Medical surgical nursing - Cardio vasCular disorders

Angina pectoris :

Chest pain due to an inadequate supply of oxygen to

the heart muscle. The pain is typically severe and
crushing, and it is characterized by a feeling of
pressure and suffocation just behind the breastbone.
Angina can accompany or be a precursor of a heart
attack.

It a condition marked by severe pain in the chest,

often also spreading to the shoulders, arms, and
neck, owing to an inadequate blood supply to the
heart.

Angina meaning
 Translated as pain (angina) in the chest (pectoris).
 Usually last a few minutes (3 to 5 minutes) and subsides with rest.

Precipitating factors
o Physical exertion o cigarette smoking
o strong emotions o sexual activity
o consumption of heavy meals o stimulants (cocaine)
o temperature extremes

Types of Angina
I. Stable angina
II. unstable angina (unpredictable)
III. Prinzmental’s angina (occurs a rest usually in response to spasm of a major
coronary artery.

Clinical Manifestations

 Chest pain  Indigestion or burning

 apprehension, dyspnea,  Feeling of anxiety
diaphoresis  SOB, cold sweats, weakness
 some deny pain but feel vague  Nausea
sensation, a strange feeling,
pressure, or ache in the chest.

Risk Factors:

Modifiable Unmodifiable
Cigarette smoking Genetic disposition
Drugs and alcohol Diabetes
Hypertension Age
Elevated Serum lipids Gender (men>women until
Stressful lifestyle 60 yr of age)
Obesity Race (african-
Physical inactivity amercians<Caucasians)

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 Medical surgical nursing - Cardio vasCular disorders

Complications
o Arrhythmia’s
o Premature contractions
o Fibrillation
Diagnostic studies
 History and physical  lipid levels
 CXR  Stress test
 EKG  Nuclear studies
 CK-MB  PET Scan
 Cardiac troponin  Echo
Collaborative Care
1. PTCA (Percutaneous transluminal coronary angioplasty)
2. Stent placement
3. Angioplasty
4. CABG(Coronary Artery Bypass Grafting)
Drug Therapy
 Antiplatelet
 ASA - Acetylsalicylic acid (drug of choice)
 Nitrates
Nitroglycerin (can be give sublingually, IV, ointment, transdermal)
 Sublingually give 1 tablet under the tongue every 5 minutes X 3.
 Beta blockers (Lopressor, Inderal, Tenormin)
 calcium channel blockers (Verapmil, Procardia, Cardizem.
Nursing Diagnosis
 Pain related to ischemic myocardium
 Anxiety related to awareness of having a heart disease, uncertainty about
the future
 decreased Cardiac output related to myocardial ischemia affecting
contractility
 Activity intolerance related to myocardial ischemia

Nursing Implementation
If the nurse is present during an anginal attack
 administer o2
 get vital signs
 12 lead EKG
 nitrates
 physical assessment of the chest
 make patient comfortable
Ambulatory and Home Care

 Take medications (antiplatelets, ASA, Ticllid, etc.)

 Nitro ointment
 Transdermal nitro
 Beta blockers
 Calcium channel blockers
 management of risk factors

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 Medical surgical nursing - Cardio vasCular disorders

Myocardial Infarction

Myocardial infarction (MI) death of

the cells of an area of the heart muscle
(myocardium) as a result of oxygen
deprivation, which in turn is caused by
obstruction of the blood supply; commonly
referred to as a “heart attack.”

Clinical Manifestations

o Pain
o Nausea and vomiting
o Diaphoresis
o Fever
o Elevated BP, heart rate then later it drops because of decreased in cardiac
output

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 Medical surgical nursing - Cardio vasCular disorders

Complications
Arrhythmias Ventricular aneurysm
CHF Pericarditis
Cardiogenic shock Dressler’s syndrome
Papillary muscle Right Ventricular Failure
dysfunction Pulmonary Emboli

