Cardiovascular diseases modified

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Cardiovascular diseases modified

  1. 1. CARDIOVASCULAR DISEASES<br />Nelia B. Perez RN, MSN<br />PCU – MJCN<br />BSN 2013<br />
  2. 2. THE CARDIOVASCULAR SYSTEM<br />
  3. 3. GENERAL CARDIAC ASSESSMENT<br />Health history<br />Demographic information<br />Family/genetic history<br />Cultural/social factors<br />Risk factors<br />Modifiable: High blood cholesterol, obesity, smoking, stress, hypertension, diabetes mellitus.<br />Nonmodifiable: Family history, increasing age, gender, race<br />
  4. 4. Pathophysiology<br />
  5. 5.
  6. 6. ASSESSING CHEST PAIN<br />
  7. 7. COMPARISON OF PHYSICAL CAUSES OF CHEST PAIN<br />
  8. 8. COMPARISON OF PHYSICAL CAUSES OF CHEST PAIN<br />
  9. 9. Angina Pectoris / Myocardial Ischemia<br /><ul><li>Ischemia – suppressed blood flow
  10. 10. Angina – to choke
  11. 11. Occurs when blood supply is inadequate to meet the heart’s metabolic demands
  12. 12. Symptomatic paroxysmal chest pain or pressure sensation associated with transient ischemia</li></li></ul><li>Pathophysiology<br />
  13. 13. Types<br />Stable angina – the common initial manifestation of a heart disease<br /><ul><li>Common cause: atherosclerosis (although those with advance atherosclerosis do not develop angina)
  14. 14. Pain is precipitated by increased work demands of the heart (i.e.. physical exertion, exposure to cold, & emotional stress)
  15. 15. Pain location: precordial or substernal chest area</li></li></ul><li><ul><li>Pain characteristics:
  16. 16. constricting, squeezing, or suffocating sensation
  17. 17. Usually steady, increasing in intensity only at the onset & end of attack
  18. 18. May radiate to left shoulder, arm, jaw, or other chest areas
  19. 19. Duration: < 15mins
  20. 20. Relieved by rest (preferably sitting or standing with support) or by use of NTG</li></li></ul><li>Variant/Vasospastic Angina (Prinzmetal Angina)<br /><ul><li>1st described by Prinzmetal & Associates in 1659
  21. 21. Cause: spasm of coronary arteries (vasospasm) due to coronary artery stenosis
  22. 22. Mechanism is uncertain (may be from hyperactive sympathetic responses, mishandling defects of calcium in smooth vascular muscles, reduced prostaglandin I2 production)</li></li></ul><li><ul><li>Pain Characteristics: occurs during rest or with minimal exercise</li></ul> - commonly follows a cyclic or regular pattern of occurrence (i.e.. Same time each day usually at early hours)<br /><ul><li>If client is for cardiac cath, Ergonovine (nonspecific vasoconstrictor) may be administered to evoke anginal attack & demonstrate the presence & location of spasm</li></li></ul><li>Cont…<br />Nocturnal Angina - frequently occurs nocturnally (may be associated with REM stage of sleep)<br />Angina Decubitus – paroxysmal chest pain occurs when client sits or stands up<br />Post-infarction Angina – occurs after MI when residual ischemia may cause episodes of angina<br />
  23. 23. Cont…<br /><ul><li>Dx: detailed pain history, ECG, TST, angiogram may be used to confirm & describe type of angina
  24. 24. Tx: directed towards MI prevention
  25. 25. Lifestyle modification (individualized regular exercise program, smoking cessation)
  26. 26. Stress reduction
  27. 27. Diet changes
  28. 28. Avoidance of cold
  29. 29. PTCA (percutaneoustransluminal coronary angioplasty) may be indicated if with severe artery occlusion</li></li></ul><li>Drug Therapy<br /><ul><li>Nitroglycerin (NTGs) – vasodilators:
  30. 30. patch (Deponit, Transderm-NTG)
  31. 31. sublingual (Nitrostat)
  32. 32. oral (Nitroglyn)
  33. 33. IV (Nitro-Bid)
  34. 34. Β-adrenergic blockers:
  35. 35. Propanolol (Inderal)
  36. 36. Atenolol (Tenormin)
  37. 37. Metoprolol (Lopressor)
