Nursing intervention for a patient with CARDIOVASCULAR DISORDERS.pptx

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CARDIOVASCULAR
DISORDERS
Prepared by: Wegene J

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Anatomical and physiologic overview of
CVS
•The heart is a hollow, muscular organ located in the
center of the thorax.
•It weighs approximately 300 g.
•Heart`s weight and size are influenced by age, gender,
body weight, extent of physical exercise and
conditioning, and heart disease.
•The heart pumps blood to the tissues, supplying them
with oxygen and other nutrients.

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Cont…
•The heart is composed of three layers
•The inner layer (endocardium) - consists of
endothelial tissue and lines the inside of the heart
and valves.
•The middle layer (myocardium) - is made up of
muscle fibers and is responsible for the pumping
action.
•The exterior layer of the heart is called the
epicardium.

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Cont…
•The heart is encased in a thin, fibrous sac called the
pericardium, which is composed of two layers.
•Adhering to the epicardium is the visceral pericardium.
•Enveloping the visceral pericardium is the parietal
pericardium, a tough fibrous tissue that attaches to the
great vessels, diaphragm, sternum, and vertebral
column and supports the heart in the mediastinum.
•The space between these two layers (pericardial space)
is normally filled with about 20 ML of fluid, which
lubricates the surface of the heart and reduces friction
during systole.

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Cont…
• The four chambers of the heart constitute the right-
and left sided pumping systems.
• The right side of the heart, made up of the right
atrium and right ventricle, distributes venous blood
(deoxygenated blood) to the lungs via the pulmonary artery
(pulmonary circulation) for oxygenation.
• The left side of the heart, composed of the left atrium
and left ventricle, distributes oxygenated blood to the
remainder of the body via the aorta (systemic
circulation).

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Cont…
•Right atrium: collects O2 poor blood from the superior
and inferior vena cava
•Left Atrium: collect O2 rich blood from the four
pulmonary veins
•Right Ventricle: Pumps blood to the lung from Rt
Atrium through pulmonary artery
•Left ventricle: pumps blood rich in oxygen to all parts
of the body

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Cont…
•The four valves in the heart permit blood to flow in
only one direction.
•There are two types of valves: atrioventricular and
semilunar.
ATRIOVENTRICULAR - The valves that separate the atria
from the ventricles
•Tricuspid valve - separates the right atrium from the
right ventricle.
•The mitral, or bicuspid (two cusps) valve, lies between
the left atrium and the left ventricle

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Cont…
SEMILUNAR VALVES - the two semilunar valves are
composed of three half-moon-like leaflets.
•The valve between the right ventricle and the
pulmonary artery is called the pulmonic valve.
•The valve between the left ventricle and the aorta is
called the aortic valve.

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Cont…
Blood supply to the heart wall
•Myocardium of the heart is a muscle with
requirement of a continuous supply of O2 and
nutrients to function with efficiency.
•The coronary arteries are responsible to supply the
above needs of the heart.
•The left and right coronary arteries and their
branches supply arterial blood to the heart.
•These arteries originate from the aorta just above
the aortic valve leaflets.

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Cont…
The Heart conduction System
►The heart pumps blood through the body
• For the heart to perform its task systematic relaxation
and contraction is required.
•During systole (contraction of the muscle), the
chambers of the heart become smaller as the blood is
ejected.
•During diastole (relaxation of the muscle), the heart
chambers fill with blood in preparation for the
subsequent ejection.

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Cont…
•Effective contractions depends on the
electrophysiological properties of the heart muscle.
►Cardiac conduction system is the electrical
conduction system that controls the heart rate
►This system creates the electrical impulses and
sends them throughout the heart.

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cont…
►These impulses make the heart contract and pump
blood.

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Cont…
The three physiologic characteristics of the cardiac
conduction cells account for this coordination
include :
1. Automaticity and rhythmicity: ability of cardiac cells
to initiate an impulse spontaneously and repetitively
with out external neuro-hormonal control.
2. Excitability: ability to respond to an electrical
impulse.
3. Conductivity: ability to transmit an electrical impulse
from one cell to another (the ability of heart muscle
fibers to propagate action potentials along and
across cell membranes.

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Assessing cardiovascular functions
Health history
Nursing history should focus on the following areas:
•Family history of incidence and age of heart disease
•High cholesterol levels
•High blood pressure, stroke, obesity
• Congenital heart disease
•Rheumatic fever
•Heart murmur, heart attack or heart failure

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Assessing cardiovascular cont…
•Present symptoms indicative of heart disease (e.g.
Fatigue, dyspnea, orthopnea, edema, cough, pain,
palpitations, syncope, hypertension, wheezing,
hemoptysis….
•Presence of problem that affect heart (e.g. Obesity,
diabetes, lung disease, endocrine disorders)
•Life style habits that are risk factors for cardiac
disease (e.g. Smoking, alcohol intake, eating &
exercise patterns, & degree of stress perceived)

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Cardiac Signs and Symptoms
Patients with cardiovascular disorders commonly
have one or more of the following signs and
symptoms:
•Chest pain or discomfort (angina pectoris, MI,
valvular heart disease)
•location? Radiation? Quality? Duration?
•What brings it on? What relieves it? Are there any
associated Symptoms, such as nausea, Vomiting,
Sweating?

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•Shortness of breath or dyspnea
•Reduced urine output (MI, left ventricular failure)
•Edema and weight gain (right ventricular failure)
•Palpitations (dysrhythmias resulting from myocardial
ischemia, valvular heart disease, ventricular aneurysm,
stress)
•Fatigue (earliest symptom associated with several
cardiovascular disorders)
•Dizziness and syncope or loss of consciousness (postural
hypotension, dysrhythmias, cerebrovascular disorders)

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•N.B: Not all chest discomfort is related to
myocardial ischemia (inadequate blood flow to the
heart)
•When a patient is experiencing chest discomfort,
questions should focus on differentiating a serious,
life threatening condition such as myocardial
infarction from conditions that are less serious.
Risk factors for cardiovascular problems
- Smoking
- Lipidemia

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- Diabetes mellitus
- Age older than 60 yrs
- Gender (men & postmenopausal women)
- Family history of cardiovascular disease
- Family history of high BP
- Family history of heart attack
- Over weight & obesity
- High cholesterol level in the blood
- Sedentary life style (no exercises)
- Stress at home or at work
- Lack of sleep

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Risk Factors in Coronary Artery Disease
•Epidemiologic Studies show that certain conditions or
behaviors are associated with a greater incidence of
coronary artery disease.
•Non modifiable risk factors:
•Positive family history for heart problems
•Increasing age
•Gender(men at greater risk than
premenopausal women)
•Race (higher incidence in African –Americans
that Caucasians)

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Modifiable risk factors:
•Elevated blood cholesterol
•Physical inactivity
•Elevated blood pressure
•Stress
•Cigarette smoking
•Use of oral contraceptives
•Elevated blood glucose
•Obesity…….

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Physical Assessment
•Assessing for physical finding is performed to
confirm data obtained in the health history.
•General appearance (alert, lethargic, stuporous,
comatose) and mental status (oriented to person,
place, time; coherence).
- Signs of distress, which include pain or discomfort,
shortness of breath, or anxiety.
Examination of Blood pressure
- The normal adult blood pressure value ranges
from 90/60 to 140/90mmHg

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Pulse pressure
•It is the difference between the systolic and the
diastolic pressure and is approximately 40mmHg
Pulse rate
•The normal pulse rate varies from a low of 50 in
healthy, athletic, young adults to 100 after exercise
or during times of excitement
Pulse rhythm
•Disturbances in pulse rhythm (dysrhythmias) often
result in a pulse deficit (a difference between the
apical rate and the peripheral rate)

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Pulse volume (amplitude)
Carotid artery is the
best.
Don’t palpate both
carotids
simultaneously

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•Hands
•Peripheral cyanosis – a bluish discoloration
of the skin – implies decreased blood flow
in the periphery as incase of carcinogenic
shock
•Pallor – can denote anemia
•Capillary refill time – should not take more
than 2 seconds

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•Edema stretches the skin and make it less pliable
•Clubbing of the fingers and toes implies chronic
hemoglobin desaturation, as in congenital heart disease
•Reduced skin turgor occurs with dehydration
Head and Neck
•Assess the lips and earlobes for peripheral cyanosis
•Jugular vein distension indicates an abnormal increase
in the volume of the venous system (right sided cardiac
failure, Valvular stenosis, Pulmonary embolism)

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Heart
•Examination of the chest wall is performed in the
following six areas:
•Aortic area- 2nd
ICS to the right of the sternum
•Pulmonic area 2nd
ICS to the left of the sternum
•Erb's point 3rd
•Tricuspid area 4th -
5th
•Apical area 5th
midlavicular
•Epigastric area below the Xiphoid process.

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Inspection and Palpation
• There is a normal pulse that is distinct and well
localized directly over the apex of heart.
• It is called apical pulse or point of maximal impulse
(PMI) and is often palpable and may be observed in
younger persons and in older persons who are thin.
N.B: If the PMI is below the 5th
ICS or lateral to the
midclavicular line, it is abnormal and the cause is left
ventricular failure.

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Percussion
•Normally, the left border of the heart is detected by
percussion
Auscultation
•All areas, except the epigastric area, are auscultated
•First heart sound (S1) “lub” is best heard with the
diaphragm. It is created by the simultaneous closure of
the mitral and tricuspid valves.
•Second heart sound (S2) “dub” is produced by the
closing of the aortic and pulmonic valves

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Common diagnostic procedures and nursing responsibilities
ECG (electro cardiograph)
•It is a graphic recording of the electrical activity of
the heart.
•It is a reflection of the electrical activity that starts
from SA node and cause the heart to contract
Lab tests
Blood chemistry
•Lipid profile – cholesterol, triglycerides, and
lipoproteins are measured to evaluate a person risk
for developing atherosclerotic disease.

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Common diagnostic procedures cont…
•Cholesterol and triglycerides are transported in the
blood by combining with protein molecules to form
lipoproteins.
•The risk of CAD increases as the ratio of LDL to HDL
•Cholesterol levels: Cholesterol is a lipid required for
hormone synthesis and cell membrane formation.
Normal level is less than 200 mg/dl: increased level is
known to increase risk for CAD (coronary artery disease).
•Serum electrolyte level – sodium, potassium and calcium
are ions that are vital to cellular function of the heart.

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•Hypokalemia increases the risk of cardiac electrical
instability, the occurrence of ventricular dysrhythmias,
& the risk of digitalis toxicity.
•It is caused by diuretic therapy, vomiting, diarrhea &
alkalosis.
•Hyponatremia => seen with heart failure, stress,
excessive IV infusion of hypotonic fluids.
•Hypocalcaemia => results from renal failure and
alkalosis can lead to serious ventricular dysrhythmias.

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•BUN: increased level may be indicative of decreased
renal perfusion as a result of a cardiac disease (from
decreased COP)
•Serum glucose level – is important to monitor as many
patients with cardiac disease also have diabetes
mellitus
•Hematological testing
Hemoglobin and hematocrite – should be monitored in
patients with coronary artery disease as there
decreased level has serous consequences like frequent
episode of Angina.

