Cardiovascular ppt. fall 08 web v1


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  • Elevation in LVEDP (left ventricular end-diastolic pressure) Increases left atrial pressure Backs into the pulmonary vascular bed "Pulmonary edema" is water on the lungs.  Fluid is not only in the lung tissues, but actually in the air spaces as well.  This is a severe degree of heart failure, and requires immediate and aggressive management. When the heart's output decreases, the body does many things to try and compensate for it. It will release hormones to make the heart beat stronger. The heart will beat faster. Many of these reflexes however, only create a short term gain, and may ultimately hurt the heart's function. When the kidneys sense a decrease in flow, they release hormones which cause the body to hold sodium and water.  In the short term, this will lead to an increase in the volume of blood which is circulating, and provide the kidneys with the blood volume they are looking for.  However, this extra volume of fluid is more than can be held in the blood vessels, and it will start to exude out into the tissues of the bo Develops when the imbalance in pump function causes an increase in lung fluid secondary to leakage from pulmonary capillaries into the interstitium and alveoli of the lung. Life threatening situation in which the lung alveoli become filled with serosanguinous fluid. Most common cause is acut L venricular failure secondary to CAD –thus producing the cymptom of pink frothy sputum---
  • Fluid in pulmonary vessels - infiltrates
  • Cardiovascular ppt. fall 08 web v1

    1. 1. The Cardiovascular System Rachel S. Natividad, RN, MSN, NP N212 Medical Surgical Nursing 1
    2. 2. Case Study Intro… <ul><li>Mrs. E is a 70 year-old female admitted for left total hip replacement. Hx of DJD, Hypertension, CHF, asthma, and allergies. She also has a history of an MI 12 years ago. </li></ul>
    3. 3. Circulation through the Heart
    4. 4. Diagnostic Studies <ul><li>CBC </li></ul><ul><li>WBC </li></ul><ul><li>RBC </li></ul><ul><ul><ul><li>HGB </li></ul></ul></ul><ul><ul><ul><li>HCT </li></ul></ul></ul><ul><li>COAGULATION </li></ul><ul><li>Platelet count </li></ul><ul><li>PT/INR </li></ul><ul><li>PTT/APTT </li></ul><ul><li>CXR </li></ul>
    5. 5. Diagnostic Studies: Blood Components
    6. 6. Diagnostic Studies: Blood Components: White Blood Cell Differential <ul><li>WBC Count : Measurement of total number of leukocytes </li></ul>
    7. 7. WBC with Differential 30-40% 55-70% 5-6% 1-2% <1%
    8. 8. Diagnostic Studies: WBC Differential–Neutrophils Segmented Neutrophils (Mature) Band Neutrophils (Immature) NEUTROPHIL MATURATION Bands Segs: Mature Bands (immature neutrophils-released into circulation In response to severe infection ( Left Shift or “ Bandemia ”)
    9. 9. Diagnostic Studies: RBC – Erythrocyte count <ul><li>Number of circulating RBCs </li></ul><ul><li>Altered in the same conditions that alter Hgb and Hct values </li></ul>Erythrocytes
    10. 10. Diagnostic Studies: Hemoglobin <ul><li>HGB LEVEL: Measurement of the oxygen -carrying capacity of RBC </li></ul><ul><li>Increased in: </li></ul><ul><li>Hemoconcentration (severe </li></ul><ul><li>dehydration, burns, shock, </li></ul><ul><li>vomiting), polycythemia vera </li></ul><ul><li>Decreased in: </li></ul><ul><li>Anemias due to blood </li></ul><ul><li>loss or poor nutrition </li></ul><ul><li>Hemodilution (fluid volume excess); </li></ul><ul><li>other anemias </li></ul>
    11. 11. Diagnostic Studies: Hematocrit <ul><li>The percentage of whole blood volume composed of erythrocytes </li></ul><ul><li>Women: 38-47 % </li></ul><ul><li>Men: 40-54 % </li></ul><ul><li>Altered in same conditions that alter Hgb </li></ul>
    12. 12. Diagnostic Studies: Case Study #1 #2 POD PE: Incision site appears pink and slightly edematous with moderate amt. serosanguinous drainage, JP drain intact draining reddish colored drainage. VS: Temp 99.8 F, Resp 20/min, P 98 BPM, BP 138/88. CBC results 2 day post-op reveal ->->->->
    13. 13. Diagnostic Studies: Coagulation <ul><li>Monitoring hemostasis </li></ul>Bleeding Clotting
    14. 14. Diagnostic Studies: Coagulation <ul><li>Platelets – critical to hemostasis and clot formation </li></ul><ul><ul><li>Platelet count – measures the number of circulating platelets </li></ul></ul><ul><ul><li>Normal range: </li></ul></ul><ul><ul><li>150,000-400,000 mm3 </li></ul></ul><ul><ul><li>Monitor in patients receiving Lovenox </li></ul></ul><ul><li>- </li></ul>