  38. 38. Calcium channel blockers:
  39. 39. Nifedipine (Calcibloc, Adalat)
  40. 40. Diltiazem (Cardizem)
  41. 41. Lipid lowering agents –statins:
  42. 42. Simvastatin
  43. 43. Anti-coagulants:
  44. 44. ASA (Aspirin)
  45. 45. Heparin sodium
  46. 46. Warfarin (Coumadin)</li></li></ul><li>Classification <br /><ul><li>Class I – angina occurs with strenuous, rapid, or prolonged exertion at work or recreation
  47. 47. Class II – angina occurs on walking or going up the stairs rapidly or after meals, walking uphill, walking more than 2 blocks on the level or going more than 1 flight of ordinary stairs at normal pace, under emotional stress, or in cold
  48. 48. Class III – angina occurs on walking 1-2 blocks on the level or going 1 flight of ordinary stairs at normal pace
  49. 49. Class IV – angina occurs even at rest</li></li></ul><li>Nursing Management<br /><ul><li>Diet instructions (low salt, low fat, low cholesterol, high fiber); avoid animal fats
  50. 50. E.g.. White meat – chicken w/o skin, fish
  51. 51. Stop smoking & avoid alcohol
  52. 52. Activity restrictions are placed within client’s limitations
  53. 53. NTGs – max of 3doses at 5-min intervals
  54. 54. Stinging sensation under the tongue for SL is normal
  55. 55. Advise clients to always carry 3 tablets
  56. 56. Store meds in cool, dry place, air-tight amber bottles & change stocks every 6months
  57. 57. Inform clients that headache, dizziness, flushed face are common side effects. </li></li></ul><li>Nursing Management<br /><ul><li>Do not discontinue the drug.
  58. 58. For patches, rotate skin sites usually on chest wall
  59. 59. Instrct on evaluation of effectiveness based on pain relief
  60. 60. Propanolols causes bronchospasm & hypoglycemia, do not administer to asthmatic & diabetic clients
  61. 61. Heparin – monitor bleeding tendencies (avoid punctures, use of soft-bristled toothbrush); monitor PTT levels; usedfor 2wks max; do not massage if via SC; have protaminesulfate available
  62. 62. Coumadin – monitor for bleeding & PT; always have vit K readily available (avoid green leafyveggies)</li></li></ul><li>Acute Coronary Syndrome<br /><ul><li>Unstable Angina/Non ST-Segment Elevation MI – a clinicalsyndrome of myocardial ischemia
  63. 63. Causes: atherosclerotic plaque disruption or significant CHD, cocaine use (risk factor)
  64. 64. Defining guidelines: (3 presentations)</li></ul>Symptoms at rest (usually prolonged, i.e.. >20mins)<br />New onset exertional angina (increased in severity of at least 1 class – to at least class III) in <2months<br />Recent acceleration of angina to at least class III in <2months<br />
  65. 65. <ul><li>Dx: based on pain severity & presenting symptoms, ECG findings & serum cardiac markers
  66. 66. When chest pain has been unremitting for >20mins, possibility of ST-Segment Elevation MI is usually considered</li></li></ul><li>Cont…<br /><ul><li>ST-Segment Elevation MI (Heart Attack)
  67. 67. Characterized by ischemic death of myocardial tissue associated with atherosclerotic disease of coronary arteries
  68. 68. Area of infarction is determined by the affected coronary artery & its distribution of blood flow (right coronary artery, left anterior descending artery, left circumflex artery)</li></li></ul><li><ul><li>Dx: based on presenting S/Sx, serum markers, & ECG (changes may not be present immediately after symptoms except dysrhythmias; PVCs/premature ventricular contractions are common after MI)
  69. 69. Typical ECG changes: ST-segment elevation, Q wave prolongation, T wave inversion</li></li></ul><li>Cont…(MI)<br />Manifestations: <br /><ul><li>chest pain – severe crushing, constricting, “someone sitting on my chest”</li></ul> - substernal radiating to left arm, neck or jaw<br /> - prolonged (>35mins) & not relieved by rest<br /><ul><li>Shortness of breath, profuse perspiration