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Chest x ray
•Usually obtained to determine Size, contour and
Position of the heart
•Pulmonary congestion from heart failure
Coronary angiography
•A radiopaque material injected into coronary arteries.
It allows visualization of coronary arterial narrowing
or occlusion.

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Echocardiography: It is a noninvasive ultrasound test that
is used to examine the size, shape, and motion of cardiac
structures.
•It is used to help & diagnose: Pericardial effusion, Valvular
disorders, Cardiac tumors etc
Cardiac enzymes: are cellular proteins released in to the
blood as a result of cell membrane injury.
Their presence in the blood confirms acute myocardial
infarction or severe cardiac damage.
- Myoglobin => useful marker of myocardial necrosis
- Creatine kinase (ck) and lactic acid dehydrogenase (LDH)
serum elevation reveals myocardial damage.

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Blood coagulation tests
Used to examine the ability of blood to clot.
•Prothrombine time (PT) (the time required for a
particular specimen of Prothrombine to induce
blood-plasma clotting under standardized
conditions.
• A normal PT is between 11.5 and 12 seconds for
normal human blood.

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Coronary vascular disorders
CORONARY ARTERY DISEASE (CAD)
•It is a narrowing of the coronary arteries that prevents
adequate blood supply to the heart muscle.
•It usually caused by atherosclerosis, it may progress to
the point where the heart muscle is damaged due to
lack of blood supply.
•Such damage may result in infarction, arrhythmias, and
heart failure.
•Coronary artery disease (CAD) is the most prevalent
type of cardiovascular disease in adults.

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Coronary Atherosclerosis
•The most common cause of cardiovascular disease is
atherosclerosis, an abnormal accumulation of lipid, or
fatty substances, and fibrous tissue in the lining of
arterial blood vessel walls.
•These substances block and narrow the coronary vessels
in a way that reduces blood flow to the myocardium.
•It involves a repetitious inflammatory response leads to
injury of the artery wall.

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Coronary Atherosclerosis cont.…..
Pathophysiology
•Atherosclerosis is thought to begin as fatty streaks of
lipids that are deposited in the intima of the arterial
wall.
•The development of atherosclerosis over many years
involves an inflammatory response, which begins with
injury to the vascular endothelium.
•The injury may be initiated by smoking, hypertension,
and other factors.

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•Smooth muscle cells within
the vessel wall subsequently
proliferate and form a
fibrous cap and filled with
lipid and inflammatory
infiltrate.
•These deposits, called
atheroma or plaques,
protrude into the lumen of
the vessel, narrowing it and
obstructing blood flow.

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Clinical Manifestations
•CAD produces symptoms and complications according to
the location and degree of narrowing of the arterial
lumen, thrombus formation, and obstruction of blood
flow to the myocardium.
•The most common manifestation of myocardial ischemia
is the onset of chest pain or discomfort (angina). The
pain may radiate to neck, arms, stomach, or upper back.
•The pain usually occurs with activity or emotion, and
goes away with rest.
•Asymptomatic, Shortness of breath, Weakness….

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Diagnosis
Electrocardiograms (ECG)
• Provide a record of the heart's electrical activity.
This simple test records any abnormal findings in the heart's
electrical impulses.
Echocardiograms (ECHOs)
• It is a test that uses sound waves to create pictures of the
heart.
• Shows a problem with the heart muscle or one of the valves
that channel blood through the heart.

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Stress tests
• They are used to show how the heart reacts to physical
exertion. Exercise stress tests are usually performed on
exercise bicycle.
Angiography
• Is the most accurate means by which to examine the coronary
arteries.
• It requires a surgical procedure called cardiac catheterization.
• During the procedure, catheters are placed in the artery of
the leg or arm, and directed using an x-ray machine to the
opening of each of the coronary arteries.

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Treatment
Lifestyle changes
•Weight control
•Smoking cessation
•Exercise
•Healthy diet

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Medications to treat coronary disease
•Cholesterol lowering medications, such as statins, are
useful to decrease the amount of "bad" (LDL)
cholesterol.
•Nitroglycerin
•ACE inhibitors, which treat hypertension and may lower
the risk of recurrent myocardial infarction
•Calcium channel blockers
•Aspirin

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Surgical intervention
•Angioplasty
•Stents
•Coronary artery bypass grafting (CABG)

PCI Procedural refinements: Stents
Expandable metal mesh tubes that supports the dilated
segment, limit restenosis.

Coronary Artery Bypass Grafting (CABG)

CABG
Procedural refinements:
• Arterial grafts
• Avoid the cardiopulmonary
bypass machine
• Smaller thoracotomy
incision rather than
sternotomy

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Angina Pectoris
•It is a clinical syndrome
usually characterized by
episodes or paroxysms
of pain or pressure in
the anterior chest.

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Angina Pectoris cont.…
•The cause is insufficient coronary blood flow,
resulting in a decreased oxygen supply when there is
increased myocardial demand for oxygen in response
to physical exertion or emotional stress.
•In other words, the need for oxygen exceeds the
supply.
•In general, the severity of the symptoms of angina is
based on the magnitude of the precipitating activity
and its effect on activities of daily living.

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Pathophysiology
•Angina is usually caused by atherosclerotic disease.
•Almost regularly, angina is associated with a significant
obstruction of at least one major coronary artery.
•Normally, the myocardium extracts a large amount of
oxygen from the coronary circulation to meet its
continuous demands.
•When there is an increase in demand, flow through the
coronary arteries needs to be increased.
•When there is blockage in a coronary artery, flow cannot
be increased, and ischemia results.

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Types of Angina
•Stable angina: predictable and consistent pain that
occurs on exertion and is relieved by rest and/or
nitroglycerin
•Unstable angina (also called preinfarction angina or
crescendo angina): symptoms increase in frequency and
severity; may not be relieved with rest or nitroglycerin.
•Intractable or refractory angina: severe incapacitating
chest pain.

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Factors are associated with typical anginal pain
•Physical exertion, which can precipitate an attack by
increasing myocardial oxygen demand
•Exposure to cold, which can cause vasoconstriction and
elevated blood pressure, with increased oxygen
demand.
•Eating a heavy meal, which increases the blood flow to
the mesenteric area for digestion, thereby reducing the
blood supply available to the heart muscle.

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•Stress or any emotion-provoking situation, causing the
release of Catecholamines, which increases blood
pressure, heart rate, and myocardial workload.
•Unstable angina is not associated with these listed
factors. It may occur at rest.

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Clinical manifestation
•Chest pain that ranges from discomfort to agonizing
pain accompanied by severe apprehension and a feeling
of impending death.
•The pain is often felt deep in the chest behind the
sternum
•The pain may radiate to the neck, jaw, shoulders, and
inner aspects of the upper arms.

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•A feeling of weakness or numbness in the arms, wrists,
and hands, as well as shortness of breath, pallor,
diaphoresis, dizziness or lightheadedness, and nausea
and vomiting may accompany the pain.
•Anxiety may occur with angina.
•An important characteristic of angina is that it subsides
with rest or administering nitroglycerin.

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Assessment and Diagnostic Findings
•History
•Electrocardiogram (ECG)
•Exercise stress test
Management
•Decrease the oxygen demand of the myocardium and to
increase the oxygen supply.
•Pharmacologic therapy and control of risk factors.

•Nitroglycerin: is administered to reduce myocardial
oxygen consumption by dilates primarily the veins and,
in higher doses, the arteries.
•Beta-Adrenergic Blocking Agents (metoprolol): reduce
myocardial oxygen consumption by blocking beta-
adrenergic sympathetic stimulation to the heart.
•Calcium Channel Blocking Agents (diltiazem): slower
heart rate and a decrease in the strength of myocardial
contraction.

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•Antiplatelet and Anticoagulant Medications (Aspirin,
Heparin): Antiplatelet medications are administered
to prevent platelet aggregation and subsequent
thrombosis, which impedes blood flow.
•Oxygen Administration: is usually initiated at the
onset of chest pain in an attempt to increase the
amount of oxygen delivered to the myocardium and
to decrease pain.

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Myocardial Infarction
•Myocardial infarction (MI) or acute myocardial
infarction (AMI), commonly known as a heart attack, is
the interruption of blood supply to part of the heart,
causing some heart cells to die.
Pathophysiology
MI refers to the process by which areas of myocardial
cells in the heart are permanently destroyed.

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Myocardial Infarction cont.…
•Like unstable angina, MI is usually caused by reduced
blood flow in a coronary artery due to atherosclerosis
and occlusion of an artery by an embolus or thrombus.
•Other causes of an MI include vasospasm (sudden
constriction or narrowing) of a coronary artery;
decreased oxygen supply (e.g. from acute blood loss,
anemia, or low blood pressure); and increased demand
for oxygen (e.g. from a rapid heart rate, thyrotoxicosis,
or ingestion of cocaine).
•In each case, a profound imbalance exists between
myocardial oxygen supply and demand.

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•MIs most often result in damage to the left ventricle,
leading to an alteration in left ventricular function.
•Infarctions can also occur in the right ventricle or in
both ventricles.
•The area of infarction takes time to develop.
•As the cells are deprived of oxygen, ischemia develops,
cellular injury occurs, and over time, the lack of oxygen
results in infarction, or the death of cells.

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•Chest pain that occurs suddenly and continues despite
rest and medication is the presenting symptom in most
patients with an MI.
•Patients may also be anxious and restless.
•They may have cool, pale, and moist skin.
•Their heart rate and respiratory rate may be faster than
normal.

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•Patient history: The patient history has two parts: the
description of the presenting symptom (e.g. pain) and
the history of previous illnesses and family health
history, particularly of heart disease. Previous history
should also include information about the patient’s risk
factors for heart disease.
•Electrocardiogram
•Laboratory test results (e.g. serial serum enzyme
values). E.G. Creatine Kinase and Myoglobin

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Medical Management
•Thrombolytic (streptokinases), analgesic (morphine
sulfate) and angiotensin-converting enzyme (ACE)
inhibitors (decreasing the oxygen demand of the heart).
•Minimizing myocardial damage is also accomplished by
reducing myocardial oxygen demand and increasing
oxygen supply with medications, oxygen administration,
and bed rest.
•Aspirin, heparin, nitroglycerin, an IV beta-blocker.

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Assessment and
Management of Patients
With Hypertension
•Defined as a systolic blood pressure greater than 140
mm Hg and a diastolic pressure greater than 90 mm
Hg based on the average of two or more accurate
blood pressure measurements taken during two or
more contacts with a health care provider.
•Worldwide prevalence estimates for HTN may be as
much as 1 billion.
•7.1 million deaths per year may be attributable to
hypertension.

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Hypertension cont.…
•Hypertension is sometimes called the “silent killer”
because people who have it are often symptom
free.
•Once identified, elevated blood pressure should be
monitored at regular intervals because
hypertension is a lifelong condition.

