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Cardiovascular

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  • 1. cardiovascular
  • 2. Disorders
  • 3. Coronary Artery Disease (CAD) <ul><li>Accumulation of fatty deposits in the inner layer of coronary arteries. </li></ul><ul><li>due to hypercholesterolemia </li></ul><ul><li>Incomplete occlusion of the coronary arteries lead to Angina (ischemia) </li></ul><ul><li>Complete occlusion of the coronary arteries lead to Myocardial Infarction </li></ul><ul><li>Manifestations depend on the severity of coronary arterial occlusion </li></ul>
  • 4. Risk Factors <ul><li>Age above 45/55 </li></ul><ul><li>Sex- Males and post-menopausal females </li></ul><ul><li>Race </li></ul><ul><li>Family History </li></ul><ul><li>Hypertension </li></ul><ul><li>Cigarette Smoking </li></ul><ul><li>Diabetes Mellitus </li></ul><ul><li>Obesity </li></ul><ul><li>Sedentary Lifestyle </li></ul><ul><li>Stress </li></ul><ul><li>Atherosclerosis </li></ul>
  • 5. Pathophysiology <ul><li>Fatty streak formation in the vascular intima  T-cells and monocytes ingest lipids in the area of deposition  atheroma  narrowing of the arterial lumen  reduced coronary blood flow  myocardial ischemia </li></ul>
  • 6. Angina <ul><li>Chest pain resulting from coronary atherosclerosis or myocardial ischemia </li></ul><ul><li>Types: </li></ul><ul><li>Stable – exertional; relieved by rest, drugs; severity does not change </li></ul><ul><li>Unstable – Occurs unpredictably during exertion and emotion; severity increases with time and pain may not be relieved by rest and drug </li></ul><ul><li>Prinzmetal (variant) – pain at rest with vasospasm </li></ul>
  • 7. Manifestations <ul><li>Characteristic of chest pain </li></ul><ul><li>- Substernal or retrosternal pain that radiates to arms, shoulders, back, neck and jaws </li></ul><ul><li>- Squeezing, heavy, burning, tight chest </li></ul><ul><li>- Precipitated by cold, eating, emotions, exertion </li></ul><ul><li> - Lasts a few minutes and then subsides </li></ul>
  • 8. <ul><li>Diaphoresis </li></ul><ul><li>Nausea and vomiting </li></ul><ul><li>Cold clammy skin </li></ul><ul><li>Sense of apprehension and doom </li></ul><ul><li>Dizziness and syncope </li></ul>
  • 9. Diagnostic Tests <ul><li>NTG test (relief from pain) </li></ul><ul><li>ECG (ST depression and T wave elevation) </li></ul><ul><li>Cardiac catheter – atherosclerotic lesions </li></ul><ul><li>Thallium 201 Imaging </li></ul><ul><li>Technetium Imaging </li></ul>
  • 10. Nursing Diagnosis <ul><li>Pain related to imbalance in myocardial oxygen demand </li></ul><ul><li>Decreased cardiac output related to reduced preload and afterload </li></ul><ul><li>Anxiety related to pain, uncertain prognosis and threatening environment </li></ul>
  • 11. Management <ul><li>Relieve pain </li></ul><ul><li>Place in comfortable position </li></ul><ul><li>Administer O2 </li></ul><ul><li>Decrease Anxiety </li></ul><ul><li>PTCA - percutaneous transluminal coronary angioplasty </li></ul><ul><ul><li>To compress the plaque against the vessel wall, increasing the arterial lumen </li></ul></ul><ul><li>CABG - coronary artery bypass graft </li></ul><ul><ul><li>To improve the blood flow to the myocardial tissue </li></ul></ul><ul><li>Explain the reasons for hospitalization, diagnostic tests and therapies </li></ul>
  • 12. &nbsp;
  • 13. <ul><li>Give antianginal drugs </li></ul><ul><li>Aspirin- prevent thrombus formation </li></ul><ul><li>Beta-blockers- reduce BP and HR </li></ul><ul><li>Calcium-channel blockers- dilate coronary artery and reduce vasospasm </li></ul><ul><li>Nitrates- to dilate the coronary arteries </li></ul>
  • 14. <ul><li>Put one nitroglycerin tablet under the tongue </li></ul><ul><li>Wait for 5 minutes </li></ul><ul><li>If not relieved, take another tablet and wait for 5 minutes </li></ul><ul><li>Another tablet can be taken (third tablet) </li></ul><ul><li>If unrelieved after THREE tablets  seek medical attention </li></ul>
  • 15. Myocardial Infarction <ul><li>Absence of O2 supply to the myocardium </li></ul><ul><li>Necrosis or death to the myocardial tissue </li></ul><ul><li>Attack may be sudden or gradual </li></ul>
  • 16. Etiology <ul><li>1. CAD </li></ul><ul><li>2. Coronary vasospasm </li></ul><ul><li>3. Coronary artery occlusion by embolus and thrombus </li></ul><ul><li>4. Conditions that decrease perfusion- hemorrhage, shock </li></ul>
