4. cardiovascular delfin

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FOR OSCAR ESPINOSA JR. EDIT A FEW BUT THIS IS A COMPLETE ONE.. I HAVE VIDEOS FOR HEART SOUNDS AND OTHER STUFF BUT DNT KNW HOW TO SEND IT.

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  • Shenell these power points are excellent. You should consider doing these professionally and get paid for them.
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  • could you please email me the full presentation? thank you. convilgarcia@msn.com
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4. cardiovascular delfin

  1. 1. CARDIO VASCULAR SYSTEM 04/04/11 sdelfin2010
  2. 2. CARDIOVASCULAR SYSTEM <ul><li>Consists: heart, arteries, veins, capillaries </li></ul><ul><li>Functions: </li></ul><ul><li>1. circulation of blood </li></ul><ul><li>2. delivery of oxygen and other nutrients to tissues of the body </li></ul><ul><li>3. removal of carbon dioxide and other products of cellular metabolism </li></ul>04/04/11 sdelfin2010
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  5. 5. CARDIOVASCULAR SYSTEM <ul><li>HEART </li></ul><ul><li>ANATOMY and PHYSIOLOGY: </li></ul><ul><li>A. Heart wall </li></ul><ul><li>1. pericardium </li></ul><ul><li>a. fibrous pericardium </li></ul><ul><li>b. serous pericardium </li></ul><ul><li>2. epicardium </li></ul><ul><li>3. myocardium </li></ul><ul><li>4. endocardium </li></ul>04/04/11 sdelfin2010
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  7. 7. CARDIOVASCULAR SYSTEM <ul><li>B. Chambers </li></ul><ul><li>1. Atria a. right </li></ul><ul><li>b. left </li></ul><ul><li>2. Ventricles a. right </li></ul><ul><li>b. left </li></ul><ul><li>C. Valves </li></ul><ul><li>1. Atrioventricular valves </li></ul><ul><li>a. Mitral valve </li></ul><ul><li>b. Tricuspid valve </li></ul>04/04/11 sdelfin2010
  8. 8. CARDIOVASCULAR SYSTEM <ul><li>c. Function: </li></ul><ul><li>- permit unidirectional flow of blood from specific atrium to specific ventricle during ventricular diastole </li></ul><ul><li>- prevent reflux during ventricular systole </li></ul><ul><li>- valve leaflets open during ventricular diastole and close during ventricular systole; valve closure produces the first heart sounds (S1) </li></ul>04/04/11 sdelfin2010
  9. 9. CARDIOVASCULAR SYSTEM <ul><li>2. Semilunar valves </li></ul><ul><li>a. Pulmonary valve </li></ul><ul><li>b. Aortic valve </li></ul><ul><li>c. Function: </li></ul><ul><li>- permit unidirectional flow of blood from specific ventricle to arterial vessel during ventricular systole </li></ul><ul><li>- prevent reflux during ventricular diastole </li></ul><ul><li>- valves open when ventricles contract and close during ventricular diastole; valve closure produces the second heart sound (S2) </li></ul>04/04/11 sdelfin2010
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  11. 11. CARDIOVASCULAR SYSTEM <ul><li>D. Conduction System </li></ul><ul><li>1. Sinoatrial (SA) node </li></ul><ul><li>2. Internodal Tracts </li></ul><ul><li>3. Atrioventricular (AV) node </li></ul><ul><li>4. Bundle of His </li></ul><ul><li>- right bundle branch </li></ul><ul><li>- left bundle branch </li></ul><ul><li>5. Purkinje fibers </li></ul><ul><li>* Electrical activity of heart can be visualized by ECG </li></ul>04/04/11 sdelfin2010
  12. 12. CONDUCTION SYSTEM <ul><li>DIASTOLE- consist of relaxation and filling of the atria and ventricles. </li></ul><ul><li>SYSTOLE- consists of contraction and emptying of the atria and ventricles. </li></ul><ul><li>SA NODE- main regulator of HR </li></ul><ul><li>- transmit impulse to the surrounding atrial muscle. </li></ul><ul><li>AV NODE- transmit impulses to the surrounding ventricular muscle. </li></ul>04/04/11 sdelfin2010
  13. 13. CONDUCTION SYSTEM <ul><li>BUNDLE OF HIS- continuation of AV Node and has a left and right bundles and fuse with purkinje fibers. </li></ul><ul><li>PURKINJE FIBERS- terminal branches of the conduction system and are responsible for carrying the wave of depolarization to both ventricular walls. </li></ul>04/04/11 sdelfin2010
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  15. 15. CARDIOVASCULAR SYSTEM <ul><li>E. Coronary Circulation </li></ul><ul><li>1. Arteries </li></ul><ul><li>a. right coronary artery </li></ul><ul><li>b. left coronary artery </li></ul><ul><li>2. Veins </li></ul><ul><li>a. coronary sinus veins </li></ul><ul><li>b. thebesian veins </li></ul>04/04/11 sdelfin2010
  16. 16. CARDIOVASCULAR SYSTEM <ul><li>VASCULAR SYSTEM </li></ul><ul><li>Function: </li></ul><ul><li>a. supply tissues with blood </li></ul><ul><li>b. remove wastes </li></ul><ul><li>c. carry unoxygenated blood back to the heart </li></ul>04/04/11 sdelfin2010
  17. 17. CARDIOVASCULAR SYSTEM <ul><li>TYPES OF BLOOD VESSELS </li></ul><ul><li>A. Arteries </li></ul><ul><li>B. Arterioles </li></ul><ul><li>C. Capillaries: the following exchanges occur: </li></ul><ul><li>- oxygen and carbon dioxide </li></ul><ul><li>- solutes between the blood and tissues </li></ul><ul><li>- fluid volume transfer between the plasma and interstitial spaces </li></ul><ul><li>D. Venules </li></ul><ul><li>E. Veins </li></ul>04/04/11 sdelfin2010
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  20. 20. CARDIAC OUTPUT CO= SV x HR <ul><li>CARDIAC OUTPUT- is the volume of blood (in liters) ejected by the heart each minute. CO ranges from 4L to 7L/ min. </li></ul><ul><li>STROKE VOLUME -is the amount of blood ejected by the left ventricle. SV ranges from 60-100 ml/min. </li></ul><ul><li>Example: </li></ul><ul><li>HR 80 bpm X SV 80 ml/min =6400ml or 6.4 L </li></ul>04/04/11 sdelfin2010
  21. 21. <ul><li>PRELOAD- the filing of the ventricles at the end of diastole. The more ventricles fill, the more the cardiac muscles are stretched, the greater the force of the contraction during systole ( Starling’s law). If there is a decrease in the preload, then there is a decrease in contractility and in cardiac output. </li></ul>04/04/11 sdelfin2010
  22. 22. <ul><li>AFTER LOAD- the pressure in the aorta that the ventricle must overcome to pump blood into the systemic circulation. A decrease in the afterload causes a decrease in the workload of the ventricles; this in turn will assist to increase the stroke volume and the cardiac output. </li></ul>04/04/11 sdelfin2010
  23. 23. 04/04/11 sdelfin2010
  24. 24. CARDIOVASCULAR SYSTEM <ul><li>ASSESSMENT </li></ul><ul><li>HEALTH HISTORY </li></ul><ul><li>A. Presenting problem </li></ul><ul><li>1. Nonspecific symptoms may include </li></ul><ul><li>- fatigue - shortness of breath </li></ul><ul><li>- cough - palpitations </li></ul><ul><li>- headache - weight loss/gain </li></ul><ul><li>- syncope - difficulty sleeping </li></ul><ul><li>- dizziness - anorexia </li></ul>04/04/11 sdelfin2010
  25. 25. CARDIOVASCULAR SYSTEM <ul><li>2. Specific signs and symptoms </li></ul><ul><li>a. chest pain </li></ul><ul><li>b. dyspnea (shortness of breath) </li></ul><ul><li>c. orthopnea / paroxysmal nocturnal dyspnea </li></ul><ul><li>d. palpitations: precipitating factors </li></ul><ul><li>e. edema </li></ul><ul><li>f. cyanosis </li></ul><ul><li>B. Lifestyle: occupation, hobbies, financial status, stressors, exercise, smoking, living conditions </li></ul>04/04/11 sdelfin2010
  26. 26. CARDIOVASCULAR SYSTEM <ul><li>C. Use of medications: OTC drugs, contraceptives, cardiac drugs </li></ul><ul><li>D. Nutrition: dietary habits, cholesterol, salt intake, alcohol consumption </li></ul><ul><li>E. Past Medical History ( RHD, MI, HPN, STD, CVA) </li></ul><ul><li>F. Family history: heart disease (congenital, acute, chronic); risk factors (DM, hypertension, obesity) </li></ul>04/04/11 sdelfin2010
  27. 27. CARDIOVASCULAR SYSTEM <ul><li>PHYSICAL EXAMINATION </li></ul><ul><li>A. Skin and mucous membranes: </li></ul><ul><li>- color/texture, temperature, hair distribution on extremities, atrophy or edema, petechiae </li></ul><ul><li>B. Peripheral pulses: </li></ul><ul><li>- palpate and rate all arterial pulses (temporal, carotid, brachial, radial, femoral, popliteal, dorsalis pedis and posterior tibial) on scale of: 0=absent, 1=palpable, 2=normal, 3=full, 4=full and bounding </li></ul>04/04/11 sdelfin2010
  28. 28. CARDIOVASCULAR SYSTEM <ul><li>C. Assess for arterial insufficiency and venous impairment </li></ul><ul><li>D. Measure and record blood pressure </li></ul><ul><li>E. Inspect and palpate the neck vessels: </li></ul><ul><li>a. jugular veins: note location, characteristics, jugular venous pressure </li></ul><ul><li>b. carotid arteries: location and characteristics </li></ul><ul><li>F. Auscultate heartsounds </li></ul><ul><li>- normal (S1, S2) </li></ul><ul><li>- abnormal (S3, S4) </li></ul><ul><li>- murmurs </li></ul><ul><li>- friction rub </li></ul>04/04/11 sdelfin2010
  29. 29. AREAS FOR AUSCULTATION 04/04/11 sdelfin2010
  30. 30. CARDIOVASCULAR SYSTEM <ul><li>LABORATORY / DIAGNOSTIC TESTS </li></ul><ul><li>NON-INVASIVE </li></ul><ul><li>A. Blood Chemistry and electrolyte analysis </li></ul><ul><li>1. Cardiac enzymes: in MI </li></ul><ul><li>a. Troponin T: detected 3-12 hours after chest pain NV =<0.2 ng/ml </li></ul><ul><li>b. Troponin I: detected 3-12 hrs </li></ul><ul><li>NV= <0.03bg/dl </li></ul><ul><li>c. Creatine phosphokinase (CPK – MB): 6-12Hrs </li></ul><ul><li>NV=by ratio </li></ul><ul><li>d. Aspartate aminotransferase (AST) (SGOT): 24 Hrs after chest pain NV= 7-40 U/ml </li></ul><ul><li>e. Lactic dehydrogenase (LDH): 36 Hrs NV= 14%- 26% </li></ul>04/04/11 sdelfin2010
  31. 31. CARDIOVASCULAR SYSTEM <ul><li>2. Electrolytes </li></ul><ul><li>a. Sodium (Na) 135-145meq/L </li></ul><ul><li>- hyponatremia: fluid excess </li></ul><ul><li>- hypernatremia: fluid deficit </li></ul><ul><li>b. Potassium (K) 3.5-5 meq /L </li></ul><ul><li>- inc. or dec. levels can cause dysrhythmias </li></ul><ul><li>c. Magnesium (Mg) 1.3-2.1 meq/L </li></ul><ul><li>- dec. levels can cause dysrhythmias </li></ul>04/04/11 sdelfin2010
  32. 32. CARDIOVASCULAR SYSTEM <ul><li>d. Calcium (Ca) 4.5-5.3 meq/L : </li></ul><ul><li>- For blood clotting and neuromuscular activity </li></ul><ul><li>- dec. levels cause tetany, inc. levels causes muscle atony </li></ul><ul><li>- dec. and inc. levels cause dysrhythmias </li></ul><ul><li>3. Serum Lipids </li></ul><ul><li>a. Total Cholesterol 150-200mg/dl: </li></ul><ul><li>- high levels predispose to atherosclerotic HD </li></ul>04/04/11 sdelfin2010
  33. 33. CARDIOVASCULAR SYSTEM <ul><li>b. High density lipids (HDL) 30-85 mg/dl </li></ul><ul><li>- low levels predispose to CVD </li></ul><ul><li>c. Low density lipids (LDL) 50-140 mg/dl: </li></ul><ul><li>- high levels predispose to atherosclerotic plaque formation </li></ul><ul><li>d. Triglycerides 10-150 mg/dl: </li></ul><ul><li>- high levels increase risk of atherosclerotic heart disease </li></ul>04/04/11 sdelfin2010