  70. 70. Feeling of impending doom</li></li></ul><li><ul><li>Complications: death (usually within 1 hr of onset)
  71. 71. Heart failure & cardiogenic shock – profound LV failure from massive MI resulting to low cardiac output
  72. 72. Thromboemboli – leads to immobility & impaired cardiac function contributing to blood stasis in veins
  73. 73. Rupture of myocardium
  74. 74. Ventricular aneurysms – decreases pumping efficiency of heart & increases work of LV</li></li></ul><li>Pathophysiology<br />Causes: atherosclerotic heart disease,<br /> thrombosis/embolism, <br />shock &/or hemorrhage, direct trauma<br />Myocardial ischemia<br />↑cellular <br />hypoxia<br />↓myocardial <br />O2 supply<br />↓ myocardial contractility<br />↓cardiac output<br />↓arterial pressure<br />Stimulation of sympathetic receptors<br />↑myocardial <br />O2 demand<br />↑peripheral <br />vasoconstriction<br />↑ afterload<br />↑ HR<br />↓myocardial <br />tissue perfusion<br />↑diastolic<br />filling <br />↑ myocardial <br />contractility<br />
  75. 75. Tissue Changes After MI<br />
  76. 76. Management of MI<br /><ul><li>Initial Management: OMEN</li></ul> - O2 therapy via nasal prongs <br /> - adequate analgesia (Morphine via IV – also has vasodilator property)<br /> - ECG monitoring<br /> -sublingual NTG (unless contraindicated; IV may be given to limit infarction size & most effective if given within 4hrs of onset)<br /><ul><li>Thrombolytic Therapy – best results occur if initiated within 60-90mins of onset (Streptokinase & Urokinase – promote conversion of plasminogen to plasmin)
  77. 77. Anti-arrhythmics: lidocaine, atropine, propanolol
  78. 78. Anticoagulants & antiplatelets: ASA, heparin
  79. 79. Stool softeners</li></li></ul><li>Surgery :<br />Revascularization<br />PTCA<br />Coronary stent implantation<br />Coronary Artery Bypass Graft (CABG) – no response to medical treatment & PTCA<br />Resection – aneurysm<br />
  80. 80.
  81. 81. ASSESSMENT<br />Subjective data:<br />PAIN!!!<br />Nausea<br />SOB<br />Apprehension<br />Objective data:<br />VS<br />Diaphoresis<br />Emotional restlessness<br />
  82. 82. ANALYSIS / NURSING DIAGNOSES<br />Decreased cardiac output related to myocardial damage<br />Impaired gas exchange related to poor perfusion, shock<br />Pain related to myocardial ischemia<br />Activity intolerance related to pain or inadequate oxygenation<br />Fear related to possibility of death<br />
  83. 83. NURSING CARE PLAN<br />Goal # 1: reduce pain / discomfort<br />Narcotics – morphine; note response; Avoid IM<br />Humidified oxygen 2-4 L/min; mouth care – O2 is drying<br />Position: semi-Fowler’s to improve ventilation<br />
  84. 84. NURSING CARE PLAN<br />Goal # 2: maintain adequate circulation; stabilize heart rhythm<br />Monitor VS/UO; observe for cardiogenic shock<br />Monitor ECG for arrhythmias<br />Medications: antiarrhythmics; anticoagulants; thrombolytics<br />Diagnostics: cardiac catheterizations, CAB surgery<br />Recognize heart failure: edema, cyanosis, dyspnea, crackles<br />Check labs: troponin, blood gases, electrolytes, clotting time<br />CVP: (5-15 cm H2O) increases with heart failure<br />ROM of lower extremities; antiembolic stockings<br />
  85. 85. NURSING CARE PLAN<br />Goal # 3: decrease oxygen demand/promote oxygenation, reduce cardiac workload<br />O2 as ordered<br />Activity: bedrest (24-48 H) with bedside commode; planned rest periods; control visitors<br />Position: semi-Fowler’s to facilitate lung expansion and decrease venous return<br />Anticipate needs of client: call light, water / Reassurance<br />Assist with feeding, turning<br />Environment: quiet and comfortable<br />Medications: CCBs, vasodilators, cardiotonics<br />
