Beta-adrenergic blockers (propranolol)

Decrease the heart’s beta-receptor response to epinephrine and norepinephrine


Antihyperlipidemics

Types of Lipoproteins Chylomicrons (mostly triglycerides)

Formed from absorption of dietary fat in intestine Very low-density lipoproteins (VLDLs)

Made up of large amounts of triglycerides that were made in the liver (pre-beta lipoproteins)

Low-density lipoproteins (LDLs) Breakdown of VLDLs linked with cholesterol and protein

High-density lipoproteins (HDLs) Clear out excess cholesterol from tissue


Path of Lipid Metabolism


Antihyperlipidemics (cont.)

HMG-CoA Reductase Inhibitors Highly effective for lowering LDL levels

Fibric Acid Derivatives Highly effective for lowering triglyceride and

increasing HDL levels Bile Acid Sequestrants

Form an insoluble compound with bile salts to reduce serum cholesterol levels

Niacin Effective at lowering LDL levels and increasing HDLs


Chapter 15

Lesson 15.2


Learning Objectives

List the general uses and actions of cardiotonic drugs

Explain the actions of different categories of drugs used to treat hypertension

Identify indications for electrolyte replacement


Internal Anatomy of the Heart


Coronary Arteries


Cardiotonics

Actions Increase the contraction strength or force

(positive inotropic action) Slow the heart rateUses Treatment of CHF and rapid or irregular

heartbeats (atrial fibrillation, atrial flutter, frequent PVCs or paroxysmal atrial tachycardia)


Cardiotonics (cont.)

Adverse Reactions Digitalis toxicity: serum digoxin levels verify The amount of medication that is helpful (therapeutic)

and the amount that is harmful (toxic) are not very different.

Don’t confuse the sound-alikes digoxin and digitoxinDrug InteractionsNursing Implications and Patient Teaching


Antihypertensives, Diuretics, and Other Drugs Affecting the Urinary Tract

Diuretics Indirectly reduce blood pressure by producing

sodium and water loss and lowering the tone or rigidity of the arteries

Types Thiazide and sulfonamide diuretics Loop diuretics Potassium-sparing diuretics


Antihypertensives, Diuretics, and Other Drugs Affecting the Urinary Tract (cont.)

Adrenergic Inhibitors Beta-adrenergic blockers

Nonselective; block beta1 and beta2 sites

Selective; block beta1 sites

Central adrenergic inhibitors Cause vascular relaxation and lower blood

pressure Peripheral adrenergic antagonists

Limit norepinephrine release, prevent vasoconstriction


Antihypertensives, Diuretics, and Other Drugs Affecting the Urinary Tract (cont.)

Alpha1-adrenergic inhibitors Lower peripheral resistance and blood pressure

Combined alpha- and beta-adrenergic blockers

Angiotensin-Related Agents Angiotensin-converting enzyme inhibitors Angiotensin II receptor antagonists

Vasodilators

Calcium Channel Blocking Agents


High Blood Pressure

Stage I: Lifestyle Changes Stage II: Drug Therapy Adverse Reactions

Drug specific Drug Interactions


Drugs Useful in Treating Urinary Problems

Urinary incontinence Treatment: anticholinergics/antispasmodics, alpha-

adrenergic agonists, estrogens, cholinergic agonists, and alpha-adrenergic antagonists

Benign prostatic hyperplasia Treatment: alpha1-adrenergic receptor blockers

Analgesia Treatment: phenazopyridine


Question 3

___________ is an electrolyte that helps move electrical impulses through cardiac tissue.

1. Calcium2. Iron3. Hemoglobin4. Oxygen


Lesson 19.1: Cardiovascular Disease

Cardiovascular disease is the leading cause of death in the United States.

Several risk factors contribute to the development of coronary heart disease and hypertension, many of which are preventable by improved food habits and lifestyle behaviors.

Other risk factors are nonmodifiable, such as age, gender, family history, and race.

125Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Introduction (p. 379)

Coronary heart disease Leading cause of death in the United States More than 615,000 deaths each year Similar in other Western developed nations More than 1 million live with various forms of

rheumatic and congestive heart disease


Atherosclerosis (p. 379)

Major cause of CVD Fatty fibrous plaques develop into fatty streaks on

inside lining of major blood vessels Plaques largely composed of cholesterol Narrows interior part of the blood vessel If affected vessel is major artery supplying heart

muscle, result could be myocardial infarction Local area of dead tissue is an infarct


Atherosclerosis (cont’d) (p. 379)

If affected vessel is major artery supplying brain, result could be cerebrovascular accident


Atherosclerosis (cont’d) (p. 379)

Identified as coronary heart disease Common symptom is angina pectoris, chest pain

usually radiating down the arm, sometimes brought on by excitement or physical effort


Key Terms Related to Atherosclerosis (p. 380)

Myocardial infarction Cerebrovascular accident Coronary heart disease Angina pectoris Lipids


Atherosclerotic Plaque (p. 381)


Relation to Fat Metabolism(p. 381)