  • 17. Risk factors <ul><li>1. Hypercholesterolemia </li></ul><ul><li>2. Smoking </li></ul><ul><li>3. Hypertension </li></ul><ul><li>4. Obesity </li></ul><ul><li>5. Stress </li></ul><ul><li>6. Sedentary lifestyle </li></ul>
  • 18. Pathophysiology <ul><li>Interrupted coronary blood flow  myocardial ischemia  anaerobic myocardial metabolism for several hours  myocardial death  depressed cardiac function  triggers autonomic nervous system response  further imbalance of myocardial O2 demand and supply </li></ul>
  • 19. <ul><li>Chest pain: </li></ul><ul><li>Severe, steady crushing and squeezing substernal pain </li></ul><ul><li>Radiates to the neck, arm, jaw and back </li></ul><ul><li>Not relieved by rest or NTG </li></ul><ul><li>May continue for 15-30 minutes </li></ul><ul><li>May produce anxiety and fear resulting to increased HR, BP and RR </li></ul>
  • 20. <ul><li>dyspnea </li></ul><ul><li>Diaphoresis </li></ul><ul><li>cold clammy skin </li></ul><ul><li>N/V </li></ul><ul><li>restlessness, sense of doom </li></ul><ul><li>tachycardia or bradycardia </li></ul><ul><li>hypotension </li></ul><ul><li>dysrhythmias </li></ul>
  • 21. &nbsp;
  • 22. Diagnostic Evaluation <ul><li>Chest pain cannt be relieved by NTG </li></ul><ul><li>ST segment elevation and T wave inversion, Q wave </li></ul><ul><li>Cardiac enzymes: increased </li></ul><ul><li>Troponin, CK MB, LDH </li></ul><ul><li>CBC- may show elevated WBC count </li></ul>
  • 23. The Cardiovascular System LABORATORY PROCEDURES <ul><li>CARDIAC Proteins and enzymes </li></ul><ul><li>CK- MB ( creatine kinase) </li></ul><ul><ul><li>Elevates in MI within 4 hours, peaks in 24 hours and then declines till 3 days </li></ul></ul>
  • 24. The Cardiovascular System LABORATORY PROCEDURES <ul><li>CARDIAC Proteins and enzymes </li></ul><ul><li>CK- MB ( creatine kinase) </li></ul><ul><ul><li>Normal value is 0-7 U/L </li></ul></ul>
  • 25. The Cardiovascular System LABORATORY PROCEDURES <ul><li>CARDIAC Proteins and enzymes </li></ul><ul><li>Lactic Dehydrogenase (LDH) </li></ul><ul><ul><li>Elevates in MI in 24 hours, peaks in 48-72 hours </li></ul></ul><ul><ul><li>Normally LDH1 is greater than LDH2 </li></ul></ul>
  • 26. The Cardiovascular System LABORATORY PROCEDURES <ul><li>CARDIAC Proteins and enzymes </li></ul><ul><li>Lactic Dehydrogenase (LDH) </li></ul><ul><ul><li>MI- LDH2 greater than LDH1 (flipped LDH pattern) </li></ul></ul><ul><ul><li>Normal value is 70-200 IU/L </li></ul></ul>
  • 27. The Cardiovascular System LABORATORY PROCEDURES <ul><li>CARDIAC Proteins and enzymes </li></ul><ul><li>Myoglobin </li></ul><ul><li>Rises within 1-3 hours </li></ul><ul><li>Peaks in 4-12 hours </li></ul><ul><li>Returns to normal in a day </li></ul>
  • 28. The Cardiovascular System LABORATORY PROCEDURES <ul><li>Troponin I and T </li></ul><ul><li>Troponin I is usually utilized for MI </li></ul><ul><li>Elevates within 3-4 hours, peaks in 4-24 hours and persists for 7 days to 3 weeks! </li></ul><ul><li>Normal value for Troponin I is less than 0.6 ng/mL </li></ul>
  • 29. The Cardiovascular System LABORATORY PROCEDURES <ul><li>Troponin I and T </li></ul><ul><li>REMEMBER to AVOID IM injections before obtaining blood sample! </li></ul><ul><li>Early and late diagnosis can be made! </li></ul>
  • 30. The Cardiovascular System LABORATORY PROCEDURES <ul><li>SERUM LIPIDS </li></ul><ul><li>Lipid profile measures the serum cholesterol, triglycerides and lipoprotein levels </li></ul><ul><li>Cholesterol= 200 mg/dL </li></ul><ul><li>Triglycerides- 40- 150 mg/dL </li></ul>
  • 31. The Cardiovascular System LABORATORY PROCEDURES <ul><li>SERUM LIPIDS </li></ul><ul><li>LDL- 130 mg/dL </li></ul><ul><li>HDL- 30-70- mg/dL </li></ul><ul><li>NPO post midnight (usually 12 hours) </li></ul>
  • 32. The Cardiovascular System LABORATORY PROCEDURES <ul><li>ELECTROCARDIOGRAM (ECG) </li></ul><ul><li>A non-invasive procedure that evaluates the electrical activity of the heart </li></ul><ul><li>Electrodes and wires are attached to the patient </li></ul>
  • 33. &nbsp;
  • 34. The Cardiovascular System LABORATORY PROCEDURES <ul><li>Holter Monitoring </li></ul><ul><li>A non-invasive test in which the client wears a Holter monitor and an ECG tracing recorded continuously over a period of 24 hours </li></ul>
  • 35. &nbsp;
  • 36. The Cardiovascular System LABORATORY PROCEDURES <ul><li>ECHOCARDIOGRAM </li></ul><ul><li>Non-invasive test that studies the structural and functional changes of the heart with the use of ultrasound </li></ul><ul><li>No special preparation is needed </li></ul>