  86. 86. NURSING CARE PLAN<br />Goal # 4: maintain fluid electrolyte, nutritional status<br />IV (KVO); CVP; vital signs<br />UO: 30 cc/hr<br />Labs: electrolytes (Na, K, Mg)<br />Monitor ECG<br />Diet: progressive low calorie, low sodium, low cholesterol, low fat, without caffeine<br />
  87. 87. NURSING CARE PLAN<br />Goal # 5: facilitate fecal elimination<br />Medications: stool softeners to prevent Valsalva maneuver; mouth breathing during bowel movement<br />Bedside commode<br />
  88. 88. NURSING CARE PLAN<br />Goal # 6: provide emotional support<br />Recognize fear of dying: denial, anger, withdrawal<br />Encourage expression of feelings, fears, concerns<br />Discuss rehabilitation, lifestyle changes: prevent cardiac-invalid syndrome by promoting self-care activities, independence<br />
  89. 89. NURSING CARE PLAN<br />Goal # 7: promote sexual functioning<br />Encourage verbalization of concerns regarding activity, inadequacy, limitations, expectations – include partner (usually resume activity 5-8 wks after uncomplicated MI or when client can climb 2 flights of stairs<br />Identify need for referral for sexual counselling<br />
  90. 90. NURSING CARE PLAN<br />Goal # 8: health teaching<br />Diagnosis and treatment regimen<br />Caution when to avoid sexual activity: after heavy meal, alcohol ingestion; when fatigued, stressed; with unfamiliar partners; in extreme temperatures<br />Information about sexual activity: less fatiguing positions<br />Support groups / Follow-up care<br />Medications: administration, importance, untoward effects; pulse taking<br />Control risk factors: rest, diet, exercise, no smoking, weight control, stress reduction<br />
  91. 91. EVALUATION<br />No complications: stable vital signs; relief of pain<br />Adheres to medication regimen<br />Activity tolerance is increased<br />Reduction or modification of risk factors<br />
  92. 92. CONGESTIVE HEART FAILURE<br />inability of the heart to pump sufficient blood to meet the needs of the tissue for oxygen and nutrient.<br />
  93. 93. PATHOPHYSIOLOGY<br />
  94. 94. ASSESSMENT<br />Subjective data:<br />Shortness of breath<br />Orthopnea (sleeps on two or more pillows)<br />Paroxysmal nocturnal dyspnea (sudden breathlessness during sleep)<br />Dyspnea on exertion (climbing stairs)<br />Apprehension; anxiety; irritability<br />Fatigue; weakness<br />Reported weight gain; feeling of puffiness<br />
  95. 95. ASSESSMENT<br />Objective data:<br />VS:<br />BP: decreasing systolic; narrowing pulse pressure<br />Pulse: pulsusalternans (alternating strong-weak-strong cardiac contraction); increased.<br />Respirations: crackles; Cheyne-Stokes<br />Edema: dependent, pitting (1+ to 4+ mm)<br />Liver: enlarged, tender<br />Distended neck veins<br />Chest X-ray: enlarged heart; dilated pulmonary vessels; lung edema<br />
  96. 96. Left Ventricular Compared with Right Ventricular Heart Failure<br />
  97. 97. ANALYSIS / NURSING DIAGNOSES<br />Decreased cardiac output related to decreased myocardial contractility<br />Activity intolerance related to generalized body weakness and inadequate oxygenation<br />Fatigue related to edema and poor oxygenation<br />
  98. 98. Fluid volume excess related to compensatory mechanisms<br />Impaired gas exchange related to pulmonary congestion<br />Anxiety related to shortness of breath<br />Sleep pattern disturbance related to paroxysmal nocturnal disturbance<br />
  99. 99. NURSING CARE PLAN<br />Goal # 1: provide physical rest/ reduce emotional stimuli<br />Position: sitting or semi-Fowler’s until tachycardia, dyspnea, edema resolved; change position frequently; pillows for support<br />Rest: planned periods; limit visitors, activity, noise. Chair and commode privileges<br />Support: stay with client who is anxious; have family member who is supportive present; administer sedatives/tranquilizers as ordered<br />Warm fluids if appropriate<br />
