CARE OF THE PATIENT

WITH CARDIOVASCULAR
DISORDERS

OBJECTIVES
At the end of this session the students should be
able to care for the clients with cardiovascular
disorders.

STRUCTURE OF THE HEART

GREAT VESSEL AND HEART

CHAMBER PRESSURES

TERMS - CARDIAC OUTPUT

Stroke volume: amount of blood ejected with each
heartbeat
Cardiac output: amount of blood pumped by
ventricle in liters per minute
Preload: degree of stretch of cardiac muscle fibers
at end of diastole
Contractility: ability of cardiac muscle to shorten
in response to electrical impulse

QUESTION
Which

of the following best defines stroke

volume?
A. The amount of blood ejected with each
heartbeat
B. Amount of blood pumped by the ventricle
in liters per minute
C. Degree of stretch of the cardiac muscle
fibers at the end of diastole
D. Ability of the cardiac muscle to shorten in
response to an electrical impulse

ANSWER
A. The amount of blood ejected with each
heartbeat
Rationale: Stroke volume is the amount of blood
ejected with each heartbeat. Cardiac output is
the amount of blood pumped by the ventricle in
liters per minute. Preload is the degree of stretch
of the cardiac muscle fibers at the end of diastole.
Contractility is the ability of the cardiac muscle
to shorten in response to an electrical impulse.

ANGINA PECTORIS
A syndrome characterized by episodes or paroxysmal
pain or pressure in the anterior chest caused by
insufficient coronary blood flow.
Physical exertion or emotional stress increases
myocardial oxygen demand and the coronary vessels
are unable to supply sufficient blood flow to meet the
oxygen demand.

ANGINA PAIN VARIES FROM MILD TO SEVERE

May be described as tightness, choking, or a heavy
sensation.
Frequently retrosternal and may radiate to neck, jaw,
shoulders, back or arms (usually left).
Anxiety frequently accompanies the pain.
Other symptoms may occur: dyspnea/shortness of breath,
dizziness, nausea, and vomiting.

ANGINA PAIN VARIES FROM MILD TO SEVERE

The pain of typical angina subsides with rest or NTG.
Unstable angina is characterized by increased frequency
and severity and is not relieved by rest and NTG.
Requires medical intervention!

TREATMENT
Treatment seeks to decrease myocardial oxygen
demand and increase oxygen supply
Medications
Oxygen
Reduce and control risk factors
Reperfusion therapy may also be done

MEDICATIONS
Nitroglycerin
Beta-adrenergic blocking agents
Calcium channel blocking agents
Antiplatelet and anticoagulant medications
Aspirin
Heparin

QUESTION
Is the following statement True or False?
Nitroglycerin tablets should never be removed and
stored in metal or plastic pillboxes.

ANSWER
True
Nitroglycerin tablets should never be removed and
stored in metal or plastic pillboxes.

NURSING PROCESS: THE CARE OF THE

PATIENT WITH ANGINA PECTORIS
ASSESSMENT
Symptoms and activities, especially those that precede
and precipitate attacks
Risk factors, lifestyle, and health promotion activities
Patient and family knowledge
Adherence to the plan of care

NURSING PROCESS: THE CARE OF THE

PATIENT WITH ANGINA PECTORIS
DIAGNOSES
Ineffective cardiac tissue perfusion
Deficient knowledge
Noncompliance, ineffective management of therapeutic
regimen

NURSING PROCESS: THE CARE OF THE

PATIENT WITH ANGINA PECTORIS
PLANNING

Goals include the immediate and appropriate

treatment of angina, prevention of angina, reduction of
anxiety, awareness of the disease process,
understanding of prescribed care, adherence to the
self-care program, and absence of complications.

TREATMENT OF ANGINA PAIN

Treatment

of angina pain is a priority nursing

concern.
Patient is to stop all activity and sit or rest in bed.
Assess the patient while performing other
necessary interventions. Assessment includes VS,
and observation for respiratory distress, and
assessment of pain. In the hospital setting, the
ECG is assessed or obtained.
Administer oxygen.
Administer medications as ordered - NTG.