  34. 34. CARDIOVASCULAR SYSTEM <ul><li>B. Hematologic Studies </li></ul><ul><li>1. CBC </li></ul><ul><li>2. Coagulation time : 5-15mins ; inc. levels indicate bleeding tendency, used to monitor heparin tx. </li></ul><ul><li>3. Prothrombin time (PT) 9.5-12sec. ; used to monitor warfarin tx. </li></ul><ul><li>4. Activated partial thromboplastin time (APTT) 20-45sec ; used to monitor heparin therapy </li></ul><ul><li>5. Erythrocyte sedimentation rate(ESR) <20mm/hr ; inc. level indicate inflamm. process </li></ul>04/04/11 sdelfin2010
  35. 35. CARDIOVASCULAR SYSTEM <ul><li>C. Urine Studies (routine U/A) </li></ul><ul><li>D. Electrocardiogram (ECG) </li></ul><ul><li>1. Noninvasive ECG – a graphic record of the electrical activity of the heart </li></ul><ul><li>2. Portable recorder (Holter monitor) – provides continuous recording of ECG for up to 24 hrs. </li></ul><ul><li>E. Exercise ECG (stress test): the ECG is recorded during prescribed exercise; may show heart disease when resting ECG does not </li></ul><ul><li>F. Echocardiogram: noninvasive recording of the cardiac structures using ultrasound </li></ul>04/04/11 sdelfin2010
  36. 36. STRESS TEST 04/04/11 sdelfin2010
  37. 37. Nursing intervention: <ul><li>Cardiac monitoring </li></ul><ul><li>Invasive diagnostic test </li></ul><ul><li>ECG </li></ul><ul><li>Hemodynamic monitoring </li></ul><ul><li>Swan gans cathether </li></ul><ul><li>Central venous pressure </li></ul>04/04/11 sdelfin2010
  38. 38. CARDIOVASCULAR SYSTEM INVASIVE DIAGNOSTICS <ul><li>G. Cardiac catheterization : invasive, but often definitive test for diagnosis of cardiac disease. </li></ul><ul><li>1. A catheter is inserted into the right or left side of the heart to obtain information </li></ul><ul><li>2. Purpose: to measure intracardiac pressures and oxygen levels in various parts of the heart; -with injection of a dye, it allows visualization of the heart chambers, blood vessels and blood flow (angiography) </li></ul>04/04/11 sdelfin2010
  39. 39. Cardiac Catheterization.mp4 04/04/11 sdelfin2010
  40. 40. CARDIOVASCULAR SYSTEM <ul><li>3. Nursing care: prior to the test </li></ul><ul><li>- informed consent </li></ul><ul><li>- any allergies esp. to iodine </li></ul><ul><li>- keep client on NPO for 8-12 hrs </li></ul><ul><li>- record height, weight, V/S </li></ul><ul><li>- inform client that a feeling of warmth and fluttering sensation as catheter is inserted </li></ul>04/04/11 sdelfin2010
  41. 41. CARDIOVASCULAR SYSTEM <ul><li>4. Nursing care: post test </li></ul><ul><li>- assess circulation to the extremity used for catheter insertion </li></ul><ul><li>- check peripheral pulses, color, sensation of affected extremity </li></ul><ul><li>- if protocol requires, keep affected ext. straight for approx. 8 hrs. </li></ul><ul><li>- observe catheter insertion site for swelling, bleeding </li></ul><ul><li>- assess V/S and report for sig. changes </li></ul>04/04/11 sdelfin2010
  42. 42. CARDIOVASCULAR SYSTEM <ul><li>H. Coronary arteriography </li></ul><ul><li>1. visualization of coronary arteries by injection of radiopaque contrast dye and recording on a movie film. </li></ul><ul><li>2. Purpose: evaluation of heart disease and angina, location of areas of infarction and extent of lesions, ruling out coronary artery disease in clients with MI. </li></ul><ul><li>3. Nursing care: same as cardiac catheterization </li></ul>04/04/11 sdelfin2010
  43. 43. Coronary arteriography 04/04/11 sdelfin2010
  44. 44. Hemodynamic monitoring <ul><li>Assessment of the patient’s circulatory status and it includes: </li></ul><ul><li>Measurement of heart rate </li></ul><ul><li>Intra-arterial pressure </li></ul><ul><li>Pulmonary artery </li></ul><ul><li>Cardiac output </li></ul><ul><li>Blood volume </li></ul>04/04/11 sdelfin2010
  45. 45. <ul><li>HEMODYNAMIC MONITORING </li></ul><ul><li>(Swan Ganz Catheter) </li></ul><ul><li>A. A multilumen catheter with a balloon tip that is advanced through the superior vena cava into the RA, RV, and PA. When it is wedged it is in the distal arterial branch of the pulmonary artery. </li></ul><ul><li>B. Purpose: </li></ul><ul><li>1. Proximal port: measures RA pressure </li></ul><ul><li>2. Distal port: </li></ul><ul><li>a. measures PA pressure and PAWP </li></ul><ul><li> b. normal values: PA systolic and diastolic less than 20mmHg; PAWP 4-12mmHg </li></ul>04/04/11 sdelfin2010
  46. 46. 04/04/11 sdelfin2010
  47. 47. PLANNING AND IMPLEMENTATION <ul><li>C. Nursing care </li></ul><ul><li>1. a sterile dry dressing should be applied to site and changed every 24 hours; inspect site daily and report signs of infection </li></ul><ul><li>2. if catheter is inserted via an extremity, immobilize extremity to prevent catheter dislodgment or trauma. </li></ul>04/04/11 sdelfin2010
  48. 48. PLANNING AND IMPLEMENTATION <ul><li>CENTRAL VENOUS PRESSURE (CVP) </li></ul><ul><li>A. Obtained by inserting a catheter into the external jugular, antecubital, or femoral vein and threading it into the vena cava. The catheter is attached to an IV infusion and H2O manometer by a three way stopcock </li></ul><ul><li>B. Purposes: </li></ul><ul><li>1. Reveals RA pressure, reflecting alterations in the RV pressure </li></ul>04/04/11 sdelfin2010
  49. 49. PLANNING AND IMPLEMENTATION <ul><li>2. Provides information concerning blood volume and adequacy of central venous return </li></ul><ul><li>3. Provides an IV route for drawing blood samples, administering fluids or medication, and possibly inserting a pacing catheter </li></ul><ul><li>C. Normal range is 5-12 cmH20; </li></ul><ul><li>elevation indicates hypervolemia, </li></ul><ul><li>decreased level indicates hypovolemia </li></ul><ul><li>EVALUATION </li></ul>04/04/11 sdelfin2010
  50. 50. 04/04/11 sdelfin2010
  51. 51. <ul><li>INTERVENTIONS </li></ul><ul><li>CARDIAC MONITORING </li></ul><ul><li>A. ECG </li></ul><ul><li>Indications for ordering an ECG: </li></ul><ul><li>To determine cardiac rate </li></ul><ul><li>To accurately define cardiac rhythm </li></ul><ul><li>To diagnose old or new myocardial infarction </li></ul><ul><li>To identify intracardiac conduction disturbances </li></ul><ul><li>To aid in the diagnosis of ischemic HD, pericarditis, myocarditis, electrolyte imbalances, and pacemaker malfunction. </li></ul>04/04/11 sdelfin2010
  52. 52. Impulse generation <ul><li>Resting state- cells is ready to receive an impulse. </li></ul><ul><li>Depolarization - flow of electrical along the cardiac membrane, initiating muscle contraction. </li></ul><ul><li>Repolarization - cells regain the electrical charge and are returned to a resting state. </li></ul>04/04/11 sdelfin2010
  53. 53. PLANNING AND IMPLEMENTATION <ul><li>1. strip: small square: 0.04secs. </li></ul><ul><li> large square: 0.2secs. </li></ul><ul><li>2. P wave: produced by atrial depolarization; indicates SA node function </li></ul>04/04/11 sdelfin2010
  54. 54. PLANNING AND IMPLEMENTATION <ul><li>3. P-R interval (N˚= 0.12 - 0.20 secs.) </li></ul><ul><li>a. indicates AV conduction time or the time it takes an impulse to travel from the atria down and through the AV node </li></ul><ul><li>b. measured from beginning of P wave to beginning of QRS complex </li></ul><ul><li>4. QRS complex (N˚= 0.06-0.10 secs.) </li></ul><ul><li>a. indicates ventricular depolarization </li></ul><ul><li>b. measured from onset of Q wave to end of S wave </li></ul>04/04/11 sdelfin2010
  55. 55. PLANNING AND IMPLEMENTATION <ul><li>5. ST segment </li></ul><ul><li>a. indicates time interval between complete depolarization of ventricles and repolarization of ventricles </li></ul><ul><li>b. measured after QRS complex to beginning of T wave </li></ul><ul><li>6. T wave </li></ul><ul><li>a. represents ventricular repolarization </li></ul><ul><li>b. follows ST segment </li></ul>04/04/11 sdelfin2010
  56. 56. Normal ECG P Q S R T 04/04/11 sdelfin2010
  57. 57. NORMAL SINUS.MP4 <ul><li>3d animation of a cardiac cycle + electrical activity.mp4 </li></ul>04/04/11 sdelfin2010
  58. 58. Position of Chest Leads <ul><li>Leads Position in the chest </li></ul><ul><li>V1 4 th ICS at the RSB </li></ul><ul><li>V2 4 th ICS at the LSB </li></ul><ul><li>V3 Halfway between V2 & V4 </li></ul><ul><li>V4 5 th ICS at the MCL </li></ul><ul><li>V5 5 th ICS at the LAAL </li></ul><ul><li>V6 5 th ICS at the LMAL </li></ul>04/04/11 sdelfin2010
  59. 59. DISORDERS OF THE CARDIOVASCULAR SYSTEM <ul><li>HEART </li></ul><ul><li>CORONARY ARTERY DISEASE (CAD) </li></ul><ul><li>A. General Information </li></ul><ul><li>1. refers to a variety of pathology that cause narrowing or obstruction of the coronary arteries, resulting in decreased blood supply to the myocardium </li></ul><ul><li>2. major causative factor: Atherosclerosis </li></ul><ul><li>3. bet 30-50 y.o., men>women </li></ul><ul><li>4. may manifest as angina pectoris or MI </li></ul>04/04/11 sdelfin2010
  60. 60. CORONARY ARTERY DISEASE <ul><li>5. Risk factors: </li></ul><ul><li>- family history of CAD - DM </li></ul><ul><li>- el. Serum lipoproteins - hypertension </li></ul><ul><li>- cigarette smoking - obesity </li></ul><ul><li>- el. serum uric acid - lifestyle </li></ul><ul><li>B. Medical management, assessment findings and nursing interventions – Angina pectoris and MI </li></ul>04/04/11 sdelfin2010
  61. 61. 04/04/11 sdelfin2010
  62. 62. ANGINA PECTORIS <ul><li>A. Gen. info: </li></ul><ul><li>1. transient, paroxysmal chest pain produced by insufficient blood flow to the myocardium resulting in myocardial ischemia </li></ul><ul><li>2. Risk factors: </li></ul><ul><li>- CAD - DM </li></ul><ul><li>- hypertension - aortic insufficiency </li></ul><ul><li>- severe anemia - atherosclerosis </li></ul><ul><li>- thromboangiitis obliterans </li></ul>04/04/11 sdelfin2010
  63. 63. ANGINA PECTORIS <ul><li>3. Precipitating factors: 5 E’s </li></ul><ul><li>- Exertion </li></ul><ul><li>- Exposure to cold </li></ul><ul><li>- Emotion </li></ul><ul><li>- Excessive eating </li></ul><ul><li>- Excessive smoking </li></ul><ul><li>B. Medical mgt: </li></ul><ul><li>1. Drug therapy: nitrates, beta adrenergic blocking agents, and/or calcium blocking agents, lipid reducing drugs if cholesterol is elevated </li></ul>04/04/11 sdelfin2010
  64. 64. ANGINA PECTORIS <ul><li>2. Lifestyle modification </li></ul><ul><li>3. Surgery: coronary bypass surgery </li></ul><ul><li>C. Assessment Findings: </li></ul><ul><li>1. Pain: substernal with possible radiation to the neck, jaw, back and arms, relieved by REST </li></ul><ul><li>2. Palpitations, tachycardia, dyspnea, diaphoresis </li></ul><ul><li>3. el. serum lipid levels </li></ul>04/04/11 sdelfin2010