  100. 100. NURSING CARE PLAN<br />Goal # 2: provide for relief of respiratory distress; reduce cardiac workload<br />Oxygen: low flow rate; encourage deep breathing (5-10 min q 2H); auscultate breath sounds for congestion, pulmonary edema.<br />Position: elevating head of bed 20-25 cm (8-10 in) alleviates pulmonary congestion<br />Medications – digitalis, ACE inhibitors, inotropic agents, diuretics, tranquilizers, vasodilators<br />
  101. 101. NURSING CARE PLAN<br />Goal # 3: provide for special safety needs<br />Skin care:<br />Inspect, massage, lubricate bony prominences<br />Use foot cradle, heel protectors; sheepskin<br />Side rails up if hypoxic (disoriented)<br />Vital signs: monitor for signs of fatigue, pulmonary emboli<br />ROM: active, passive; elastic stockings<br />
  102. 102. NURSING CARE PLAN<br />Goal # 4: maintain fluid and electrolyte balance, nutritional status<br />Urine output: 30 cc/hr minimum; estimate insensible loss in client who s diaphoretic. Monitor BUN, serum creatinine, and electrolytes.<br />Daily weight; same time, clothes, scale<br />IV: IV infusion pump to avoid circulatory overload; strict I/O<br />Diet<br />Low sodium<br />Small, frequent feedings<br />Discuss food preferences with client.<br />
  103. 103. NURSING CARE PLAN<br />Goal # 5: health teaching<br />Diet restrictions; meal preparation<br />Activity restrictions; planned rest periods<br />Medications: schedule (e.g. diuretics in early morning); purpose; dosage; side effects (pulse taking, daily weights, intake of potassium-containing foods)<br />Refer to available communityresources for dietary assistance, weight reduction, exercise program.<br />
  104. 104. EVALUATION <br />Increase in activity level tolerance – fatigue decreased<br />No complications – pulmonary edema, respiratory distress<br />Reduction in dependent edema<br />
  105. 105. DAY 3 <br />of <br />Cardiovascular<br />diseases<br />
  106. 106. hyperlipidemia means high lipid levels. <br />High lipid levels can speed up a process called atherosclerosis, or hardening of the arteries.<br />
  107. 107. Most hyperlipidemia is caused by lifestyle habits or treatable medical conditions. Lifestyle contributors include obesity, not exercising, and smoking. Conditions that cause hyperlipidemia include diabetes, kidney disease, pregnancy, and an underactive thyroid gland.<br />
  108. 108. You can also inherit hyperlipidemia. The cause may be genetic if you have a normal body weight and other members of your family have hyperlipidemia.<br />
  109. 109. You have a greater chance of developing hyperlipidemia if you are a man older than age 45 or a woman older than age 55. If a close relative had early heart disease (father or brother affected before age 55, mother or sister affected before age 65), you also have an increased risk.<br />
  110. 110. Treatment of Hyperlipidemia<br />It is necessary to first identify and treat any potential underlying medical problems, such as diabetes or hypothyroidism, that may contribute to hyperlipidemia. Treatment of hyperlipidemia itself includes dietary changes, weight reduction and exercise. If lifestyle modifications cannot bring about optimal lipid levels, then medications may be necessary.<br />
  111. 111. Medications most commonly used to treat high LDL cholesterol levels are statins, such as atorvastatin (Lipitor) or simvastatin (Mevacor). These medications work by reducing the production of cholesterol within the body. <br />
  112. 112. CARDIOMYOPATHIESHeart muscle disease associated with cardiac dysfunction<br />CARDIOMYOPATHIES<br />1. Dilated Cardiomyopathy<br />2. Hypertrophic Cardiomyopathy<br />3. Restrictive cardiomyopathy<br />