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Types of hypertension
Primary hypertension
•The reason for the elevation in blood pressure
cannot be identified.
•Accounts 90% to 95%
•Primary or essential hypertension has multiple risk
factors, including obesity and a family history of
hypertension.

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Secondary hypertension
•It is high blood pressure from an identified cause.
•These causes include narrowing of the renal arteries,
renal parenchymal disease, hyperaldosteronism
(mineralocorticoid hypertension), certain medications,
pregnancy, and coarctation of the aorta.
•Accounts 5% to 10%

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•Hypertension often accompanies other risk factors for
atherosclerotic heart disease, such as dyslipidemia
(abnormal blood fat levels), obesity, diabetes mellitus,
metabolic syndrome, and a sedentary lifestyle.
•The prevalence is also higher in persons who have
other cardiovascular conditions including heart failure,
coronary artery disease, and a history of having had a
stroke

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•High blood pressure can be viewed in three ways: as
a sign, a risk factor for atherosclerotic
cardiovascular disease, or a disease.
•As a sign, elevated pressure may indicate an
excessive dose of vasoconstrictive medication or
other problems.
•As a risk factor, hypertension contributes to the rate
at which atherosclerotic plaque accumulates within
arterial walls.
•As a disease, hypertension is a major contributor to
death from cardiac, cerebrovascular, renal, and
peripheral vascular disease.

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•Prolonged blood pressure elevation eventually
damages blood vessels throughout the body,
particularly in target organs such as the heart,
kidneys, brain, and eyes.
•The usual consequences of prolonged, uncontrolled
hypertension are myocardial infarction, heart
failure, renal failure, strokes, and impaired vision.
•Hypertrophy (enlargement) of the left ventricle of
the heart may occur as it works to pump blood
against the elevated pressure.

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Pathophysiology
•Blood pressure is the product of cardiac output
multiplied by peripheral resistance.
•Hypertension can result from an increase in cardiac
output, an increase in peripheral resistance
(constriction of the blood vessels), or both.
•In addition, there must also be a problem with the
control systems that monitor or regulate pressure.
•Although no precise cause can be identified for
most cases of hypertension, it is understood that
hypertension is a multifactorial condition.

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Many factors have been implicated as causes of hypertension:
• Increased sympathetic nervous system activity related to
dysfunction of the autonomic nervous system
• Increased renal reabsorption of sodium, chloride, and water
related to a genetic variation in the pathways by which the
kidneys handle sodium
• Increased activity of the renin–angiotensin–aldosterone system,
resulting in expansion of extracellular fluid volume and increased
systemic vascular resistance
• Decreased vasodilation of the arterioles related to dysfunction of
the vascular endothelium
• Resistance to insulin action, which may be a common factor
linking hypertension, type 2 diabetes mellitus,
hypertriglyceridemia, obesity, and glucose intolerance

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Gerontologic Considerations
•Structural and functional changes in the heart and
blood vessels contribute to increases in blood pressure
that occur with aging.
•These changes include accumulation of atherosclerotic
plaque, fragmentation of arterial elastins, increased
collagen deposits, and impaired vasodilation.
•The result of these changes is decreased elasticity of
the major blood vessels.
•Consequently, the aorta and large arteries are less able
to accommodate the volume of blood pumped out by
the heart (stroke volume), and the energy that would
have stretched the vessels.

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•May be asymptomatic and remain so for many years.
•P/E may reveal no abnormalities other than elevated
blood pressure.
•Occasionally, retinal changes such as hemorrhages,
exudates (fluid accumulation) and arteriolar narrowing
occur.
•In severe hypertension, papilledema (swelling of the
optic disk) may be seen.
•Vascular damage, with specific manifestations related to
the organs served by the involved vessels.
•Coronary artery disease with angina and myocardial
infarction are common consequences of hypertension.

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• Left ventricular hypertrophy occurs in response to the
increased workload placed on the ventricle as it contracts
against higher systemic pressure.
• When heart damage is extensive, heart failure follows.
• Pathologic changes in the kidneys (indicated by increased
blood urea nitrogen [BUN] and serum creatinine levels)
may manifest as nocturia.
• Cerebrovascular involvement may lead to a stroke or
transient ischemic attack (TIA), manifested by alterations
in vision or speech, dizziness, weakness, a sudden fall, or
transient or permanent paralysis on one side
(hemiplegia). Cerebral infarctions account for most of the
strokes and TIAs in patients with hypertension.

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Assessment and Diagnostic Evaluation
•health history and physical examination
•Retinal examination
•laboratory tests to assess possible target organ
damage
•Routine laboratory tests include urinalysis, blood
chemistry (i.e, analysis of sodium, potassium,
creatinine, fasting glucose, and total and high-density
lipoprotein [HDL] cholesterol
•ECG
•Echocardiography to assess left ventricular hypertrophy
•Renal damage may be suggested by elevations in BUN
and creatinine levels

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Management
•The goal of hypertension treatment is to prevent
complications and death by achieving and
maintaining the arterial blood pressure at 140/90
mm Hg or lower.
•The management options for hypertension are
lifestyle modifications and pharmacologic therapy.

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Pharmacology therapy
1. Diuretics
• Thiazide (hydrochlorothiazide)
• Loop diuretics (lasix)
• Potassium-sparing diuretics (Sprinolactone)
2. Sympatholytics
• Adrenergic neuron blockers e.g. Reserpine, Guannethedine)
• Alpha adrenergic blockers e.g. Prazosin
• Beta adrenergic blockers : e.g. Propanolol
3. Vasodilators: e.g. Hydralizine, Sodium nitroprusside
4. Calcium channel blockers : e.g. Verapamil, Nifedipine, Diltiazem
5. Angotensin converting enzyme inhibitors: e.g. Captopril,
Enalapril

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Complication of hypertension
•Atherosclerosis
•Coronary artery disease
•Myocardial infarction or failure
•Left ventricular hypertrophy
•Stroke
•Renal insufficiency and failure
•Retinal hemorrhage

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Hypertensive Crises
•Two classes of hypertensive crisis that require
immediate intervention are hypertensive emergency
and hypertensive urgency.
•Both may occur in patients whose hypertension has
been poorly controlled, whose hypertension has
been undiagnosed, or in those who have abruptly
discontinued their medications.
A hypertensive emergency
•It is a situation in which blood pressure is extremely
elevated (more than 180/120 mm Hg) and must be
lowered immediately (not necessarily to less than
140/90 mm Hg) to halt or prevent damage to the
target organs.

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Hypertensive crises cont.….
•Assessment will reveal actual or developing clinical
dysfunction of the target organ.
•Conditions associated with a hypertensive emergency
include hypertension of pregnancy, acute myocardial
infarction, dissecting aortic aneurysm, and intracranial
hemorrhage.
•Hypertensive emergencies are acute, life-threatening
blood pressure elevations that require prompt treatment
in an intensive care setting because of the serious target
organ damage that may occur.
•The medications of choice in hypertensive emergencies are
those that have an immediate effect as intravenous
vasodilators E.G. sodium nitroprusside.

99
A hypertensive urgency
•Describes a situation in which blood pressure is very
elevated but there is no evidence of impending or
progressive target organ damage.
•Elevated blood pressures associated with severe
headaches, nosebleeds, or anxiety are classified as
urgencies.
•In these situations oral agents can be administered
with the goal of normalizing blood pressure within
24 to 48 hours.

100
•Oral doses of fast-acting agents such as beta-
adrenergic blocking agents (eg, labetalol ) or ACE
inhibitors (eg, captopril) are recommended for the
treatment of hypertensive urgencies.
•Extremely close hemodynamic monitoring of the
patient’s blood pressure and cardiovascular status is
required during treatment of hypertensive
emergencies and urgencies

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Heart failure
•HF is the inability of the heart to pump sufficient
blood to meet the needs of the tissues for oxygen
and nutrients.
•In the past, HF was often referred to as congestive
heart failure (CHF),because many patients
experience pulmonary or peripheral congestion.
•Currently HF is recognized as a clinical syndrome
characterized by signs and symptoms of fluid
overload or of inadequate tissue perfusion.
•Fluid overload and decreased tissue perfusion result
when the heart cannot generate a sufficient CO to
meet the body’s demands.

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Heart failure cont.…..
•The term HF indicates myocardial disease in which there
is a problem with contraction of the heart (systolic
dysfunction) or filling of the heart (diastolic dysfunction)
that may or may not cause pulmonary or systemic
congestion.
•Some cases of HF are reversible, depending on the
cause. Most often, HF is a progressive, life-long
condition that is managed with lifestyle changes and
medications to prevent episodes of acute
decompensated heart failure.
•They are associated with increased hospitalizations,
increased health care costs, and decreased quality of
life.

103
•As with coronary artery disease, the incidence of HF
increases with age.
Classification
•Two major types of HF are identified by assessment
of left ventricular functioning, usually by
echocardiogram.
•The more common type is an alteration in
ventricular contraction called systolic heart failure,
which is characterized by a weakened heart muscle.
•The less common type is diastolic heart failure,
which is characterized by a stiff and noncompliant
heart muscle, making it difficult for the ventricle to
fill.

104
The New York Heart Association (NYHA)
Classification

105
The American College of Cardiology and the
American Heart Association (ACC/AHA classification

106
Pathophysiology
• HF results from a variety of cardiovascular conditions.
• These conditions can result in systolic failure, diastolic
failure, or both.
• Significant myocardial dysfunction usually occurs before the
patient experiences signs and symptoms of HF such as
shortness of breath, edema, or fatigue.
• As HF develops, the body activates neurohormonal
compensatory mechanisms.
• These mechanisms represent the body’s attempt to cope
with the HF and are responsible for the signs and symptoms
that eventually develop.

108
Etiology
•Myocardial dysfunction is most often caused by
coronary artery disease (more than 60%) ,
cardiomyopathy (disease of the myocardium E.G.
myocarditis) , hypertension, or valvular disorders.
•Several systemic conditions, including progressive
renal failure, contribute to the development and
severity of HF.
•Cardiac dysrhythmias may cause HF or may be a
result of HF; either way, the altered electrical
stimulation impairs myocardial contraction and
decreases the overall efficiency of myocardial
function.

109
•The clinical manifestations produced by the
different types of HF (systolic, diastolic, or both) are
similar and therefore do not assist in differentiating
the types of HF.
•The signs and symptoms of HF can be related to
which ventricle is affected.
•Left-sided heart failure causes different
manifestations than right-sided heart failure.
•In chronic HF, patients may have signs and
symptoms of both left and right ventricular failure.

111
Left-Sided Heart Failure
•Pulmonary congestion occurs when the left
ventricle cannot effectively pump blood out of the
ventricle into the aorta and the systemic circulation.
•The blood volume and pressure in the left atrium
increases, which decreases blood flow from the
pulmonary vessels.
•Pulmonary venous blood volume and pressure
increase, forcing fluid from the pulmonary
capillaries into the pulmonary tissues and alveoli,
causing pulmonary edema and impaired gas
exchange.