NURSING INTERVENTIONS

Maintain bed rest in position of comfort during acute

episodes. Decreases oxygen consumption and myocardial
workload.
Monitor vital signs. Tachycardia may be present because of
pain.
Administer oxygen as prescribed. Increases oxygen
available for myocardial uptake to contractility and reduces
ischemia.
Administer medications as prescribed calcium channel
blockers e.g. Nifedipine. Preventing and terminating
ischemia induced by coronary artery spasm.
Provide for adequate rest periods. Conserves energy, reduces
cardiac workload.

ANXIETY
Use a calm manner
Stress-reduction techniques
Patient teaching
Addressing patient spiritual needs may assist in
allaying anxieties
Address both patient and family needs

PATIENT TEACHING
Lifestyle changes and reduction of risk factors
Explore, recognize, and adapt behaviors to avoid to
reduce the incidence of episodes of ischemia
Teaching regarding disease process
Medications
Stress reduction
When to seek emergency care

MYOCARDIAL INFARCTION

An area of the myocardium is permanently destroyed.

Usually caused by reduced blood flow in a coronary
artery due to rupture of an atherosclerotic plaque and
subsequent occlusion of the artery by a thrombus.

MYOCARDIAL INFARCTION
In unstable angina, the plaque ruptures but the artery
is not completely occluded. Unstable angina and acute
myocardial infarction are considered the same process
but at different point on the continuum.
The term acute coronary syndrome includes unstable
angina and myocardial infarction.

EFFECTS OF ISCHEMIA, INJURY, AND

INFARCTION ON ECG

CLINICAL MANIFESTATIONS
Pressure, tightness, pain, or a squeezing or
aching sensation in your chest or arms that may
spread to your neck, jaw or back)
A feeling of fullness, nausea, indigestion,
heartburn or abdominal pain
Shortness of breath
Sweating or a cold sweat

CLINICAL MANIFESTATIONS
Feelings of anxiety or an impending sense of
doom
Fatigue
Trouble sleeping
Lightheadedness or dizziness

QUESTION
What is the purpose of an echocardiogram?
A. Evaluate arterial function of the heart
B. Evaluate ventricular function of the heart
C. Detect hyperkinetic wall motion
D. Identify ischemia changes

ANSWER
B

The echocardiogram is used to evaluate

ventricular function.

INFECTIVE ENDOCARDITIS
A microbial infection of the endothelial surface of the
heart. Vegetative growths occur and may embolize to
tissues throughout the body.
Usually develops in people with prosthetic heart valves or
structural cardiac defects. Also occurs in patients who
are IV drug abusers and in those with debilitating
diseases, indwelling catheters, or prolonged IV therapy.

CLINICAL MANIFESTATIONS
Fever
Chills
A new or changed heart murmur abnormal
heart sounds made by blood rushing through
your heart
Fatigue
Aching joints and muscles
Night sweats
Shortness of breath
Paleness

CLINICAL MANIFESTATIONS

Persistent cough
Swelling in your feet, legs or abdomen
Unexplained weight loss
Blood in your urine (either visible or found in a
doctor's viewing of your urine under a microscope)
Tenderness in your spleen an infection-fighting
abdominal organ on your left side, just below your rib
cage
Osler's nodes red, tender spots under the skin of
your fingers
Petechiae tiny purple or red spots on the skin,
whites of your eyes or inside your mouth

DIAGNOSTIC TESTS
Blood tests. The most important test is a blood
culture used to identify bacteria in the
bloodstream.
Transesophageal echocardiogram. An
echocardiogram uses sound waves to produce
images of your heart at work. During this test, an
ultrasound device is passed through the mouth
and into your esophagus the tube that
connects the mouth and stomach.

