This document discusses cardiovascular diseases and provides information on their assessment and management. It covers topics like angina pectoris, myocardial infarction, congestive heart failure, and hyperlipidemia. For angina, it describes the different types, symptoms, pathophysiology, diagnosis, and treatment including medications and lifestyle modifications. It also discusses assessing and managing acute coronary syndromes and MI, including complications. Nursing care plans are provided for MI focusing on pain management, circulation, oxygenation, and emotional support. Congestive heart failure and its pathophysiology, signs, diagnoses, and a nursing care plan are also outlined. The document concludes with a brief overview of hyperlipidemia causes.

1. CARDIOVASCULAR DISEASESNelia B. Perez RN, MSNPCU – MJCNBSN 2013

2. THE CARDIOVASCULAR SYSTEM

3. GENERAL CARDIAC ASSESSMENTHealth historyDemographic informationFamily/genetic historyCultural/social factorsRisk factorsModifiable: High blood cholesterol, obesity, smoking, stress, hypertension, diabetes mellitus.Nonmodifiable: Family history, increasing age, gender, race

4. Pathophysiology

6. ASSESSING CHEST PAIN

7. COMPARISON OF PHYSICAL CAUSES OF CHEST PAIN

8. COMPARISON OF PHYSICAL CAUSES OF CHEST PAIN

9. Angina Pectoris / Myocardial IschemiaIschemia – suppressed blood flow

10. Angina – to choke

11. Occurs when blood supply is inadequate to meet the heart’s metabolic demands

12. Symptomatic paroxysmal chest pain or pressure sensation associated with transient ischemiaPathophysiology

13. TypesStable angina – the common initial manifestation of a heart diseaseCommon cause: atherosclerosis (although those with advance atherosclerosis do not develop angina)

14. Pain is precipitated by increased work demands of the heart (i.e.. physical exertion, exposure to cold, & emotional stress)

15. Pain location: precordial or substernal chest areaPain characteristics:

16. constricting, squeezing, or suffocating sensation

17. Usually steady, increasing in intensity only at the onset & end of attack

18. May radiate to left shoulder, arm, jaw, or other chest areas

19. Duration: < 15mins

20. Relieved by rest (preferably sitting or standing with support) or by use of NTGVariant/Vasospastic Angina (Prinzmetal Angina)1st described by Prinzmetal & Associates in 1659

21. Cause: spasm of coronary arteries (vasospasm) due to coronary artery stenosis

22. Mechanism is uncertain (may be from hyperactive sympathetic responses, mishandling defects of calcium in smooth vascular muscles, reduced prostaglandin I2 production)Pain Characteristics: occurs during rest or with minimal exercise - commonly follows a cyclic or regular pattern of occurrence (i.e.. Same time each day usually at early hours)If client is for cardiac cath, Ergonovine (nonspecific vasoconstrictor) may be administered to evoke anginal attack & demonstrate the presence & location of spasmCont…Nocturnal Angina - frequently occurs nocturnally (may be associated with REM stage of sleep)Angina Decubitus – paroxysmal chest pain occurs when client sits or stands upPost-infarction Angina – occurs after MI when residual ischemia may cause episodes of angina

23. Cont…Dx: detailed pain history, ECG, TST, angiogram may be used to confirm & describe type of angina

24. Tx: directed towards MI prevention\

25. Lifestyle modification (individualized regular exercise program, smoking cessation)

26. Stress reduction

27. Diet changes

28. Avoidance of cold

29. PTCA (percutaneoustransluminal coronary angioplasty) may be indicated if with severe artery occlusionDrug TherapyNitroglycerin (NTGs) – vasodilators:

30. patch (Deponit, Transderm-NTG)

31. sublingual (Nitrostat)

32. oral (Nitroglyn)

33. IV (Nitro-Bid)

34. Β-adrenergic blockers:

35. Propanolol (Inderal)

36. Atenolol (Tenormin)

37. Metoprolol (Lopressor)

38. Calcium channel blockers:

39. Nifedipine (Calcibloc, Adalat)

40. Diltiazem (Cardizem)

41. Lipid lowering agents –statins:

42. Simvastatin

43. Anti-coagulants:

44. ASA (Aspirin)

45. Heparin sodium

46. Warfarin (Coumadin)Classification Class I – angina occurs with strenuous, rapid, or prolonged exertion at work or recreation