112
•The clinical manifestations of pulmonary congestion
include dyspnea, cough, pulmonary crackles, and
low oxygen saturation levels.
•Dyspnea, or shortness of breath, may be
precipitated by minimal to moderate activity
•The patient may report orthopnea, difficulty
breathing when lying flat.

113
Right-Sided Heart Failure
•When the right ventricle fails, congestion in the
peripheral tissues and the viscera predominates.
•This occurs because the right side of the heart cannot
eject blood and cannot accommodate all the blood
that normally returns to it from the venous
circulation.
•Increased venous pressure leads to JVD and increased
capillary hydrostatic pressure throughout the venous
system.

114
•The systemic clinical manifestations include edema
of the lower extremities (dependent edema),
hepatomegaly (enlargement of the liver),
ascites(accumulation of fluid in the peritoneal
cavity), anorexia and nausea, and weakness and
weight gain due to retention of fluid

115
•HF may go undetected until the patient presents
with signs and symptoms of pulmonary and
peripheral edema.
•However, the physical signs that suggest HF may
also occur with other diseases, such as renal failure
and COPD.
•Assessment of ventricular function is an essential
part of the initial diagnostic workup.
•An echocardiogram is usually performed to confirm
the diagnosis of HF.

116
•A chest x-ray and an electrocardiogram (ECG) are
obtained to assist in the diagnosis.
•Laboratory studies usually performed during the
initial workup include serum electrolytes, blood
urea nitrogen (BUN), creatinine, complete blood cell
count, and routine urinalysis.

117
Management
•The overall goals of management of HF are to relieve
patient symptoms, to improve functional status and
quality of life, and to extend survival.
•Medical management is based on the type, severity,
and cause of HF.
•Treatment options may include oral and IV
medications, major lifestyle changes, supplemental
oxygen, implantation of assistive devices, and
surgical approaches, including cardiac
transplantation.

118
Lifestyle recommendations include restriction of
dietary sodium; avoidance of excessive fluid intake,
alcohol, and smoking; weight reduction when
indicated; and regular exercise.
Pharmacologic Therapy
•Several medications are routinely prescribed for HF,
including ACE inhibitors, beta-blockers, diuretics,
and digitalis.

120
Nursing Management
•The nurse is responsible for administering the
medications and for assessing their beneficial and
detrimental effects to the patient.
Nursing actions to evaluate therapeutic effectiveness
include:
•Keeping an intake and output record to identify a
negative balance (more output than input)
•Weighing the patient daily at the same time and on
the same scale, usually in the morning after urination;
•Auscultating lung sounds at least daily to detect an
increase or decrease in pulmonary crackles.

121
•Determining the degree of JVD
•Identifying and evaluating the severity of
dependent edema
•Monitoring pulse rate and blood pressure, as well as
monitoring for postural hypotension and making
sure that the patient does not become hypotensive
from dehydration
•Examining skin turgor and mucous membranes for
signs of dehydration
•Assessing symptoms of fluid overload (e.g.
orthopnea, paroxysmal nocturnal dyspnea, and
dyspnea on exertion) and evaluating changes

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MONITORING AND MANAGING POTENTIAL
COMPLICATIONS
•Profuse and repeated diuresis can lead to
hypokalemia. Signs are weak pulse, faint heart
sounds, hypotension, muscle flabbiness, diminished
deep tendon reflexes and generalized weakness.
•Hypokalemia poses new problems for the patient
with HF because it markedly weakens cardiac
contractions.
•In patients receiving digoxin, hypokalemia can lead
to digitalis toxicity. Digitalis toxicity and
hypokalemia increase the likelihood of dangerous
dysrhythmias.

123
•Low levels of potassium may also indicate a low
level of magnesium, which can add to the risk for
dysrhythmias.
•Hyperkalemia may also occur, especially with the
use of ACEIs or ARBs and spironolactone.
•Prolonged diuretic therapy may also produce
hyponatremia which results in apprehension,
weakness, fatigue, malaise, muscle cramps and
twitching, and a rapid, thready pulse.

124
NURSING PROCESS: THE PATIENT WITH
HEART FAILURE
Assignment

125
PULMONARY EDEMA
•It is defined as abnormal accumulation of fluid in the
lung tissue, the alveolar space, or both.
•It is a severe, life-threatening condition.
Pathophysiology
•Pulmonary edema most commonly occurs as a result of
increased micro vascular pressure from abnormal cardiac
function.
•The backup of blood into the pulmonary vasculature
resulting from inadequate left ventricular function
causes an increased micro vascular pressure, and fluid
begins to leak into the interstitial space and the alveoli.
•Pulmonary edema can also be caused by non cardiac
disorders, such as renal failure, liver failure, and
oncologic conditions that cause the body to retain fluid.

126
Pulmonary edema cont.….
•Increasing respiratory distress, characterized by
dyspnea, air hunger, and central cyanosis, is present.
• Patients are usually very anxious and often agitated.
•As the fluid leaks into the alveoli and mixes with air, a
foam or froth is formed.
•The patient coughs up (or the nurse suctions out)
these foamy, frothy, and often blood-tinged
secretions.

127
•Auscultation reveals crackles in the lung bases. These
crackles are caused by the movement of air through
the alveolar fluid.
•The chest x-ray reveals pulmonary veins are
engorged.
•The patient may have tachycardia.
•Pulse oximetry values begin to fall, and arterial blood
gas analysis demonstrates worsening hypoxemia.

128
Medical Management
•Management focuses on correcting the underlying
disorder.
•If the pulmonary edema is cardiac in origin, then
improvement in left ventricular function is the goal.
Vasodilators (IV nitroglycerin or nitroprusside),
afterload or preload agents (Milrinone), or contractility
medications (Dobutamine) may be administered.
•If the problem is fluid overload, diuretics are
administered and fluids are restricted.
•Oxygen is administered to correct the hypoxemia.
•The patient is extremely anxious, and morphine is
prescribed to reduce anxiety and control pain.

129
Nursing Management
•Administration of oxygen and medications.
•Monitors the patient’s responses.
•Positioning the patient to promote circulation. Proper
positioning can help reduce venous return to the
heart
•Providing psychological support
- As the ability to breathe decreases, the patient’s
sense of fear and anxiety rises proportionately, making
the condition more severe.

130
INFECTIOUS DISEASE OF THE HEART
Introduction
•Any of the heart’s three layers may be affected by
an infectious process.
•The infections are named for the layer of the heart
most involved : infective endocarditis
(endocardium), myocarditis (myocardium), and
pericarditis (pericardium).
•Rheumatic endocarditis is a unique infective
endocarditis syndrome.
•The ideal management for all infectious diseases is
prevention.

131
Rheumatic endocarditis/ Rheumatic heart disease
•Acute rheumatic fever, which occurs most often in
school age children, may develop after an episode of
group A beta hemolytic streptococcal pharyngitis.
•Patients with rheumatic fever may develop rheumatic
heart disease as evidenced by a new heart murmur,
cardiomegaly, pericarditis, and heart failure.
•Prompt treatment of “strep” throat with antibiotics
can prevent the development of rheumatic fever.
•Although the bacteria are the causative agents,
malnutrition, overcrowding, poor hygiene, and lower
socioeconomic status may predispose individuals to
rheumatic fever.

132
Rheumatic endocarditis cont.…
•Acute rheumatic fever (ARF) is an illness caused by
a reaction to a bacterial infection, which often
results in lasting damage to heart valves.
•This is known as rheumatic heart disease (RHD) and
it is an important cause of premature mortality.
•ARF is an auto-immune response to bacterial
infection with group A streptococcus (GAS).
•People with ARF are often in great pain and require
hospitalization.
•It is characterized mainly by carditis, arthritis and
chorea appearing, alone or in combination, with
residual chronic heart disease.

133
Etiology: A delayed sequel to a GAS infection of the upper
respiratory system usually pharyngeal infection, not the
bacteria themselves.
Pathogenesis :Antibodies produced against the streptococci
antigen cross and cause immunologic damage to the:
• Heart valves
• Heart muscle
• Pericardium
• Joint synovium ( arthritis)
• Nervous tissue (syden ham’s chorea).
• Subcutaneous tissue (subcutaneous nodule).
The latent period i.e. the duration between sore throat and
acute rheumatic fever is usually 1-3 weeks.

134
Carditis
•Occurs in 40-80% of patients.
•It presents as breathlessness, fever and cough.
•Tachycardia, mitral regurgitation, systolic murmur
and cardiac enlargement.
•In severe cases there are signs of heart failure.
Arthritis
•It is the commonest manifestation.
•Is a migratory poly arthralgia and involves several
larger joints (knee, ankle, elbow and wrist).
•The affected joint is swollen, red, warm and tender.

135
Sydenham’s chorea
•CNS involvement may manifest late after the initial
infection (6 months or more), with those affected
exhibiting spasmodic unintentional movements and
possible altered speech.
Erythema marginatum
•Occurs in 10-20 % of children.
•It starts as red macules which fade in the center but
remain red at the edges.
Subcutaneous nodules
• Small painless nodules which occur more frequently on
the extensor surface of large joints (elbow, wrist &
knee) and spine.

137
Diagnostic evaluation
•Evidence of a systemic illness (nonspecific):
Leukocytosis, Raised ESR.
•Evidence of preceding streptococcal infection
(specific): Throat swab culture, Anti streptolysine
antibodies elevated titers.
•Evidence of carditis: Chest radiograph
( Cardiomegaly)

138
Medical management
•Anti streptococcal therapy:
- Ten- days’ course of Amoxicillin or a single IM
injection of Benzanthin penicillin.
•Anti inflammatory drugs- to control the clinical
features:
- Aspirin – usually relieves symptoms of arthritis
rapidly. Starting 60mg/kg/ body weight per day into
six divided doses for 4 weeks.
- Corticosteroids (Prednisolon) : produce more rapid
symptomatic relief than aspirin, and are indicated in
cases with carditis or severe arthritis.
•Digoxin and diuretic for the heart failure.

139
Prevention
•Primary prevention early (with in 1 week):
Treatment of streptococcal pharyngitis to prevent
an initial attack of acute rheumatic fever.
•Secondary prevention: Prevent recurrence so as to
reduce the damage to heart valves and the risk of
chronic rheumatic heat disease. Secondary
prophylaxis with BPG is recommended for all people
with a history of ARF or RHD. Four-weekly BPG is
currently the treatment of choice. Prophylaxis
should continue for at least 10 years from the last
episode of acute thematic fever.

140
Infective endocarditis
•It is a microbial infection of the endothelial surface of
the heart.
•It usually develops in people with prosthetic heart
valves or structural cardiac defects (e.g. valve
disorders)
•It is more common in older people, who are more likely
to have degenerative or calcific valve lesions, reduced
immunologic
response to infection, and the metabolic alterations
associated
with aging.
•Staphylococcal endocarditis infections of the valves in
the right side of the heart are common among IV
injection drug users.