  • 37. &nbsp;
  • 38. The Cardiovascular System LABORATORY PROCEDURES <ul><li>Stress Test </li></ul><ul><li>Pre-test: consent may be required, adequate rest , eat a light meal or fast for 4 hours and avoid smoking, alcohol and caffeine </li></ul>
  • 39. The Cardiovascular System LABORATORY PROCEDURES <ul><li>Post-test: instruct client to notify the physician if any chest pain, dizziness or shortness of breath . Instruct client to avoid taking a hot shower for 10-12 hours after the test </li></ul>
  • 40. The Cardiovascular System LABORATORY PROCEDURES <ul><li>Pharmacological stress test </li></ul><ul><li>Use of dipyridamole </li></ul><ul><li>Maximally dilates coronary artery </li></ul><ul><li>Side-effect: flushing of face </li></ul>
  • 41. The Cardiovascular System LABORATORY PROCEDURES <ul><li>Pharmacological stress test </li></ul><ul><li>Pre-test: 4 hours fasting, avoid alcohol, caffeine </li></ul><ul><li>Post test: report symptoms of chest pain </li></ul>
  • 42. Nursing Diagnosis <ul><li>Pain related to an imbalance in oxygen supply and demand </li></ul><ul><li>Anxiety related to chest pain, fear of death and threatening environment </li></ul><ul><li>Decreased cardiac output related to impaired contraction of the heart </li></ul>
  • 43. <ul><li>Altered tissue perfusion (myocardial) related to coronary stenosis </li></ul><ul><li>Activity intolerance related to insufficient oxygenation </li></ul><ul><li>Risk for injury (bleeding) related to dissolution of clots </li></ul><ul><li>Ineffective individual coping related to threats to self esteem </li></ul>
  • 44. Management <ul><li>Oxygen therapy </li></ul><ul><li>Provide adequate rest periods </li></ul><ul><li>Minimize metabolic demands </li></ul><ul><ul><li>Provide soft diet </li></ul></ul><ul><ul><li>Provide a low-sodium, low cholesterol and low fat diet </li></ul></ul><ul><ul><li>Passive ROM </li></ul></ul><ul><li>Minimize anxiety </li></ul><ul><ul><li>Reassure client and provide information as needed </li></ul></ul>
  • 45. <ul><li>Check fluids – overload is dangerous if CO is compromised </li></ul><ul><li>Avoid anaerobic exercise and exposure to cold </li></ul><ul><li>Post-MI: recognize risk of sensory overload </li></ul>
  • 46. Pharmacologic Therapy <ul><li>Thrombolytic agents - Dissolve clots in the coronary artery allowing blood to flow </li></ul><ul><li>ie TPA tissue plasminogen activator (Alteplase), Streptokinase (streptase), Urokinase </li></ul><ul><li>* S/E: bleeding and urticaria </li></ul><ul><li>Have aminocaproic acid ready( fibrinolysis inhibitor) </li></ul>
  • 47. <ul><li>Anticoagulant – prevents formation of new blood clots </li></ul><ul><li>ie Heparin, Warfarin </li></ul><ul><li>S/S: fever, chills(hypersensitivity), rash, bleeding, diarrhea </li></ul><ul><li>Monitor blood work (INR, PT-warfarin, PTT-heparin) </li></ul><ul><li>Avoid ASA and invasive procedures </li></ul><ul><li>Bleeding precautions </li></ul><ul><li>Subcutaneous heparin- abdomen, do not aspirate or massage </li></ul><ul><li>antidotes: </li></ul>
  • 48. <ul><li>Antiplatelet – hypersensitivity to aspirin </li></ul><ul><li>ie Ticlopidine, Clopidogrel </li></ul><ul><li>Beta adrenergic blocking agents – reduce myocardial O2 demand by blocking sympathetic stimulation; dec HR, contractility, BP ie Propranolol </li></ul><ul><li>Calcium channel blockers – dec contraction, HR; relax blood vessels ie Diltiazem </li></ul>
  • 49. <ul><ul><li>Morphine - reduces pain and anxiety </li></ul></ul><ul><ul><li>- Relaxes bronchioles to enhance oxygenation </li></ul></ul><ul><ul><li>ACE Inhibitors - Prevents formation of angiotensin II w/c causes vasoconstriction; dec O2 demand </li></ul></ul><ul><ul><li>Limits the area of infarction </li></ul></ul>
  • 50. <ul><li>Antihyperlipidemics- lowers serum lipids by decreasing triglycerides or cholesterol </li></ul><ul><li>Ex. HMG-CoA reductase( statins), Fibrates( Gemfibrozil), bile acid sequestrants( cholestyramine) </li></ul><ul><li>S/E: N/V, diarrhea, musculskeletal injury, hepatic toxicity, rash, reduced absorption of fat and fat-soluble vitamins. Visual disturbances(lovastatin &amp; gemfibrozil) </li></ul><ul><li>Administer statins at HS to inc absorption, other meds wt meals to dec GI irritation, cholestyramine shld be mixed wt full glass of liquid </li></ul>
  • 51. <ul><li>Surgical revascularization: </li></ul><ul><li>Percutaneous Transluminal Coronary Angioplasty (PTCA); </li></ul><ul><li>coronary artery bypass graft (CABG ) After the condition had been stabilized: </li></ul><ul><li>- CBR without BP (complete bedrest without bathroom privilege) </li></ul><ul><li>- Gradual resumption of ADL to full recovery </li></ul>