DIAGNOSTIC TESTS

Electrocardiogram (ECG). The doctor may order

this noninvasive test if he or she thinks endocarditis
may be causing an irregular heartbeat. An ECG
measures the timing and duration of each electrical
phase in your heartbeat.
Chest X-ray. X-ray images displays the condition of
the lungs and heart. The doctor can use X-ray images
to see if endocarditis has caused your heart to enlarge
or if infection has spread to your lungs.
Computerized tomography (CT) scan or
magnetic resonance imaging (MRI). You may
need a CT or MRI scan of the brain, chest or other
parts of the body if the doctor thinks that infection
has spread to these areas.

HEALTH EDUCATION
To help prevent endocarditis, make sure to
practice good hygiene:
Pay special attention to dental health brush
and floss your teeth and gums often, and have
regular dental checkups.
Avoid procedures that may lead to skin
infections, such as body piercings or tattoos.
Seek prompt medical attention if you develop any
type of skin infection or open cuts or sores that
don't heal properly.

PERICARDITIS

Pericarditis is a condition in which the sac-like covering

around the heart (pericardium) becomes inflamed.

CLINICAL MANIFESTATION
Chest pain is almost always present. The pain:
May be felt in the neck, shoulder, back, or
abdomen
Often increases with deep breathing and lying
flat, and may increase with coughing and
swallowing
Can be a sharp, stabbing pain
Is often relieved by sitting up and leaning or
bending forward

MEDICAL TREATMENT
High doses of nonsteroidal anti-inflammatory
drugs (NSAIDs) such as ibuprofen are often
given. These medicines will decrease your pain
and reduce the swelling or inflammation in the
sac around your heart.
A medicine called colchicine may be added,
especially if pericarditis does not go away after 1
to 2 weeks or it comes back weeks or months
later.

MEDICAL TREATMENT
If the cause of pericarditis is an infection:
Antibiotics will be used for bacterial infections
Antifungal medications will be used for fungal
pericarditis
Other medicines that may be used are:
Corticosteroids such as prednisone (in some
patients)

MEDICAL TREATMENT
Diuretics administered to remove excess fluid
If the buildup of fluid makes the heart function
poorly, treatment may include:
Draining the fluid from the sac. This procedure,
called pericardiocentesis, may be done using an
echocardiography-guided needle.

MEDICAL TREATMENT

Cutting a small hole (window) in the pericardium

(subxiphoid pericardiotomy) to allow the infected
fluid to drain into the abdominal cavity

ATHEROSCLEROSIS

Hardening of the arteries, also called

atherosclerosis, is a common disorder. It occurs
when fat, cholesterol, and other substances build
up in the walls of arteries and form hard
structures called plaques.

PROGRESSION OF ATHEROSCLEROSIS

COMMON SITES OF ATHEROSCLEROTIC

OBSTRUCTION

RISK FACTORS FOR ATHEROSCLEROSIS

MODIFIABLE
NONMODIFIABLE
Nicotine
Diet
Hypertension
Diabetes
Obesity
Stress
Sedentary lifestyle
C-reactive protein
Hyperhomcysteinemia

Age
Gender
Familial
predisposition/genetics

QUESTION
What is a nonmodifiable risk factor for
atherosclerosis?
A.

Hypertension

B.

Diabetes

C.

Obesity

D.

Familial predisposition/genetics

ANSWER
D
Hypertension, diabetes, and obesity are modifiable
risk factors for atherosclerosis. Familial
predisposition/genetics is a nonmodifiable risk
factor.

MEDICAL MANAGEMENT
Prevention
Exercise program
Medications
Pentoxifylline (Trental) and cilostazol (Pletal)
Use of antiplatelet agents
Surgical management

PATIENT TEACHING

Lifestyle modifications:
Smoking

cessation.
Diet - increased fruit and vegetables, reduced fat
intake, increased omega-3 fatty acid intake.
Regular physical exercise.
Avoiding excess alcohol.

PATIENT TEACHING
Foods high in soluble fibre also are part of a
healthy diet. They help prevent the digestive
tract from absorbing cholesterol. These foods
include:
Whole-grain cereals such as oatmeal and oat
bran
Fruits such as apples, bananas, oranges, pears,
and prunes
Legumes such as kidney beans, lentils, chick
peas, black-eyed peas, and lima beans

PULMONARY EMBOLISMDEFINITION

Pulmonary embolism refers to the obstruction of

the pulmonary artery or one of its branches by a
thrombus that originates somewhere in the
venous system or in the right side of the heart.
Deep venous thrombosis a related condition,
refers to thrombus formation in the deep veins,
usually in the calf or thigh, but sometimes in the
arm especially in patients with peripherally
central catheters.