141
Infective endocarditis cont.…
•Hospital-acquired infective endocarditis occurs most
often in patients with debilitating disease or indwelling
catheters and in patients who are receiving
hemodialysis or prolonged IV fluid or antibiotic therapy.
•Patients taking immunosuppressive medications or
corticosteroids are more susceptible to fungal
endocarditis.
•Invasive procedures, particularly those involving
mucosal surfaces, can cause a bacteremia, and if a
patient has any anatomic cardiac defects, bacteremia
can cause bacterial endocarditis.

142
Pathophysiology
•A deformity or injury of the endocardium leads to accumulation
on the endocardium of fibrin and platelets (clot formation).
•Infectious organisms, usually staphylococci, streptococci,
enterococci, pneumococci, or chlamydia, invade the clot and
endocardial lesion.
•Other causative micro-organisms include fungi (e.g. Candida,
Aspergillus) and Rickettsiae.
•The infection may erode through the endocardium into the
underlying structures (e.g. valve leaflets), causing tears or other
deformities of valve leaflets, dehiscence of prosthetic valves,
deformity of the chordae tendineae, or mural abscesses.

143
• The primary presenting symptoms of infective endocarditis are
fever and a heart murmur.
• Clusters of petechiae may be found on the body.
• Small, painful nodules may be present in the pads of fingers or
toes.
• Hemorrhages with pale centers (Roth spots) caused by emboli
may be observed in the fundi of the eyes.
• Cardiomegaly, heart failure, tachycardia, or splenomegaly may
occur.
• Central nervous system manifestations include headache;
temporary or transient cerebral ischemia; and strokes, which may
be caused by emboli to the cerebral arteries.

Petechiae of infective endocarditis.
04/27/2025 Bedilu D,(MSc. N) 144

splinter or subungual Hemorrhages:petechiae, red, linear, or flame-shaped streaks in the
nail bed of the digits

147
•Although the previously described characteristics may
indicate infective endocarditis, the signs and
symptoms may indicate other diseases as well.
•Vague complaints of malaise, anorexia, weight loss,
cough, and back and joint pain may be mistaken for
influenza.
•A definitive diagnosis is made when a micro-organism
is found in two separate blood cultures, in a
vegetation, or in an abscess.
•Doppler echocardiography may assist in the diagnosis
by demonstrating a mass on the valve, prosthetic
valve, or supporting structures

148
Medical Management
•The objective of treatment is to eradicate the invading
organism through adequate doses of an appropriate
antimicrobial agent.
•Antibiotic therapy is usually administered parenterally
in a continuous IV infusion for 2 to 6 weeks.
•Penicillin is usually the medication of choice.
•Blood cultures are taken periodically to monitor the
effect of therapy.
•In fungal endocarditis, an antifungal agent, such as
amphotericin B is the usual treatment.

149
Surgical management
•It may be required if the infection does not respond
to medications, the patient has a prosthetic heart
valve endocarditis, has a vegetation larger than 1
cm, or develops complications such as a septal
perforation.
•Surgical interventions include valve debridement or
excision, debridement and closure of an abscess,
and closure of a fistula.

150
Nursing Management
•The nurse monitors the patient’s temperature.
• Heart sounds are assessed.
•The nurse monitors for signs and symptoms of systemic
embolization, signs and symptoms of organ damage such as
stroke, meningitis, heart failure, myocardial infarction,
glomerulonephritis, and splenomegaly.
•The patient and family are instructed about activity
restrictions, medications, and signs and symptoms of
infection.

151
Prevention
•Although rare, bacterial endocarditis may be life-
threatening.
•A key strategy is primary prevention in high-risk
patients (e.g. those with previous infective endocarditis,
prosthetic heart valves).
•Antibiotic prophylaxis is recommended for high-risk
patients immediately before and sometimes after the
following procedures:
- Dental procedures
- Tonsillectomy or adenoidectomy

152
- Surgical procedures that involve respiratory mucosa
- Bronchoscopy with biopsy or incision of respiratory
tract mucosa
- Cystoscopy or urinary tract manipulation for
patients with enterococcal urinary tract infections or
colonization
- Surgery involving infected skin or musculoskeletal
tissue

153
Myocarditis
•It is an inflammatory process involving the
myocardium, can cause heart dilation and thrombi
on the heart wall (mural thrombi).
•Mortality varies with the severity of symptoms.
•Most patients with mild symptoms recover
completely, but some patients develop
cardiomyopathy and heart failure.

154
Myocarditis cont.….
Pathophysiology
•Myocarditis usually results from viral (e.g.
coxsackievirus A and B, human immunodeficiency
virus [HIV], influenza A), bacterial, rickettsial, fungal,
parasitic, metazoal, protozoal or spirochetal
infection.
• It also may be immune related, occurring after
acute systemic infections such as rheumatic fever.
•It may develop in patients receiving
immunosuppressive therapy or those with infective
endocarditis, Crohn disease, or systemic lupus
erythematosus.

155
•The symptoms of acute myocarditis depend on the
type of infection, the degree of myocardial damage,
and the capacity of the myocardium to recover.
•Patients may be asymptomatic, with an infection that
resolves on its own.
•However, they may develop fatigue and dyspnea,
palpitations, and occasional discomfort in the chest
and upper abdomen.
•The most common symptoms are flulike.
•Patients may also sustain sudden cardiac death or
quickly develop severe congestive heart failure.

156
•Assessment of the patient may reveal no detectable
abnormalities; as a result, the entire illness can go
undiagnosed.
•Patients may be tachycardic or may report chest
pain
•Cardiac MRI with contrast may be diagnostic and
can guide to sites for endocardial biopsies
•The WBC count and ESR may be elevated.

157
Medical Management
•Patients are given specific treatment for the
underlying cause if it is known (e.g. penicillin for
hemolytic streptococci) and are placed on bed rest
to decrease cardiac workload.
Prevention
•Prevention of infectious diseases by means of
appropriate immunizations (e.g. influenza, hepatitis)
and early treatment.

158
Nursing Management
•The nurse assesses for resolution of tachycardia,
fever, and any other clinical manifestations.
•The cardiovascular assessment focuses on signs and
symptoms of heart failure and dysrhythmias.
•Anti-embolism stockings and passive and active
exercises should be used because embolization
from venous thrombosis and mural thrombi can
occur, especially in patients on bed rest.

159
Pericarditis
•It refers to an inflammation of the pericardium, the
membranous sac enveloping the heart.
•It may be a primary illness or it may develop during
various medical and surgical disorders.
- For example, pericarditis may occur after
pericardectomy (opening of the pericardium)
following cardiac surgery.
- Pericarditis also may occur 10 days to 2 months
after acute myocardial infarction.

160
Pericarditis cont.….
•Pericarditis may be sub acute, acute, or chronic.
•It is classified either as adhesive (constrictive),
because the layers of the pericardium become
attached to each other and restrict ventricular
filling, or by what accumulates in the pericardial
sac: serous (serum), purulent (pus), calcific (calcium
deposits), fibrinous (clotting proteins), or
sanguinous (blood).
•Pericarditis also may be described as exudative or
non-effusive.

162
Pathophysiology
• The inflammatory process may lead to an accumulation of fluid in
the pericardial sac (pericardial effusion) and increased pressure on
the heart.
• Frequent or prolonged episodes of pericarditis may also lead to
thickening and decreased elasticity of the pericardium, or scarring
may fuse the visceral and parietal pericardium.
• These conditions restrict the heart’s ability to fill with blood
(constrictive pericarditis).
• With less filling, the ventricles pump less blood, leading to
decreased cardiac output and signs and symptoms of heart failure.
• Restricted diastolic filling may result in increased systemic venous
pressure, causing peripheral edema and hepatic failure.

163
•Pericarditis may be asymptomatic
•The most characteristic symptom is chest pain and it may
worsen with deep inspiration and when lying down or turning.
•The most characteristic sign is friction rub heard most clearly at
the left lower sternal border
•Other signs may include a mild fever, increased WBC count,
anemia, and an elevated ESR
•Patients may have a nonproductive cough.
•Dyspnea and other signs and symptoms of heart failure may
occur as the result of pericardial compression due to
constrictive pericarditis.

164
•The diagnosis is most often made on the basis of
the history, signs, and symptoms.
•An echocardiogram may detect inflammation,
pericardial effusion, and heart failure.
•Computed tomography (CT) may be the best
diagnostic tool for determining the size, shape, and
location of pericardial effusions

165
Medical Management
•When cardiac output is impaired, the patient is placed on
bed rest until the fever, chest pain, and friction rub have
subsided.
•Analgesics and non-steroidal anti-inflammatory drugs
(NSAIDs) such as aspirin or ibuprofen may be prescribed
for pain relief during the acute phase.
•Corticosteroids (e.g. prednisone) may be prescribed if the
pericarditis is severe or if the patient does not respond to
NSAIDs.

166
•Pericardiocentesis, may be performed to assist in
the identification of the cause or relieve symptoms,
especially if there are signs and symptoms of heart
failure.
•Pericardial fluid is cultured if bacterial, tubercular,
or fungal disease is suspected, and a sample is sent
for cytology if neoplastic disease is suspected.
•A pericardial window, a small opening made in the
pericardium, may be performed to allow continuous
drainage into the chest cavity.

167
Nursing Management
• Patients with acute pericarditis require pain management
with analgesics, positioning, and psychological support.
• To minimize complications, the nurse helps the patient
with activity restrictions until the pain and fever subside.
• The nurse educates the patient and family about a
healthy lifestyle to enhance the patient’s immune
system.
• The nurse monitors the patient for heart failure.

168
Management of patients with dysrhythmias
and conduction problems
Introduction
•Without a regular rate and rhythm, the heart may
not perform efficiently as a pump to circulate
oxygenated blood and other life-sustaining
nutrients to all of the body’s tissues and organs
(including the heart itself).
•With an irregular or erratic rhythm, the heart is
considered to be dysrhythmic (sometimes called
arrhythmic).
•This is a potentially dangerous condition.

169
Dysrhythmias
•Dysrhythmias are disorders of the formation or
conduction (or both) of the electrical impulse within
the heart.
•These disorders can cause disturbances of the heart
rate, the heart rhythm, or both.
•Dysrhythmias may initially be evidenced by change
in the pumping action of the heart and cause
decreased blood pressure.
•Dysrhythmias are diagnosed by analyzing the
electrocardiographic (ECG) waveform.

170
Dysrhythmias cont.….
•Their treatment is based on frequency and severity
of symptoms produced.
•Dysrhythmias are named according to the site of
origin of the impulse and the mechanism of
formation or conduction involved. For example, an
impulse that originates in the sinoatrial (SA) node
and at a slow rate is called sinus bradycardia.

Reading assignment
Types of Dysrhythmias

172
VARICOSE VEINS
•Varicose veins (varicosities) are abnormally dilated,
tortuous, superficial veins caused by incompetent venous
valves.
•Most commonly, this condition occurs in the lower
extremities, the saphenous veins, or the lower trunk, but it
can occur elsewhere in the body.
•It is estimated that varicose veins occur in up to 60% of the
adult population in the United States, with an increased
incidence correlated with increased age.
•Varicose veins are rare before puberty.