  • 52. <ul><li>1. Give 1 example of preloader </li></ul><ul><li>2. Aspirin toxicity is manifested by </li></ul><ul><li>a. laryngitis c. hepatotoxicity </li></ul><ul><li>b. Tinnitus d. ear ache </li></ul><ul><li>3. Captopril can ______ the TPR </li></ul><ul><li>aIncreases </li></ul><ul><li>b. Decreases </li></ul><ul><li>c. No effect </li></ul><ul><li>4. What is the pacemaker of the heart? </li></ul><ul><li>a. SA node c. node of ranvier </li></ul><ul><li>b. AV node d. bundle of his </li></ul>
  • 53. <ul><li>5. Nitrates is best stored in </li></ul><ul><li>refrigerator </li></ul><ul><li>Amber colored glass </li></ul><ul><li>In open containers </li></ul><ul><li>The garden </li></ul>
  • 54. <ul><li>6. A patient complained of chest pain. This is true angina if the ECG reading showed </li></ul><ul><li>a.ST depression </li></ul><ul><li>b. ST elevation </li></ul><ul><li>c. Q wave invertion </li></ul><ul><li>d. T wave invertion </li></ul><ul><li>7. IM injections should be avoided_____ taking cardiac enzymes specimen </li></ul><ul><li>a. Before </li></ul><ul><li>b. After </li></ul><ul><li>c. never </li></ul>
  • 55. <ul><li>8. Thrombolytic agents are given in MI. What is the antidote </li></ul><ul><li>Aminocaproic acid </li></ul><ul><li>Aminobutyric acid </li></ul><ul><li>Protamine sulfate </li></ul><ul><li>Vt. K </li></ul><ul><li>9. Partial occlusion usually results in </li></ul><ul><li>Ischemia </li></ul><ul><li>Infarction </li></ul><ul><li>Necrosis </li></ul><ul><li>death </li></ul>
  • 56. <ul><li>10. This is a type of angina felt at rest ,caused by vasospasm </li></ul><ul><li>Stable </li></ul><ul><li>Variant </li></ul><ul><li>Unstable </li></ul><ul><li>Semi-stable </li></ul>
  • 57. Congestive Heart Failure CHF <ul><li>A syndrome of congestion of both pulmonary and systemic circulation caused by inadequate cardiac function and inadequate cardiac output to meet the metabolic demands of tissues </li></ul>
  • 58. Predisposing Factors <ul><li>Myocardial Infarction </li></ul><ul><li>Arrhythmias </li></ul><ul><li>Pregnancy </li></ul><ul><li>Pulmonary Embolism </li></ul><ul><li>Anemia </li></ul><ul><li>Renal Failure </li></ul><ul><li>CAD </li></ul><ul><li>Valvular heart diseases </li></ul><ul><li>Hypertension </li></ul><ul><li>Cardiomyopathy </li></ul><ul><li>Pericarditis and cardiac tamponade </li></ul>
  • 59. New York Heart Association <ul><li>Class 1 </li></ul><ul><li>Ordinary physical activity does NOT cause chest pain and fatigue </li></ul><ul><li>No pulmonary congestion </li></ul><ul><li>Asymptomatic </li></ul><ul><li>NO limitation of ADLs </li></ul><ul><li>Class 2 </li></ul><ul><li>SLIGHT limitation of ADLs </li></ul><ul><li>NO symptom at rest </li></ul><ul><li>Symptom with INCREASED activity </li></ul><ul><li>Basilar crackles and S3 </li></ul>
  • 60. <ul><li>Class 3 </li></ul><ul><li>Markedly limitation on ADLs </li></ul><ul><li>Comfortable at rest BUT symptoms present in LESS than ordinary activity </li></ul><ul><li>Class 4 </li></ul><ul><li>SYMPTOMS are present at rest </li></ul>
  • 61. PATHOPHYSIOLOGY <ul><li>LEFT Ventricular pump failure  back up of blood into the pulmonary veins  increased pulmonary capillary pressure  pulmonary congestion </li></ul>
  • 62. <ul><li>LEFT ventricular failure  decreased cardiac output  decreased perfusion to the brain, kidney and other tissues  oliguria, dizziness </li></ul>
  • 63. PATHOPHYSIOLOGY <ul><li>RIGHT ventricular failure  blood pooling in the venous circulation  increased hydrostatic pressure  peripheral edema </li></ul>
  • 64. <ul><li>RIGHT ventricular failure  blood pooling  venous congestion in the kidney, liver and GIT </li></ul>
  • 65. LEFT SIDED CHF ASSESSMENT FINDINGS <ul><li>1. Dyspnea on exertion </li></ul><ul><li>2. PND </li></ul><ul><li>3. Orthopnea </li></ul><ul><li>4. Pulmonary crackles/rales </li></ul><ul><li>5. cough with Pinkish, frothy sputum </li></ul><ul><li>6. Tachycardia </li></ul>
  • 66. <ul><li>7. Cool extremities </li></ul><ul><li>8. Cyanosis </li></ul><ul><li>9. decreased peripheral pulses </li></ul><ul><li>10. Fatigue </li></ul><ul><li>11. Oliguria </li></ul><ul><li>12. signs of cerebral anoxia </li></ul>