RISK FACTORS

Prolonged immobilization
Prolonged periods of sitting or travelling
Varicose veins
Vascular diseases
Obesity
Pregnancy
COPD
Spinal cord injury
Tumour (gastrointetsinal, breast, lung)

PATHOPHYSIOLOGY

PE is due to a blood clot or thrombus. However,

there are other types of emboli: air, fat, amniotic
fluid and septic (from bacterial invasion of the
thrombus). When a thrombus completely or
partially obstructs a pulmonary artery or its
branches, the alveolar dead space is increased.
The area, although continuing to be ventilated,
receives little or no blood flow. Therefore gas
exchange is impaired.

PATHOPHYSIOLOGY

Thrombus formation may occur in the deep veins

of the legs; in pelvic, renal, or hepatic veins; in
the right heart; and in the upper extremities. In
addition, various substances are released from
the clot and surrounding area that cause regional
blood vessels and bronchioles to constrict.

PATHOPHYSIOLOGY

This results in an increase in pulmonary

vascular resistance. Unrelieved obstruction may
result in right ventricular heart failure and
shock; total occlusion of the main pulmonary
artery is rapidly fatal.

CLINICAL MANIFESTATIONS
Dyspnea
Chest pain
Sycope
Tachycardia
Decreased breath sounds on auscultation and
crackles, usually with pleural friction rub.
Diaphoresis
Cough

CLINICAL MANIFESTATIONS
Tachypnea
Sense of impending doom
Anxiety and restlessness
Death

DIAGNOSTIC TEST
Chest x - rays
Transbronchial biopsy (in which a tissue
specimen is obtained through the bronchial wall)
Pulmonary function test
Arterial blood gas
Pulmonary angiogram detects intraarterial
filling defects and obstruction of the pulmonary
artery branch.

NURSING MANAGEMENT

Nasal oxygen is administered to relieve

hypoxemia, respiratory distress and central
cyanosis.
Administer prescribed medications. Eg heparin
or warfarin
Place patient in semi fowlers position to assist
patient in breathing comfortable.
Advise client not to sit or lie in bed for prolonged
periods, not to cross the legs, and not to wear
constrictive clothing.

NURSING MANAGEMENT
Encourage patient to talk about any concerns or
fears related to this frightening episode.
Monitor vital signs.
Observe for side effects from medications.
If patient underwent a surgical embolectomy, the
nurse monitors urinary output.
Elevates the foot of the bed to promote venous
return

NURSING MANAGEMENT
Encourages isometric exercises, use of antiembolism stockings and walking when patient is
permitted out of bed.
Monitors pulse oximetry
Encourages deep breathing and incentive
spirometry.
Monitor for complications such as cardiogenic
shock or right ventricular heart failure.

ANEURYSM

An aneurysm is an abnormal widening or

ballooning of a portion of an artery due to
weakness in the wall of the blood vessel.

COMMON LOCATIONS FOR

ANEURYSMS
The major artery from the heart (the aorta)
The brain (cerebral aneurysm)
In the leg behind the knee popliteal artery
aneurysm)
Intestine (mesenteric artery aneurysm)
An artery in the spleen (splenic artery
aneurysm)

COMMON LOCATIONS FOR

ANEURYSMS

COMMON LOCATIONS FOR

ANEURYSMS

CLINICAL MANIFESTATIONS
The symptoms depend on the location of the
aneurysm. If the aneurysm occurs near the
body's surface, pain and swelling with a
throbbing mass is often seen.
Aneurysms within the body or brain often cause
no symptoms.
If an aneurysm ruptures, pain, low blood
pressure, a rapid heart rate, and lightheadedness
may occur. The risk of death after a rupture is
high.