Diagnostic Studies
 12 lead EKG
 Cardiac enzymes
 Troponin levels
Collaborative Care
 Take to CCU  Antiarrythmic drugs
 IV route  Bed rest
 Morphine  Recording I/O’s
 O2  PTCA (Percutaneous
 Monitor V/S transluminal coronary angioplasty)
 Lidocaine drip  CABG(Coronary Artery Bypass
 Thrombolytic therapy Grafting)
 Anticoagulant therapy (ASA)
Drug therapy

 IV Nitro  Calcium channel blockers

 Antiarrythmic drugs  Angio-tension-converting
 Morphine enzyme inhibitors
 Positive Inotropic drugs  Stool softeners
 Beta blockers
Nutritional Therapy
 Low fat diet
 Low cholesterol
 Low salt

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 Medical surgical nursing - Cardio vasCular disorders

Nursing Implementation
o Pain
o monitoring
o rest and comfort
o anxiety
o Emotional and behavioral reactions
Ambulatory and Home Care
 ASA (Acetylsalicylic acid)  Diet
80-325 mg per day  Dietary restrictions
 Patient education (cause  Management of risk factors
and effect, terms, s/s, risk  Exercise
factors)  Sexual activity
 Rest
Sudden Cardiac death
 -Unexpected death from cardiac causes.
 -In SCD there is a disruption in cardiac function, producing an abrupt loss of
cerebral blood flow.
 -Death occurs within 1 hour of the onset of acute symptoms.
 Occurs to approximately 350,000 deaths a year in the U.S.
 Only 20% of SCD are discharge form the hospital without neurological
problems.

Risk Factors
 -Male gender  -HTN
 -Family history of  -Cardiomeagely
premature atherosclerosis  -Ejection fraction of less
 -Cigarette smoking than 40%
 _DM  -History of ventricular
 -Hypercholesterolemia arrhythmia

Collaborative Management
o -Several cardiac enzymes o -24 hour holter monitor if
o -EKG they are known to have
o -Cardiac cath arrhythmia’s
o -PTCA o -Electrophysiology study
o -CABG (EPS)

Nursing Care
 *Mostly talking to patients and educating the patient and families to relieve
some anxieties and fears.
 -Must patients have a feeling that they are a “time bomb” waiting to
happen.
 -Wives usually blames themselves for this occurrence.
 -Patients and families have a lot of fear and anxiety.
 -Depression

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 Medical surgical nursing - Cardio vasCular disorders

Woman and CAD

Number one killer in the women.

Approximately 500,000 deaths a year.
Women manifest CAD 10 years later than men.
Most women have symptoms of angina than men.
The stress test has a low sensitivity in women, and 30-40% jfo women have
false-positive results. (This is due to women having low HCT, higher
pulmonary and systolic BP responses to exercise, and ST segment depression
form circulating estrogen).
Women have a higher mortality rate within one year following an MI than
men. (due to developing CAD later than men)
Woman and CAD
o More likely to have Diabetes, HTN, and heart failure.
o Women after CABG have higher mortality rate than men and more
complications (this is because women have smaller arteries, are older, and
are referred more frequently for CABG with severe angina or unstable
angina requiring urgent or emergency surgery).
o Women also have higher rate of coronary dissection and hospital mortality
than men following PTCA, but men have a higher incidence of restenosis.

Implication for nursing

· -Aggressive education about the reduction of risk factors.
· -Education, education, education
ODE to the Node
o ODE to a Node
o Have a heart, and have no fear
o The SA node is over here
o Beating at a constant rate
o 60-100 is really great.
o The AV node can make a show
o If SA node has gone too slow.
o 40-60 is not bad
o If it’s all you’ve got you will be glad.
o Should the whole thing drop its speed
o His and bundle branches will take the lead.
o And that, my friend is the whole and part,
o Of the conduction system of your heart.