  • 67. RIGHT SIDED CHF ASSESSMENT FINDINGS <ul><li>1. Peripheral dependent, pitting edema </li></ul><ul><li>2. Weight gain </li></ul><ul><li>3. Distended neck vein </li></ul><ul><li>4. hepatomegaly </li></ul><ul><li>5. Ascites </li></ul><ul><li>6. Body weakness </li></ul><ul><li>7. Anorexia, nausea </li></ul><ul><li>8. Pulsus alternans </li></ul>
  • 68. Diagnostics <ul><li>EKG - heart strain </li></ul><ul><li>Chest X-ray - cardiomegaly and pleural effusion </li></ul><ul><li>CVC Central Venous Catheter and Swan-Ganz Catheter are able to record high pressure in the chambers and pulmonary capillaries. </li></ul><ul><li>Echocardiogram may show hypokinetic heart </li></ul><ul><li>ABG and Pulse oximetry may show decreased O2 saturation </li></ul>
  • 69. Nursing Considerations <ul><li>goal of treatment - improve pump function and reverse the compensatory mechanism of the heart. </li></ul><ul><li>complete bed rest and reduce myocardial oxygen demand. </li></ul><ul><li>FVE management and prevent complications </li></ul><ul><li>Diuretics and Digoxin, vasodilators and hypolipidemics </li></ul><ul><li>LOW sodium diet </li></ul><ul><li>Limit fluid intake </li></ul><ul><li>Monitor daily weight and report signs of fluid retention </li></ul>
  • 70. <ul><li>Complications: </li></ul><ul><li>Acute Pulmonary Edema </li></ul><ul><li>Treatment: </li></ul><ul><li>Bed rest and maintain high fowler’s position </li></ul><ul><li>O2 therapy </li></ul><ul><li>Morphine administration to dilate blood vessels </li></ul><ul><li>Dopamine to increase myocardial contractility and ↑ CO </li></ul><ul><li>Diuretics to reduce blood volume </li></ul><ul><li>Steroids to reduce inflammation </li></ul>
  • 71. Shock <ul><li>Hypovolemic- occurs 2 to loss of fluid resulting in decrease perfusion </li></ul><ul><li>Neurogenic- caused by rapid vasodilation and subsequent pooling of blood within the peripheral system( drugs, spinal anesthesia etc) </li></ul><ul><li>Anaphylactic- caused by an allergic reaction which cause histamine release-vasodilation </li></ul><ul><li>Septic-2 to infection which cause plasma leakage </li></ul>
  • 72. CARDIOGENIC SHOCK <ul><li>Heart fails to pump adequately resulting to a decreased cardiac output and decreased tissue perfusion </li></ul><ul><li>ETIOLOGY </li></ul><ul><li>Massive MI </li></ul><ul><li>Severe CHF </li></ul><ul><li>Cardiomyopathy </li></ul><ul><li>Cardiac trauma </li></ul><ul><li>Cardiac tamponade </li></ul>
  • 73. ASSESSMENT FINDINGS <ul><li>HYPOTENSION </li></ul><ul><li>oliguria (less than 30 ml/hour) </li></ul><ul><li>tachycardia </li></ul><ul><li>narrow pulse pressure </li></ul><ul><li>weak peripheral pulses </li></ul><ul><li>cold clammy skin </li></ul><ul><li>changes in sensorium/LOC </li></ul><ul><li>pulmonary congestion </li></ul>
  • 74. LABORATORY FINDINGS <ul><li>Increased CVP </li></ul><ul><ul><li>Normal is 4-10 cmH2O </li></ul></ul>
  • 75. Management <ul><li>modified Trendelenburg (shock ) position </li></ul><ul><li>IVF, vasopressors and inotropics such as DOPAMINE and DOBUTAMINE, diuretics, nitrates </li></ul><ul><li>Administer O2 </li></ul><ul><li>Morphine is administered to decrease pulmonary congestion and to relieve pain </li></ul><ul><li>Assist in intubation, mechanical ventilation, PTCA, CABG, insertion of Swan-Ganz cath and IABP </li></ul><ul><li>Monitor urinary output, BP and pulses </li></ul>
  • 76. CARDIAC TAMPONADE <ul><li>heart is unable to pump blood due to accumulation of fluid in the pericardial sac (pericardial effusion) </li></ul><ul><li>restricts ventricular filling resulting to decreased cardiac output </li></ul><ul><li>Acute tamponade - sudden accumulation of more than 50 ml fluid in the pericardial sac </li></ul>
  • 77. Risk Factors <ul><li>Cardiac trauma </li></ul><ul><li>Complication of Myocardial infarction </li></ul><ul><li>Pericarditis </li></ul><ul><li>Cancer metastasis </li></ul>
  • 78. Manifestations <ul><li>BECK’s Triad- Jugular vein distention, hypotension and distant/muffled heart sound </li></ul><ul><li>Pulsus paradoxus </li></ul><ul><li>Increased CVP </li></ul><ul><li>decreased cardiac output </li></ul><ul><li>Syncope </li></ul><ul><li>anxiety </li></ul><ul><li>dyspnea </li></ul><ul><li>Percussion- Flatness across the ant. chest </li></ul>
  • 79. Diagnostics <ul><li>Echocardiogram </li></ul><ul><li>CXR </li></ul>
  • 80. Management <ul><li>Assist in PERICARDIOCENTESIS </li></ul><ul><li>Administer IVF </li></ul><ul><li>Monitor ECG, urine output and BP </li></ul><ul><li>Monitor for recurrence of tamponade </li></ul>