  113. 113. DILATED CARDIOMYOPATHY ASSOCIATED FACTORS<br />1. Heavy alcohol intake<br />2. Pregnancy<br />3. Viral infection<br />4. Idiopathic<br />
  114. 114. DILATED CARDIOMYOPATHYPATHOPHYSIOLOGY<br />Diminished contractile proteins - poor contraction -decreased blood ejection -increased blood remaining in the ventricle -ventricular stretching and dilatation.-<br />SYSTOLIC DYSFUNCTION<br />
  115. 115. HYPERTROPHIC CARDIOMYOPATHY<br />Associated factors:<br />1. Genetic<br />2. Idiopathic<br />
  116. 116. HYPERTROPHIC CARDIOMYOPATHY<br />Pathophysiology<br />Increased size of myocardium - reduced ventricular volume - increased resistance to ventricular filling - diastolic dysfunction<br />
  117. 117. RESTRICTIVE CARDIOMYOPATHY<br />Associated factors<br />1. Infiltrative diseases like AMYLOIDOSIS<br />2. Idiopathic<br />
  118. 118. RESTRICTIVE CARDIOMYOPATHYPathophysiology<br />Rigid ventricular wall -impaired stretch and diastolic filling -decreased output - Diastolic dysfunction<br />
  119. 119. CARDIOMYOPATHIES<br />Assessment findings<br />1. PND<br />2. Orthopnea<br />3. Edema<br />4. Chest pain<br />5. Palpitations<br />6. dizziness<br />7. Syncope with exertion<br />
  120. 120. CARDIOMYOPATHIES<br />Laboratory Findings<br />1. CXR- may reveal cardiomegaly<br />2. ECHOCARDIOGRAM<br />3. ECG<br />4. Myocardial Biopsy<br />
  121. 121. CARDIOMYOPATHIES<br />Medical Management<br />1. Surgery<br />2. pacemaker insertion<br />3. Pharmacological drugs for symptom relief<br />
  122. 122. CARDIOMYOPATHIES<br />Nursing Management<br />1.Improve cardiac output<br />Adequate rest<br />Oxygen therapy<br />Low sodium diet<br />
  123. 123. CARDIOMYOPATHIES<br />Nursing Management<br />2. Increase patient tolerance<br />Schedule activities with rest periods in between<br />
  124. 124. CARDIOMYOPATHIES<br />Nursing Management<br />3. Reduce patient anxiety<br />Support<br />Offer information about transplantations<br />Support family in anticipatory grieving<br />
  125. 125. Infective endocarditis<br />Infection of the heart valves and the endothelial surface of the heart<br />Can be acute or chronic<br />
  126. 126. Infective endocarditis<br />Etiologic factors<br />1. Bacteria- Organism depends on several factors<br />2. Fungi<br />
  127. 127. Infective endocarditis<br />Risk factors<br />1. Prosthetic valves<br />2. Congenital malformation<br />3. Cardiomyopathy<br />4. IV drug users<br />5. Valvular dysfunctions<br />
  128. 128. Infective endocarditis<br />Pathophysiology<br />Direct invasion of microbes  microbes adhere to damaged valve surface and proliferate  damage attracts platelets causing clot formation  erosion of valvular leaflets and vegetation can embolize<br />
  129. 129. Infective endocarditis<br />Assessment findings<br />1. Intermittent HIGH fever<br />2. anorexia, weight loss<br />3. cough, back pain and joint pain<br />4. splinter hemorrhages under nails<br />
  130. 130. Infective endocarditis<br />Assessment findings<br />5. Osler’s nodes- painful nodules on fingerpads<br />6. Roth’s spots- pale hemorrhages in the retina<br />
  131. 131. Infective endocarditis<br />Assessment findings<br />7. Heart murmurs<br />8. Heart failure<br />
  132. 132. Infective endocarditis<br />Prevention<br />Antibiotic prophylaxis if patient is undergoing procedures like dental extractions, bronchoscopy, surgery, etc.<br />
  133. 133. Infective endocarditis<br />LABORATORY EXAM<br />Blood Cultures to determine the exact organism<br />
  134. 134. Infective endocarditis<br />Nursing management<br />1. regular monitoring of temperature, heart sounds<br />2. manage infection<br />3. long-term antibiotic therapy<br />