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 Medical surgical nursing - Cardio vasCular disorders

Congestive Heart Failure

Definition
o CHF is a cardiovascular condition in which the heart is unable to pump an
adequate amount of blood to met the metabolic needs of the body’s tissue.
o It is not a disease……..IT IS A SYNDROME
o CHF is characterized by LVH, reduced exercise intolerance, diminished
quality of life, and shortened life expectancy.
CHF
֎ Is associated with HTN and CAD.
֎ More than half of the deaths from heart disease is associated to end-stage
CHF.
֎ 23 million people in the world wide have CHF.
֎ AHA says that about 400,000 get CHF/year.
֎ Mortality rate is 50%
֎ About 20% of people who had MI will be disabled with heart failure within 6
years.
CHF

‡ CHF is the single most frequent cause of hospitalization for people age 65
and older.
‡ CHF has a poor prognosis and is likely to remain a major clinical and health
care problem.
Risk factors
¤ CAD
¤ HTN
¤ diabetes
¤ cigarette smoking
¤ obesity
¤ High cholesterol
¤ proteinuria
Etiology
† CHF may be caused by any interference with the normal mechanisms
regulating cardiac output.
† CO depends on: Preload, afterload, myocardial contractility, heart rate and
metabolic state of the individual.
† Any alteration of these results in CHF.

Compensatory Mechanisms
· Dilation
· Hypertrophy
· Sympathetic nervous system
· Hormonal response

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 Medical surgical nursing - Cardio vasCular disorders

Common causes
· CAD · Acute MI
· HTN · Arrhythmias
· Rheumatic heart disease · Pulmonary emboli
· Congenital heart disease · Hypertensive crisis
· Cor Pulmonale · Ventricular septal defect
· Anemia

Type of CHF
· Left sided CHF
· Right sided CHF
Left sided
· Results from LV dysfunction, which causes blood to back up through the left
atrium and into the pulmonary veins.
· This increase causes to go from the pulmonary capillaries bed to the
interstitium and then the alveoli, causing pulmonary congestion and edema.
· Pulmonary congestion
· pulmonary edema
· Fatigue
· Dyspnea
· dry, hacking cough
· Nocturia
· Crackles
Right-sided heart failure
· Failure from the right ventricular that causes backflow to the right atrium
and venous circulation.
· The primary cause of right-sided failure is left sided failure

Right-sided heart failure

† Dependent edema
† Weight gain
† Juglar vein distention
† Hepatomegaly (liver engorgement)
† Fatigue
† Right upper quadrant pain
† Anorexia and GI bloating
† Nausea
Complication of heart failure
‡ Pleural effusion
‡ Arrhythmia’s
‡ Left Ventricular thrombus
‡ Hepatomegaly

Diagnostic studies
¤ History and physical
¤ ABG’s
¤ Liver profile

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 Medical surgical nursing - Cardio vasCular disorders

¤ CXR
¤ 12 lead EKG
¤ Echo
¤ Nuclear studies
¤ Cardiac cath

Nursing management for acute CHF and pulmonary edema

Goal therapy is to improve:

· left ventricular function by decreasing intravascular volume
· decrease afterload
· Improve gas exchange
· Improve O2, CO and reduce anxiety

Nursing management for Chronic Heart Failure

֎ Positive Inotropic drugs
֎ Digitalis preparation
֎ Beta-adrengeric agonist
֎ Diuretics
֎ Vasodilator drugs
֎ Sodium Nirtoprusside
֎ Nitrates
֎ Angiotension-converting enzyme inhibitors
֎ Beta-adrenergic blocking agents

Nutritional therapy
o Diet education
o Weight management
o Low sodium (2 g NA diet)
¤ More severe is 500-1000mg.
o Fluid restrictions
o Weight Daily (THIS IS IMPORTANT)
¤ same day everyday, preferably before breakfast.

Nursing Diagnosis
· Activity intolerance
· sleep pattern disturbance
· fluid volume excess
· Risk for skin integrity
· Impaired gas exchange
· Anxiety

Patient teaching
· Rest · Activity program
· Drug therapy · Ongoing monitoring
· Dietary therapy

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 Medical surgical nursing - Cardio vasCular disorders