  65. 65. ANGINA PECTORIS <ul><li>4. Diagnostic tests: </li></ul><ul><li>- ECG may reveal ST segment depression and T-wave inversion during chest pain </li></ul><ul><li>- Stress test may reveal an abnormal ECG during exercise </li></ul><ul><li>D. Nursing interventions: </li></ul><ul><li>1. administer oxygen </li></ul><ul><li>2. give prompt pain relief with nitrates or narcotic analgesics as ordered. </li></ul>04/04/11 sdelfin2010
  66. 66. ANGINA PECTORIS <ul><li>3. Monitor V/S, status of cardiopulmonary function, monitor ECG </li></ul><ul><li>4. place patient in semi-high Fowler’s position </li></ul><ul><li>5. provide emotional support, health teachings and discharge instructions. </li></ul><ul><li>6. Instruct client to notify physician immediately if pain occurs and persists, despite rest and medication administration. </li></ul>04/04/11 sdelfin2010
  67. 67. MYOCARDiAL INFARCTiON <ul><li>A. General information: </li></ul><ul><li>1. The death of myocardial cells from inadequate oxygenation, often caused by a sudden complete blockage of a coronary artery; characterized by localized formation of necrosis (tissue destruction) with subsequent healing by scar formation and fibrosis. </li></ul><ul><li>2. Risk factors: </li></ul><ul><li>- atherosclerotic CAD - DM </li></ul><ul><li>- thrombus formation - hypertension </li></ul>04/04/11 sdelfin2010
  68. 68. 04/04/11 sdelfin2010
  69. 69. MYOCARDiAL INFARCTiON <ul><li>B. Assessment findings: </li></ul><ul><li>1. Pain same as in angina, crushing, viselike with sudden onset; UNRELIEVED by rest or nitrates </li></ul><ul><li>2. nausea/vomiting “indigestion”, dyspnea </li></ul><ul><li>3. skin: cool & clammy </li></ul><ul><li>4. elevated temperature </li></ul><ul><li>5. initial increase in BP and pulse, with gradual drop in BP </li></ul><ul><li>6. Restlessness </li></ul>04/04/11 sdelfin2010
  70. 70. MYOCARDiAL INFARCTiON <ul><li>7. Diagnostic tests: </li></ul><ul><li>a. elevated WBC, cardiac enzymes (troponin, CPK-MB, LDH, SGOT) </li></ul><ul><li>b. ECG changes (specific changes dependent on location of myocardial damage and phase of the MI; inverted T wave and ST segment changes seen with myocardial ischemia </li></ul><ul><li>c. inc. ESR, el. serum cholesterol </li></ul>04/04/11 sdelfin2010
  71. 71. Acute myocardial injury: Inc. ST elevation, T wave invertion 04/04/11 sdelfin2010
  72. 72. Old MI (healed/ scarred) : Normal ST & T Waves, Q wave persists 04/04/11 sdelfin2010
  73. 73. <ul><li>Myocardial Infarction- Animation.mp4 </li></ul>04/04/11 sdelfin2010
  74. 74. MYOCARDiAL INFARCTiON <ul><li>C. Nursing interventions: </li></ul><ul><li>1. establish a patent IV line </li></ul><ul><li>2. provide pain relief; morphine sulfate IV </li></ul><ul><li>3. Administer O2 as ordered to relieve dyspnea and prevent arrhythmias </li></ul><ul><li>4. Provide bed rest with semi fowler’s position </li></ul><ul><li>5. Monitor ECG and hemodynamic procedures </li></ul><ul><li>6. Administer anti-arrhythmias as ordered. </li></ul>04/04/11 sdelfin2010
  75. 75. MYOCARDiAL INFARCTiON <ul><li>7. Monitor I & O, report if UO <30 ml/hr </li></ul><ul><li>8. Maintain full liquid diet with gradual increase to soft, low salt </li></ul><ul><li>9. Maintain quiet environment </li></ul><ul><li>10. Administer stool softeners as ordered </li></ul><ul><li>11. Relieve anxiety associated with CCU environment </li></ul><ul><li>12. Administer anticoagulants, thrombolytics (tpa or streptokinase) as ordered and monitor for S/E </li></ul>04/04/11 sdelfin2010
  76. 76. MYOCARDiAL INFARCTiON <ul><li>13. Provide client teaching and discharge instruction concerning: </li></ul><ul><li>- effects of MI, healing process and treatment regimen </li></ul><ul><li>- Medication regimen: name, purpose, schedule, dosage, S/E </li></ul><ul><li>- Risk factors with necessary lifestyle modification </li></ul><ul><li>- Dietary restrictions: low salt, low cholesterol, avoidance of caffeine </li></ul><ul><li>- Resumption of sexual activity as ordered (usually 4- 6weeks) </li></ul>04/04/11 sdelfin2010
  77. 77. MYOCARDiAL INFARCTiON <ul><li>- Need to report the ff. symptoms: </li></ul><ul><li>* increased persistent chest pain </li></ul><ul><li>* pain, dyspnea, weakness, fatigue </li></ul><ul><li>* persistence palpitations, light headedness </li></ul><ul><li>- Enrollment of client in a cardiac rehabilitation program </li></ul>04/04/11 sdelfin2010
  78. 78. 04/04/11 sdelfin2010
  79. 79. PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY (PTCA) <ul><li>A. General information: </li></ul><ul><li>1. PTCA can be performed instead of coronary artery bypass graft surgery in various clients with single vessel CAD. </li></ul><ul><li>2. Aim: revascularize the myocardium </li></ul><ul><li>decrease angina – increase survival </li></ul><ul><li>3. a balloon tipped catheter is inserted into the stenotic, diseased coronary artery. The balloon is inflated with a controlled pressure and thereby decreases the stenosis of the vessel </li></ul>04/04/11 sdelfin2010
  80. 80. 04/04/11 sdelfin2010
  81. 81. <ul><li>Coronary Stent Animation.mp4 </li></ul>04/04/11 sdelfin2010
  82. 82. CORONARY ARTERY BYPASS SURGERY <ul><li>A. General information: </li></ul><ul><li>1. A coronary artery bypass graft is the surgery of choice for clients with severe CAD </li></ul><ul><li>2. new supply of blood brought to diseased/occluded coronary artery by bypassing the obstruction with a graft that is attached to the aorta proximally and to the coronary artery distally </li></ul><ul><li>3. Procedure requires use of extracorporeal circulation (heart-lung machine, cardiopulmonary bypass) cORONARY aRTERY bYPASS gRAFT 2.mp4 </li></ul>04/04/11 sdelfin2010
  83. 83. heart-lung machine 04/04/11 sdelfin2010
  84. 84. CORONARY ARTERY BYPASS SURGERY 04/04/11 sdelfin2010
  85. 85. CORONARY ARTERY BYPASS SURGERY <ul><li>B. Nursing interventions: preoperative </li></ul><ul><li>1. Explain anatomy of the heart, function of coronary arteries, effects of CAD </li></ul><ul><li>2. Explain events of the day of surgery </li></ul><ul><li>3. Orient to the critical and coronary care units and introduce to staff </li></ul><ul><li>4. Explain equipments to be used (monitors, hemodynamic procedures, ventilators, ET, etc) </li></ul><ul><li>5. Demonstrate activity and exercise </li></ul><ul><li>6. Reassure availability of pain medications </li></ul>04/04/11 sdelfin2010
  86. 86. CORONARY ARTERY BYPASS SURGERY <ul><li>C. Nursing interventions: post-operative </li></ul><ul><li>1. Maintain patent airway </li></ul><ul><li>2. Promote lung re-expansion </li></ul><ul><li>3. monitor cardiac status </li></ul><ul><li>4. maintain fluid and electrolyte balance </li></ul><ul><li>5. maintain adequate cerebral circulation </li></ul><ul><li>6. provide pain relief </li></ul><ul><li>7. prevent abdominal distension </li></ul>04/04/11 sdelfin2010
  87. 87. CORONARY ARTERY BYPASS SURGERY <ul><li>8. Monitor for and prevent the ff. complications: </li></ul><ul><li>a. Thrombophlebitis / pulmonary embolism </li></ul><ul><li>b. Cardiac tamponade </li></ul><ul><li>c. arrhythmias </li></ul><ul><li>d. CHF </li></ul><ul><li>9. Provide client teaching and discharge planning concerning: </li></ul><ul><li>a. limitation with progressive increase in activities </li></ul>04/04/11 sdelfin2010
  88. 88. CORONARY ARTERY BYPASS SURGERY <ul><li>b. sexual intercourse can usually be resumed by 3 rd or 4 th week post-op </li></ul><ul><li>c. medical regimen </li></ul><ul><li>d. meal planning with prescribed modifications </li></ul><ul><li>e. Symptoms to be reported: </li></ul><ul><li> - fever, dyspnea, chest pain with minimal exertion </li></ul><ul><li>CORONARY BYPASS SURGERY real .mp4 </li></ul>04/04/11 sdelfin2010
  89. 89. DYSRHYTHMIAS <ul><li>An arrhythmia is a disruption in the normal events of the cardiac cycle. It may take a variety of forms. </li></ul><ul><li>Treatment varies on the type dysrhythmias </li></ul><ul><li>SINUS TACHYCARDIA </li></ul><ul><li>A. General Information: </li></ul><ul><li>1. A heart rate of over 100 beats/min, originating in the SA node </li></ul>04/04/11 sdelfin2010
  90. 90. DYSRHYTHMIAS <ul><li>2. May be caused by: </li></ul><ul><li>- fever - anemia </li></ul><ul><li>- apprehension - hyperthyroidism </li></ul><ul><li>- physical activity - myocardial ischemia </li></ul><ul><li>- caffeine - drugs (epi., theo) </li></ul><ul><li>B. Assessment findings: </li></ul><ul><li>1. Rate: 100-160 beats /min </li></ul><ul><li>2. Rhythm: regular </li></ul>04/04/11 sdelfin2010
  91. 91. DYSRHYTHMIAS <ul><li>3. P wave: precedes each QRS complex with normal contour </li></ul><ul><li>4. P-R interval: normal (0.08 sec) </li></ul><ul><li>5. QRS complex: normal (0.06 sec) </li></ul><ul><li>C. Treatment; </li></ul><ul><li>- correction of underlying cause, elimination of stimulants, sedatives, propranolol (Inderal) </li></ul>04/04/11 sdelfin2010
  92. 92. Sinus tachycardia <ul><li>SINUS TACH.mp4 </li></ul>04/04/11 sdelfin2010
  93. 93. DYSRHYTHMIAS <ul><li>SINUS BRADYCARDIA </li></ul><ul><li>A. General Information: </li></ul><ul><li>1. A slowed heart rate initiated by SA node </li></ul><ul><li>2. Caused by: </li></ul><ul><li>- excessive vagal or decreased sympathetic tone </li></ul><ul><li>- MI - IC tumors </li></ul><ul><li>- meningitis </li></ul><ul><li>- cardiac fibrosis </li></ul>04/04/11 sdelfin2010
  94. 94. DYSRHYTHMIAS <ul><li>B. Assessment findings: </li></ul><ul><li>1. Rate: <60 beats/min </li></ul><ul><li>2. Rhythm: regular </li></ul><ul><li>3. P wave: precedes each QRS with a normal contour </li></ul><ul><li>4. P-R interval: normal </li></ul><ul><li>5. QRS complex: normal </li></ul><ul><li>C. Treatment: usually not needed </li></ul><ul><li>- if cardiac output is inadequate: atropine and isoproterenol; pacemaker </li></ul>04/04/11 sdelfin2010
  95. 95. Sinus Bradycadia <ul><li>SINUS BRADY.mp4 </li></ul>04/04/11 sdelfin2010
  96. 96. DYSRHYTHMIAS <ul><li>ATRIAL FIBRILLATION </li></ul><ul><li>A. General information </li></ul><ul><li>1. An arrhythmia in which ectopic foci cause rapid, irregular contractions of the heart </li></ul><ul><li>2. seen in clients with </li></ul><ul><li>- rheumatic mitral stenosis - thyrotoxicosis </li></ul><ul><li>- cardiomyopathy - pericarditis </li></ul><ul><li>- hypertensive heart disease - CHD </li></ul>04/04/11 sdelfin2010
  97. 97. DYSRHYTHMIAS <ul><li>B. Assessment findings: </li></ul><ul><li>1. Rate: 350-600 beats/min </li></ul><ul><li>2. Rhythm: atrial and ventricular regularly irregular </li></ul><ul><li>3. P wave: no definite P wave; </li></ul><ul><li>4. P-R interval: not measurable </li></ul><ul><li>5. QRS complex: generally normal </li></ul>04/04/11 sdelfin2010
  98. 98. Atrial Fibrillation <ul><li>ATRIAL FIB.mp4 </li></ul>04/04/11 sdelfin2010
