Medical Surgical Nursing I Mukhtar Abobaker

Nursing Management Of Cardiovascular Disorders

Ischemic Heart Disease

- Angina Pectoris
- Myocardial Infarction
Angina Pectoris
* Angina Pectoris:
Angina pectoris is a clinical syndrome usually characterized by chest pain or pressure in the anterior chest due
to imbalance of O2 supply and O2 demand .
* Causes of angina include:-
+ ↑ O2 demand .
- cardiac hypertrophy
+ ↑ O2 supply.
- coronary embolism,
- coronary artery spasm,
- atherosclerotic disease,
- aortic stenosis,
- cardiomyopathy,
- severe anemia,
- thyrotoxicosis.
- hypoxia
* Risk Factors:
→ Modifiable factors
x Cigarette smoking
x Elevated blood pressure
x High blood cholesterol (hyperlipidemia)(Obesity)
x Hyperglycemia (diabetes mellitus)
x Physical inactivity
x Use of oral contraceptives
x Infection (e.g., gingivitis): possibly associated
x Behavior patterns ( stress, aggressiveness )
x Exposure to cold
x Intercourse
→ Non-modifiable factors
x Positive family history ( first degree relative with cardiovascular disease at age 55 or less for males at age 65 or
less for female .
x Age ( more than 45 yrs. for men, more than 55 yrs for women)
x Gender ( occurs 3 times more often in men than in women)
x Race: higher incidence in Africans Americans than in Caucasian.
* Patterns of angina
1. Stable angina
- Stable angina also called exertional angina.
- Stable angina occurs with activities that involve exertion or emotional stress and is relieved with rest or
nitroglycerin.
- Stable angina usually has a stable pattern of onset, duration, severity, and relieving factors.
2. Unstable angina
- Unstable angina also is called preinfarction angina.

1
Medical Surgical Nursing I Mukhtar Abobaker
- Unstable angina occurs with an unpredictable degree of exertion or emotion and increases in occurrence,
duration, and severity over time.
- Pain may not be relieved with nitroglycerin.
3. Variant angina
- Variant angina also is called Prinzmetal’s or vasospastic angina.
- Variant angina results from coronary artery spasm.
- Variant angina may occur at rest.
- Attacks may be associated with ST segment elevation noted on the electrocardiogram.
* clnlinical manifestation:
+ Difference of the pain of Angina and Myocardial Infarction:-
Angina Pectoris Myocardial Infarction
Predisposing/ Precipitating Factors Exertion, especially in colds;
emotional stress; heavy meals May
transpire during rest
Quality Pressing, tight, squeezing, viselike Pressing, tight, squeezing, viselike
heavy occasionally burning heavy occasionally burning
Region/ Radiation Substernal or retrosternal, which Substernal or retrosternal, which
may radiate to shoulder, arms, may radiate to shoulder, arms,
neck, lower jaw, or upper abdomen neck, lower jaw, or upper abdomen
slight to the left side. slight to the left side.
Severity Mild to moderate, rarely to be More severe
described as severe
Timing Pain usually is 1 to 3 minutes up to Pain usually last for 20 minutes or
10 minutes long, or may even last even hours. This type of pain is not
up to 15 to 20 minutes. This pain relieved by rest or Nitroglycerin,
can be relieved by rest or but could be addressed by
Nitroglycerin (vasodilator) Morphine Sulfate (narcotic
analgesic).
Associated Symptoms Dyspnea, nausea and vomiting, Dyspnea, nausea and vomiting,
sweating, and weakness. sweating, and weakness.

Pathophysiology A temporary myocardial ischemia A prolonged myocardial ischemia

which is usually secondary which leads to an irreversible
coronary atherosclerosis. myocardial damage or necrosis.

* Diagnostic Evaluation
- ECG : Readings are normal during rest, with ST depression or elevation and/or T wave inversion during an
episode of pain.
- Cardiac enzyes and troponins: Findings are normal in angina.
- ECHO
* Medical Management
The goals of medical management are to decrease the oxygen demands of the myocardium and to increase the
oxygen supply through pharmacologic therapy and risk factor control.
* Pharmacologic Intervention:
+ Nitrates, the mainstay of therapy (nitroglycerin)
+ Beta-adrenergic blockers (metoprolol [Toprol])
+ Calcium ion antagonists and calcium-channel blockers (amlodipine [Norvase] and diltiazem [Cardizem])
+ Antiplatelet and anticoagulant medications (aspirin, clopidogrel (Plavix], ticlopidine [Ticlid], or heparin)

2
Medical Surgical Nursing I Mukhtar Abobaker
+ Oxygen therapy
* Nursing Care: -
• Instruct patient to stop activity at the first sign of anginal pain
• Monitor vital signs, noting changes or abnormalities
• Assess for diaphoresis
• Assess anxiety level
• Note location, intensity, radiation,and duration of pain
• Assessforfeeling ofimpending death
• Assess any precipitating factors that resulted in angina pain
• Assess for changes in frequency or worsening of symptoms
• Determinewhether pain has occurred before and what has relieved it
• Give Nitroglycerin (NTG) sublingual, as ordered, and tell patient to lie down
• If pain not relieved after one tablet, or as directed by physician, instruct patient to go to emergency room
or if in acute care, notify the nursing staff
• Administer oxygen as ordered
• Promoterestand avoid activities that increase workload on the heart