  135. 135. Infective endocarditis<br />Medical management<br />1. Pharmacotherapy<br />IV antibiotic for 2-6 weeks<br />Antifungal agents are given – amphotericin B<br />
  136. 136. Infective endocarditis<br /><ul><li>Medical management
  137. 137. 2. Surgery
  138. 138. Valvular replacement</li></li></ul><li>CARDIOGENIC SHOCK<br /><ul><li>Heartfailsto pump adequately resulting to a decreased cardiac output and decreased tissue perfusion
  139. 139. ETIOLOGY
  140. 140. 1. Massive MI
  141. 141. 2. Severe CHF
  142. 142. 3. Cardiomyopathy
  143. 143. 4. Cardiac trauma
  144. 144. 5. Cardiac tamponade</li></li></ul><li>CARDIOGENIC SHOCK<br />ASSESSMENT FINDINGS<br />1. HYPOTENSION<br />2. oliguria (less than 30 ml/hour)<br />3. tachycardia<br />4. narrow pulse pressure<br />5. weak peripheral pulses<br />6. cold clammy skin<br />7. changes in sensorium/LOC<br />8. pulmonary congestion<br />
  145. 145. CARDIOGENIC SHOCK<br />LABORATORY FINDINGSIncreased CVP<br />Normal is 4-10 cmH2O<br />
  146. 146. CARDIOGENIC SHOCK<br /><ul><li>NURSING INTERVENTIONS
  147. 147. 1. Place patient in a modified Trendelenburg (shock ) position
  148. 148. 2. Administer IVF, vasopressors and inotropics such as DOPAMINE and DOBUTAMINE
  149. 149. 3. Administer O2
  150. 150. 4. Morphine is administered to decreased pulmonary congestion and to relieve pain</li></li></ul><li>CARDIOGENIC SHOCK<br /><ul><li>5. Assist in intubation, mechanical ventilation, PTCA, CABG, insertion of Swan-Ganzcath and IABP
  151. 151. 6. Monitor urinary output, BP and pulses
  152. 152. 7. cautiously administer diuretics and nitrates</li></li></ul><li>CARDIAC TAMPONADE<br />A condition where the heart is unable to pump blood due to accumulation of fluid in the pericardial sac (pericardial effusion)<br />
  153. 153. CARDIAC TAMPONADE<br /><ul><li>This condition restricts ventricular filling resulting to decreased cardiac output
  154. 154. Acute tamponade may happen when there is a sudden accumulation of more than 50 ml fluid in the pericardial sac</li></li></ul><li>CARDIAC TAMPONADE<br /><ul><li>Causative factors
  155. 155. 1. Cardiac trauma
  156. 156. 2. Complication of Myocardial infarction
  157. 157. 3. Pericarditis
  158. 158. 4. Cancer metastasis</li></li></ul><li>CARDIAC TAMPONADE<br /><ul><li>ASSESSMENT FINDINGS
  159. 159. 1. BECK’s Triad- Jugular vein distention, hypotension and distant/muffled heart sound
  160. 160. 2. Pulsusparadoxus
  161. 161. 3. Increased CVP
  162. 162. 4. decreased cardiac output</li></li></ul><li>CARDIAC TAMPONADE<br /><ul><li>ASSESSMENT FINDINGS
  163. 163. 5. Syncope
  164. 164. 6. anxiety
  165. 165. 7. dyspnea
  166. 166. 8. Percussion- Flatness across the anterior chest</li></li></ul><li>CARDIAC TAMPONADE<br /><ul><li>Laboratory FINDINGS
  167. 167. 1. Echocardiogram
  168. 168. 2. Chest X-ray</li></li></ul><li>CARDIAC TAMPONADE<br /><ul><li>NURSING INTERVENTIONS
  169. 169. 1. Assist in PERICARDIOCENTESIS
  170. 170. 2. Administer IVF
  171. 171. 3. Monitor ECG, urine output and BP
  172. 172. 4. Monitor for recurrence of tamponade</li></li></ul><li><ul><li>Pericardiocentesis
  173. 173. Patient is monitored by ECG
  174. 174. Maintain emergency equipments
  175. 175. Elevate head of bed 45-60 degrees
  176. 176. Monitor for complications- coronary artery rupture, dysrhythmias, pleural laceration and myocardial trauma</li></li></ul><li>HYPERTENSION<br />A systolic BP greater than 140 mmHg and a diastolic pressure greater than 90 mmHg over a sustained period, based on two or more BP measurements .<br />
  177. 177. HYPERTENSION<br /><ul><li>Types of Hypertension
  178. 178. 1. Primary or ESSENTIAL
  179. 179. Most common type
  180. 180. 2. Secondary
  181. 181. Due to other conditions like Pheochromocytoma, renovascular hypertension, Cushing’s, Conn’s , SIADH</li></li></ul><li>
  182. 182.
  183. 183.