  99. 99. DYSRHYTHMIAS <ul><li>C. Treatment: digitalis preparations, propanolol, verapamil in conjunction with digitalis; direct current cardioversion </li></ul><ul><li>PREMATURE VENTRICULAR CONTRACTIONS </li></ul><ul><li>A. General Information: </li></ul><ul><li>1. Irritable impulses originate in the ventricles </li></ul><ul><li>2. Caused by: </li></ul><ul><li>- electrolyte imbalance (hypokalemia) </li></ul><ul><li>- digitalis drug therapy </li></ul>04/04/11 sdelfin2010
  100. 100. DYSRHYTHMIAS <ul><li>Cont’d: (causes) </li></ul><ul><li>- stimulants( caffeine, epinephrine, isoproterenol) </li></ul><ul><li>- hypoxia </li></ul><ul><li>- CHF </li></ul><ul><li>B. Assessment findings: </li></ul><ul><li>1. Rate: varies according to no. of PVC’s </li></ul><ul><li>2. Rhythm: irregular because of PVC’s </li></ul><ul><li>3. P wave: normal; however, often lost in QRS complex </li></ul>04/04/11 sdelfin2010
  101. 101. DYSRHYTHMIAS <ul><li>4. P-R interval: often not measurable </li></ul><ul><li>5. QRS complex: greater then 0.12secs, wide </li></ul><ul><li>C. Treatment: </li></ul><ul><li>1. IV push of Lidocaine (50-100mg) followed by IV drip of lidocaine at rate of 1-4 mg/min </li></ul><ul><li>2. Procainamide, quinidine </li></ul><ul><li>3. Treatment of underlying cause </li></ul>04/04/11 sdelfin2010
  102. 102. PVC <ul><li>PVC'S & ARREST.mp4 </li></ul>04/04/11 sdelfin2010
  103. 103. DYSRHYTHMIAS <ul><li>VENTRICULAR TACHYCARDIA </li></ul><ul><li>A. General information: </li></ul><ul><li>1. 3 or more consecutive PVC’s; occurs from repetitive firing of an ectopic focus in the ventricles </li></ul><ul><li>2. caused by: </li></ul><ul><li>- MI - CAD </li></ul><ul><li>- digitalis intoxication - hypokalemia </li></ul>04/04/11 sdelfin2010
  104. 104. DYSRHYTHMIAS <ul><li>B. Assessment findings: </li></ul><ul><li>1. Rate: ventricular: 110-250 beats/min </li></ul><ul><li>2. Rhythm: atrial(regular), ventricular (occly. irregular) </li></ul><ul><li>3. P wave: often lost in QRS complex </li></ul><ul><li>4. P-R interval usually not measurable </li></ul><ul><li>5. QRS complex: greater than 0.12 secs, wide </li></ul>04/04/11 sdelfin2010
  105. 105. Ventricular Tachycardia 04/04/11 sdelfin2010
  106. 106. DYSRHYTHMIAS <ul><li>C. Treatment: </li></ul><ul><li>1. IV push of lidocaine (50-100mg), then IV drip of lidocaine 1-4 mg/min </li></ul><ul><li>2. Procainamide via IV infusion of 2-6 mg/min </li></ul><ul><li>3. direct current cardioversion </li></ul><ul><li>4. bretylium, propanolol </li></ul>04/04/11 sdelfin2010
  107. 107. CONGESTIVE HEART FAILURE <ul><li>A. Gen. Info: </li></ul><ul><li>- Inability of the heart to pump an adequate supply of blood to meet the metabolic needs of the body </li></ul><ul><li>B. Types: </li></ul><ul><li>1. Left sided heart failure </li></ul><ul><li>2. Right sided heart failure </li></ul>04/04/11 sdelfin2010
  108. 108. CONGESTIVE HEART FAILURE <ul><li>1. LEFT SIDED HEART FAILURE </li></ul><ul><li>a. Left ventricular damage causes blood to back up through the left atrium and into the pulmonary veins. Increased pressure causes transudation into the interstitial tissues of the lungs with resultant pulmonary congestion </li></ul><ul><li>b. Caused by: </li></ul><ul><li>- left ventricular damage (MI, CAD) </li></ul><ul><li>- hypertension, aortic valve disease (AS) </li></ul><ul><li>- mitral stenosis, cardiomyopathy </li></ul>04/04/11 sdelfin2010
  109. 109. CONGESTIVE HEART FAILURE <ul><li>c. Assessment findings: </li></ul><ul><li>Signs: </li></ul><ul><li>- easy fatigability, dyspnea on exertion, PND, orthopnea, cough, nocturia, confusion </li></ul><ul><li>Symptoms: </li></ul><ul><li>- S3 gallop, tachycardia, tachypnea, rales, wheezing, pleural effusion </li></ul>04/04/11 sdelfin2010
  110. 110. CONGESTIVE HEART FAILURE <ul><li>d. Diagnostic tests: </li></ul><ul><li>- ECG, chest x-ray (cardiomegaly, pleural effusion), echocardiography, cardiac catheterization </li></ul><ul><li>2. RIGHT SIDED HEART FAILURE </li></ul><ul><li>a. weakened RV is unable to pump blood into the pulmonary system; systemic venous congestion occurs as pressure builds up. </li></ul>04/04/11 sdelfin2010
  111. 111. CONGESTIVE HEART FAILURE <ul><li>b. caused by: </li></ul><ul><li>- left sided heart failure </li></ul><ul><li>- RV infarction </li></ul><ul><li>- atherosclerotic heart disease </li></ul><ul><li>- COPD, pulmonic stenosis, pulmonary embolism </li></ul><ul><li>c. Assessment findings: </li></ul><ul><li>Symptoms: </li></ul><ul><li>- easy fatigability, lower extremity swelling, RUQ discomfort </li></ul>04/04/11 sdelfin2010
  112. 112. CONGESTIVE HEART FAILURE <ul><li>Signs: </li></ul><ul><li>- elevated jugular venous pressure, hepatomegaly, ascites, lower extremity edema </li></ul><ul><li>d. Diagnostic tests: </li></ul><ul><li>- chest x-ray: reveals cardiac hypertrophy </li></ul><ul><li>- echocardiography: indicates inc. size of cardiac chambers </li></ul><ul><li>- elevated CVP, dec. PO2, inc. ALT(SGPT) </li></ul>04/04/11 sdelfin2010
  113. 113. CONGESTIVE HEART FAILURE <ul><li>C. Medical Management: </li></ul><ul><li>1. determination and elimination/control of underlying cause </li></ul><ul><li>2. Drug therapy: </li></ul><ul><li>- Diuretics: Furosemide, Spironolactone </li></ul><ul><li>- Dilators: ACE inhibitors, nitrates </li></ul><ul><li>- Digitalis: digoxin </li></ul><ul><li>3. Diet: low salt, low cholesterol </li></ul><ul><li>* If medical therapies unsuccessful, mechanical assist devices (intra-aortic balloon pump), cardiac transplantation or mechanical hearts may be employed. </li></ul>04/04/11 sdelfin2010
  114. 114. CONGESTIVE HEART FAILURE <ul><li>D. Nursing Interventions: </li></ul><ul><li>1. Monitor respiratory status and provide adequate ventilation (when CHF progresses to pulmonary edema) </li></ul><ul><li>2. Provide physical and emotional rest </li></ul><ul><li>3. Increase cardiac output </li></ul><ul><li>4. Reduce/eliminate edema </li></ul><ul><li>5. Provide client teaching and discharge planning </li></ul>04/04/11 sdelfin2010
  115. 115. CARDIAC ARREST <ul><li>A. General Info: </li></ul><ul><li>- sudden, unexpected cessation of breathing and adequate circulation of blood by the heart </li></ul><ul><li>B. Medical management: </li></ul><ul><li>1. Cardiopulmonary resuscitation (CPR) </li></ul><ul><li>2. Drug therapy: </li></ul><ul><li>a. lidocaine, procainamide, verapamil </li></ul><ul><li>b. Dopamine, isoproterenol, Norepinephrine </li></ul>04/04/11 sdelfin2010
  116. 116. CARDIAC ARREST <ul><li>c. Epinephrine to enhance myocardial automaticity, excitability, conductivity, and contractility </li></ul><ul><li>d. Atropine sulfate to reduce vagus nerve’s control over the heart, thus increasing the heart rate </li></ul><ul><li>e. Sodium bicarbonate : administered during first few moments of a cardiac arrest to correct respiratory and metabolic acidosis </li></ul><ul><li>f. Calcium chloride : calcium ions help the heart beat more effectively by enhancing the myocardium's contractile force </li></ul>04/04/11 sdelfin2010
  117. 117. <ul><li>3. Defibrillation </li></ul>04/04/11 sdelfin2010
  118. 118. CARDIAC ARREST <ul><li>C. Assessment findings: </li></ul><ul><li>- unresponsiveness, cessation of respiration, pallor, cyanosis, absence of heart rate/ BP/pulses, dilation of pupils, ventricular fibrillation </li></ul><ul><li>D. Nursing interventions: </li></ul><ul><li>1. Begin precordial thump and if successful, administer lidocaine </li></ul><ul><li>2. If unsuccessful, defibrillation - CPR </li></ul><ul><li>3. Assist with administration of and monitor effects of emergency drugs </li></ul>04/04/11 sdelfin2010
  119. 119. CARDIOPULMONARY RESUSCITATION <ul><li>A. General info: process of externally supporting the circulation and respiration of a person who has had a cardiac arrest </li></ul><ul><li>B. Nursing interventions: unwitnessed cardiac arrest </li></ul><ul><li>1. Assess LOC </li></ul><ul><li>a. Shake victim’s shoulder and shout </li></ul><ul><li>b. if no response, summon for help </li></ul><ul><li>2. Position victim supine on a firm surface </li></ul>04/04/11 sdelfin2010
  120. 120. C P R <ul><li>3. Open airway </li></ul><ul><li>a. Use head tilt, chin lift maneuver </li></ul><ul><li>b. Place ear into nose and mouth </li></ul><ul><li>- look to see if chest is moving </li></ul><ul><li>- listen for escape of air </li></ul><ul><li>- feel for movement of air against face </li></ul><ul><li>c. If no respiration, proceed to #4 </li></ul><ul><li>4. Ventilate twice, allowing for deflation between breaths </li></ul>04/04/11 sdelfin2010
  121. 121. C P R <ul><li>5. Assess circulation: if not present, proceed to #6 </li></ul><ul><li>6. Initiate external cardiac compressions </li></ul><ul><li>a. Proper placement of hands: lower half of the sternum </li></ul><ul><li>b. Depth of compressions: 1½ - 2 in. for adults </li></ul><ul><li>c. One rescuer: 15 compressions (80-100/min) with 2 ventilations </li></ul><ul><li>d. Two rescuers: 5 compressions (80-100/min) </li></ul><ul><li>with 1 ventilation </li></ul>04/04/11 sdelfin2010
  122. 122. <ul><li>WHEN TO S.T.O.P. CPR </li></ul><ul><li>1. SPONTANEOUS signs of circulation are restored. </li></ul><ul><li>2. TURNED over to medical services or properly trained and authorized personnel. </li></ul><ul><li>3. OPERATOR is already exhausted and cannot continue CPR. </li></ul><ul><li>4. PHYSICIAN assumes responsibility (declares death, take over, etc.). </li></ul>04/04/11 sdelfin2010
  123. 123. INFLAMMATORY DISEASES OF THE HEART <ul><li>ENDOCARDITIS </li></ul><ul><li>A. General Info: </li></ul><ul><li>1. Inflammation of the endocardium; platelets and fibrin deposit on the mitral and/or aortic valves causing deformity, insufficiency or stenosis </li></ul><ul><li>2. caused by bacterial infection: </li></ul><ul><li>- commonly S. aureus. S. viridans, B hemolytic streptococcus, gonococcus </li></ul>04/04/11 sdelfin2010
  124. 124. ENDOCARDITIS <ul><li>B. Medical management: </li></ul><ul><li>1. Drug therapy: </li></ul><ul><li>a. antibiotics specific to sensitivity or organism cultured </li></ul><ul><li>b. PenG and streptomycin if org. not known </li></ul><ul><li>c. antipyretics </li></ul><ul><li>2. Cardiac surgery to replace valve </li></ul>04/04/11 sdelfin2010
  125. 125. ENDOCARDITIS <ul><li>C. Assessment findings: </li></ul><ul><li>1. Fever, malaise, fatigue, dyspnea and cough acute upper quadrant pain, joint pain </li></ul><ul><li>2. petechiae, murmurs, edema, splenomegaly, hemiplegia and confusion, hematuria </li></ul><ul><li>3. elevated WBC & ESR, decreased Hgb & Hct. </li></ul><ul><li>4. Diagnostic tests: positive blood culture for causative organism </li></ul>04/04/11 sdelfin2010