NORMAL SINUS RHYTHM

· Rhythm is regular
· Rate is 60-100 beats/min
· PR Interval is 0.12-0.20 seconds
· Upright P wave
· QRS is 0.12 seconds or less
Sinus Bradycardia
· Rhythm is regular
· Rate is below 60 beats/min
· PR Interval is 0.12-0.20 seconds
· Upright P wave
· QRS is 0.12 seconds or less
· Resting heart rates below 60 might be normal in athletes
· Watch for hypotension
Sinus Tachycardia
o Rhythm is regular
o Rate is between 101 and 150 beats/min
o PR Interval is 0.12-0.20 seconds
o Upright P wave
o QRS is 0.12 seconds or less
o Is considered SVT when greater than 150 unless in children
o ATRIAL FLUTTER
Atrial Flutter
 Rhythm may be regular or irregular
 Atrial rate is 230-350 beats/min
 Ventricular rate varies
 PR Interval is usually nonexistent
 Flutter waves replace the P waves; they resemble a “saw tooth”
 QRS is 0.12 seconds or less
 Will see the saw tooth waves across the baseline
Atrial Fib
o Rhythm is irregular and usually erratic
o Atrial rate is 350-400 beats/min
o Ventricular rate varies
o There is usually no PR Interval
o P waves are erratic and baseline appears “wavy”
o QRS is 0.12 seconds or less
o If on medications, can see a slower atrial rate but still a-fib

VENTRICULAR TACHYCARDIA
 Rhythm is usually regular
 Ventricular rate is greater than 100 beats/min
 QRS is wide and is greater than 0.12 seconds
 There is no P wave
 Can be stable or unstable
 Can have a pulse or no pulse
 If have more than 3 is a run of v-tach

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 Medical surgical nursing - Cardio vasCular disorders

VENTRICULAR FIBRILLATION
o Rhythm is chaotic and no regularity noted
o No identifiable QRS complexes
o No P waves
o Total chaotic electrical activity creates the baseline
o Can be coarse or fine
o No pulse
ASYSTOLE
o No PQRST
o Baseline straight or slightly wavy
o Must be confirmed in 2 leads
o No pulse

Peripheral Vascular Disease

¤ Definition

· Intermittent claudication due to an inadequate oxygen supply.

o It occurs when the patient is walking, exercising, etc. Patient will get leg
pain and cramps.
o SMOKING IS THE NUMBER ONE REASON FOR PVD
¤ Inspection
o Assess skin color, hair distribution, and venous blood flow.
o Extremities should be assessed for thromophlebitis, varcoise veins, and
lesions such as stasis ulcers.
o Check capillary refills, edema, pulses
o Homan’s sign: Presence of calf pain during sharp dorsiflexion of foot. This is
nonspecific and can be elicited from any painful condition of the calf.
o Pulses
 0- absent
 1t= weak, thready
 2t= normal
 3t= full, bounding
¤ Auscultation
· If the artery is narrowed or bulging it will create an abnormal buzzing sound
(BRUIT).
· Other things you can hear:
· Bounding: sharp and brisk rising pulse
· thready: weak, slow rising pulse
· Thrill: vibration
Things that can occur

Pulmonary Embolism

· most common pulmonary complication in hospitalized patients.

· Estimated that about 500,000 die each year for PE.
· Most arise in the deep veins of the legs.

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 Medical surgical nursing - Cardio vasCular disorders

· Other sites are the right side of the heart (AFIB), upper ext. (rare) and
pelvic veins (especially after childbirth).
Emboli
· Mobil clot that generally do not stop moving until they lodge at a narrowed
part of the circulatory system.
· The lungs are an ideal location for emboli to lodge because of their
extensive arterial and capillary network.The presence of a deep vein
thrombosis is usually unsuspected until a pulmonary embolism occurs.
· Thrombi in the deep vein can dislodge spontaneously.
 Assessment of DVT: a warm, reddish blue extremity.
· More common mechanism that throws a clot is sudden standing and changes
of the rate of blood flow, such as valsalva’s maneuver.

Clinical Manifestations
This depends on the size of the emboli and the number of blood vessels occluded.
· Sudden onset of unexplained dyspnea
· Tachypnea
· Tachycardia
· Cough
· Chest pain
· hemoptysis
· crackles
· fever
· changes in mental status

Massive Emboli
The patient will suddenly collapse and experience.
· shock, pallor, have sever dyspnea, and crushing chest pain.
· Pulse is rapid and weak
· BP is low
When rapid obstruction of 50% or more occurs, acute Cor Pulmonale may result because
of right ventricle can no longer pump blood into the lungs.
Death occurs in over 60% of patients.