Myocardial Infarction
* Myocardial Infarction: The death of a segment of the heart muscle.
* Immediate Treatment of a Myocardial Infarction Client “MONA TASS”
M: Morphine
Analgesic drugs such as morphine are to reduce pain and anxiety, also has other beneficial effects as a
vasodilator and decreases the workload of the heart by reducing preload and afterload.
O: Oxygen
To provide and improve oxygenation of ischemic myocardial tissue; enforced together with bedrest to help
reduce myocardial oxygen consumption. Given via nasal cannula at 2 to 4 L/min.
N: Nitroglycerine
First-line of treatment for angina pectoris and acute MI; causes vasodilation and increases blood flow to the
myocardium.
A: Aspirin
Aspirin prevents the formation of thromboxane A2 which causes platelets to aggregate and arteries to constrict.
The earlier the patient receives ASA after symptom onset, the greater the potential benefit.
T: Thrombolytics
To dissolve the thrombus in a coronary artery, allowing blood to flow through again, minimizing the size of the
infarction and preserving ventricular function; given in some patients with MI.
A: Anticoagulants
Given to prevent clots from becoming larger and block coronary arteries. They are usually given with other
anticlotting medicines to help prevent or reduce heart muscle damage.
S: Stool Softeners
Given to avoid intense straining that may trigger arrhythmias or another cardiac arrest.
S: Sedatives
In order to limit the size of infarction and give rest to the patient. Valium or an equivalent is usually given.

* Myocardial Infarction Management: “INFARCTIONS”

Goals of treatment during MI are to minimize myocardial damage, preserve myocardial function, and prevent
complications. These goals can be achieved by reperfusing the area with the emergency use of thrombolytic

3
Medical Surgical Nursing I Mukhtar Abobaker
medications or by PCI. Reducing myocardial oxygen demand, and increasing oxygen supply with medications,
oxygen administration and bed rest can minimize myocardial damage.
- I: IV access:- Two IV lines are placed usually to ensure that access is available for administering emergency
medications.
- N: Narcotic analgesics:- Morphine is the analgesic of choice for MI and is administered in IV boluses to reduce
pain and anxiety; reduces preload and afterload and relaxes bronchioles to enhance oxygenation.
- F: Facilities for defibrillation (DF):- Have the crash cart available and ready.
- A: Aspirin:- Inhibits platelet aggregation. Treatment should be initiated immediately and continued for years.
- R: Rest:- Bed rest promotes comfort and healing.
- C: Converting enzyme inhibitor:- ACE-inhibitors lowers the blood pressure and the kidneys excrete sodium and
fluid.
- T: Thrombolytics:- Administered via IV to dissolve the thrombus in a coronary artery, allowing blood
reperfusion, minimizing the size of the infarction and preserving ventricular function.
- I: IV beta blocker:- Long-term therapy with beta-blockers decreases the future incidences of cardiac events.
- O: Oxygen:- Administer at a modest flow rate for 2 to 3 LPM.
- N: Nitrates:- To increase cardiac output and reduce myocardial workload; relieves pain by redistributing blood
to ischemic areas of the myocardium.
- S: Stool Softeners:- To prevent straining during defecation, which causes vagal stimulation and may slow the
heart rate.

* Myocardial Infarction Nursing Management: “BEE CAB SCORE”

Nursing care for patients who suffered MI is directed towards detecting complications, preventing further
myocardial damage, and promoting comfort, rest, and emotional well-being.
• B: Bed rest
Bed rest helps reduce myocardial oxygen consumption.
• E: ECG Monitoring
Frequently monitor ECG to detect rate changes or arrhythmias; place rhythm strips in the patient’s chart for
evaluation.
• E: Emotional support
Provide support and help reduce stress and anxiety; administer tranquilizers as needed.
• C: Cluster/Organize Patient Care
To maximize periods of uninterrupted rest.
• A: Antiembolism stockings
Can help prevent venostasis and thrombophlebitis.
• B: Bedside commode
Allow use of bedside commode and provide privacy as much as possible.
• S: Stool Softener
To prevent straining during defecation causing vagal stimulation and slow heart rate.
• C: Cardiac Rehabilitation Program
Includes education regarding heart disease, exercise, and emotional support for the patient and the family.
• O: Oxygen therapy
Increases available oxygen; set at 2-3 LPM.
• R: Range-of-motion Exercises
Provides physical activity for the patient; if immobilized, turn him often.
• E: Educate and inform
Explain procedures and answer questions.

4
Medical Surgical Nursing I Mukhtar Abobaker
Hypertension

• Hypertension is defined as a systolic blood pressure greater than 140 mm Hg and a diastolic pressure greater
than 90 mmHg, based on two or more measurements.

