GENERAL CARDIAC ASSESSMENT Health history Demographic information Family/genetic history Cultural/social factors Risk factors Modifiable: High blood cholesterol, obesity, smoking, stress, hypertension, diabetes mellitus. Nonmodifiable: Family history, increasing age, gender, race
Relieved by rest (preferably sitting or standing with support) or by use of NTG
Variant/Vasospastic Angina (Prinzmetal Angina)
1st described by Prinzmetal & Associates in 1659
Cause: spasm of coronary arteries (vasospasm) due to coronary artery stenosis
Mechanism is uncertain (may be from hyperactive sympathetic responses, mishandling defects of calcium in smooth vascular muscles, reduced prostaglandin I2 production)
Pain Characteristics: occurs during rest or with minimal exercise
- commonly follows a cyclic or regular pattern of occurrence (i.e.. Same time each day usually at early hours)
If client is for cardiac cath, Ergonovine (nonspecific vasoconstrictor) may be administered to evoke anginal attack & demonstrate the presence & location of spasm
Cont… Nocturnal Angina - frequently occurs nocturnally (may be associated with REM stage of sleep) Angina Decubitus – paroxysmal chest pain occurs when client sits or stands up Post-infarction Angina – occurs after MI when residual ischemia may cause episodes of angina
Class I – angina occurs with strenuous, rapid, or prolonged exertion at work or recreation
Class II – angina occurs on walking or going up the stairs rapidly or after meals, walking uphill, walking more than 2 blocks on the level or going more than 1 flight of ordinary stairs at normal pace, under emotional stress, or in cold
Class III – angina occurs on walking 1-2 blocks on the level or going 1 flight of ordinary stairs at normal pace
Symptoms at rest (usually prolonged, i.e.. >20mins) New onset exertional angina (increased in severity of at least 1 class – to at least class III) in <2months Recent acceleration of angina to at least class III in <2months
- O2 therapy via nasal prongs - adequate analgesia (Morphine via IV – also has vasodilator property) - ECG monitoring -sublingual NTG (unless contraindicated; IV may be given to limit infarction size & most effective if given within 4hrs of onset)
Thrombolytic Therapy – best results occur if initiated within 60-90mins of onset (Streptokinase & Urokinase – promote conversion of plasminogen to plasmin)
ASSESSMENT Subjective data: PAIN!!! Nausea SOB Apprehension Objective data: VS Diaphoresis Emotional restlessness
ANALYSIS / NURSING DIAGNOSES Decreased cardiac output related to myocardial damage Impaired gas exchange related to poor perfusion, shock Pain related to myocardial ischemia Activity intolerance related to pain or inadequate oxygenation Fear related to possibility of death
NURSING CARE PLAN Goal # 1: reduce pain / discomfort Narcotics – morphine; note response; Avoid IM Humidified oxygen 2-4 L/min; mouth care – O2 is drying Position: semi-Fowler’s to improve ventilation
NURSING CARE PLAN Goal # 2: maintain adequate circulation; stabilize heart rhythm Monitor VS/UO; observe for cardiogenic shock Monitor ECG for arrhythmias Medications: antiarrhythmics; anticoagulants; thrombolytics Diagnostics: cardiac catheterizations, CAB surgery Recognize heart failure: edema, cyanosis, dyspnea, crackles Check labs: troponin, blood gases, electrolytes, clotting time CVP: (5-15 cm H2O) increases with heart failure ROM of lower extremities; antiembolic stockings
NURSING CARE PLAN Goal # 3: decrease oxygen demand/promote oxygenation, reduce cardiac workload O2 as ordered Activity: bedrest (24-48 H) with bedside commode; planned rest periods; control visitors Position: semi-Fowler’s to facilitate lung expansion and decrease venous return Anticipate needs of client: call light, water / Reassurance Assist with feeding, turning Environment: quiet and comfortable Medications: CCBs, vasodilators, cardiotonics
NURSING CARE PLAN Goal # 4: maintain fluid electrolyte, nutritional status IV (KVO); CVP; vital signs UO: 30 cc/hr Labs: electrolytes (Na, K, Mg) Monitor ECG Diet: progressive low calorie, low sodium, low cholesterol, low fat, without caffeine
NURSING CARE PLAN Goal # 5: facilitate fecal elimination Medications: stool softeners to prevent Valsalva maneuver; mouth breathing during bowel movement Bedside commode
NURSING CARE PLAN Goal # 6: provide emotional support Recognize fear of dying: denial, anger, withdrawal Encourage expression of feelings, fears, concerns Discuss rehabilitation, lifestyle changes: prevent cardiac-invalid syndrome by promoting self-care activities, independence
NURSING CARE PLAN Goal # 7: promote sexual functioning Encourage verbalization of concerns regarding activity, inadequacy, limitations, expectations – include partner (usually resume activity 5-8 wks after uncomplicated MI or when client can climb 2 flights of stairs Identify need for referral for sexual counselling
NURSING CARE PLAN Goal # 8: health teaching Diagnosis and treatment regimen Caution when to avoid sexual activity: after heavy meal, alcohol ingestion; when fatigued, stressed; with unfamiliar partners; in extreme temperatures Information about sexual activity: less fatiguing positions Support groups / Follow-up care Medications: administration, importance, untoward effects; pulse taking Control risk factors: rest, diet, exercise, no smoking, weight control, stress reduction
EVALUATION No complications: stable vital signs; relief of pain Adheres to medication regimen Activity tolerance is increased Reduction or modification of risk factors
CONGESTIVE HEART FAILURE inability of the heart to pump sufficient blood to meet the needs of the tissue for oxygen and nutrient.