Medium-sized emboli
Can cause pleuritic chest pain accompanied by:
· Dyspnea
· slight fever
· productive cough with blood streaked sputum
· Tachycardia
· Friction rub

Small emboli
· Undetected or produce vague, transient symptoms.
Complications

1. Pulmonary Infarction
· Death of lung tissue occurs in less than 10% of patients with emboli.

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 Medical surgical nursing - Cardio vasCular disorders

· It is more likely to occur in patients with: occlusion of a large or medium-

sized pulmonary vessel (<2mm)
· Insufficient collateral blood flow from the bronchial circulation
Preexisting lung disease

Pulmonary Hypertension
· Occurs when more than 50% of the area of the pulmonary bed is
compromised.
· Also results form hypoxemia.
· Only if the emboli is massive will this occur.
· But small to medium emboli that are recurrent can cause pulmonary
hypertension.
Diagnostic test
· History and physical
· Venous studies (venous Doppler’s, lung scans, pulmonary arteriogram).
· CXR
· ABG’s
· CBC
Collaborative care
· Oxygen mask or cannula.
· IV site
· IV heparin
· Bed rest
· Narcotics for pain
· Thrombolytic agents
· Vena cava filter
· Pulmonary embolectomy
Drug therapy
· Diuretics (if heart failure occurs).
· Heparin
· Coumadin
HEPARIN
¤ It is an anticoagulant.
¤ Should be started immediately.
¤ The dosage of heparin is adjusted according to its effect on the PTT.
¤ Normal PTT is 35-45
¤ Bolus is always given first
¤ PTT should be one and half to two and half times normal to be therapeutic.
Coumadin
 Anticoagulant
 PT is monitored
 Doc adjusted according to PT levels. The most significant is the INR.
 PT is always drawn with the INR.

Nursing management
 Health promotion
 Bed rest
 Semi-fowler’s position.

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 Medical surgical nursing - Cardio vasCular disorders

 IV line for medications and fluid therapy.

 Careful monitoring of ABG’s, ECG, and lung sounds.
 Nurse should explain the situation to patient/family.

Education
Educate patient with s/s and explain what is going on because they feel:
‡ Pain
‡ sense of doom
‡ inability to breathe
‡ explain situation and provide emotional support.

Ambulatory and home care

 Emotional support
 teach, teach, teach

Diagnosis
 Adequate tissue perfusion.
 Adequate cardiac output
 Increased level of comfort

Arterial Blood gases

· Normal ABG Values
· Ph- 7.35-7.45
· Sat- 95-100%
· PaO2- 80-100
· pCO2- 35-45
· HCO3- 22-28
 Use pH, pCO2 and HCO3 components to determine acid-base balance.
 Begin at pH. Based on you answer to questions, follow the sequence of the
diagram.
 Determine what you primary disturbance is. Be sure to check all components
(remember you have 2 primary disturbances I.e., metabolic and respiratory
acidosis)
 Once the primary disturbance is identified, determine if compensation is present.
 Ask yourself is the pH normal
 YES: then ask is the pCO2 WNL
 YES: Normal-acid base balance
 Is the pH normal
 NO: if decreased it is acidosis and if it’s increased it’s alkalosis.
 Now ask if the pH is not normal:
 pH is decreased (acidosis) look at the pCo2. If it is HIGH it is Respiratory Acidosis if
the HCO3 is also High then it is Respiratory acidosis compensated with Metabolic
acidosis.
 pH is decreased: acidosis now look at the HCO3 if low it is metabolic acidosis if the
pCO2 is low. It is metabolic acidosis compensated with respiratory alkalosis.
 IF pH is elevated (ALKALOSIS)
 look at pCO2 if low = Respiratory alkalosis
 and if HCO3 is low it is respiratory alkalosis compensated with metabolic acidosis.

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 Medical surgical nursing - Cardio vasCular disorders

 If HCO3 is high= metabolic alkalosis

 and pCO2 is high=metabolic alkalosis compensating with respiratory acidosis.

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