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. Class III – angina occurs on walking 1-2 blocks on the level or going 1 flight of ordinary stairs at normal pace

49. Class IV – angina occurs even at restNursing ManagementDiet instructions (low salt, low fat, low cholesterol, high fiber); avoid animal fats

50. E.g.. White meat – chicken w/o skin, fish

51. Stop smoking & avoid alcohol

52. Activity restrictions are placed within client’s limitations

53. NTGs – max of 3doses at 5-min intervals

54. Stinging sensation under the tongue for SL is normal

55. Advise clients to always carry 3 tablets

56. Store meds in cool, dry place, air-tight amber bottles & change stocks every 6months

57. Inform clients that headache, dizziness, flushed face are common side effects. Nursing ManagementDo not discontinue the drug.

58. For patches, rotate skin sites usually on chest wall

59. Instrct on evaluation of effectiveness based on pain relief

60. Propanolols causes bronchospasm & hypoglycemia, do not administer to asthmatic & diabetic clients

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. Coumadin – monitor for bleeding & PT; always have vit K readily available (avoid green leafyveggies)Acute Coronary SyndromeUnstable Angina/Non ST-Segment Elevation MI – a clinicalsyndrome of myocardial ischemia

63. Causes: atherosclerotic plaque disruption or significant CHD, cocaine use (risk factor)

64. Defining guidelines: (3 presentations)Symptoms at rest (usually prolonged, i.e.. >20mins)New onset exertional angina (increased in severity of at least 1 class – to at least class III) in <2monthsRecent acceleration of angina to at least class III in <2months

65. Dx: based on pain severity & presenting symptoms, ECG findings & serum cardiac markers

66. When chest pain has been unremitting for >20mins, possibility of ST-Segment Elevation MI is usually consideredCont…ST-Segment Elevation MI (Heart Attack)

67. Characterized by ischemic death of myocardial tissue associated with atherosclerotic disease of coronary arteries

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)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. Typical ECG changes: ST-segment elevation, Q wave prolongation, T wave inversionCont…(MI)Manifestations: chest pain – severe crushing, constricting, “someone sitting on my chest” - substernal radiating to left arm, neck or jaw - prolonged (>35mins) & not relieved by restShortness of breath, profuse perspiration

70. Feeling of impending doomComplications: death (usually within 1 hr of onset)

71. Heart failure & cardiogenic shock – profound LV failure from massive MI resulting to low cardiac output

72. Thromboemboli – leads to immobility & impaired cardiac function contributing to blood stasis in veins

73. Rupture of myocardium

74. Ventricular aneurysms – decreases pumping efficiency of heart & increases work of LVPathophysiologyCauses: atherosclerotic heart disease, thrombosis/embolism, shock &/or hemorrhage, direct traumaMyocardial ischemia↑cellular hypoxia↓myocardial O2 supply↓ myocardial contractility↓cardiac output↓arterial pressureStimulation of sympathetic receptors↑myocardial O2 demand↑peripheral vasoconstriction↑ afterload↑ HR↓myocardial tissue perfusion↑diastolicfilling ↑ myocardial contractility

75. Tissue Changes After MI

76. Management of MIInitial Management: OMEN - O2 therapy via nasal prongs - adequate analgesia (Morphine via IV – also has vasodilator property) - ECG monitoring -sublingual NTG (unless contraindicated; IV may be given to limit infarction size & most effective if given within 4hrs of onset)Thrombolytic Therapy – best results occur if initiated within 60-90mins of onset (Streptokinase & Urokinase – promote conversion of plasminogen to plasmin)

77. Anti-arrhythmics: lidocaine, atropine, propanolol

78. Anticoagulants & antiplatelets: ASA, heparin

79. Stool softenersSurgery :RevascularizationPTCACoronary stent implantationCoronary Artery Bypass Graft (CABG) – no response to medical treatment & PTCAResection – aneurysm

81. ASSESSMENTSubjective data:PAIN!!!NauseaSOBApprehensionObjective data:VSDiaphoresisEmotional restlessness

82. ANALYSIS / NURSING DIAGNOSESDecreased cardiac output related to myocardial damageImpaired gas exchange related to poor perfusion, shockPain related to myocardial ischemiaActivity intolerance related to pain or inadequate oxygenationFear related to possibility of death