* Stage of Hypertension can be classified as follows:

• Normal: systolic less than 120 mm Hg; diastolic less than 80 mm Hg
• Prehypertension: systolic 120 to 139 mm Hg; diastolic 80 to 89 mm Hg
• Stage 1: systolic 140 to 159 mm Hg; diastolic 90 to 99 mm Hg
• Stage 2: systolic 160 mm Hg; diastolic 100 mm Hg
* Typesof Hypertensive :
1 – Essential (Primary) Hypertension
. A most common 95%
. Occur in adults in age 35 - 55 yrs
. Unknown cause
. Modifiable
. -ve family history risk factor
2 – Secondary Hypertension
. A less common 5%
. Occur in adults in age 25 - 55 yrs
. Known of medical cause as (renal or heart disease )
. Nonmodifiable
. +ve family history
* Risk Factors of HTN (Modifiable) :
. Weight(obesity ) . Diet(↑ Sodium) . Caffeine . Alcohol use . Inactivity 3-4X er
. Smoking . Stress . Sleep disturbances
Never make suggestions to patient out of these guide lines, refer them to MD if need be.
* Risk Factors of HTN (Nonmodifiable) :
. Family HX, . Age, . Ethnicity, . Diabetes
3– Accelerated and Malignant Hypertension:-
• More serious • Abrupt onset • One leads to the other
• Found in previously undiagnosed • Lack follow-up • Poor compliance
• Fatal if untreated
* Signs and Symptoms of HTN :-
• Asymptomatic None "Silent Killer"
• Rare= headache, bloody nose, anxiety, dyspnea,N/V,confusion
• ↑ Bp > 140/90 mmHg
* Diagnosis of HTN :-
HX, S&S, kidney or heart disease, home BP readings, ECG, blood glucose, HCT, K+, CA+, lipoprotein,
cholesterol, triglycerides

* Hypertension Complications “5 C’s of Hypertension Complications”

C: Coronary Artery Disease
Can lead to narrowing of blood vessels making them more likely to block from blood clots or fat breaking off
from the lining of the blood vessel wall; also weakens the walls.
C: Chronic Renal Failure
Constant high blood pressure can damage small blood vessels in the kidneys making it not to function properly.

5
Medical Surgical Nursing I Mukhtar Abobaker
C: Congestive Heart Failure
Pumping blood against the higher pressure in the vessels causes the heart muscles to thicken. Eventually, the
heart muscles may have a hard time pumping enough blood to meet the physiologic needs of the body leading
to heart failure.
C: Cardiac Arrest
High blood pressure can cause CAD, damaged arteries cannot deliver enough oxygen to other parts of the body
eventually leading to heart attack as( MI , Left Ventricular Hypertrophy ).
C: Cerebrovascular Accident
Hypertension leads to atherosclerosis and hardening of the large arteries. This, in turn, can lead to blockage of
small blood vessels in the brain. It can also weaken the blood vessels in the brain causing them to balloon and
burst.

* Medical treatment:
• Goal is to lower B/P & minimize or prevent complicat
–TX risk factors – also known as lifestyle changes
• Diet ↓ salt ↓ fat diet
• controk Weight
• Smoking cessation
• Exercise
– Treatment of causative disease if secondary hypertension )
* Nursing TX for HTN: -
• patient education, Knowledge ( Disease, Diet, Drugs)
• Lifelong BP control(self care measures, prescribed Antihypertensives drugs ) as:
– Diuretics – Calcium Channel blockers – ACE I – Beta Blockers
– Alpha Blockers – Alpha – Beta Blockers – Beta Blockers
• Safety issues
– hypotension

Valvular Heart disorders

* Pathophysiology
The valves of the heart act like one-way doors to keep the blood flowing in the appropriate direction. The
valves open when blood pushes through and close when the chamber is filled.

Disorder Structure Affected Physical Findings Nursing Care

• Valvular stenosis • Occurs when the valve
becomes thick
• Valvular insufficiency • Narrowing of the
opening between the
heart valves
• Valve is unable to close
completely
• Interferes with the
blood flow through
the heart structures
• Heart murmur • Monitor
• Wheezesand crackles in ▶ Vital signs
the lungs or edema ▶ Cardiac monitoring if in
(pitting or non-pitting) acute care
• Anxiety ▶ Signs and symptoms
• Dyspnea associated with
• Weakness/faintness complications
• Nausea • Give medication to lower
• Pallor blood pressure and prevent
• Erratic behavior clot formation
• Hypotension, shock • Encourage techniques to
• History of rheumatic reduce anxiety or tension

6
Medical Surgical Nursing I
fever
• Fatigue or weakness
when performing
activities of daily living
(ADLs)
• Chest pain
• Dizziness, fainting
• Complaints of heart
palpitations
• Weight gain
• Exertional dyspnea,
nocturnal dyspnea
Mukhtar Abobaker
• Instruct patient to drink
fluids often unless in heart
failure
• Assess for pain if
occlusion to extremities is
suspected
• Assist with ambulation
and encourage movement
of extremities
• Administer oxygen
• Maintain homeostasis
• Control dysrhythmias
• Monitor for heart failure