173
Varicose veins cont.….
•The condition is most common in women and in
people whose occupations require prolonged
standing, such as sales people, hair stylists, teachers,
nurses and auxiliary medical personnel, and
construction workers.
•A hereditary weakness of the vein wall may
contribute to the development of varicosities, and it
commonly occurs in several members of the same
family.
•Pregnancy may cause varicosities because of
hormonal effects related to decreased venous
outflow, increased pressure by the gravid uterus, and
increased blood volume

174
Pathophysiology
•Varicose veins may be primary (without
involvement of deep veins) or secondary (resulting
from obstruction of deep veins).
•A reflux of venous blood in the veins results in
venous stasis.
•If only the superficial veins are affected, the person
may have no symptoms but may be troubled by
their appearance.

175
•Symptoms, if present, may include dull aches,
muscle cramps, increased muscle fatigue in the
lower legs, ankle edema, and a feeling of heaviness
of the legs.
•Nocturnal cramps are common. When deep venous
obstruction results in varicose veins, the patient
may develop the signs and symptoms of chronic
venous insufficiency: edema, pain, pigmentation,
and ulcerations.
•Susceptibility to injury and infection is increased.

176
•Duplex ultrasound scan, which documents the
anatomic site of reflux and provides a quantitative
measure of the severity of valvular reflux.
•Air plethysmography measures the changes in venous
blood volume.
•Venography is not routinely performed to evaluate for
valvular reflux.

177
Prevention
•The patient should avoid activities that cause
venous stasis,
such as wearing socks that are too tight, crossing
the legs at the thighs, and sitting or standing for
long periods.
•Changing position frequently, elevating the legs
when they are tired, and getting up to walk for
several minutes of every hour promote circulation.
•The patient is encouraged to walk each day if there
are no contraindications. Walking up the stairs
rather than using the elevator or escalator is
helpful, and swimming is good exercise.
•The overweight patient should be encouraged to
begin a weight reduction plan.

178
Management
Ligation and Stripping
• Surgery for varicose veins requires that the deep veins be patent and
functional.
• The saphenous vein is ligated and also, the vein may be removed
(stripped).
• After the vein is ligated, an incision is made 2 to 3 cm below the knee,
and a metal or plastic wire is passed the full length of the vein to the
point of ligation.
• The wire is then withdrawn, pulling (removing, stripping) the vein as
it is removed.
Sclerotherapy
• Sclerotherapy involves injection of an irritating chemical into a vein to
produce localized phlebitis and fibrosis, thereby obliterating the
lumen of the vein.

179
VENOUS DISORDERS
Venous Thromboembolism
•Deep vein thrombosis (DVT) and pulmonary
embolism (PE) collectively make up the condition
known as venous
thromboembolism (VTE).
•The incidence of VTE is 10% to 20% in general medical
patients, 20% to 50% in patients who have had a
stroke, and up to 80% in critically ill patients.
•The extent of the problem is underestimated, possibly
because DVT and PE are often clinically silent.
•It is estimated that as many as 30% of patients
hospitalized with VTE develop long-term post
thrombotic complications.

180
Venous Thromboembolism cont.…
Pathophysiology
•Although the exact cause of VTE remains unclear,
three factors, known as Virchow’s triad, are believed
to play a significant role in its development: stasis of
blood (venous stasis), vessel wall injury, and altered
blood coagulation.
1. Venous stasis occurs when blood flow is reduced, as
in heart failure or shock; when veins are dilated, as
with some medication therapies; and when skeletal
muscle contraction is reduced, as in immobility,
paralysis of the extremities, or anesthesia. Moreover,
bed rest reduces blood flow in the legs by at least 50%

181
2. Damage to the intimal lining of blood vessels creates a site
for clot formation.
•Direct trauma to the vessels, as with fractures or dislocation,
diseases of the veins, and chemical irritation of the vein from
IV medications or solutions, can damage veins.
3. Increased blood coagulability occurs most commonly in
patients for whom anticoagulant medications have been
abruptly withdrawn.
•Oral contraceptive use and several blood abnormalities also
can lead to hypercoagulability
•Normal pregnancy is accompanied by an increase in clotting
factors that may not return to baseline until longer than 8
weeks postpartum, increasing the risk of thrombosis.

183
•Formation of a thrombus frequently accompanies
phlebitis, which is an inflammation of the vein walls.
•When a thrombus develops initially in the veins as a
result of stasis or hypercoagulability but without
inflammation, the process is referred to as
Phlebothrembosis.
•Venous thrombosis can occur in any vein, but it occurs
more often in the veins of the lower extremities.
•The superficial and deep veins of the extremities may
be affected.
•Upper extremity venous thrombosis is not as common
as lower extremity thrombosis.

184
•Upper extremity venous thrombosis is more
common in patients with IV catheters or in patients
with an underlying disease that causes
hypercoagulability.
•Venous thrombi are aggregates of platelets attached
to the vein wall that have a tail-like appendage
containing fibrin, white blood cells, and many red
blood cells.
•A propagating venous thrombosis is dangerous
because parts of the thrombus can break off and
occlude the pulmonary blood vessels.

185
• A major problem associated with recognizing DVT is that the
signs and symptoms are nonspecific.
• The exception is massive iliofemoral venous
thrombosis, in which the entire extremity becomes massively
swollen, tense, painful, and cool to the touch.
Deep Veins
• With obstruction of the deep veins comes edema and swelling
of the extremity because the outflow of venous blood is
inhibited.
• Tenderness, which usually occurs later, is produced by
inflammation of the vein wall
• Homans’ sign (pain in the calf after the foot is sharply
dorsiflexed)

186
Superficial Veins
•Thrombosis of superficial veins produces pain or
tenderness, redness, and warmth in the involved
area.
•The risk of the superficial venous thrombi becoming
dislodged or fragmenting into emboli is very low
because most of them dissolve spontaneously.
•This condition can be treated at home with bed
rest, elevation of the leg, analgesic agents, and
possibly anti-inflammatory medication.

187
•Careful assessment is vital in detecting early signs of
venous disorders of the lower extremities.
•Patients with a history of varicose veins,
hypercoagulation, neoplastic disease,
cardiovascular disease, or recent major surgery or
injury are at high risk.
•Other patients at high risk include those who are
obese or elderly and women taking oral
contraceptives.

188
•When performing the nursing assessment, key
concerns include limb pain, a feeling of heaviness,
functional impairment, ankle engorgement, and
edema; differences in leg circumference bilaterally
from thigh to ankle; increase in the surface
temperature of the leg, particularly the calf or
ankle; and areas of tenderness or superficial
thrombosis (i.e. cordlike venous segment).

189
Prevention
• VTE can be prevented, especially if patients who are
considered at high risk are identified and preventive
measures are instituted without delay.
• Preventive measures include the application
compression stockings, and encouragement of early
mobilization and leg exercises.
• An additional method to prevent venous thrombosis in
surgical patients is administration of heparin.
• Patients should be advised to make lifestyle changes as
appropriate, which may include weight loss, smoking
cessation, and regular exercise.

190
Medical Management
•The objectives of treatment for DVT are to prevent the
thrombus from growing and fragmenting (thus risking
PE), and recurrent thromboemboli.
•Combining anticoagulation therapy E.G. Heparin (to
delay the clotting time of blood, prevent the formation
of a thrombus in postoperative patients, and forestall
the extension of a thrombus after it has formed) with
thrombolytic therapy E.G. Alteplase (dissolve a
thrombus that has already formed) may eliminate
venous obstruction, maintain venous patency by early
removal of the thrombus

191
Surgical management
•It is necessary for DVT when anticoagulant or
thrombolytic therapy is contraindicated, the danger
of pulmonary embolism is extreme,
or venous drainage is so severely compromised that
permanent damage to the extremity is likely.
•A thrombectomy may be necessary. This mechanical
method of clot removal may involve using
intraluminal catheters with a balloon or other
devices.

192
Nursing Management
•If the patient is receiving anticoagulant therapy, the
nurse must frequently monitor the partial
thromboplastin time (PTT), prothrombin time (PT),
hemoglobin and hematocrit values, platelet count,
and fibrinogen level.
•Close observation is also required to detect
bleeding; if bleeding occurs, it must be reported
immediately and anticoagulant therapy
discontinued

193
Management of Hematologic Disorders
•Unlike many other body systems, the hematologic
system encompasses the entire human body.
•Patients with hematologic disorders often have
significant abnormalities in blood tests but few or no
symptoms.
•Therefore, the nurse must have a good
understanding of the pathophysiology of the
patient’s condition and the ability to make a
thorough assessment that relies heavily on the
interpretation of laboratory tests.

194
ANEMIA
•Anemia is a condition in which the hemoglobin
concentration is lower than normal; it reflects the
presence of fewer than the normal number of
erythrocytes within the circulation.
•As a result, the amount of oxygen delivered to body
tissues is also diminished.
•Anemia is not a specific disease state but a sign of
an underlying disorder.
•It is by far the most common hematologic condition.

195
Anemia cont.….
Classification of Anemia
•Anemia may be classified in several ways.
•A physiologic approach classifies anemia according to
whether the deficiency in erythrocytes is caused by:
• A defect in their production (hypoproliferative
anemia)
•Their destruction (hemolytic anemia), or
• Their loss (bleeding).

196
Anemia cont.….
•In hypoproliferative anemia, the marrow cannot
produce adequate numbers of erythrocytes.
•Inadequate production of erythrocytes may result
from marrow damage due to medications (e.g.
chloramphenicol) or chemicals (e.g. benzene) or
from a lack of factors (e.g. iron, vitamin B12, folic
acid, erythropoietin) necessary for erythrocyte
formation.

197
Anemia cont.….
•Hemolysis can result from an abnormality within
the erythrocyte itself (e.g. sickle cell
anemia, glucose-6-phosphate dehydrogenase [G-6-
PD] deficiency) or within the plasma (e.g. immune
hemolytic anemia), or from direct injury to the
erythrocyte within the circulation (e.g. hemolysis
caused by mechanical heart valve).
•Loss of RBCs—occurs with bleeding, potentially
from any major source, such as the gastrointestinal
tract, the uterus, the nose, or a wound.

199
Anemia cont.….
•Aside from the severity of the anemia itself, several
factors influence the development of anemia-
associated symptoms:
• The rapidity with which the anemia has developed,
the duration of the anemia (i.e. its chronicity),
•The metabolic requirements of the patient, other
concurrent disorders or disabilities (e.g. cardiac or
pulmonary disease), and
•Complications of the condition that produced the
anemia.

200
Anemia cont.….
•In general, the more rapidly an anemia develops, the
more severe its symptoms.
•An otherwise healthy person can often tolerate as much
as a 50% gradual reduction in hemoglobin without
pronounced symptoms or significant incapacity, whereas
the rapid loss of as little as 30% may precipitate
profound vascular collapse in the same person.
•A person who has become gradually anemic, with
hemoglobin levels between 9 and 11 g/dL, usually has
few or no symptoms other than slight tachycardia on
exertion and fatigue.