83. NURSING CARE PLANGoal # 1: reduce pain / discomfortNarcotics – morphine; note response; Avoid IMHumidified oxygen 2-4 L/min; mouth care – O2 is dryingPosition: semi-Fowler’s to improve ventilation

84. NURSING CARE PLANGoal # 2: maintain adequate circulation; stabilize heart rhythmMonitor VS/UO; observe for cardiogenic shockMonitor ECG for arrhythmiasMedications: antiarrhythmics; anticoagulants; thrombolyticsDiagnostics: cardiac catheterizations, CAB surgeryRecognize heart failure: edema, cyanosis, dyspnea, cracklesCheck labs: troponin, blood gases, electrolytes, clotting timeCVP: (5-15 cm H2O) increases with heart failureROM of lower extremities; antiembolic stockings

85. NURSING CARE PLANGoal # 3: decrease oxygen demand/promote oxygenation, reduce cardiac workloadO2 as orderedActivity: bedrest (24-48 H) with bedside commode; planned rest periods; control visitorsPosition: semi-Fowler’s to facilitate lung expansion and decrease venous returnAnticipate needs of client: call light, water / ReassuranceAssist with feeding, turningEnvironment: quiet and comfortableMedications: CCBs, vasodilators, cardiotonics

86. NURSING CARE PLANGoal # 4: maintain fluid electrolyte, nutritional statusIV (KVO); CVP; vital signsUO: 30 cc/hrLabs: electrolytes (Na, K, Mg)Monitor ECGDiet: progressive low calorie, low sodium, low cholesterol, low fat, without caffeine

87. NURSING CARE PLANGoal # 5: facilitate fecal eliminationMedications: stool softeners to prevent Valsalva maneuver; mouth breathing during bowel movementBedside commode

88. NURSING CARE PLANGoal # 6: provide emotional supportRecognize fear of dying: denial, anger, withdrawalEncourage expression of feelings, fears, concernsDiscuss rehabilitation, lifestyle changes: prevent cardiac-invalid syndrome by promoting self-care activities, independence

89. NURSING CARE PLANGoal # 7: promote sexual functioningEncourage 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 stairsIdentify need for referral for sexual counselling

90. NURSING CARE PLANGoal # 8: health teachingDiagnosis and treatment regimenCaution when to avoid sexual activity: after heavy meal, alcohol ingestion; when fatigued, stressed; with unfamiliar partners; in extreme temperaturesInformation about sexual activity: less fatiguing positionsSupport groups / Follow-up careMedications: administration, importance, untoward effects; pulse takingControl risk factors: rest, diet, exercise, no smoking, weight control, stress reduction

91. EVALUATIONNo complications: stable vital signs; relief of painAdheres to medication regimenActivity tolerance is increasedReduction or modification of risk factors

92. CONGESTIVE HEART FAILUREinability of the heart to pump sufficient blood to meet the needs of the tissue for oxygen and nutrient.

93. PATHOPHYSIOLOGY

94. ASSESSMENTSubjective data:Shortness of breathOrthopnea (sleeps on two or more pillows)Paroxysmal nocturnal dyspnea (sudden breathlessness during sleep)Dyspnea on exertion (climbing stairs)Apprehension; anxiety; irritabilityFatigue; weaknessReported weight gain; feeling of puffiness

95. ASSESSMENTObjective data:VS:BP: decreasing systolic; narrowing pulse pressurePulse: pulsusalternans (alternating strong-weak-strong cardiac contraction); increased.Respirations: crackles; Cheyne-StokesEdema: dependent, pitting (1+ to 4+ mm)Liver: enlarged, tenderDistended neck veinsChest X-ray: enlarged heart; dilated pulmonary vessels; lung edema

96. Left Ventricular Compared with Right Ventricular Heart Failure

97. ANALYSIS / NURSING DIAGNOSESDecreased cardiac output related to decreased myocardial contractilityActivity intolerance related to generalized body weakness and inadequate oxygenationFatigue related to edema and poor oxygenation

98. Fluid volume excess related to compensatory mechanismsImpaired gas exchange related to pulmonary congestionAnxiety related to shortness of breathSleep pattern disturbance related to paroxysmal nocturnal disturbance