ASSESSMENT Subjective data: Shortness of breath Orthopnea (sleeps on two or more pillows) Paroxysmal nocturnal dyspnea (sudden breathlessness during sleep) Dyspnea on exertion (climbing stairs) Apprehension; anxiety; irritability Fatigue; weakness Reported weight gain; feeling of puffiness
Left Ventricular Compared with Right Ventricular Heart Failure
ANALYSIS / NURSING DIAGNOSES Decreased cardiac output related to decreased myocardial contractility Activity intolerance related to generalized body weakness and inadequate oxygenation Fatigue related to edema and poor oxygenation
Fluid volume excess related to compensatory mechanisms Impaired gas exchange related to pulmonary congestion Anxiety related to shortness of breath Sleep pattern disturbance related to paroxysmal nocturnal disturbance
NURSING CARE PLAN Goal # 1: provide physical rest/ reduce emotional stimuli Position: sitting or semi-Fowler’s until tachycardia, dyspnea, edema resolved; change position frequently; pillows for support Rest: planned periods; limit visitors, activity, noise. Chair and commode privileges Support: stay with client who is anxious; have family member who is supportive present; administer sedatives/tranquilizers as ordered Warm fluids if appropriate
NURSING CARE PLAN Goal # 2: provide for relief of respiratory distress; reduce cardiac workload Oxygen: low flow rate; encourage deep breathing (5-10 min q 2H); auscultate breath sounds for congestion, pulmonary edema. Position: elevating head of bed 20-25 cm (8-10 in) alleviates pulmonary congestion Medications – digitalis, ACE inhibitors, inotropic agents, diuretics, tranquilizers, vasodilators
NURSING CARE PLAN Goal # 3: provide for special safety needs Skin care: Inspect, massage, lubricate bony prominences Use foot cradle, heel protectors; sheepskin Side rails up if hypoxic (disoriented) Vital signs: monitor for signs of fatigue, pulmonary emboli ROM: active, passive; elastic stockings
NURSING CARE PLAN Goal # 4: maintain fluid and electrolyte balance, nutritional status Urine output: 30 cc/hr minimum; estimate insensible loss in client who s diaphoretic. Monitor BUN, serum creatinine, and electrolytes. Daily weight; same time, clothes, scale IV: IV infusion pump to avoid circulatory overload; strict I/O Diet Low sodium Small, frequent feedings Discuss food preferences with client.
NURSING CARE PLAN Goal # 5: health teaching Diet restrictions; meal preparation Activity restrictions; planned rest periods Medications: schedule (e.g. diuretics in early morning); purpose; dosage; side effects (pulse taking, daily weights, intake of potassium-containing foods) Refer to available communityresources for dietary assistance, weight reduction, exercise program.
EVALUATION Increase in activity level tolerance – fatigue decreased No complications – pulmonary edema, respiratory distress Reduction in dependent edema
hyperlipidemia means high lipid levels. High lipid levels can speed up a process called atherosclerosis, or hardening of the arteries.