  • 81. Vascular Disorders <ul><li>Venous Thrombosis </li></ul><ul><li>CVI </li></ul><ul><li>Arterosclerosis </li></ul><ul><li>Raynaud’s Phenomenon </li></ul><ul><li>Aneurysm </li></ul><ul><li>Hypertension </li></ul>
  • 82. Venous Thrombosis <ul><li>Due to: </li></ul><ul><li>Stasis of blood </li></ul><ul><li>Injury to the vessel wall </li></ul><ul><li>Altered blood coagulation </li></ul>
  • 83. <ul><li>High Risk: </li></ul><ul><li>Fractures, cast and joint replacement </li></ul><ul><li>Obesity and smoking </li></ul><ul><li>Immobilized patient </li></ul><ul><li>Heart problems </li></ul>
  • 84. <ul><li>May progress to: </li></ul><ul><li>Phlebitis-inflammation of the vessel wall </li></ul><ul><li>Superficial thrombophlebitis - greater and lesser saphenous veins affected. </li></ul><ul><li>Deep vein thrombosis - deep veins affected; pulmonary embolism is a complication </li></ul>
  • 85. Manifestations <ul><li>(+) Homan’s sign </li></ul><ul><li>fever and chills </li></ul><ul><li>swelling and cyanosis of the affected leg/arm </li></ul><ul><li>Diagnostics: </li></ul><ul><li>Venous duplex ultrasound </li></ul><ul><li>Impedance plethysmography </li></ul><ul><li>RF testing (radioactive fibrinogen) fibrinogen I 125 </li></ul><ul><li>Venography </li></ul><ul><li>Coagulation Profiles: </li></ul><ul><li>APTT, PT/INR </li></ul>
  • 86. Management <ul><li>Prevent complications </li></ul><ul><li>Bed rest for 5 days </li></ul><ul><li>Prevent muscle contraction if possible to prevent dislodging the clot </li></ul><ul><li>Elevation of affected part 10-20 degree above the heart </li></ul><ul><li>Anti-embolic stockings </li></ul><ul><li>Anticoagulant </li></ul><ul><li>Thrombolytic </li></ul><ul><li>Green-field filter (IVC) </li></ul><ul><li>Thrombectomy </li></ul>
  • 87. Chronic Venous Insufficiency <ul><li>Destruction of the valves because of chronic blood pooling or trauma. </li></ul><ul><li>Venous return is decreased ↓ </li></ul><ul><li>chronic venous stasis ↓ </li></ul><ul><li>edema formation ↓ </li></ul><ul><li>veins becomes distorted or tortuous (varicosities) ↓ </li></ul><ul><li>stasis ulcer, cellulites and recurrent thrombosis manifest later </li></ul>
  • 88. Manifestations <ul><li>Edema </li></ul><ul><li>Altered pigmentation </li></ul><ul><li>Pain </li></ul><ul><li>Stasis dermatitis </li></ul><ul><li>Dilated superficial veins </li></ul><ul><li>Stasis ulcers </li></ul>
  • 89. Management <ul><li>Elevate legs </li></ul><ul><li>Elastic compression stockings </li></ul><ul><li>Skin should be kept clean and dry </li></ul>
  • 90. Raynaud’s Phenomenon <ul><li>Arteriolar vasospastic disease with unusual sensitivity to cold or emotional stress. </li></ul><ul><li>cause is unknown but may be secondary to Autoimmune Diseases </li></ul>
  • 91. ASSESSMENT <ul><li>Pallor then cyanosis </li></ul><ul><li>Hyperemia when blood returns to digits after vasospasm </li></ul><ul><li>Numbness, tingling and burning pain </li></ul>
  • 92. Management <ul><li>Avoid primary stimuli (cold, tobacco) </li></ul><ul><li>Ca channel blocker </li></ul><ul><li>Nifedipine for vasospasm </li></ul><ul><li>Safety measures </li></ul>
  • 93. Arteriosclerosis <ul><li>hardening of the arterial blood vessel walls related to aging. </li></ul><ul><li>Atherosclerosis-common type of arteriosclerosis due to atheromas. </li></ul>
  • 94. <ul><li>Aging and atheromas ↓ </li></ul><ul><li>impeding the lumen of the arterial walls </li></ul><ul><li>(incomplete or incomplete occlusions ) ↓ </li></ul><ul><li>systemic effects depending on the </li></ul><ul><li>blood vessel affected ↓ </li></ul>
  • 95. <ul><li>asymptomatic or may manifest if damaged is obvious ↓ </li></ul><ul><li>systemic effects ↓ </li></ul><ul><li>↑ PVR to heart strain to hypertension </li></ul><ul><li>weakening the muscles of the wall that leads to aneurysm </li></ul>
  • 96. <ul><li>TIA to CVA </li></ul><ul><li>Angina to MI </li></ul><ul><li>ATN to Renal Failure </li></ul><ul><li>Retinopathy to Blindness </li></ul><ul><li>Peripheral Occlusive Disease (TAO) to Gangrene Formation </li></ul><ul><li>Hepatic Infarction </li></ul><ul><li>Pulmonary Infarction </li></ul>
  • 97. Diagnostic Evaluation: <ul><li>Arteriography </li></ul><ul><li>CT Scan </li></ul><ul><li>MRI </li></ul><ul><li>Duplex UTZ </li></ul><ul><li>EKG </li></ul>
  • 98. Management: <ul><li>Modification of risk factors (CAD and hyperlipidemia) </li></ul><ul><li>Anticoagulants </li></ul><ul><li>Antiplatelets </li></ul><ul><li>Lipid Lowering Agent </li></ul><ul><li>Antihypertensive </li></ul><ul><li>Vascular Rehabilitation/Exercise </li></ul>
