Gender
Family History
Stress
Elevated cholesterol Hypertension
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Angina Pectoris
Pain in the chest from coronary insufficiency, in the absence of myocardial infarction
Types: Stable
Predictable pattern 4 Es
Relieved by rest
Leads to MI
Prinzmetal's ("variant")
is primarily attributable to vasospasm
Typical Anginal Pain Provocative- Pain is caused by activity/relieved by rest / NTG Quality - heavy crushing dull Region - Over sternum, epigastric area, jaw, back shoulder Severity -mild to severe Timing -usually related to activity/stress lasts 1-5 mins
Collaborative Management
Nitroglycerin (drug of choice)
B-adrenergic blocking agents propanolol, metoprolol, etc Ca-channel blocker verapamil, nifedipine, diltiazem Platelet-aggregating inhibitors ASA, dypiridamole, ticlopidine Anticoagulants heparin Na, Warfarin Na (Coumadin), dicumarol
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Surgeries
Percutaneous Transluminal Coronary Angioplasty (PTCA)
Compresses the plaque by using balloon tipped catheter under fluoroscopic guidance. Ideal in single vessel coronary artery disease Intravascular Stenting - done to prevent restenosis after PTCA
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Nursing Interventions
Administer, as ordered:
Oxygen Nitroglycerine
Rest Diet
Low fat, low Na, low cholesterol diet Avoid saturated fats Read food labels
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Myocardial Infarction
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ischemic myocardial cell necrosis Caused by coronary artery obstruction due to:
progressive development of atherosclerosis coronary artery spasm Embolism
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Manifestations
Provocative
Quality Region Severity
Timing
-No relation to activity -No relief from rest / NTG -Heavy crushing dull -Over sternum, epigastric area, jaw, back, shoulder -Mild to severe often includes feeling of doom, nausea and vomiting , diaphoresis -Lasts more >15mins
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Diagnostic Studies
Enzymes: Troponin elevates in 30 minutes CPK-MB elevates in 2 to 4 hours AST peaks in 24 to 36 hours LDH peaks in 48 to 72 hours.
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ECG changes:
ST elevation = myocardial injury ST depression = ischemia T wave inversion = myocardial ischemia large Q waves = necrosis
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"O BATMAN!": O - xygen B - eta blocker A anti-thrombotics (ASA etc.) T - hrombolytics (streptokinase etc) M - orphine A CE inhibitors N - itroglycerin
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Collaborative Management
Nursing Interventions
Administer, as ordered: Morphine sulfate Oxygen IVF to run KVO CBR Monitor: vital signs every 1 to 2 hours. cardiac rhythm for dsyrhythmias signs of congestive heart failure
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Is the inability of the heart to maintain an adequate output of blood from one or more ventricles results to an inadequate supply of blood to the vital parts of the body
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TYPES OF CHF
LEFT-SIDED CHF
usually pulmonary by nature
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CAUSES
Coronary Artery Disease Faulty Heart Valves Cardiomyopathy Congenital Heart Defects Heart Arrythmias Kidney Failure Hypertension (or related increase in BV)
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Persistent wheezing or cough with white or pink blood-tinged phlegm Pronounced neck veins
Peripheral edema
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Ascites
Diagnostic Procedures
Chest X-ray ECG Echocardiogram Coronary Catheterization Blood Test
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MANAGEMENT
Digitalis Therapy The major therapy for CHF (+) inotropic, (-) chronotropic effects, (-)dromotropic effects
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Bradycardia
Dysrythmias (most dangerous) Yellow / green visions; halos around the light (elderly) In males: gynecomastia, decreased libido and impotence
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DIURETIC THERAPY
To decrease cardiac workload by reducing circulating BV Nsg. Implications: Assess for s/sx of hypokalemia when giving thiazides and loop diuretics Give potassium supplements Best given early AM or early PM
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1.
Chlorthiazide (Diuril)
Hyrochlorthiazide (Esixdrix Hyrdodiuril) Furosemide (Lasix) Bumetamide (Burmex) Spironolactone (Aldactone) Triamterene (Dyrenium)
2.
Loop Diuretics
3.