99. NURSING CARE PLANGoal # 1: provide physical rest/ reduce emotional stimuliPosition: sitting or semi-Fowler’s until tachycardia, dyspnea, edema resolved; change position frequently; pillows for supportRest: planned periods; limit visitors, activity, noise. Chair and commode privilegesSupport: stay with client who is anxious; have family member who is supportive present; administer sedatives/tranquilizers as orderedWarm fluids if appropriate

100. NURSING CARE PLANGoal # 2: provide for relief of respiratory distress; reduce cardiac workloadOxygen: low flow rate; encourage deep breathing (5-10 min q 2H); auscultate breath sounds for congestion, pulmonary edema.Position: elevating head of bed 20-25 cm (8-10 in) alleviates pulmonary congestionMedications – digitalis, ACE inhibitors, inotropic agents, diuretics, tranquilizers, vasodilators

101. NURSING CARE PLANGoal # 3: provide for special safety needsSkin care:Inspect, massage, lubricate bony prominencesUse foot cradle, heel protectors; sheepskinSide rails up if hypoxic (disoriented)Vital signs: monitor for signs of fatigue, pulmonary emboliROM: active, passive; elastic stockings

102. NURSING CARE PLANGoal # 4: maintain fluid and electrolyte balance, nutritional statusUrine output: 30 cc/hr minimum; estimate insensible loss in client who s diaphoretic. Monitor BUN, serum creatinine, and electrolytes.Daily weight; same time, clothes, scaleIV: IV infusion pump to avoid circulatory overload; strict I/ODietLow sodiumSmall, frequent feedingsDiscuss food preferences with client.

103. NURSING CARE PLANGoal # 5: health teachingDiet restrictions; meal preparationActivity restrictions; planned rest periodsMedications: schedule (e.g. diuretics in early morning); purpose; dosage; side effects (pulse taking, daily weights, intake of potassium-containing foods)Refer to available communityresources for dietary assistance, weight reduction, exercise program.

104. EVALUATION Increase in activity level tolerance – fatigue decreasedNo complications – pulmonary edema, respiratory distressReduction in dependent edema

105. DAY 3 of Cardiovasculardiseases

106. hyperlipidemia means high lipid levels. High lipid levels can speed up a process called atherosclerosis, or hardening of the arteries.

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.

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.

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.

110. Treatment of HyperlipidemiaIt 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.

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.

112. CARDIOMYOPATHIESHeart muscle disease associated with cardiac dysfunctionCARDIOMYOPATHIES1. Dilated Cardiomyopathy2. Hypertrophic Cardiomyopathy3. Restrictive cardiomyopathy

113. DILATED CARDIOMYOPATHY ASSOCIATED FACTORS1. Heavy alcohol intake2. Pregnancy3. Viral infection4. Idiopathic

114. DILATED CARDIOMYOPATHYPATHOPHYSIOLOGYDiminished contractile proteins - poor contraction -decreased blood ejection -increased blood remaining in the ventricle -ventricular stretching and dilatation.-SYSTOLIC DYSFUNCTION

115. HYPERTROPHIC CARDIOMYOPATHYAssociated factors:1. Genetic2. Idiopathic

116. HYPERTROPHIC CARDIOMYOPATHYPathophysiologyIncreased size of myocardium - reduced ventricular volume - increased resistance to ventricular filling - diastolic dysfunction

117. RESTRICTIVE CARDIOMYOPATHYAssociated factors1. Infiltrative diseases like AMYLOIDOSIS2. Idiopathic

118. RESTRICTIVE CARDIOMYOPATHYPathophysiologyRigid ventricular wall -impaired stretch and diastolic filling -decreased output - Diastolic dysfunction

119. CARDIOMYOPATHIESAssessment findings1. PND2. Orthopnea3. Edema4. Chest pain5. Palpitations6. dizziness7. Syncope with exertion

120. CARDIOMYOPATHIESLaboratory Findings1. CXR- may reveal cardiomegaly2. ECHOCARDIOGRAM3. ECG4. Myocardial Biopsy

121. CARDIOMYOPATHIESMedical Management1. Surgery2. pacemaker insertion3. Pharmacological drugs for symptom relief