  • 99. Surgical Intervention: <ul><li>PTA-Percutaneous Transluminal Angioplasty-introduce a balloon-tipped catheter to the stenosis to reduce or eliminate the obstruction </li></ul><ul><li>Laser Angioplasty- vaporizes the plaque </li></ul><ul><li>Embolectomy-removal of clot from the artery </li></ul><ul><li>Thrombectomy-removal of thrombus from the artery </li></ul><ul><li>Endarterectomy-removal of plaque from the artery </li></ul><ul><li>Bypass Graft </li></ul>
  • 100. Aneurysm <ul><li>Dilation involving an artery formed at a weak point in the vessel wall </li></ul><ul><li>Saccular= when one side of the vessel is affected </li></ul><ul><li>Fusiform= when the entire segment becomes dilated </li></ul>
  • 101. RISK FACTORS <ul><li>Atherosclerosis </li></ul><ul><li>Infection= syphilis </li></ul><ul><li>Connective tissue disorder </li></ul><ul><li>Genetic disorder= Marfan’s Syndrome </li></ul>
  • 102. PATHOPHYSIOLOGY <ul><li>Damage to the intima and media  weakness  outpouching </li></ul><ul><li>Dissecting aneurysm  tear in the intima and media with dissection of blood through the layers </li></ul>
  • 103. Manifestations: <ul><li>Asymptomatic </li></ul><ul><li>Pulsatile sensation on the abdomen </li></ul><ul><li>bruit </li></ul><ul><li>Diagnostics </li></ul><ul><li>CT scan </li></ul><ul><li>Ultrasound </li></ul><ul><li>X-ray </li></ul><ul><li>Aortography </li></ul>
  • 104. Management <ul><li>Anti-hypertensives </li></ul><ul><li>Synthetic graft </li></ul><ul><li>Nsg: </li></ul><ul><li>Administer medications </li></ul><ul><li>Emphasize the need to avoid increased abdominal pressure </li></ul><ul><li>No deep abdominal palpation </li></ul><ul><li>Remind patient the need for serial ultrasound to detect diameter changes </li></ul>
  • 105. Hypertension <ul><li>“ Silent killer” </li></ul><ul><li>disease of vascular regulation that leads to high blood pressure </li></ul><ul><li>due to alteration of Central Nervous System, Renin-Angiotensin-Aldosterone System, Extracellular Fluid Volume </li></ul>
  • 106. Primary or Essential Hypertension <ul><li>Other causes are absent </li></ul><ul><li>Average BP exceeds the upper limits (taken at rest 3x with several days interval) </li></ul><ul><li>Diastolic is 90 mm Hg or higher </li></ul><ul><li>Represents 95% of patients with hypertension </li></ul>
  • 107. Secondary Hypertension <ul><li>Due to: </li></ul><ul><li>Renal Pathology </li></ul><ul><li>Coarctation of the Aorta </li></ul><ul><li>Endocrine Disturbance </li></ul><ul><li>Drugs (estrogens, sympathomimetics, NSAIDs, steroids) </li></ul><ul><li>Malignant Hypertension </li></ul><ul><li>It is a combination of both which is BP is uncontrolled. </li></ul>
  • 108. Risk Factors <ul><li>Old age </li></ul><ul><li>male </li></ul><ul><li>Race </li></ul><ul><li>Overweight </li></ul><ul><li>Family History </li></ul><ul><li>Smoking </li></ul><ul><li>Sedentary Lifestyle </li></ul><ul><li>Diabetes Mellitus </li></ul>
  • 109. Manifestations <ul><li>1. Headache </li></ul><ul><li>2. Visual changes </li></ul><ul><li>3. chest pain </li></ul><ul><li>4. dizziness </li></ul><ul><li>5. N/V </li></ul>
  • 110. Diagnostic Evaluation <ul><li>Monitor BP </li></ul><ul><li>EKG, Blood Sugar, Blood Chem etc. </li></ul><ul><li>Management: </li></ul><ul><li>Control of all risk factors:. </li></ul><ul><ul><li>Lose weight, limit alcohol, cut sodium to 2.4 g/day, </li></ul></ul><ul><ul><li>stop smoking, reduce dietary saturated fat and cholesterol, reduce coffee intake. </li></ul></ul>
  • 111. <ul><ul><li>Despite lifestyle changes and BP remains high drug therapy should be started: </li></ul></ul><ul><li>Diuretics </li></ul><ul><li>Beta blockers </li></ul><ul><li>Calcium channel blockers </li></ul><ul><li>ACE inhibitors </li></ul><ul><li>A2 Receptor blockers </li></ul><ul><li>Vasodilators </li></ul>
  • 112. Nursing Management <ul><li>Health teaching on: </li></ul><ul><ul><li>Lifestyle changes ie activities, nutrition, weight, diet (low fat, low Na), cessation of smoking </li></ul></ul><ul><ul><li>treatment regimen ie drugs </li></ul></ul><ul><ul><li>BP monitoring </li></ul></ul><ul><ul><li>Follow up </li></ul></ul>
  • 113. Cardiovascular Drugs : <ul><li>Anti Anginal </li></ul><ul><ul><li>Opiate Analgesic – Morphine Sulfate </li></ul></ul><ul><ul><li>↓ cardiac workload and BP, improve LOC and sedative effect </li></ul></ul><ul><li>Vasodilators </li></ul><ul><ul><li>Nitroglycerin NTG, hydralazine, nitroprusside </li></ul></ul><ul><ul><li>Relax smooth muscle, dec. BP and alleviate headache </li></ul></ul><ul><ul><li>Increase blood vessel diameter and improves blood flow </li></ul></ul><ul><li>S.E. – dizziness and flushing, B6, B12 dec </li></ul><ul><li>Can be given SL or IV (Isordil) and topical (Nitrobid) </li></ul>