CLINICAL MANIFESTATIONS OF A
RUPTURED ANEURYSMS
Sudden, extremely severe headache
Nausea and vomiting
Stiff neck
Blurred or double vision
Sensitivity to light
Seizure
A drooping eyelid
Loss of consciousness
Confusion

DIAGNOSTIC TESTS
Physical exam.
CT scan
Ultrasound

PATIENT TEACHING
Don't smoke or use recreational drugs.
Eat a healthy diet and exercise.
Limit caffeine.
Avoid straining.
Be cautious of aspirin use.

HYPERTENSION
High blood pressure
Defined by the Seventh Report of the Joint National
Commission on the Prevention, Detection, Evaluation,
and Treatment of High Blood Pressure (JNC 7) as a
systolic pressure greater than 140 mm Hg and a
diastolic pressure greater than 90 mm Hg. based on
the average of two or more accurate blood pressure
measurements taken during two or more contacts with
a health care provider.

CLASSIFICATION OF BLOOD PRESSURE FOR

ADULTS AGE 18 AND OLDER

MANIFESTATIONS OF HYPERTENSION
Usually NO symptoms other than elevated blood pressure
Symptoms seen related to organ damage are seen late
and are serious

Retinal

and other eye changes

Renal damage
Myocardial infarction
Cardiac hypertrophy
Stroke

PREDISPOSING FACTORS FOR HTN

Hereditary Predisposition (Family History)
Too much salt (sodium) in the diet
Weight
Chronic Conditions
Alcohol Consumption
Smoking
Serum Lipid Levels (Cholesterol and LDL)
Sedentary Lifestyle
Age
Socioeconomic Status
Stress

NURSING HISTORY AND ASSESSMENT

History and risk factors
Assess potential symptoms of target organ damage

Angina,

shortness of breath, altered speech, altered vision,

nosebleeds, headaches, dizziness, balance problems,
nocturia
Cardiovascular assessment: apical and peripheral pulses

Personal, social, and financial factors that will

influence the condition or its treatment

NURSING DIAGNOSES
Noncompliance with therapeutic regimen related to
side effects of prescribed therapy
Knowledge Deficit related to lack of information about
the disease process and self-care.

QUESTION
Is the following statement True or False?
A hypertensive urgency is a situation in which
blood pressure is severely elevated and there is
evidence of actual or probable target organ
damage.

ANSWER
False
A hypertensive emergency is a situation in which
blood pressure is severely elevated and there is
evidence of actual or probable target organ
damage. A hypertensive urgency is a situation in
which blood pressure is severely elevated but
there is no evidence of actual or probable target
organ damage.

HYPERTENSIVE CRISES

Hypertensive emergency
Blood

pressure > 180/120 and must be lowered immediately

to prevent damage to target organs

Hypertensive urgency
Blood

pressure is very high but no evidence of immediate or

progressive target organ damage

HYPERTENSIVE EMERGENCY
Reduce BP 25% in first hour.
Reduce to 160/100 over 6 hours.
Then gradual reduction to normal over a period of
days.
Exceptions are ischemic stroke and aortic dissection.

HYPERTENSIVE EMERGENCY

Medications
IV

vasodilators: sodium nitroprusside, nicardipine,

fenodopam mesylate, enalaprilat, nitrogylcerin

Need very frequent monitoring of BP and

cardiovascular status.

HYPERTENSIVE URGENCY
Patient requires close monitoring of blood pressure
and cardiovascular status.
Assess for potential evidence of target organ damage.
Medications

Fast-acting

oral agents: beta adrenergic blocker labetalol;

angiotensin-converting enzyme inhibitor captopril; or
alpha2-agonistclonidine

REDUCING SODIUM IN THE DIET

Use fresh poultry, fish and lean meat, rather than
canned or processed.
Buy fresh, plain frozen or canned with no salt
added vegetables.
Use herbs, spices and salt-free seasoning blends in
cooking and at the table; decrease or eliminate use
of table salt.
Choose convenience foods that are lower in
sodium.