  126. 126. ENDOCARDITIS <ul><li>D. Nursing interventions: </li></ul><ul><li>1. antibiotics as ordered </li></ul><ul><li>2. control temperature </li></ul><ul><li>3. assess for vascular complications and pulm. embolism </li></ul><ul><li>4. Provide client teaching and discharge planning </li></ul><ul><li>- types of procedures, antibiotic therapy </li></ul><ul><li>- S/S to report: persistent fever, fatigue, chills, anorexia, joint pains </li></ul><ul><li>- avoidance of individuals with known infections </li></ul>04/04/11 sdelfin2010
  127. 127. MYOCARDITIS <ul><li>A. General Info: an acute or chronic inflammation of the myocardium as a result of pericarditis, systemic infection or allergic response. </li></ul><ul><li>B. Assessment: </li></ul><ul><li>- fever, pericardial friction rub, </li></ul><ul><li>- murmur, signs of heart failure, fatigue, dyspnea </li></ul><ul><li>- tachycardia, chest pain </li></ul>04/04/11 sdelfin2010
  128. 128. MYOCARDITIS <ul><li>C. Implementation: </li></ul><ul><li>1. Assist client to assume a position of comfort </li></ul><ul><li>2. Administer analgesics, salicylates, NSAIDS </li></ul><ul><li>3. Administer O2, provide adequate rest periods </li></ul><ul><li>4. Limit activities, to dec. workload of heart </li></ul><ul><li>5. Treat underlying cause </li></ul><ul><li>6. Administer meds. as ordered: </li></ul><ul><li>- antibiotics, diuretics, ACE inhibitors, digitalis </li></ul><ul><li>7. Monitor complications: thrombus, heart failure, cardiomyopathy </li></ul>04/04/11 sdelfin2010
  129. 129. PERICARDITIS <ul><li>A. General Info: </li></ul><ul><li>1. An inflammation of the visceral and parietal pericardium </li></ul><ul><li>2. caused by bacterial, viral, or fungal infection; collagen diseases; trauma; acute MI, drugs (procainamide, hydralazine, Doxorubicin HCL) </li></ul>04/04/11 sdelfin2010
  130. 130. PERICARDITIS <ul><li>B. Medical management: </li></ul><ul><li>1. Determination and elimination/control of underlying cause </li></ul><ul><li>2. Drug therapy </li></ul><ul><li>a. Medication for pain relief </li></ul><ul><li>b. Corticosteroids, *salicylates (aspirin), indomethacin, to reduce inflammation </li></ul><ul><li>3. Specific antibiotic therapy against the causative organism may be indicated </li></ul>04/04/11 sdelfin2010
  131. 131. PERICARDITIS <ul><li>C. Assessment findings: </li></ul><ul><li>1. chest pain with deep inspiration (relieved by sitting up), cough, hemoptysis, malaise </li></ul><ul><li>2. tachycardia, fever, pericardial friction rub, cyanosis or pallor, jugular vein distension </li></ul><ul><li>3. Elevated WBC and ESR, normal or inc. SGOT </li></ul><ul><li>4. Diagnostic test: </li></ul><ul><li>a. chest x-ray may show increased heart size </li></ul><ul><li>b. ECG: ST elevation, T wave inversion </li></ul>04/04/11 sdelfin2010
  132. 132. PERICARDITIS <ul><li>D. Nursing Interventions: </li></ul><ul><li>1. Ensure comfort, bed rest with semi- or high Fowler’s position </li></ul><ul><li>2. Monitor hemodynamic parameters </li></ul><ul><li>3. Administer medications as ordered and monitor effects </li></ul><ul><li>4. Provide client teaching and discharge planning: </li></ul><ul><li>- S/S of pericarditis indicative of recurrence (chest pain intensified by lying down and relieved when sitting up; medication regimen </li></ul>04/04/11 sdelfin2010
  133. 133. HAVE A BREAK… 04/04/11 sdelfin2010
  134. 134. CONGENITAL HEART DISEASE (CHD) <ul><li>A. General Info: </li></ul><ul><li>1. CHDs are structural defects of the heart, great vessels, or both that are present from birth </li></ul><ul><li>2. 2 nd only to prematurity as a cause of death in the first year of life </li></ul><ul><li>B. Clinical Classification of Congenital heart disease </li></ul><ul><li>1. Acyanotic: PDA, ASD, VSD </li></ul><ul><li>2. Cyanotic: TOF, TGV, Truncus arteriosus </li></ul><ul><li>3. Obstructive: Coarctation of Aorta, AS, PS </li></ul>04/04/11 sdelfin2010
  135. 135. ACYANOTIC CHD (PDA) <ul><li>ACYANOTIC CHD </li></ul><ul><li>A. PATENT DUCTUS ARTERIOSUS (PDA) </li></ul><ul><li>- results when the fetal ductus arteriosus fails to close completely after birth </li></ul><ul><li>1. Pathophysiology </li></ul><ul><li>- blood flows from the aorta through the PDA and back to the pulmonary artery and lungs, causing inc. LV workload and increase pulmonary vascular congestion </li></ul>04/04/11 sdelfin2010
  136. 136. 04/04/11 sdelfin2010
  137. 137. ACYANOTIC CHD (PDA) <ul><li>2. Assessment findings: </li></ul><ul><li>a. Clinical manifestations: </li></ul><ul><li>1. if defect is small, child may be aysmptomatic </li></ul><ul><li>2. a loud machine like murmur is characteristic </li></ul><ul><li>3. child may have frequent resp. infections </li></ul><ul><li>4. child may have CHF with poor feeding, fatigue, poor weight gain, tachypnea and irritability </li></ul><ul><li>5. widened pulse pressure and bounding pulse rate maybe detected </li></ul>04/04/11 sdelfin2010
  138. 138. ACYANOTIC CHD (PDA) <ul><li>b. Laboratory and diagnostic findings: </li></ul><ul><li>1. ECG – normal but may show ventricle enlargement if the shunt is large </li></ul><ul><li>3. Nursing management: </li></ul><ul><li>a. Provide family teaching abt. treatment options </li></ul><ul><li>- some close spont; others can be closed surgically or nonsurgically </li></ul><ul><li>b. In premature infants, PDA sometimes can be closed using prostaglandin synthetase inhibitors (Indomethacin) w/c stimulate closure of the ductus arteriosus </li></ul>04/04/11 sdelfin2010
  139. 139. ACYANOTIC CHD (ASD) <ul><li>B. ATRIAL SEPTAL DEFECT </li></ul><ul><li>- an abnormal communication between the atria; results when the atrial septal tissue does not fuse properly during embryonic devt. </li></ul><ul><li>1. Pathophysiology </li></ul><ul><li>a. pressure is higher in the left atrium than the right, causing blood to shunt from left to right </li></ul><ul><li>b. the RV and PA enlarge because they are handling more blood </li></ul>04/04/11 sdelfin2010
  140. 140. 04/04/11 sdelfin2010
  141. 141. ACYANOTIC CHD (ASD) <ul><li>2. Assessment findings: </li></ul><ul><li>a. Clinical manifestations: </li></ul><ul><li>- most infants tend to be aysmptomatic until early childhood and many defects close spont. By 5y.o. </li></ul><ul><li>- symptoms vary with the size of the defect, fatigue and dyspnea on exertion are the most common </li></ul><ul><li>- slow weight gain and frequent respiratory infections may occur </li></ul><ul><li>- systolic ejection murmur may be auscultated, usually most prominent at the 2 nd ICS </li></ul>04/04/11 sdelfin2010
  142. 142. ACYANOTIC CHD (ASD) <ul><li>b. Laboratory and diagnostic study findings: </li></ul><ul><li>- echocardiography with doppler gen. reveals the enlarged R side of the heart and the inc. pulmonary circulation </li></ul><ul><li>- cardiac catheterization demonstrates the separation of the R atrial septum and the inc. oxygen saturation in the R atrium </li></ul><ul><li>3. Nursing management: </li></ul><ul><li>a. Provide family teaching abt. treatment options: </li></ul><ul><li>- defects are usually repaired in girls due to possibility of clot formation during child bearing years </li></ul><ul><li>- small ASDs are left open in boys, larger ones are repaired </li></ul><ul><li>- surgical closure is performed during the school age years </li></ul>04/04/11 sdelfin2010
  143. 143. ACYANOTIC CHD (VSD) <ul><li>C. VENTRICULAR SEPTAL DEFECT </li></ul><ul><li>- the most common CHD, is an abnormal opening between the right and left ventricles </li></ul><ul><li>- the degree of this defect vary from a pinhole between the R & L ventricles to an absent septum </li></ul><ul><li>1. Pathophysiology </li></ul><ul><li>a. pressure from the LV causes blood to flow through the defect to RV, resulting in increased pulmonary vascular resistance and right heart enlargement </li></ul>04/04/11 sdelfin2010
  144. 144. 04/04/11 sdelfin2010
  145. 145. ACYANOTIC CHD (VSD) <ul><li>b. RV and PA pressures increase, leading eventually to obstructive pulmonary vascular disease </li></ul><ul><li>2. Assessment findings: </li></ul><ul><li>- symptoms vary with the size of the defect, age and amt of resistance, usually the child is asymp. </li></ul><ul><li>- failure to thrive, excessive sweating, fatigue </li></ul><ul><li>- more susceptible to pulmonary infections </li></ul><ul><li>- may exhibit s/s of CHF </li></ul>04/04/11 sdelfin2010
  146. 146. ACYANOTIC CHD (VSD) <ul><li>b. Laboratory and diagnostic study findings: </li></ul><ul><li>- Echocardiography with Doppler U/S or MRI reveals RVH and possible PA dilatation from the inc. blood flow </li></ul><ul><li>- ECG shows RVH </li></ul><ul><li>3. Nursing management </li></ul><ul><li>a. provide family teaching abt treatment options </li></ul><ul><li>- some VSDs close spontaneously </li></ul><ul><li>- others are closed with a Dacron patch, recommended for large defects, PA hypertension, CHF, recurrent resp. infxns. FTT </li></ul>04/04/11 sdelfin2010
  147. 147. CYANOTIC CHD (TOF) <ul><li>CYANOTIC CHD </li></ul><ul><li>A. TETRALOGY OF FALLOT (TOF) </li></ul><ul><li>- consists of 4 major anomalies: </li></ul><ul><li>a. VSD c. PS </li></ul><ul><li>b. RVH d. overriding aorta </li></ul><ul><li>1. Pathophysiology </li></ul><ul><li>a. PS impedes the flow of blood to the lungs, causing increased pressure in the RV, forcing deoxygenated blood through the septal defect to the LV </li></ul>04/04/11 sdelfin2010
  148. 148. 04/04/11 sdelfin2010
  149. 149. CYANOTIC CHD (TOF) <ul><li>b. the increased workload on the RV causes hypertrophy. The overriding aorta receives blood from both right and left ventricles. </li></ul><ul><li>2. Assessment findings: </li></ul><ul><li>a. Clinical manifestations: vary, depending on the size of the VSD and the degree of PS. </li></ul><ul><li>1. Acute episodes of cyanosis (“tet spells”) and transient cerebral ischemia. “Tet spells” are char. By irritability, pallor, and blackouts or convulsions. </li></ul><ul><li>2. Cyanosis occurring at rest (as PS worsens) </li></ul>04/04/11 sdelfin2010
  150. 150. CYANOTIC CHD (TOF) <ul><li>3. Squatting (a char. posture of older children that serves to decrease the return of poorly oxygenated venous blood from the lower extremities and to inc. SVR, w/c increases pulmonary blood flow and eases respiratory effort) </li></ul><ul><li>4. slow weight gain </li></ul><ul><li>5. clubbing, exertional dyspnea, fainting, or fatigue slowness due to hypoxia </li></ul><ul><li>6. a murmur may be heard at the mid-lower left sternal border </li></ul>04/04/11 sdelfin2010
  151. 151. CYANOTIC CHD (TOF) <ul><li>b. Laboratory and diagnostic study findings </li></ul><ul><li>1. echocardiography and ECG show the enlarged chambers of the right side of the heart </li></ul><ul><li>2. echocardiography also demonstrates the decrease in the size of the PA and the reduced blood flow through the lungs </li></ul><ul><li>3. cardiac catheterization and angiography allow definitive evaluation of the extent of the defect, particularly the PS and the VSD </li></ul><ul><li>4. CBC reveals polycythemia, ABG demonstrate reduced oxygen saturation </li></ul>04/04/11 sdelfin2010