  • 114. <ul><li>Calcium Channel Blockers </li></ul><ul><ul><li>Nifidepine (Procardia) Diazepam (Cardizem) </li></ul></ul><ul><ul><li>Decrease muscle tone, interferes contraction, decrease BP </li></ul></ul><ul><ul><li>S.E. – bradycardia, diarrhea and rashes </li></ul></ul><ul><li>Beta Blocking Agent </li></ul><ul><ul><li>Propranolol </li></ul></ul><ul><ul><li>Decrease workload </li></ul></ul><ul><ul><li>Blocks beta receptors and capable of decreasing HR </li></ul></ul><ul><li>S.E. – vomiting, nausea and depression </li></ul>
  • 115. <ul><li>Diuretics- K- waster, sparer </li></ul><ul><li>S/E: hyponatremia, GI irritration, hyperurecemia, hypomagnesemia, dec. Ziinc( except K- sparers) </li></ul><ul><li>Furosemide- competes w/ ASA for renal excretion—inc. ASA levels </li></ul><ul><li>Hypocalcemia- sparers (spirinolactone, amiloride, triamterene) </li></ul><ul><li>Thiazides and loop diuretics- hyperglycemia in pxs w/ DM </li></ul><ul><li>All drugs are better administered in AM </li></ul>
  • 116. <ul><li>Digitalis, Digoxin </li></ul><ul><li>- Positive Inotropic (Increases contraction of the heart) </li></ul><ul><li>- Increase emptying capacity of the heart </li></ul><ul><li>- Negative chronotropic (Decreases HR) AV node control </li></ul><ul><li>- Increase CO (improves stroke volume) </li></ul><ul><li>S.E. – GIT disturbance, CNS depression and flashes of light </li></ul><ul><li>Dopamine – diuresis effect </li></ul><ul><li>- Increase Na excretion (kidney) </li></ul><ul><li>Dobutamine </li></ul><ul><li>- Increase CO </li></ul><ul><li>- More potent on contraction </li></ul>
  • 117. <ul><li>Anti dysrhythmic drug </li></ul><ul><ul><li>Lidocaine (Xylocaine) for PVC </li></ul></ul><ul><ul><li>Atropine for Mobitz type I </li></ul></ul><ul><ul><li>Isoproterenol (Isuprel) for sinus bradycardia </li></ul></ul><ul><ul><li>Norepinephrine (Levophed) powerful vasoconstrictor </li></ul></ul><ul><ul><li>Epinephrine – increase conduction, contractility and automaticity </li></ul></ul><ul><ul><li>Quinidine for atrial fib </li></ul></ul>
  • 118. <ul><li>Thrombolytic/Fibrinolytic Agent </li></ul><ul><li>- Streptokinase – lyses the clot (20T IU IV bolus or 4T IU/min drip) </li></ul><ul><li>- Urokinase – avtivates plasminogen to plasmin (intracoronary) </li></ul>
  • 119. <ul><li>Blood thinner </li></ul><ul><ul><li>Heparin – prevent formation of new clot (4-8T IU/30 min) </li></ul></ul><ul><li>Antidote – Protamine Sulfate </li></ul><ul><li>Warfarin (Coumadine) – decrease viscosity of blood (PO) home meds </li></ul><ul><li>Don’t give to pregnant women </li></ul><ul><li>Antidote – Vitamin K </li></ul>
  • 120. Cardiac catheterization
  • 121. The Cardiovascular System LABORATORY PROCEDURES <ul><li>Pretest: Ensure Consent, assess for allergy to seafood and iodine, NPO, document weight and height, baseline VS, blood tests and document the peripheral pulses </li></ul>
  • 122. The Cardiovascular System LABORATORY PROCEDURES <ul><li>Pretest: Fast for 8-12 hours, teachings, medications to allay anxiety </li></ul>
  • 123. The Cardiovascular System LABORATORY PROCEDURES <ul><li>Intra-test: inform patient of a fluttery feeling as the catheter passes through the heart; inform the patient that a feeling of warmth and metallic taste may occur when dye is administered </li></ul>
  • 124. The Cardiovascular System LABORATORY PROCEDURES <ul><li>Post-test: Monitor VS and cardiac rhythm </li></ul><ul><li>Monitor peripheral pulses, color and warmth and sensation of the extremity distal to insertion site </li></ul><ul><li>Maintain sandbag to the insertion site if required to maintain pressure </li></ul><ul><li>Monitor for bleeding and hematoma formation </li></ul>
  • 125. The Cardiovascular System LABORATORY PROCEDURES <ul><li>Maintain strict bed rest for 6-12 hours </li></ul><ul><li>Client may turn from side to side but bed should not be elevated more than 30 degrees and legs always straight </li></ul><ul><li>Encourage fluid intake to flush out the dye </li></ul><ul><li>Immobilize the arm if the antecubital vein is used </li></ul><ul><li>Monitor for dye allergy </li></ul>
  • 126. &nbsp;
  • 127. &nbsp;
  • 128. Thank You!

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