NURSING INTERVENTIONSDECREASED CARDIAC OUTPUT

Monitor blood pressure, measure in both

arms/thighs three times, use correct cuff size and
accurate technique.
Rationale : Comparison of pressures provides a
more complete picture of vascular
involvement/scope of problem. Systolic
hypertension also is an established risk factor for
cerebrovascular disease and ischemic heart
disease, when diastolic pressure is elevated.

NURSING INTERVENTIONSDECREASED CARDIAC OUTPUT

Note dependent/general edema.
Rationale : May indicate heart failure, renal or
vascular impairment.
Note presence, quality of central and peripheral
pulses.
Rationale : Pulses in the legs/feet may be
diminished, reflecting effects of vasoconstriction
(increased systemic vascular resistance [SVR])
and venous congestion.

NURSING INTERVENTIONSDECREASED CARDIAC OUTPUT

Observe skin color, moisture, temperature, and

capillary refill time.
Rationale : Presence of pallor; cool, moist skin;
and delayed capillary refill time may be due to
peripheral vasoconstriction or reflect cardiac
decompensation/decreased output.

NURSING INTERVENTIONS- ACUTE

PAIN

Assess pain scale. Determine specifics of pain, e.g.,

location, characteristics.
Rationale : Helpful in evaluating effectiveness of
therapy.
Encourage bedrest during acute phase.
Rationale : Minimizes stimulation/promotes
relaxation.
Assist patient with ambulation as needed.
Rationale : Patient may also experience episodes of
postural hypotension, causing weakness when
ambulating.
Minimize vasoconstricting activities that may
aggravate headache.
Rationale : Activities that increase vasoconstriction
accentuate the headache in the presence of increased
cerebral vascular pressure.

NURSING INTERVENTIONS
Describe the nature of the disease and the
purpose of the procedure and the treatment of
hypertension.
Explain the importance of a peaceful
environment and management of stressors.
Discuss the importance of maintaining a stable
weight.
Discuss the need for low-calorie diet, and low
sodium diet.

NURSING INTERVENTIONS
Discuss the importance of avoiding fatigue in the
activity.
Explain the need to avoid constipation in the
bowel movement.
Discuss the symptoms of relapse or progression
of complications reported to the doctor: headache,
dizziness, fainting, nausea and vomiting.

NURSING INTERVENTIONS

Talk about drugs: the name, dosage, time of

administration, purpose and side effects or toxic
effects.

REFERENCES
Burton, M.J, et al. (2007). Infective endocarditis
prevention: Update on 2007 guidelines. The
American Journal of Medicine. 11:484.
Genest, J., Libby, P.(2011). Lipoprotein disorders
and cardiovascular disease. In: Bonow RO, Mann
DL, Zipes DP, Libby P, eds. Braunwald's Heart
Disease: A Textbook of Cardiovascular Medicine.
9th ed. Philadelphia, Pa: Saunders Elsevier.

REFERENCES
Hauser, S.C. (2011).Vascular diseases of the
gastrointestinal tract. In:Goldman L, Schafer AI,
eds. Cecil Medicine. 24th ed. Philadelphia, Pa:
Saunders Elsevier.
Isselbacher, E.M. (2011).Diseases of the aorta. In:
Goldman L, Schafer AI, eds. Cecil Medicine. 24th
ed. Philadelphia, Pa: Saunders Elsevier.

REFERENCES
Lewis, S. L., Heitkemper, M. M., Dirksen, S. R.,
OBrien, P. G., & Bucher, L. (2007). MedicalSrugical Nursing: Assessment and Management
of Clinical Problems. Missouri: Mosby.
LeWinter, M.M., Tischler, M.D. (2011).
Pericardial diseases. In: Bonow RO, Mann DL,
Zipes DP, Libby P, eds. Braunwald's Heart
Disease: A Textbook of Cardiovascular Medicine.
9th ed. Philadelphia, Pa: Saunders Elsevier.

REFERENCES
Tseng, C, et al. (2012). A predictive model for risk
of prehypertension and hypertension and
expected benefit after population-based life-style
modification (KCIS No. 24). American Journal of
Hypertension.