201
Anemia cont.….
•People who usually are very active or who have
significant demands on their lives (e.g. a working
mother of small children) are more likely to have
symptoms, than more sedentary people.
•Patients with coexistent cardiac, vascular, or
pulmonary disease may develop more
pronounced symptoms of anemia (e.g. dyspnea,
chest pain, muscle pain or cramping) at a higher
hemoglobin level than those without these
concurrent health problems.

202
Anemia cont.….
•In an initial evaluation, the hemoglobin, hematocrit,
reticulocyte count, and RBC indices, particularly the
mean corpuscular volume (MCV) and red cell
distribution width (RDW), are particularly useful.
• Iron studies (serum iron level, total iron-binding
capacity [TIBC], percent saturation, and ferritin), as
well as serum vitamin B12 and folate levels, are also
frequently obtained.
•Other tests include haptoglobin and erythropoietin
levels.

203
Anemia cont.….
•The remaining CBC values are useful in determining
whether the anemia is an isolated problem or part
of another hematologic condition, such as leukemia
or myelodysplastic syndrome (MDS).
• Bone marrow aspiration may be performed.
•In addition, other diagnostic studies may be
performed to determine the presence of underlying
chronic illness, such as malignancy, or the source of
any blood loss, such as polyps or ulcers within the
GI tract.

204
Anemia cont.….
Complications
• General complications of severe anemia include heart
failure, paresthesias, and delirium.
• Patients with underlying heart disease are far more likely to
have angina or symptoms of heart failure than those
without heart disease.
Medical Management
• Management of anemia is directed toward correcting or
controlling the cause of the anemia; if the anemia is severe,
the erythrocytes that are lost or destroyed may be replaced
with a transfusion of packed red blood cells (PRBCs).

205
Anemia cont.….
IRON DEFICIENCY ANEMIA
•Iron deficiency anemia typically results when the intake
of dietary iron is inadequate for hemoglobin synthesis.
•The body can store about one fourth to one third of its
iron, and it is not until those stores are depleted that
iron deficiency anemia actually begins to develop.
•Iron deficiency anemia is the most common type of
anemia in all age groups, and it is the most common
anemia in the world.
•It is particularly prevalent in developing countries,
where inadequate iron stores can result from
inadequate intake of iron (seen with vegetarian diets)
or from blood loss (e.g. from intestinal hookworm).

206
Anemia cont.….
•The most common cause of iron deficiency anemia
in men and postmenopausal women is bleeding
from ulcers, gastritis, inflammatory bowel disease,
or GI tumors.
•The most common causes of iron deficiency anemia
in premenopausal women are menorrhagia (i.e.
excessive menstrual bleeding) and pregnancy with
inadequate iron supplementation.
•Patients with chronic alcoholism often have chronic
blood loss from the GI tract, which causes iron loss
and eventual anemia.

207
Anemia cont.….
•If the deficiency is severe or prolonged, they may
also have a smooth, sore tongue; brittle and ridged
nails; and angular cheilosis. These signs subside
after iron replacement therapy.
•The health history may be significant for multiple
pregnancies, GI bleeding, and pica.

208
Anemia cont.….
•The definitive method of establishing the diagnosis of
iron deficiency anemia is bone marrow aspiration.
•Hematocrit and RBC levels are also low in relation to
the hemoglobin level.
•Currently, the most reliable and clinically useful
laboratory findings in evaluating iron deficiency
anemia are the ferritin and hemoglobin values.

209
Anemia cont.….
Medical Management
•Except in the case of pregnancy, the cause of iron
deficiency should be investigated.
•Anemia may be a sign of a curable GI cancer or of
uterine fibroid tumors.
•Stool specimens should be tested for occult blood.
•People 50 years of age or older should have periodic
colonoscopy, endoscopy, or x-ray examination of
the GI tract to detect ulcerations, gastritis, polyps,
or cancer.

210
Anemia cont.….
•Several oral iron preparations—ferrous sulfate,
ferrous gluconate, and ferrous fumarate—are
available for treating iron deficiency anemia
•Iron store replenishment takes much longer, so it is
important that the patient continue taking the iron
for as long as 6 to 12 months.

211
Anemia cont.….
Nursing Management
•Preventive education is important, because iron
deficiency anemia is common in menstruating and
pregnant women.
•Food sources high in iron include organ meats
(e.g. beef or calf’s liver, chicken liver), other meats,
beans, leafy green vegetables….
•Taking iron-rich foods with a source of vitamin C
(e.g. orange juice) enhances the absorption of iron.
•The nurse helps the patient select a healthy diet.

212
Anemia cont.….
•Because iron is best absorbed on an empty
stomach, the patient is instructed to take the
supplement an hour before meals.
•If taking iron on an empty stomach causes gastric
distress, the patient may need to take it with meals.
•Antacids or dairy products should not be taken with
iron, because they greatly diminish its absorption.

213
HEMOPHILIA
•Two inherited bleeding disorders—hemophilia A and
hemophilia B—are clinically indistinguishable, although
they can be distinguished by laboratory tests.
•Hemophilia A is caused by a genetic defect that results in
deficient or defective factor VIII.
•Hemophilia B (also called Christmas disease) stems from a
genetic defect that causes deficient or defective factor IX.
•Hemophilia is a relatively rare disease; hemophilia A,
which occurs in 1 of every 5000 births, is three times
more common than hemophilia B.

214
Hemophilia cont.….
•Both types of hemophilia are inherited as X-linked
traits, so almost all affected people are males;
females can be carriers but are almost always
asymptomatic.
•Hemophilia is recognized in early childhood, usually
in the toddler age group.
•However, patients with mild hemophilia may not be
diagnosed until they experience severe trauma (e.g.
a high-school football injury) or surgery.

215
• Hemophilia is manifested by hemorrhages into various parts
of the body; these hemorrhages can be severe and can
occur even after minimal trauma.
• About 75% of all bleeding in patients with hemophilia
occurs into joints. The most commonly affected joints are
the knees, elbows, ankles, shoulders, wrists, and hips.
• Patients often note pain in a joint before they are aware of
swelling and limitation of motion.
• Recurrent joint hemorrhages can result in damage so severe
that chronic pain or ankylosis (fixation) of the joint occurs.
• Bleeding is not limited to the joints. Spontaneous hematuria
and GI bleeding can occur.

216
•Bleeding is also common in mucous membranes, such
as the nasal passages.
•The most dangerous site of hemorrhage is in the head
(intracranial or extracranial).
• Any head trauma requires prompt evaluation and
treatment.
•Surgical procedures typically result in excessive
bleeding at the surgical site.
•Because clot formation is poor, wound healing is also
poor.
•Bleeding is most commonly associated with dental
extraction.

217
Medical Management
•In the past, the only treatment for hemophilia was
infusion of fresh-frozen plasma, which had to be
administered in such large quantities that patients
experienced fluid volume overload.
•Now factor VIII and factor IX concentrates are
available to all blood banks.
•Patients are given concentrates when they are
actively bleeding or as a preventive measure
before traumatic procedures (e. g. lumbar
puncture, dental extraction, surgery).

218
•The patient and family are taught how to administer
the concentrate intravenously at home at the first
sign of bleeding.
•Aminocaproic acid inhibits fibrinolysis and therefore
stabilizes the clot; it is very effective as an
adjunctive measure after oral surgery and in
treating mucosal bleeding.
•Another agent, desmopressin (DDAVP), induces a
significant but transient rise in factor VIII levels.

219
Nursing Management
• The nurse should emphasize safety at home and in the
workplace.
• Patients with hemophilia are instructed to avoid any agents
that interfere with platelet aggregation, such as aspirin,
NSAIDs, herbs, nutritional supplements, and alcohol.
• Dental hygiene is very important as a preventive measure
because dental extractions are so hazardous.
• Applying pressure may be sufficient to control bleeding
resulting from minor trauma if the factor deficiency is not
severe.
• Nasal packing should be avoided because bleeding frequently
resumes when the packing is removed.
• Splints and other orthopedic devices may be useful in
patients with joint or muscle hemorrhages.

220
•All injections should be avoided; invasive procedures
(e.g. endoscopy, lumbar puncture) should be
minimized or performed after administration of
appropriate factor replacement.
• Patients with hemophilia should been encourage to
carry or wear medical identification.
•During hemorrhagic episodes, the extent of bleeding
must be assessed carefully. Patients who are at risk for
significant compromise (e.g. bleeding into the
respiratory tract or brain) warrant close observation
and systematic assessment for emergent complications
(e.g. respiratory distress, altered level of
consciousness).

221
•If the patient has had recent surgery, the nurse
frequently and carefully assesses the surgical site for
bleeding.
•Frequent vital sign monitoring is needed until the nurse
is certain that there is no excessive postoperative
bleeding.
•Analgesics are commonly required to alleviate the pain
associated with hematomas and hemorrhage into joints.
•Many patients report that warm baths promote
relaxation, improve mobility, and lessen pain. However,
during bleeding episodes, heat, which can accentuate
bleeding, is avoided; applications of cold are used
instead.

222
THROMBOCYTOPENIA
Thrombocytopenia (low platelet level) can result
from various factors:
•Decreased production of platelets within the bone
marrow,
•Decreased destruction of platelets, or
• Increased consumption of platelets.

225
Thrombocytopenia cont…
•Bleeding and petechiae usually do not occur with
platelet counts greater than 50,000/mm3, although
excessive bleeding can follow surgery or other trauma.
•When the platelet count drops to less than
20,000/mm3, petechiae can appear, along with nasal
and gingival bleeding, excessive menstrual bleeding,
and excessive bleeding after surgery or dental
extractions.
•When the platelet count is less than 5000/mm3,
spontaneous, potentially fatal central nervous system
or GI hemorrhage can occur.

226
•A platelet deficiency that results from decreased
production (e.g. leukemia, MDS) can usually be
diagnosed by examining the bone marrow via
aspiration and biopsy.
•If platelet destruction is the cause of
thrombocytopenia, the marrow shows increased
megakaryocytes (the cells from which the platelets
originate) and normal or even increased platelet
production as the body attempts to compensate for
the decreased platelets in circulation.

227
Medical Management
•The management of secondary thrombocytopenia is
usually treatment of the underlying disease.
•If platelet production is impaired, platelet
transfusions may increase the platelet count and stop
bleeding or prevent spontaneous hemorrhage. If
excessive platelet destruction occurs, transfused
platelets are also destroyed, and the platelet count
does not increase.
•In some instances splenectomy can be a useful.

228
POLYCYTHEMIA
•Polycythemia refers to an increased volume of
erythrocytes.
•The term is used when the hematocrit is elevated
(more than 55% in males, more than 50% in
females).
•Polycythemia is classified as either primary or
secondary.
Polycythemia vera
•Polycythemia vera (“P vera”), or primary
polycythemia, is a proliferative disorder of the
myeloid stem cells (in which the myeloid stem cells
seem to have escaped normal control mechanisms).