  152. 152. CYANOTIC CHD (TOF) <ul><li>3. Nursing management </li></ul><ul><li>a. Provide family teaching about treatment options </li></ul><ul><li>1. elective repair is usually performed during the infant’s 1 st year of life, but palliative repairs may be warranted for infants who cannot undergo primary repair </li></ul><ul><li>2. total repair involves VSD closure, infundibular stenosis resection, and pericardial patch to enlarge RV outflow tract </li></ul><ul><li>b. Provide preoperative and postoperative care </li></ul>04/04/11 sdelfin2010
  153. 153. CYANOTIC CHD (TGV) <ul><li>B. TRANSPOSITION OF GREAT VESSELS (TGV) </li></ul><ul><li>- in TGV, the PA leaves the LV and the aorta exits the RV, there is no communication between the systemic and pulmonary circulations </li></ul><ul><li>1. Pathophysiology </li></ul><ul><li>a. this defect results in two separate circulatory patterns; the right heart manages systemic circulation and the left manages pulmonary circulation </li></ul><ul><li>b. to sustain life, the child must have an associated defect. </li></ul>04/04/11 sdelfin2010
  154. 154. 04/04/11 sdelfin2010
  155. 155. CYANOTIC CHD (TGV) <ul><li>Associated defects such as septal defects or a PDA, permit oxygenated blood into the systemic circulation but cause increased cardiac workload. </li></ul><ul><li>c. Potential complications include CHF, infective endocarditis, brain abscess, and cerebral vascular accidents resulting from hypoxia or thrombosis. </li></ul><ul><li>2. Assessment findings: </li></ul><ul><li>a. Clinical manifestations vary, depending on associated defects </li></ul>04/04/11 sdelfin2010
  156. 156. CYANOTIC CHD (TGV) <ul><li>1. In infants with minimal communication (no associated defects), severe respiratory depression and cyanosis, will be evident at birth </li></ul><ul><li>2. In infants with associated defects, there is less cyanosis but the infant may have symptoms of CHF </li></ul><ul><li>3. easily fatigued, FTT </li></ul>04/04/11 sdelfin2010
  157. 157. CYANOTIC CHD (TGV) <ul><li>3. Nursing management </li></ul><ul><li>a. Provide family teaching about the treatment options </li></ul><ul><li>1. Prostaglandin E is administered to maintain a PDA and further blood mixing. </li></ul><ul><li>2. An arterial switch procedure within the 1 st week of life is the surgical procedure of choice </li></ul><ul><li>C. TRUNCUS ARTERIOSUS </li></ul><ul><li>- failure of normal septation and division of the embryonic bulbar trunk into the PA and aorta, resulting in a single vessel that overrides both ventricles </li></ul>04/04/11 sdelfin2010
  158. 158. 04/04/11 sdelfin2010
  159. 159. CYANOTIC CHD <ul><li>1. Pathophysiology </li></ul><ul><li>a. blood ejected from the ventricles enters the common artery and flows either the lungs or aortic arch. </li></ul><ul><li>b. pressure in both ventricles is high and blood flow to the lungs is markedly increased. </li></ul><ul><li>2. Assessment findings: </li></ul><ul><li>a. neonates with this defect appear normal; however, as pulmonary vascular resistance decreases after birth, severe pulmonary edema and CHF commonly develop </li></ul>04/04/11 sdelfin2010
  160. 160. CYANOTIC CHD <ul><li>2. marked cyanosis, especially on exertion; S/S of CHF; LVH, dyspnea, marked activity intolerance, and retarded growth </li></ul><ul><li>3. loud systolic murmur best heard at the lower left sternal border and radiating throughout the chest </li></ul><ul><li>b. Laboratory and diagnostic study findings: </li></ul><ul><li>- echocardiography reveals the defect </li></ul><ul><li>4. Nursing management </li></ul><ul><li>a. surgical repair is necessary in the 1 st few months of life, the mortality rate associated with surgery is greater than 10%; w/o surgery, children die w/in 1 yr. </li></ul>04/04/11 sdelfin2010
  161. 161. OBSTRUCTIVE CHD (COA) <ul><li>OBSTRUCTIVE CHD </li></ul><ul><li>A. COARCTATION OF AORTA (COA) </li></ul><ul><li>- a defect that involves a localized narrowing of the aorta </li></ul><ul><li>1. Pathophysiology </li></ul><ul><li>a. COA is char. by inc. pressure proximal to the defect and decreased pressure distal to it </li></ul><ul><li>b. restricted blood flow through the narrowed aorta increases the pressure on the LV and causes dilation of the proximal aorta and LVH, w/c may lead to LVF </li></ul>04/04/11 sdelfin2010
  162. 162. 04/04/11 sdelfin2010
  163. 163. OBSTRUCTIVE CHD (COA) <ul><li>c. eventually, collateral vessels develop to bypass the coarctated segment and supply circulation to the LE </li></ul><ul><li>2. Assessment findings: </li></ul><ul><li>a. Clinical manifestations </li></ul><ul><li>1. the child may be asymptomatic or may experience the classic difference in BP and pulse quality between the upper and lower ext. – the BP is elevated in the UE and dec. in the LE while the pulse is bounding in the UE and dec. or absent in the LE. Thus femoral pulse are weak or absent </li></ul>04/04/11 sdelfin2010
  164. 164. OBSTRUCTIVE CHD (COA) <ul><li>2. epistaxis, headaches, fainting and lower leg cramps </li></ul><ul><li>3. a systolic murmur may be heard over the left anterior chest and between the scapula posteriorly </li></ul><ul><li>4. rib notching may be observed in an older child </li></ul><ul><li>b. Laboratory and diagnostic findings </li></ul><ul><li>1. ECG, echocardiography, and chest x-ray may reveal left sided heart enlargement resulting from back pressure </li></ul><ul><li>2. the radiograph may also demonstrate rib notching from enlarged collateral vessels </li></ul>04/04/11 sdelfin2010
  165. 165. OBSTRUCTIVE CHD (COA) <ul><li>3. Nursing management </li></ul><ul><li>a. repair involves surgical removal of the stenotic area </li></ul><ul><li>b. nonsurgical repair via balloon angioplasty </li></ul><ul><li>B. AORTIC STENOSIS (AS) </li></ul><ul><li>- a defect that primarily involves an obstruction to the LV outflow of the valve </li></ul><ul><li>1. Pathophysiology </li></ul><ul><li>a. LV pressure inc. to overcome resistance of the obstructed valve and allow blood to flow into the aorta, eventually producing LVH </li></ul>04/04/11 sdelfin2010
  166. 166. OBSTRUCTIVE CHD (AS) <ul><li>b. MI may develop as the inc. O2 demands of the hypertrophied LV go unmet </li></ul><ul><li>2. Assessment findings: </li></ul><ul><li>a. clinical manifestations: </li></ul><ul><li>1. faint pulse, hypotension, tachycardia, and poor feeding pattern </li></ul><ul><li>2. exercise intolerance, chest pain, and dizziness when standing for long periods </li></ul><ul><li>3. a systolic ejection murmur may be heard best at the 2 nd ICS </li></ul>04/04/11 sdelfin2010
  167. 167. OBSTRUCTIVE CHD (AS) <ul><li>b. Laboratory and diagnostic study findings: </li></ul><ul><li>1. ECG or echocardiography reveals LVH </li></ul><ul><li>2. cardiac catheterization demonstrates degree of the stenosis </li></ul><ul><li>3. Nursing management: </li></ul><ul><li>a. if the child’s symptoms warrant, surgical aortic valvulotomy or prosthetic valve replacement is necessary </li></ul><ul><li>b. balloon angioplasty can be used to dilate the narrow valve </li></ul>04/04/11 sdelfin2010
  168. 168. OBSTRUCTIVE CHD (PS) <ul><li>C. PULMONIC STENOSIS (PS) </li></ul><ul><li>- a defect that involves obstruction of blood flow from the right ventricle </li></ul><ul><li>1. Pathophysiology </li></ul><ul><li>a. RV pressure increases leading to RVH and eventually RV failure may occur </li></ul><ul><li>2. Assessment findings: </li></ul><ul><li>a. Clinical manifestations </li></ul><ul><li>1. may be asymptomatic or may have mild cyanosis or CHF </li></ul>04/04/11 sdelfin2010
  169. 169. OBSTRUCTIVE CHD (PS) <ul><li>2. a systolic murmur may be heard over the pulmonic area; a thrill may be heard if stenosis is severe </li></ul><ul><li>3. in severe cases, decreased exercise tolerance, dyspnea, precordial pain and generalized cyanosis may occur </li></ul><ul><li>b. Laboratory and diagnostic findings: </li></ul><ul><li>1. ECG or echocardiography reveals RVH </li></ul><ul><li>2. cardiac catheterization demonstrates the degree of stenosis </li></ul>04/04/11 sdelfin2010
  170. 170. OBSTRUCTIVE CHD (PS) <ul><li>3. Nursing management </li></ul><ul><li>a. provide family teaching about treatment options </li></ul><ul><li>1. Balloon angioplasty techniques are being widely used to treat PS </li></ul><ul><li>2. Surgical valvulotomy may be performed (although the need for surgery is uncommon due to the widespread use of balloon angioplasty techniques) </li></ul><ul><li>b. provide preoperative and postoperative care </li></ul>04/04/11 sdelfin2010
  171. 171. <ul><li>POST TEST? </li></ul>04/04/11 sdelfin2010
  172. 172. THE BLOOD VESSELS <ul><li>A. HYPERTENSION </li></ul><ul><li>- persistent elevation of the SBP above 140mmHg and of DBP above 90mmHg (WHO) </li></ul><ul><li>manifestations: </li></ul><ul><li>asymptomatic, occipital headache is a common complaint. </li></ul>04/04/11 sdelfin2010
  173. 173. HYPERTENSION <ul><li>Risk Factors: </li></ul><ul><li>- (+) family history, obesity, stress, cigarette smoking, hypercholesterolemia, inc. sodium intake </li></ul><ul><li>B. Medical management: </li></ul><ul><li>1. Diet and weight reduction (restricted sodium, kcal, cholesterol) </li></ul><ul><li>2. Lifestyle changes: alcohol moderation, exercise regimen, cessation of smoking </li></ul><ul><li>3. Antihypertensive drug therapy </li></ul>04/04/11 sdelfin2010
  174. 174. 04/04/11 sdelfin2010
  175. 175. ARTERIOSCLEROSIS OBLITERANS <ul><li>- a chronic occlusive arterial disease that may affect the abdominal aorta or the LE. The obstruction to blood flow with resultant ischemia usually affects the femoral, popliteal, aortic and iliac arteries </li></ul><ul><li>- occurs most often in men ages 50-60 </li></ul><ul><li>- caused by atherosclerosis </li></ul><ul><li>- Risk Factors: cigarette smoking, hyperlipidemia, hypertension, DM </li></ul>04/04/11 sdelfin2010
  176. 176. ARTERIOSCLEROSIS OBLITERANS <ul><li>B. Medical management: </li></ul><ul><li>1. Drug therapy </li></ul><ul><li>a. Vasodilators: papaverine, Isoxsuprine Hcl (Vasodilan), Nylidrin Hcl (Arlidin), nicotinyl alcohol (Roniacol) cyclandelate (Cyclospasmol), tolazoline Hcl (priscoline) to improve arterial circulation; </li></ul><ul><li>b. Analgesics to relieve ischemic pain c. Anticoagulants to prevent thrombus formation </li></ul><ul><li>d. Lipid reducing drug: simvastatin, (Lopid), niacin, lovastatin (Mevacor), atorvastatin </li></ul>04/04/11 sdelfin2010