Potassim-sparing
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VASODILATORS
Decreases resistance to ventricular emptying, thereby decreasing afterload. Most commonly used as follows: 1. Nitroprusside (Nipride) 2. Hydralazine (Apresoline) 3. Nifedipine (a Calcium-channel blocker with vasodilator effect) 4. Captopril (an antihypertensive agent with vasodilator effect)
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Stop smoking
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Priority NDx Decreased cardiac output Fluid volume excess Activity intolerance
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NURSING MANAGEMENT
Provide oxygenation Promote rest and activity Decrease anxiety Facilitate fluid balance Provide skin care Promote nutrition Promote elimination Facilitate learning
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VASCULAR CONDITIONS
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Hypertension
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May be:
systolic
diastolic
both pressures A sustained pressure = hypertension:
systolic = 140 mmHg diastolic = 90 mmHg
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Types
Primary / Essential / Idiopathic
unknown etiology
Predisposing factors Heredity
Age
Stress Secondary / Non-essential Secondary to other diseases Alcoholism Prolonged use of oral contraceptives
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Hypertensive crisis sudden elevation in blood pressure life threatening Isolated systolic hypertension an elevation in systole only (>140 mmHg) affects elderly persons
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Alcohol Stress
P ills Obesity
DM
Cigarette Smoking
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Collaborative Management
Lifestyle changes
alcohol moderation exercise regimen cessation of smoking
Nursing Interventions
Record baseline BP in 3 positions (lying, sitting, standing) and in both arms Continuously assess BP and report any erratic change Administer antihypertensive agents as ordered
monitor closely and assess for S/E
Monitor I & O
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Aneurysm
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Arteriosclerosis
Syphilis
Hypertension
Infection Trauma to the BV
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Manifestations
Often asymptomatic Deep, diffuse chest pain Hoarseness Dysphagia
Dyspnea
Pallor Rupture = hemorrhage
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Diagnostic Test
Aortography - exact location X-rays
chest film abnormal widening of aorta abdominal film - calcification within walls of aneurysm
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Collaborative Management
Hypertension control Surgery
resection of the aneurysm and replacement with a Teflon/Dacron graft
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Nursing Interventions
Prepare for surgery and implement postop care Watch out for signs of shock Advise client to prevent increased IAP
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Hereditary
2 years history Raynauds phenomenon
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Manifestations
Pain (secondary to ischemia) Paresthesia Coldness Tingling in one or more digits Intermittent color changes (pallor, cyanosis) Small ulcerations Gangrene tips of digits
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Nursing Interventions
Client teaching
importance of stopping smoking need to maintain warmth Protection of the hands (gloves)
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Thromboangitiis Obliterans
(Buergers Disease)
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Characterized by inflammatory changes in both arteries and veins resulting in destruction of small and medium vessels Usually affects the lower extremities
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Manifestations
Intermittent claudication Sensitivity to cold (skin may at first be white, changing to blue then red) Pulselessness Ulceration and gangrene (advanced)
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Drugs:
Collaborative Management
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Surgery
bypass grafting balloon catheter dilation amputation (if necessary)
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Nursing Interventions
Health teachings
stop smoking Maintaining warmth
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Venous Thrombosis
(Thrombophlebitis)
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Refers to inflammation of a vein Precipitated by a thrombus formation Commonly occurs in the veins of the extremities: Saphenous Femoral Popliteal
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Types
Deep vein thrombosis (DVT)
A stationary clot in deeper veins of the legs
Superficial thrombophlebitis
inflammation of a vein closer to the surface accompanied by formation of a stationary clot within the vein
Phlebitis
inflammation of one or more veins without resultant clot formation.