    15. 15. Diagnostic Studies: How would you proceed? <ul><li>You are to administer Lovenox 40 mg SQ once daily. </li></ul><ul><li>Pt.’s Plt. Count = 250,000 mm3 </li></ul><ul><li>Pt’s Plt. Count = 80,000 mm3 </li></ul><ul><li>Pt’s Plt. Count = 450,000 mm3 </li></ul>
    16. 16. Diagnostic Studies: Case Study #2
    17. 17. Diagnostic Studies: Coagulation Cont. <ul><li>How long does it take for blood to clot? </li></ul><ul><li>PT & INR </li></ul><ul><ul><li>Assessment of extrinsic coagulation </li></ul></ul><ul><ul><li>To monitor patients taking certain medications as well as to help diagnose clotting disorders </li></ul></ul><ul><ul><li>Used primarily to evaluate oral anticoagulant therapy: warfarin (Coumadin) </li></ul></ul>
    18. 18. Diagnostic Studies: Coagulation Cont. <ul><li>PTT & aPTT </li></ul><ul><ul><li>Assessment of intrinsic coagulation </li></ul></ul><ul><ul><li>Used to monitor therapeutic Heparin </li></ul></ul>
    19. 19. <ul><li>Diagnostic Studies: CXR </li></ul><ul><li>Examine lung fields and heart size </li></ul><ul><li>Check for normal heart size and contour, change in heart chambers, displaced heart, presence of extra fluid around the heart </li></ul>                                                                                                                                 
    20. 20. Cardinal Signs and Symptoms (pp 687-688) <ul><li>Chest Pain </li></ul><ul><li>Palpitations </li></ul><ul><li>Dyspnea </li></ul><ul><li>Edema </li></ul><ul><li>Fatigue </li></ul><ul><li>Pallor </li></ul><ul><li>Syncope </li></ul>
    21. 21. Chest Pain: Angina <ul><li>Chest pain due to reversible ischemia to myocardium </li></ul><ul><li>reduced blood flow to the heart </li></ul>Coronary Artery Disease
    22. 22. Chest Pain: Myocardial Infarction (MI) <ul><li>Ischemia to the heart muscle is irreversible and results in tissue damage (infarction) and necrosis </li></ul><ul><li>Obstruction of blood flow </li></ul><ul><ul><li>Atheroma (plaque) </li></ul></ul><ul><ul><li>Thrombosis </li></ul></ul><ul><ul><li>Embolism </li></ul></ul>
    23. 23. Chest Pain: Myocardial Infarction- Cont. CAD with Thrombosis <ul><li>Diminished coronary perfusion </li></ul><ul><ul><li>► Ischemia – Angina </li></ul></ul><ul><ul><li>► Infarction – Necrosis </li></ul></ul><ul><ul><ul><li>Fibrous scarring </li></ul></ul></ul>
    24. 24. Chest Pain: Pericarditis <ul><li>Inflammation of pericardium </li></ul><ul><li>Pleuritic type chest pain </li></ul><ul><li>pericardial scarring and fibrosis </li></ul>
    25. 25. Chest Pain: What’s the difference? ANGINA MI PERICARDITIS Cause Ischemia Onset; Precipitating factors Sudden No precip. Factors Often early am Quality Severity squeezing stabbing pain or pressure Severe Sharp stabbing Moderate to severe Location Region Substernal May spread to chest, arms, back, Substernal May spread to ant. Chest, arms, back, jaw, neck Substernal Usually spreads to left side or back Duration, Relieving Factors < 15 min Rest, Nitro, O2 30 min or longer Not relived by rest Relieved with opioids
    26. 26. Locations of Chest Pain <ul><li>Other Symptoms- Ask about: </li></ul><ul><ul><li>SOB </li></ul></ul><ul><ul><li>Diaphoresis </li></ul></ul><ul><ul><li>N/V </li></ul></ul><ul><ul><li>Cold/clammy skin </li></ul></ul><ul><ul><li>Palpitations </li></ul></ul><ul><ul><li>Fainting </li></ul></ul><ul><ul><li>Loss of consciousness </li></ul></ul>
    27. 27. Heart Failure (Pump Failure) <ul><li>A disorder in which the heart loses its ability to pump blood efficiently throughout the body </li></ul><ul><li>Affects Cardiac Output </li></ul><ul><ul><li>SV X HR </li></ul></ul><ul><li>End result: </li></ul><ul><li>↓ Cardiac Output </li></ul>
    28. 28. Causes of Heart Failure <ul><li>Acute/Chronic ♥ Problems </li></ul><ul><li>HTN -#1 </li></ul><ul><li>CAD </li></ul><ul><li>MI </li></ul><ul><li>Valvular ♥ Disease </li></ul>
    29. 29. Heart Failure Pathophysiology: Impaired Cardiac Function <ul><li>Failure to pump: </li></ul><ul><li>Failure to empty ventricles </li></ul><ul><li>& reduced delivery of blood into circulation ( ↓ CO) </li></ul><ul><li>Increased ventricular pressures </li></ul><ul><li>Elevated pulmonary and systemic pressures </li></ul><ul><li>further ↓ CO </li></ul><ul><li>Series of compensatory mechanisms </li></ul>
    30. 30. Heart Failure Compensatory mechanisms of low CO… <ul><li>1. SNS stimulation… ↑ HR and </li></ul><ul><li>cardiac contractility… ↑ CO </li></ul><ul><li>3. Ventricular hypertrophy … cardiac contractility… ↑ CO </li></ul><ul><li>2. Starling’s Law/… </li></ul><ul><li>Ventricular dilation : ↑ CO </li></ul>4 . Decreased renal blood flow…increasing Na & H20 retention…increases blood volume, ↑ HR & CO.