229
Polycythemia cont…
• The bone marrow is hypercellular, and the erythrocyte,
leukocyte, and platelet counts in the peripheral blood are
elevated. However, erythrocyte elevation predominates;
the hematocrit can exceed 60%.
• This phase can last for an extended period of 10 years or
more.
• Over time, the spleen resumes its function of
hematopoiesis and enlarges.
• Eventually, the bone marrow may become fibrotic, with a
resultant inability to produce as many cells (“burnt out” or
spent phase).
• The estimated incidence of polycythemia vera is 2 per
100,000 people and the median age at onset is 65 years.

230
•Patients typically have a splenomegaly.
•Symptoms result from increased blood volumes
(headache, dizziness, tinnitus, fatigue, paresthesias,
and blurred vision), or from increased blood viscosity
and ( angina, dyspnea, and thrombophlebitis,
particularly if the patient has atherosclerotic blood
vessels.
•For this reason, blood pressure is often elevated.
•Generalized pruritus, which may be caused by
histamine release due to an increased number of
basophils.

231
•Diagnosis is based on an elevated erythrocyte mass,
a normal oxygen saturation level, and often an
enlarged spleen.
•Other factors useful in establishing the diagnosis
include elevated leukocyte and platelet counts.
•Causes of secondary erythrocytosis should not be
present

232
Medical Management
•The objective of management is to reduce the high
blood cell mass.
•Phlebotomy is an important part of therapy. It
involves removing enough blood (initially 500 mL
once or twice weekly) to reduce blood viscosity and
to deplete the patient’s iron stores, thereby rendering
the patient iron deficient and consequently unable to
continue to manufacture erythrocytes excessively.
•Chemotherapeutic agents (e.g. hydroxyurea) can be
used to suppress marrow function, but this may
increase the risk of leukemia.

233
•Anagrelide , which inhibits platelet aggregation, can
also be useful in controlling the thrombocytosis
associated with polycythemia vera.
Secondary polycythemia
•It is caused by excessive production of erythropoietin.
•This may occur in response to a reduced amount of
oxygen, which acts as a hypoxic stimulus, as in
heavy cigarette smoking, chronic obstructive
pulmonary disease, or cyanotic heart disease, or in
non pathologic conditions such as living at a high
altitude.

234
Medical Management
•When secondary polycythemia is mild, treatment may
not be necessary; when treatment is necessary, it
involves treating the primary conditions.
•If the cause cannot be corrected (e.g. by improving
pulmonary function with smoking cessation),
therapeutic phlebotomy may be necessary in
symptomatic patients to reduce blood viscosity and
volume as well as when the hematocrit is significantly
elevated.

235
LEUKOPENIA
•Leukopenia, a condition in which there are fewer
leukocytes than normal, results from neutropenia
(diminished neutrophils) or lymphopenia (diminished
lymphocytes).
•Even if other types of leukocytes (e.g. monocytes,
basophils) are diminished, their numbers are too few
to reduce the total leukocyte count significantly.
Neutropenia
• It is a neutrophil count of less than 2000/mm3
results from decreased production of neutrophils or
increased destruction of these cells.

237
Neutropenia cont…
•Neutrophils are essential in preventing and limiting
bacterial infection.
•A patient with neutropenia is at increased risk for
infection from both exogenous and endogenous
sources. (The GI tract and skin are common
endogenous sources.)
•The risk of infection increases proportionately with the
decrease in neutrophil count.
•There are no definite symptoms of neutropenia until
the patient becomes infected.

239
Neutropenia cont…
Medical Management
• Treatment of the neutropenia varies depending on its cause.
• If the neutropenia is medication induced, the offending agent
is stopped immediately, if possible.
• Treatment of an underlying neoplasm.
• Corticosteroids may be used if the cause is an
immunologic disorder.
• If the neutropenia is accompanied by fever, the patient is
considered to have an infection and usually is admitted to
the hospital.
• To ensure adequate therapy against the infectious organisms,
broad-spectrum antibiotics are initiated.

240
Lymphopenia
•Lymphopenia (a lymphocyte count less than
1500/mm3)
•It can result from ionizing radiation, long-term use of
corticosteroids, some neoplasms (e.g. breast and
lung cancers, advanced Hodgkin disease), and some
protein losing enteropathies (in which the
lymphocytes within the intestines are lost).
•Although when lymphopenia is mild it is often
without sequelae, when severe, it can result in
bacterial infections (due to low B lymphocytes) or in
opportunistic infections (due to low T lymphocytes).

241
LEUKEMIA
•The term leukocytosis refers to an increased level of
leukocytes in the circulation.
•Typically, only one specific cell type is increased.
•Because the proportions of several types of leukocytes
(e.g. eosinophils, basophils, monocytes) are small,
only an increase in neutrophils or lymphocytes can be
great enough to elevate the total leukocyte count.
•Although leukocytosis can be a normal response to
increased need (e.g. in acute infection), the elevation
in leukocytes should decrease as the physiologic need
decreases.

242
Leukemia cont…
•A prolonged or progressively increasing elevation in
leukocytes is abnormal and should be evaluated.
•A significant cause of persistent leukocytosis is
hematologic malignancy.
•Hematopoiesis is characterized by a rapid, continuous
turnover of cells.
•Normally, production of specific blood cells from their
stem cell precursors is carefully regulated according to
the body’s needs.
• If the mechanisms that control the production of
these cells are disrupted, the cells can proliferate
excessively.

243
Leukemia cont…
•Hematopoietic malignancies are often classified by the
cells involved.
•Leukemia is a neoplastic proliferation of one particular
cell type (granulocytes, monocytes, lymphocytes, or
infrequently erythrocytes or megakaryocytes).
•The defect originates in the hematopoietic stem cell,
the myeloid, or the lymphoid stem cell.
•The lymphomas are neoplasms of lymphoid tissue,
usually derived from B lymphocytes.
•Multiple myeloma is a malignancy of the most mature
form of B lymphocyte, the plasma cell.

244
Leukemia cont…
•The common feature of the leukemias is an
unregulated proliferation of leukocytes in the bone
marrow.
• In acute forms (or late stages of chronic forms), the
proliferation of leukemic cells leaves little room for
normal cell production.
•There can also be a proliferation of cells in the liver
and spleen (extramedullary hematopoiesis).
•With acute forms, there can be infiltration of
leukemic cells in other organs, such as the
meninges, lymph nodes, gums, and skin.

245
Leukemia cont…
Cause
•Not fully known, but there is some evidence that genetic
influences and viral pathogenesis may be
involved
•Bone marrow damage from radiation exposure or from chemicals
such as benzene and alkylating agents (e.g. melphalan {An
anticancer drug used to
treat multiple myeloma} can cause leukemia.
Classification
•They are commonly classified according to the
stem cell line involved, either lymphoid or myeloid.
•They are also classified as either acute or chronic, based on the
time it takes for symptoms to evolve.

246
Leukemia cont…
•In acute leukemia, the onset of symptoms is abrupt,
often occurring within a few weeks.
• Acute leukemia progresses very rapidly; death
occurs within weeks to months without aggressive
treatment.
•In chronic leukemia, symptoms evolve over a period
of months to years, and the majority of leukocytes
produced are mature.
•Chronic leukemia progresses more slowly; the
disease course can extend for years.

247
ACUTE MYELOID LEUKEMIA (AML)
•AML results from a defect in the hematopoietic
stem cell that differentiates into all myeloid cells:
monocytes, granulocytes (e.g. neutrophils,
basophils, eosinophils), erythrocytes, and platelets.
•All age groups are affected, although it infrequently
occurs before age 40 and the incidence rises with
age, with a peak incidence at age 67 years.
•AML is the most common non lymphocytic
leukemia.
•The prognosis is highly variable.

248
Acute myeloid leukemia (AML) cont…
•Patient age is a significant factor; patients who are
younger may survive for 5 years or more after
diagnosis of AML.
•However, patients who are older or have a more
undifferentiated form of AML tend to have a worse
prognosis.

249
•Most signs and symptoms of AML result from
insufficient production of normal blood cells.
•Fever and infection result from neutropenia,
weakness and fatigue from anemia, and
bleeding tendencies from thrombocytopenia.
•The proliferation of leukemic cells within organs
leads to a variety of additional symptoms: pain from
an enlarged liver or spleen, hyperplasia of the gums,
and bone pain from expansion of marrow.

250
•AML develops without warning, with symptoms
occurring over a period of weeks to months.
•The CBC shows a decrease in both erythrocytes and
platelets. Although the total leukocyte count can be
low, normal, or high, the percentage of normal cells
is usually vastly decreased.
•A bone marrow analysis shows an excess of
immature blast cells (more than 20%).

251
Medical Management
•The overall objective of treatment is to achieve complete
remission in which there is no detectable evidence of
residual leukemia remaining in the bone marrow.
•Aggressive administration of chemotherapy, called
induction therapy, which usually requires hospitalization
for several weeks.
•Induction therapy typically involves high doses of
cytarabine and daunorubicin or mitoxantrone or
idarubicin.
•The aim of induction therapy is to eradicate the leukemic
cells, but this is also accompanied by the eradication of
normal types of myeloid cells.

252
•Thus, the patient becomes severely neutropenic,
anemic, and thrombocytopenic.
•During this time, the patient is typically very ill, with
bacterial, fungal, and occasionally viral infections;
bleeding; and severe mucositis, which causes
diarrhea and an inability to maintain adequate
nutrition.
•Supportive care consists of administering blood
products (PRBCs and platelets) and promptly
treating infections.

253
Acute lymphocytic leukemia (ALL)
•It results from an uncontrolled proliferation of
immature cells (lymphoblasts) derived from the
lymphoid stem cell.
•The cell of origin is the precursor to the B
lymphocyte in approximately 75% of ALL cases; T-
lymphocyte ALL occurs in approximately 25% of
cases.
•ALL is most common in young children, with boys
affected more often than girls; the peak incidence is
4 years of age.
•After 15 years of age, it is relatively uncommon.

254
Acute lymphocytic leukemia (ALL) cont…
• ALL is responsive to treatment; complete remission rates
are extremely high in children (98%) and 85% for adults
• Immature lymphocytes proliferate in the marrow and
impede the development of normal myeloid cells.
• As a result, normal hematopoiesis is inhibited, resulting
in reduced numbers of leukocytes, erythrocytes, and
platelets.
• Leukocyte counts may be either low or high, but there is
always a high proportion of immature cells.

255
•Manifestations of leukemic cell infiltration into
other organs are more common with ALL than with
other forms of leukemia and include pain from an
enlarged liver or spleen and bone pain.
•The central nervous system is frequently a site for
leukemic cells; thus, patients may exhibit headache
and vomiting because of meningeal involvement.
•Other extra nodal sites include the testes and
breasts.

256
Medical Management
•The expected outcome of treatment is complete remission.
•Because ALL frequently invades the central nervous system,
preventive cranial irradiation or intrathecal chemotherapy
(e.g. methotrexate) or both is also a key part of the
treatment plan.
•Treatment protocols for ALL tend to be complex, using a
wide variety of chemotherapeutic agents.
•Infections, especially viral infections, are common.
•The use of corticosteroids to treat ALL increases the
patient’s susceptibility to infection.
•Patients with ALL tend to have a better response to
treatment than do patients with AML.

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