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Oral contraceptives
Trauma Sepsis Cigarette smoking Dehydration Severe anemias Complication of surgery
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Manifestations
Pain in the affected extremity
Superficial vein
Tenderness Redness Induration along course of the vein
Deep vein
Swelling
Venous distension of limb (+) Homans sign
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DVT and phlebitis may result in pulmonary embolism (when clot break off)
Sudden chest pain Dyspnea Decreased blood oxygen (Po2) Agitation Cyanosis Tachycardia
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Collaborative Management
Anticoagulants: Heparin blocks conversion of prothrombin to thrombin and reduces formation of thrombus Prolongs PTT Warfarin (coumadin) blocks prothrombin synthesis by interfering with vitamin K synthesis Prolongs PT
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Nursing Interventions
Deep Vein Thrombosis Assess respiratory and circulatory functions Admister medications, as prescribed: Anticoagulant therapy Thrombolytic therapy Avoid manipulation (eg, massage) Elevate the extremity Observe the extremity for edema
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Superficial thrombophlebitis Apply warm compresses over the affected site. Elevate the extremity. Administer anti-inflammatory agents, as prescribed.
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Superficial thrombophlebitis Apply warm compresses over the affected site. Elevate the extremity. Administer anti-inflammatory agents, as prescribed.
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Health Teaching Avoid: Standing & sitting for long periods constrictive clothing Crossing legs at the knees Smoking Oral contraceptives Importance of adequate hydration Use of elastic stockings when ambulatory
Importance of: planned rest with elevation of feet weight reduction and exercise
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PERICARDITIS
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b. Chronic
increase in inflammatory exudate that continues beyond an anticipated period of time
c. Constrictive
a. scar tissue that forms between the visceral and parietal layers of pericardium
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Manifestations
Acute Chest pain
worsens with deep breathing, coughing, swallowing, and changing position
Fever Malaise Flu like symptoms Chronic pericarditis Established by routine chest film.
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Constrictive pericarditis fibrous scarring and calcification (encases the heart) Pericardial effusion Complication:
Cardiac tamponade - compression that results from an excessive accumulation of fluid or blood in the pericardial space.
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Nursing Interventions
Prepare the patient for diagnostic procedures
Administer, ordered:
Antibiotic
Anti-inflammatory
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Monitor vital signs frequently. Provide support and reassurance. Provide patient teaching covering:
Disease process Causative factors Preventive measures
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INFECTIVE ENDOCARDITIS
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Etiology
Acute - hematogenous
Staphylococcus aureus B-hemolytic Streptococcus
Subacute
Streptococcus viridans non hemolytic and microaerophilic streptococci
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Manifestations
Valve with damage (due to colonization)
Microbes that are in the blood adhere to the area then proliferate.
Initial damage to the valves (also known as endothelium) exposes the basement membrane
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Sloughing of disease, with erosion of valve leaflets or myocardial damage Congestive heart failure
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1. Other Manifestations:
Sudden fever Septicemia Valvular insufficiency Heart failure Stroke
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1. Provide supportive therapy to prevent and manage heart failure. 2. Prepare the patient for valve replacement surgery if medical intervention fails. 3. Prevent the disease by administering antibiotics prophylactically before the patient undergoes any procedure that may cause bacteremia.
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MYOCARDITIS
Focal or diffuse inflammation of the myocardium; may be viral (most common) or bacterial (rare).
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Etiology
Viral myocarditis may be caused by coxsackie virus. Bacterial myocarditis is associated with rheumatic fever and the diphtheria toxin. Other causes include hypersensitivity reactions, autoimmune responses, chemical and physical agents, and radiation therapy.
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1.In young adults, sudden death has occurred; in adults, viral myocarditis is likely to be benign and self-limiting.
1.Laboratory analysis reveals leukocytosis and elevated ALT, AST and LDH.
1.Manifestation of right and left heart failure can occur with advanced disease.
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Nursing Interventions
1. 1. Obtain viral antigen detection or serologic testing, as ordered, to aid in diagnosis. 2. 2. Prepare the patient for myocardial biopsy, which may also aid diagnosis. 3. 3. Administer appropriate antibiotics for bacterial myocarditis, as ordered. 4. 4. Institute measures to decrease cardiac workload, such as bed rest.
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1.
A. For the patient with heart failure: a. 1. Administer digitalis, diuretics, and oxygen therapy, as ordered. b. 2. Restrict sodium. c. 3. Encourage activities that improve oxygen supply and decrease oxygen demand. 2. B. Administer antiarrthymics, with caution, for dysrhythmias; administer anticoagulants for thromboembolic events, as prescribed. 3. C. Use immunosuppressive therapy, as prescribed, to resolve inflammation.
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