  184. 184. Alterations inBlood Flow in the Systemic Circulation<br />
  185. 185. Buerger’s Disease<br />Also known as Thromboangiitisobliterans<br />Usually a disease of heavy cigarette smoker/tobacco user men, 25-40y/o<br />Inflammatory arterial disorder that causes thrombus formation often extends to adjacent veins & nerves<br />
  186. 186. Affects medium-sized arteries (usually plantar & digital vessels in the foot or lower legs)<br />unknown pathogenesis but it had been suggested that:<br />tobacco may trigger an immune response or <br />unmask a clotting defect; <br />-> these 2 can incite an inflammatory reaction of the vessel wall<br />
  187. 187. Manifestations <br /><ul><li>Pain – predominant symptom; R/T distal arterial ischemia
  188. 188. Intermittent claudication in the arch of foot & digits
  189. 189. Increased sensitivity to cold (due to impaired circulation
  190. 190. Absent/diminished peripheral pulses</li></li></ul><li><ul><li>Color changes in extremity (cyanotic on dependent position; digits may turn reddish blue)
  191. 191. Thick malformed nails (chronic ischemia)
  192. 192. Disease progression ulcerate tissues & gangrenous changes may arise; may necessitate amputation </li></li></ul><li>Diagnosis & Treatment<br />Diagnostic methods – those that assess blood flow (Doppler ultrasound & MRI)<br />Tx: mandatory to stop smoking or using tobacco<br />Meds to increase blood flow to extremities<br />Surgery (surgical sympathectomy)<br />amputation<br />
  193. 193. Rynaud’s Disease<br /><ul><li>Mechanism: intensive vasospasm of arteries & arterioles in thefingers
  194. 194. Cause: unknown
  195. 195. Usually affects young women
  196. 196. Precipitated by exposure to cold & strong emotions
  197. 197. Raynaud’s phenomenon – associated with previous injury (i.e.. Frostbite, occupational trauma associated with use of heavy vibrating tools, collagen diseases, neuro d/o, chronic arterial occlusive d/o)</li></li></ul><li>Manifestations <br />Period of ischemia (ischemia due to vasospasm) <br />change in skin color = pallor to cyanotic<br />1st noticed at the fingertips later moving to distal phalanges<br />Cold sensation<br />Sensory perception changes (numbness & tingling)<br /> Period of hyperemia – intense redness<br />Throbbing<br />Paresthesia<br />
  198. 198. Return to normal color<br />Note: although all of the fingers are affected symmetrically, only 1-2digits may be involved<br />Severe cases: arthritis may arise (due to nutritional impairment)<br />Brittle nails<br />Thickening of the skin of fingertips<br />Ulceration & superficial gangrene of fingers (rare occasions)<br />
  199. 199. Diagnosis & Treatment<br /><ul><li>Dx: initial = based on Hx of vasospastic attacks
  200. 200. Immersion of hand in cold water to initiate attack aids in the Dx
  201. 201. Doppler flow velocimetry – used to quantify blood flow during temperature changes
  202. 202. Serial Computed thermography (finger skin temp) – for diagnosing the extent of disease</li></li></ul><li><ul><li>Tx: directed towards eliminating factors causing vasospasm & protecting fingers from injury during ischemic attacks
  203. 203. PRIORITIES: Abstinence in smoking & protection from cold
  204. 204. Avoidance of emotional stress (anxiety & stress may precipitate vascular spasm)
  205. 205. Meds: avoid vasoconstrictors (i.e.. Decongestants)</li></ul> -Calcium channel blockers (Diltiazem, Nifedipine, Nicardipine) – decrease episodes of attacks<br />
  206. 206. Care Plan for Clients with Altered Cardiovascular Oxygenation<br />Goals:<br />Relief of pain & symptoms<br />Prevention of further cardiac damage<br />Nursing Interventions:<br />Pain control<br />Proper medications<br />Decrease client’s anxiety<br />Health teachings (meds, activities, diet, exercise, etc)<br />Assessment:<br />Hx of symptoms (pain, esp. chest pain; palpitations; dyspnea)<br />v/s<br />Nursing Dx: <br />ineffective tissue perfusion (cardiopulmonary)<br />Impaired gas exchange<br />Anxiety due to fear of death (clients with MI or Angina)<br />

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