Most hyperlipidemia is caused by lifestyle habits or treatable medical conditions. Lifestyle contributors include obesity, not exercising, and smoking. Conditions that cause hyperlipidemia include diabetes, kidney disease, pregnancy, and an underactive thyroid gland.
You can also inherit hyperlipidemia. The cause may be genetic if you have a normal body weight and other members of your family have hyperlipidemia.
You have a greater chance of developing hyperlipidemia if you are a man older than age 45 or a woman older than age 55. If a close relative had early heart disease (father or brother affected before age 55, mother or sister affected before age 65), you also have an increased risk.
Treatment of Hyperlipidemia It is necessary to first identify and treat any potential underlying medical problems, such as diabetes or hypothyroidism, that may contribute to hyperlipidemia. Treatment of hyperlipidemia itself includes dietary changes, weight reduction and exercise. If lifestyle modifications cannot bring about optimal lipid levels, then medications may be necessary.
Medications most commonly used to treat high LDL cholesterol levels are statins, such as atorvastatin (Lipitor) or simvastatin (Mevacor). These medications work by reducing the production of cholesterol within the body.
CARDIOMYOPATHIES Nursing Management 2. Increase patient tolerance Schedule activities with rest periods in between
CARDIOMYOPATHIES Nursing Management 3. Reduce patient anxiety Support Offer information about transplantations Support family in anticipatory grieving
Infective endocarditis Infection of the heart valves and the endothelial surface of the heart Can be acute or chronic
Infective endocarditis Etiologic factors 1. Bacteria- Organism depends on several factors 2. Fungi
Infective endocarditis Risk factors 1. Prosthetic valves 2. Congenital malformation 3. Cardiomyopathy 4. IV drug users 5. Valvular dysfunctions
Infective endocarditis Pathophysiology Direct invasion of microbes microbes adhere to damaged valve surface and proliferate damage attracts platelets causing clot formation erosion of valvular leaflets and vegetation can embolize
Infective endocarditis Assessment findings 1. Intermittent HIGH fever 2. anorexia, weight loss 3. cough, back pain and joint pain 4. splinter hemorrhages under nails
Infective endocarditis Assessment findings 5. Osler’s nodes- painful nodules on fingerpads 6. Roth’s spots- pale hemorrhages in the retina
Alterations inBlood Flow in the Systemic Circulation
Buerger’s Disease Also known as Thromboangiitisobliterans Usually a disease of heavy cigarette smoker/tobacco user men, 25-40y/o Inflammatory arterial disorder that causes thrombus formation often extends to adjacent veins & nerves
Affects medium-sized arteries (usually plantar & digital vessels in the foot or lower legs) unknown pathogenesis but it had been suggested that: tobacco may trigger an immune response or unmask a clotting defect; -> these 2 can incite an inflammatory reaction of the vessel wall
Disease progression ulcerate tissues & gangrenous changes may arise; may necessitate amputation
Diagnosis & Treatment Diagnostic methods – those that assess blood flow (Doppler ultrasound & MRI) Tx: mandatory to stop smoking or using tobacco Meds to increase blood flow to extremities Surgery (surgical sympathectomy) amputation
Precipitated by exposure to cold & strong emotions
Raynaud’s phenomenon – associated with previous injury (i.e.. Frostbite, occupational trauma associated with use of heavy vibrating tools, collagen diseases, neuro d/o, chronic arterial occlusive d/o)
Manifestations Period of ischemia (ischemia due to vasospasm) change in skin color = pallor to cyanotic 1st noticed at the fingertips later moving to distal phalanges Cold sensation Sensory perception changes (numbness & tingling) Period of hyperemia – intense redness Throbbing Paresthesia
Return to normal color Note: although all of the fingers are affected symmetrically, only 1-2digits may be involved Severe cases: arthritis may arise (due to nutritional impairment) Brittle nails Thickening of the skin of fingertips Ulceration & superficial gangrene of fingers (rare occasions)
Care Plan for Clients with Altered Cardiovascular Oxygenation Goals: Relief of pain & symptoms Prevention of further cardiac damage Nursing Interventions: Pain control Proper medications Decrease client’s anxiety Health teachings (meds, activities, diet, exercise, etc) Assessment: Hx of symptoms (pain, esp. chest pain; palpitations; dyspnea) v/s Nursing Dx: ineffective tissue perfusion (cardiopulmonary) Impaired gas exchange Anxiety due to fear of death (clients with MI or Angina)