    31. 31. Pulmonary Edema The most severe manifestation of Left Heart Failure Fluid leak into the pulmonary interstitial spaces (Pulmonary congestion/edema) Hypoxia and poor 02 exchange
    32. 32. Clinical picture… Left Heart Failure <ul><li>Dyspnea/Dyspnea on exertion (most sensitive: absence indicates Tx effective) </li></ul><ul><li>Cough orthopnea </li></ul><ul><li>Paroxysmal nocturnal dyspnea (PND) </li></ul><ul><li>Productive cough with pink frothy sputum </li></ul><ul><li>Tachypnea </li></ul><ul><li>Pale, possible cyanotic </li></ul><ul><li>Clammy and cold skin </li></ul><ul><li>Crackles/Wheezes </li></ul><ul><li>Extra heart sounds – S3, S4 </li></ul><ul><li>Heart murmur </li></ul>
    33. 33. CXR: Left Heart Failure Pulmonary edema
    34. 34. Systemic Edema Unresolved Left failure : eventually leads to right sided failure by venous congestion in the systemic circulation Also other causes …
    35. 35. Right Heart Failure <ul><li>Clinical picture…( Congestion ) </li></ul><ul><ul><li>JVD, hepatomegaly and dependent edema (LEs, thighs, abdomen-ascites) </li></ul></ul>
    36. 36. Heart Failure Clinical manifestations : Pulmonary Congestion (L) and Systemic Congestion (R) Right Heart Failure Left Heart Failure Pulmonary fluid overload Peripheral fluid overload
    37. 37. BNP - Test <ul><li>Brain Natriuretic Peptide (BNP) </li></ul><ul><ul><li>BNP is a substance secreted from the ventricles or lower chambers of the heart in response to changes in pressure that occur when heart failure develops and worsens. </li></ul></ul><ul><ul><li>BNP level in the blood increases when heart failure symptoms worsen </li></ul></ul><ul><ul><li>BNP level in the blood decreases when the heart failure condition is stable. </li></ul></ul>
    38. 38. Review: Subjective Data <ul><li>Pt. may c/o </li></ul><ul><li>anxiety </li></ul><ul><li>DOE </li></ul><ul><li>PND </li></ul><ul><li>orthopnea </li></ul><ul><li>productive cough with pink frothy sputum </li></ul><ul><li>Fatigue and weakness </li></ul>
    39. 39. Review: Objective Data <ul><li>PA may reveal: </li></ul><ul><li>Left heart Failure </li></ul><ul><li>Tachypnea/SOB </li></ul><ul><li>Use of accessory muscles </li></ul><ul><li>Wheezes/Crackles </li></ul><ul><li>skin </li></ul><ul><ul><li>Clammy/cold </li></ul></ul><ul><ul><li>pale/cyanotic </li></ul></ul><ul><li>Right Heart Failure </li></ul><ul><li>peripheral edema </li></ul><ul><li>JVD </li></ul><ul><li>Ascites, enlarged spleen/liver </li></ul>
    40. 40. Review: Heart Failure <ul><li>Left Heart Failure – pulmonary congestion </li></ul><ul><li>Right Heart Failure – systemic congestion </li></ul><ul><li>Left Heart failure often leads to Right sided heart failure causing biventricular failure </li></ul><ul><li>-> Cor Pulmonale </li></ul><ul><li>Note: There are other causes of R Heart Failure </li></ul>