Elevated blood lipids associated with coronary heart disease Triglycerides: Simple fats in body or food Cholesterol: Fat-related compound produced in

body; also in foods from animals Lipoproteins: “Packages” wrapped with protein

that carry fat in the bloodstream


Types of Lipoproteins (p. 381)

Chylomicrons Lipoprotein particles that carry absorbed dietary triglycerides

to fat and tissues Very-low-density lipoproteins (VLDLs)

Carry large load of fat to cells Intermediate-density lipoproteins (IDLs)

After VLDLs deposit triglycerides, IDLs remain in circulation Low-density lipoproteins (LDLs)

Carry two thirds of total plasma cholesterol to body tissues High-density lipoproteins (HDLs)

Carry less total fat and more protein


Cholesterol and Lipoprotein Profile (p. 383)


Risk Factors (p. 382)

Gender: CVD more common in men until women reach menopause

Age: risk increases with age Family history Heredity: certain ethnic groups Compounding diseases: type 2 diabetes,

hypertension, metabolic syndrome Blood cholesterol profile: high total and LDL and low

HDL cholesterol


Case Study

Mr. Elliott is a 68-year-old male who is referred to the dietitian for a fat-controlled meal plan. Mr. Elliott is 5 feet 10 inches tall and weighs 250 lbs. His blood pressure is 155/95. Recent labs reveal a total cholesterol of 245 mg/dL, LDL 171 mg/dL, HDL 36 mg/dL, and TG 200 mg/dL.


Case Study (cont’d)

List Mr. Elliott’s risk factors for heart disease. Which risk factors can be modified? What additional information would be helpful to look

at risk factors?



What other lab value and assessment data would you consider in assessing Mr. Elliott? Why?


Dietary Recommendations(p. 383)

Dietary recommendations for reduced risk Reduce fat and cholesterol National Cholesterol Education Program (NCEP): reduce

high blood cholesterol Therapeutic Lifestyle Changes (TLC):

• Total energy intake equals energy expenditure

• Exercise to expend at least 200 kcal/day

• Total fat no more than 25% to 35% of intake

• Avoid trans-fatty acids

• Carbohydrates equal 50% to 60% of energy intake

• Protein equals about 15% of energy intake

• Total cholesterol intake less than 200 mg/day


Drug Therapy (p. 386)

NCEP ATP III guidelines: drug therapy initiated depending on risk factors

TLC guidelines should be continued as adjunct therapy



Discuss interventions that could assist Mr. Elliott in reducing his cardiovascular risk.


Acute Cardiovascular Disease(p. 387)

Acute cardiovascular disease: myocardial infarction Cardiac rest: analgesics Principles of medical nutrition therapy

• Energy intake reduced to reduce load on heart

• Soft or easily digested foods

• Fat: Mediterranean-type diet

• Limited sodium


Heart Failure (p. 388)

Objective: control of pulmonary edema Fluid shift mechanism Hormonal alterations

Principles of diet therapy Sodium restriction Fluid restriction Texture Nutritional adequacy Little or no alcohol


Lesson 19.2: Hypertension

Hypertension, or chronically elevated blood pressure, may be classified as essential (primary) or secondary hypertension.

Hypertension damages the endothelium of blood vessels.

Early education is critical for the prevention of cardiovascular disease.


Essential Hypertension (p. 389)

Incidence and nature 31% of American adults have high blood pressure

(hypertension) Injury to inner lining of blood vessel wall appears

to be underlying link to cause Secondary hypertension is symptom or side effect

of another primary condition Hypertension called the “silent disease”


Hypertensive Blood Pressure Levels (p. 390)

Prehypertension: focus on lifestyle modifications Stage 1 hypertension: diet therapy and drugs as

needed Stage 2 hypertension: diet therapy and vigorous drug

therapy



What stage of hypertension does Mr. Elliott have?


Principles of Medical Nutrition Therapy (p. 391)

Weight management: lose excess weight and maintain healthy weight

Sodium control: limit sodium to 1500 to 2400 mg/day DASH diet: lower blood pressure through diet alone Additional lifestyle factors: limit alcohol, stop

smoking, reduce saturated fat, increase aerobic activity



Discuss additional nutrition factors that may assist Mr. Elliott in controlling his blood pressure.


Education and Prevention(p. 393)

Food planning and purchasing Control energy intake; read labels Eat fresh foods with small selection of processed

foods Food preparation

Use less salt and fat Use seasonings instead (herbs, spices, lemon,

onion, garlic, etc.) Special needs

Personal desires, ethnic diets, food habits


Education Principles (p. 396)

Start early Prevention begins in childhood, especially with

children in high-risk families Focus on high-risk groups

Direct education to people and families with risk of heart disease and hypertension

Use variety of resources National organizations, community programs,

registered dietitians


chapter 8 care of the patient with a cardiovascular or a peripheral vascular disorder mosby items...

Documents

heart slide

derived items

physiology heart

affiliate of elsevier

heart myocardium

heart muscle tissue

overview of anatomy

apex heart wall