  177. 177. ARTERIOSCLEROSIS OBLITERANS <ul><li>2. Surgery: bypass grafting, endarterectomy, balloon catheter dilation, lumbar sympathectomy (to increase blood flow), amputation may be necessary </li></ul><ul><li>C. Assessment findings: </li></ul><ul><li>1. Pain both intermittent claudication and rest pain, numbness or tingling of the toes </li></ul><ul><li>2. Pallor after 1-2 mins. Of elevating feet, and dependent hyperemia/rubor; diminished or absent dorsalis pedis, posterior tibial and femoral pulses; shiny, taut skin with hair loss on lower legs </li></ul>04/04/11 sdelfin2010
  178. 178. ARTERIOSCLEROSIS OBLITERANS <ul><li>3. Diagnostic tests: </li></ul><ul><li>a. Oscillometry may reveal decrease pulse volume </li></ul><ul><li>b. Doppler U/S reveals decreased blood flow through affected vessels </li></ul><ul><li>c. Angiography reveals location and extent of obstructive process </li></ul><ul><li>4. Elevated serum triglycerides; sodium </li></ul><ul><li>D. Nursing Interventions: </li></ul><ul><li>1. Encourage slow, progressive physical activity </li></ul>04/04/11 sdelfin2010
  179. 179. ARTERIOSCLEROSIS OBLITERANS <ul><li>2. Administer medications as ordered </li></ul><ul><li>3. Assist with Buerger-Allen exercises qid </li></ul><ul><li>a. client lies with legs elevated above heart for 2-3 mins </li></ul><ul><li>b. client sits on edge of bed with legs and feet dependent and exercises feet and toes – upward and downward, inward and outward – for 3 mins </li></ul><ul><li>c. client lies flat with legs at heart level for 5 mins </li></ul><ul><li>4. Assess for sensory function; protect client from injury </li></ul><ul><li>5. Provide client teaching and discharge planning: stop cigarette smoking, diet, drug compliance, exercise </li></ul>04/04/11 sdelfin2010
  180. 180. THROMBOANGIITIS OBLITERANS (BUERGER’S DISEASE) <ul><li>- Acute inflammatory disorder affecting medium/smaller arteries and veins of the LE. Occurs as focal, obstructive process; results in occlusion of a vessel with subsequent development of collateral circulation </li></ul><ul><li>- Most often affects men ages 25-40; disease is idiopathic; high incidence among smokers </li></ul><ul><li>A. Medical management: same as arteriosclerosis obliterans but only cessation of smoking is effective treatment </li></ul>04/04/11 sdelfin2010
  181. 181. THROMBOANGIITIS OBLITERANS (BUERGER’S DISEASE) <ul><li>B. Assessment findings: </li></ul><ul><li>1. Intermittent claudication, sensitivity to cold (skin of extremity may at first be white, changing to blue then red) </li></ul><ul><li>2. Decreased or absent peripheral pulses (post. tibial and dorsalis pedis), ulceration and gangrene (advanced) </li></ul><ul><li>3. Diagnostic tests: same as arteriosclerosis obliterans </li></ul><ul><li>C. Nursing Interventions: </li></ul><ul><li>1. Prepare client for surgery </li></ul>04/04/11 sdelfin2010
  182. 182. THROMBOANGIITIS OBLITERANS (BUERGER’S DISEASE) <ul><li>2. Provide client teaching and discharge planning </li></ul><ul><li>- drug regimen, avoidance of trauma to the affected extremity, need to maintain warmth esp. during cold weathers, importance of stopping smoking </li></ul>04/04/11 sdelfin2010
  183. 183. RAYNAUD’S PHENOMENON <ul><li>- intermittent episode of arterial spasms, most frequently involving the fingers; most often affects women between the teenage years and age 40; cause unknown </li></ul><ul><li>- Predisposing factors: collagen diseases (SLE, RA), trauma (from typing, playing piano) </li></ul><ul><li>A. Medical management: vasodilators </li></ul>04/04/11 sdelfin2010
  184. 184. RAYNAUD’S PHENOMENON <ul><li>B. Assessment findings: </li></ul><ul><li>1. coldness, numbness, tingling in one or more digits; pain (usually pptd. By exposure to cold, emotional upsets, tobacco use) </li></ul><ul><li>2. intermittent color changes (pallor, cyanosis, rumor); small ulcerations and gangrene tips of digits </li></ul><ul><li>C. Nursing interventions </li></ul><ul><li>1. provide client teaching concerning: </li></ul><ul><li>- importance of stopping smoking; need to maintain warmth; need to use gloves in handling cold objects; drug regimen </li></ul>04/04/11 sdelfin2010
  185. 185. ANEURYSM <ul><li>- a sac formed by dilation of an artery secondary to weakness and stretching of an arterial wall. The dilation may involve one or all layers of the arterial wall. </li></ul><ul><li>Classification </li></ul><ul><li>1. Fusiform: uniform spindle shape involving the entire circumference of the artery </li></ul><ul><li>2. Saccular: outpouching on one side only, affecting part of the arterial circumference </li></ul>04/04/11 sdelfin2010
  186. 186. ANEURYSM <ul><li>3. Dissecting: separation of the arterial wall layers to form a cavity that fills with blood </li></ul><ul><li>4. False: the vessel wall is disrupted, blood escapes into surrounding area but is held in place by surrounding tissue </li></ul><ul><li>A. General info: </li></ul><ul><li>1. usually occurs in men ages 50-70; caused by arteriosclerosis, infection, syphilis, hypertension </li></ul>04/04/11 sdelfin2010
  187. 187. ANEURYSM <ul><li>B. Medical management: </li></ul><ul><li>1. control of underlying hypertension </li></ul><ul><li>2. Surgery: resection of the aneurysm and replacement with a Teflon/Dacron graft; coiling and clipping. </li></ul><ul><li>aneurysym.mp4 </li></ul>04/04/11 sdelfin2010
  188. 188. ANEURYSM <ul><li>3. Diagnostic tests: </li></ul><ul><li>a. Aortography shows exact location of the aneurysm </li></ul><ul><li>b. X-rays: chest film reveals abnormal widening of aorta; abdominal film may show calcification within walls of aneurysm </li></ul><ul><li>4. Nursing interventions: </li></ul><ul><li>Do not vigorously palpate the area </li></ul><ul><li>Maintain BP normal to dec. risk of rupture </li></ul><ul><li>Monitor for hemorrhage </li></ul><ul><li>Prepare client for surgery </li></ul>04/04/11 sdelfin2010
  189. 189. THROMBOPHLEBITIS <ul><li>A. General info: </li></ul><ul><li>1. Inflammation of the vessel wall with formation of a clot (thrombus); may affect superficial or deep veins </li></ul><ul><li>2. Most frequent veins affected are the saphenous, femoral, and popliteal. </li></ul><ul><li>3. Can result in damage to the surrounding tissues, ischemia and necrosis </li></ul><ul><li>4. Risk Factors: obesity, CHF, prolonged immobility, MI, pregnancy, oral contraceptives, trauma, sepsis, cigarette smoking, dehydration, severe anemias, venous cannulation, complication of surgery </li></ul>04/04/11 sdelfin2010
  190. 190. THROMBOPHLEBITIS <ul><li>B. Medical management: </li></ul><ul><li>1. Anticoagulation therapy: </li></ul><ul><li>a. Heparin: blocks conversion of prothrombin to thrombin and reduces formation of thrombus </li></ul><ul><li>- S/E: spontaneous bleeding, injection site reactions, ecchymoses, tissue irritation and sloughing, reversible transient alopecia, cyanosis, pain in arms or legs, thrombocytopenia </li></ul><ul><li>b. Warfarin (coumadin): blocks prothrombin synthesis by interfering with vit. K synthesis </li></ul><ul><li>- S/E: GI: anorexia, nausea/vomiting, diarrhea, stomatitis </li></ul>04/04/11 sdelfin2010
  191. 191. THROMBOPHLEBITIS <ul><li>2. Surgery </li></ul><ul><li>a. Vein ligation and stripping </li></ul><ul><li>b. venous thrombectomy: removal of a clot in the iliofemoral region </li></ul><ul><li>c. insertion of an umbrella-like prosthesis into the lumen of the vena cava to filter incoming clots </li></ul>04/04/11 sdelfin2010
  192. 192. THROMBOPHLEBITIS <ul><li>C. Assessment findings: </li></ul><ul><li>1. Pain in the affected extremity </li></ul><ul><li>2. Superficial vein: tenderness, redness, induration along course of the vein </li></ul><ul><li>3. Deep vein: swelling, venous distension of limb, tenderness over involoved vein, (+) Homan’s sign </li></ul><ul><li>4. Elevated WBC and ESR </li></ul><ul><li>5. Diagnostic tests: </li></ul><ul><li>a. venography (phlebography): inc. uptake of radioactive material </li></ul>04/04/11 sdelfin2010
  193. 193. THROMBOPHLEBITIS <ul><li>b. Doppler ultrasonography: impairment of blood flow ahead of thrombus </li></ul><ul><li>D. Nursing interventions </li></ul><ul><li>1. Provide bed rest, elevating involved extremity </li></ul><ul><li>2. Apply continuous warm, moist soaks to dec. lymphatic congestion </li></ul><ul><li>3. Administer anticoagulants as ordered </li></ul>04/04/11 sdelfin2010
  194. 194. THROMBOPHLEBITIS <ul><li>a. Heparin </li></ul><ul><li>1. monitor PTT, use infusion pump to administer IV heparin </li></ul><ul><li>2. assess for bleeding tendencies (hematuria; hematemesis; bleeding gums; epistaxis, melena) </li></ul><ul><li>3. have antidote ( protamine sulfate) available </li></ul><ul><li>b. Warfarin (Coumadin) </li></ul><ul><li>1. assess PT daily, advise client to withhold dose and notify physician immediately if bleeding or signs of bleeding occurs </li></ul><ul><li>2. instruct client to use a soft toothbrush and to floss gently, prepare antidote: Vit. K </li></ul>04/04/11 sdelfin2010
  195. 195. THROMBOPHLEBITIS <ul><li>4. monitor for chest pain or SOB (possible pulmonary embolism) </li></ul><ul><li>5. Provide client teaching and discharge planning: </li></ul><ul><li>a. need to avoid standing, sitting for long periods; constrictive clothing; crossing legs at the knees; smoking; oral contraceptives </li></ul><ul><li>b. importance of adequate hydration </li></ul><ul><li>c. use of elastic stockings when ambulatory </li></ul><ul><li>d. importance of planned rest with elevation of feet </li></ul><ul><li>e. importance of weight reduction and exercise </li></ul>04/04/11 sdelfin2010
  196. 196. VARICOSE VEINS <ul><li>A. General info: </li></ul><ul><li>1. Dilated veins that occur most often in the lower extremities and trunk. As the vessel dilates, the valves become stretched and incompetent with resultant venous pooling/edema </li></ul><ul><li>2. most common between ages 30-50 </li></ul><ul><li>3. predisposing factor: congenital weakness of the veins, thrombophlebitis, pregnancy, obesity, heart disease </li></ul><ul><li>B. Medical management: </li></ul><ul><li>sclerotherapy </li></ul><ul><li>vein ligation (involves ligating the saphenous vein where it joins the femoral vein and stripping the saphenous vein system from groin to ankle) </li></ul>04/04/11 sdelfin2010
  197. 197. VARICOSE VEINS <ul><li>C. Assessment findings: </li></ul><ul><li>1. Pain after prolonged standing (relieved by elevation) </li></ul><ul><li>2. Swollen, dilated, tortuous skin veins </li></ul><ul><li>3. Diagnostic tests: </li></ul><ul><li>a. Trendelenburg test: varicose veins distend very quickly (less than 35 secs) </li></ul><ul><li>b. Doppler U/S: decreased or no blood flow heard after calf or thigh compression </li></ul><ul><li>D. Nursing interventions: </li></ul><ul><li>1. Elevate legs above heart level </li></ul>04/04/11 sdelfin2010
  198. 198. VARICOSE VEINS <ul><li>2. Apply knee length elastic stockings </li></ul><ul><li>3. Provide adequate rest </li></ul><ul><li>4. Prepare client for vein ligation, if necessary </li></ul><ul><li>a. Provide routine pre-op care </li></ul><ul><li>b. keep affected extremity elevated above the level of the heart to prevent edema </li></ul><ul><li>c. apply elastic bandages and stockings, which should be removed every 8hrs for short periods. </li></ul><ul><li>d. assist out of bed within 24hrs, ensuring that elastic stockings are applied. </li></ul><ul><li>e. assess for increased bleeding </li></ul>04/04/11 sdelfin2010
  199. 199. RHEUMATIC FEVER <ul><li>Main problem: </li></ul><ul><li>An inflammatory autoimmune disease that affects connective tissue of the heart, joints, subcutaneous tissues and blood vessels of the CNS; most serious complication- RHD affecting the cardiac valves; presents 2-6 wks following an untreated group A hemolytic strep </li></ul>04/04/11 sdelfin2010
  200. 200. RHEUMATIC FEVER <ul><li>INITIAL MANIFESTATIONS: </li></ul><ul><li>Signs of carditis, SOB, edema of the face, abdomen or ankles, precordial pain; signs of polyarthritis: edema, inflammation of the large joints, joint pain; erythema marginatum: macular rash on trunk and extremities; subcutaneous nodules; fever </li></ul>04/04/11 sdelfin2010
  201. 201. RHEUMATIC FEVER <ul><li>LABORATORY DATA: </li></ul><ul><li>elevated ESR; elevated WBC </li></ul>04/04/11 sdelfin2010
  202. 202. RHEUMATIC FEVER <ul><li>NURSING INTERVENTION: </li></ul><ul><li>Dec. activity; bed rest if pulse rate is inc. or if child is febrile </li></ul><ul><li>Friends may visit for short periods; child is not contagious </li></ul><ul><li>Maintain adequate hydration </li></ul><ul><li>Maintain adequate nutrition </li></ul>04/04/11 sdelfin2010
  203. 203. RHEUMATIC FEVER <ul><li>Administer analgesics for arthralgia </li></ul><ul><li>Teach parents importance or preventing recurring infxn </li></ul><ul><li>Importance of prophylactic therapy before invasive medical proc. </li></ul><ul><li>Continue medical follow-up for the development of valvular prob. as child grows. </li></ul>04/04/11 sdelfin2010
  204. 204. RHEUMATIC HEART DISEASE <ul><li>Rheumatic heart disease is an inflammatory disease, primarily affecting connective tissue, especially cardiac valves. </li></ul><ul><li>A. Usually preceded by a group A beta-hemolytic streptococcal infection. </li></ul><ul><li>1. Tissue damage is believed to be related to an autoimmune process. </li></ul><ul><li>2. Antibiotics produced in response to streptoccocal infection react with connective tissue ( cardiac tissue, joints) </li></ul>04/04/11 sdelfin2010
  205. 205. RHEUMATIC HEART DISEASE <ul><li>B. Myocardial involvement is characterized by inflammation of the endocardium, pericardium, and myocardium. </li></ul><ul><li>1. Endocarditis produces scarring of the cardiac valves. </li></ul><ul><li>2. Mitral and aortic valves are most commonly affected, either by valvular stenosis or valvular insufficiency. </li></ul>04/04/11 sdelfin2010
  206. 206. RHEUMATIC HEART DISEASE <ul><li>ASSESSMENT: </li></ul><ul><li>Risk factors/etiology: previous infection by beta hemolytic streptococcus. </li></ul><ul><li>Clinical manifestations: symptoms vary; no specific symptoms or sign is diagnostic of rheumatic fever. Criteria for the diagnosis require a combination of sympyoms to be present: </li></ul><ul><li>1. carditis </li></ul><ul><li>2. migratory polyarthritis </li></ul><ul><li>3. erythema marginatum </li></ul><ul><li>4. subcutaneous nodules </li></ul>04/04/11 sdelfin2010
  207. 207. RHEUMATIC HEART DISEASE <ul><li>TREATMENT </li></ul><ul><li>Adequate tx of streptococcal infxn </li></ul><ul><li>Bed rest until tachycardia subsides </li></ul><ul><li>Salicylates to control inflammatory process </li></ul><ul><li>Prophylactic tx: </li></ul><ul><li>Initiated after immediate therapy </li></ul><ul><li>Monthly administration of penicillin </li></ul><ul><li>Administration of prophylactic pen. Before and after medical proc. </li></ul>04/04/11 sdelfin2010
  208. 208. RHEUMATIC HEART DISEASE <ul><li>COMPLICATION: </li></ul><ul><li>Severe valvular damage precipitates the development of CHF and may require open heart surgery for replacement of diseased valve. </li></ul>04/04/11 sdelfin2010
  209. 209. CARDIAC TAMPONADE <ul><li>Main problem: </li></ul><ul><li>Fluid accumulation in the pericardial sac </li></ul><ul><li>Initial manifestation: </li></ul><ul><li>Hypotension muffled heart sounds is a common sign </li></ul>04/04/11 sdelfin2010
  210. 210. CARDIAC TAMPONADE <ul><li>Laboratory data: </li></ul><ul><li>ECG reveals ST and T wave abnormalities </li></ul><ul><li>Intervention: </li></ul><ul><li>Prepare the px for pericardiocentesis. This involves aspirating the fluid or air from the pericardial sac. </li></ul>04/04/11 sdelfin2010
  211. 211. PERICARDIOCENTESIS 04/04/11 sdelfin2010
  212. 212. COMPLETE HEART BLOCK <ul><li>Main problem: </li></ul><ul><li>Altered transmission of wave impulses from the SA node to the AV node </li></ul><ul><li>Initial manifestation: BRADYCARDIA </li></ul><ul><li>Laboratory data: </li></ul><ul><li>ECG reveals prolonged PR inteval </li></ul>04/04/11 sdelfin2010
  213. 213. COMPLETE HEART BLOCK <ul><li>Nursing interventions: </li></ul><ul><li>Monitor patients’ ECG </li></ul><ul><li>Prepare patient for pacemaker insertion </li></ul><ul><li>A common sign of pacemaker failure is hiccups </li></ul><ul><li>Atropine sulfate is given as a vagolytic </li></ul>04/04/11 sdelfin2010
  214. 214. Artificial pacemaker 04/04/11 sdelfin2010
  215. 215. 04/04/11 sdelfin2010
  216. 216. SICKLE CELL ANEMIA <ul><li>Gen. info: </li></ul><ul><li>Sickle cell anemia is a problem characterized by the sickling effect of the erythrocytes. </li></ul><ul><li>Sickle cell dse is a genetic disorder. </li></ul><ul><li>Sickling problem is not apparent until around 6 months of age </li></ul><ul><li>Predominantly a problem of children and adolescents. A child maybe asymptomatic between crises. </li></ul>04/04/11 sdelfin2010
  217. 217. Inheritance pattern for sickle cell disease 04/04/11 sdelfin2010
  218. 218. SICKLE CELL ANEMIA <ul><li>Pathological changes of sickle cell dse results from: </li></ul><ul><li>Inc. viscosity of blood </li></ul><ul><li>Inc. RBC destruction </li></ul><ul><li>Inc. viscosity eventually precipitates ischemia & tissue necrosis caused by capillary stasis and thrombosis </li></ul><ul><li>Cycle of occlusion, ischemia, & infarction to vascular organs. </li></ul>04/04/11 sdelfin2010
  219. 219. SICKLE CELL ANEMIA <ul><li>Sickle cell disease is a multiple body systems involvement. </li></ul>04/04/11 sdelfin2010
  220. 220. 04/04/11 sdelfin2010
  221. 221. <ul><li>Implementation : </li></ul><ul><li>Administer oxygen and blood transfusions </li></ul><ul><li>Administer analgesics </li></ul><ul><li>Maintain adequate hydration and blood flow with IV normal saline as prescribed and with oral fluids </li></ul><ul><li>Avoid putting strain on painful joints </li></ul><ul><li>Encourage consumption of a high calorie, high protein diet with folic acid supplementation </li></ul><ul><li>Monitor for signs of increasing anemia and shock (pallor, vital sign changes) </li></ul>04/04/11 sdelfin2010
  222. 222. Hemophilia <ul><li>Deficiency of clotting factors. Sex-linked trait more common in males. Von willebrands disease is transmitted to both male and female offspring of a carrier. </li></ul><ul><li>Males to manifest, female carrier </li></ul>04/04/11 sdelfin2010
  223. 223. Hemophilia <ul><li>X linked recessive trait </li></ul><ul><li>Males inherit hemophilia from their mothers and females inherit the carrier status from their fathers. </li></ul>04/04/11 sdelfin2010
  224. 224. Hemophilia <ul><li>2 forms: </li></ul><ul><li>Classic hemophilia </li></ul><ul><li>hemophilia A Factor VIII def. </li></ul><ul><li>Christmas factor </li></ul><ul><li>hemophilia B Factor IX </li></ul>04/04/11 sdelfin2010
  225. 225. <ul><li>Assessment: </li></ul><ul><li>Prolonged bleeding after minor injury </li></ul><ul><li>1. after cutting a cord at birth </li></ul><ul><li>2. following circumcision </li></ul><ul><li>3. following IM immunization </li></ul><ul><li>4. increase bruising as child learns to crawl and walk </li></ul><ul><li>Abnormal bleeding in response to trauma </li></ul>04/04/11 sdelfin2010
  226. 226. <ul><li>Joint bleeding- pain, tenderness, swelling limited range of motion tendency to bruise easily </li></ul><ul><li>Prolonged PTT </li></ul>04/04/11 sdelfin2010
  227. 227. <ul><li>Implementation: </li></ul><ul><li>Prepare to administer Factor VIII concentrate/ cryoprecipitate </li></ul><ul><li>Monitor for bleeding </li></ul><ul><li>Monitor for joint pain; immobilize the affected extremity if joint pain occurs </li></ul><ul><li>Monitor urine for hematuria </li></ul><ul><li>Control bleeding by immobilization, elevation, application of ice; apply pressure (15 mins) for superficial bleeding </li></ul><ul><li>Avoidance of contact sports </li></ul>04/04/11 sdelfin2010
  228. 228. Disseminated Intravascular Coagulation (DIC) <ul><li>Main problem: wide spread coagulation all over the body resulting to subsequent depletion of clotting factors </li></ul><ul><li>Initial manifestation: petechiae and ecchymosis on the skin, mucous membrane, heart, lungs and other organs </li></ul>04/04/11 sdelfin2010
  229. 229. <ul><li>Laboratory data: prolonged PT and PTT </li></ul><ul><li>Interventions: </li></ul><ul><li>Monitor for signs of bleeding ( tarry stool, hemoptysis, nosebleeding) </li></ul><ul><li>Administer heparin as ordered. Heparin inhibits thrombin thus preventing further clot formation and allowing coagulation factors to accumulate. Administer blood transfusion as ordered. </li></ul>04/04/11 sdelfin2010
  230. 230. Kawasaki disease (mucocutaneous lymph node syndrome) <ul><li>Main problem: acute systemic inflammatory illness of unknown cause; cardiac involvement- most serious complication. </li></ul><ul><li>Initial manifestations: fever, conjunctival infection, red throat, “strawberry tongue”, swollen hands, rash, enlargement of the cervical lymph nodes. </li></ul>04/04/11 sdelfin2010
  231. 231. <ul><li>Interventions : </li></ul><ul><li>Monitor temperature frequently </li></ul><ul><li>Assess heart sounds and rhythm </li></ul><ul><li>Assess extremities for edema, redness, desquamation </li></ul><ul><li>Monitor mucus membrane for inflammation </li></ul><ul><li>Weigh daily </li></ul><ul><li>Administer IV immune globulin </li></ul>04/04/11 sdelfin2010
  232. 232. NO PERMIT, NO EXAM <ul><li>THE END </li></ul><ul><li>GODBLESS ON YOUR EXAM </li></ul><ul><li>PLEASE READ YOUR BOOKS </li></ul>04/04/11 sdelfin2010
  233. 233. WAIT FOR ME AMERICA!! IM COMING!! 04/04/11 sdelfin2010

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