Unit 5
Nursing Care for Patients
with Cardiovascular
Problems
1
STRUCTURE OF THE HEART
2
Assessment :
1. Assess for chest pain, palpitations,
fatigue
2. Habits ( smoking, alcohol intake, use of
drugs, exercise and dietary
3. Hereditary (heart disease, diabetes, high
cholesterol levels, hypertension, stroke,
or rheumatic heart disease.)
4. Peripheral circulation( leg cramps,
numbness swelling or cyanosis of feet,
ankles, or hand.)
3
Auscultation:
1.
2.
3.


Count heart rate for 1 minute.
Normal heart sounds ( S1& S2 ).
Abnormal heart sounds:
Rubs: friction sounds heard in heart infections.
Murmurs: If available, assess for thrill, which is a
continuous palpable sensation like the purring of a
cat.
4
Examination:
A.
B.
Blood pressure:
Pulse
• Carotid arteries: The carotid arteries
supply oxygenated blood to the head and
neck.
C. Peripheral Arteries:
1.
Assess each peripheral artery for elasticity of the
vessel wall, strength, regularity, and equality.
2 . Allen's test: to assess collateral circulation of ulnar
and radial.
3. Tissue Perfusion:
5
Difference between Venous and Arterial occlusion
criteria
Venous
occlusion
Arterial occlusion
Color
Normal or
cyanotic
Pale; worsened by elevation of
extremity. dark red when extremity
is lowered
Temperature
Normal
Cool
Pulse
Normal
Decreased or absent
Edema
Often marked
Absent or mild
Skin changes
Brown
pigmentation
around ankles
Thin, shiny skin; decreased hair
growth; thickened nails
6
Cardiac Diagnostic Testing
Serum Enzymes: Enzymes are available in cell of
the organs, when the cell is damaged; these
Enzymes will release in the serum.
Enzymes are:



Creatine phosphokinase (CPK): CPK found in: brain,
heart muscles, and skeletal muscles.
CPK normal value is:




Male: less than 99 unit / liter.
Female: less than 57 unit / liter
Lactic dehydrogenase (LDH): is available in most tissue.
Normal value is less than 115 international unit/L.
7
Cardiac enzyme
Enzymes
Normal
value
CPK
Onset of
elevation
Peak time
for
elevation
Duration of
elevation
Male: <99
4-6 hours
U/L
Female:<57U/
L
12-24 hours
3-4 days
CPK-MB
7 – 10
international
unit/L
4-6 hours
12-24 hours
2-3-4 days
LDH
< 115 IU/L
L8-12 hours
hours24-48
hours10-14
days.
8
Diagnostic procedures
3.
Chest X-ray
Echocardiography
Doppler Ultrasonography
4.
Cardiac Catheterization
1.
2.
It is an invasive diagnostic procedure designed to study the
anatomical and mechanical aspects of the cardiac function.
Complications: Cardiac arrest and Dysrhythmias.
Acute myocardial infarction.
Anaphylactic shock.
Emboli to the lung or brain
9
5. Cardiac Monitoring / ECG
EKG Waveform:
EKG or ECG is a visual representation of the electrical
activity of the heart on a special paper called the EKG
paper is a graphic in which horizontal and vertical.
Horizontal:

A. 1mm = small box = 0.04 second.

B. 5mm = large box= 0.2 second.
For 1 minute = 300 large box or 1500 small box.
Vertical: 10 mm = 1 mv amplitude

Conduction System and EKG Strip.
10
11
ECG strip
1.
P wave: contraction of the atrium.
2.
QRS wave: contraction of the ventricles.
3.
T wave: relaxation of the ventricles.
4.
PR interval: 0.12 seconds.
5.
ST segment: normally not elevated more than
1mm or 0.047 second.
6.
QRS wave: duration: 0.04 – 0.1 second.
12
6. Stress Test/ Exercise tolerance test (ETT) / treadmill
test
It can assess the heart’s
reaction
under
physical
stress.
During an exercise ST, an EKG is performed while the patient
exercises in a controlled manner on a treadmill or stationary
bicycle at varied speeds and elevations. During a pharmacological
ST, a medication (e.g., dobutamine) is given to the patient, which
causes the heart to react as if it were under the physical stress of
exercise, though he is actually at rest.
13
7. CORONARY ANGIOGRAM
How it works: This procedure is the gold standard for 
viewing the arteries that nourish the heart. Doctors
insert a catheter through an artery in the leg and shake it
up toward the heart. They then send a special dye
through the tube that highlights the arteries under x-rays
and exposes any blockages.
Limitations: Because they are invasive angiograms 
have some risks: catheters can tear artery walls,
requiring surgical repair. (In 1% of cases, serious
complications including death, may occur.) Afterward,
patients need to lie still for four to six hours until the
blood vessel in the leg seals.
14
Dysrhythmias
Dysrhythmias or Arrhythmias: is an irregularity in the
rate, rhythm, or conduction of the electrical system of
the heart. The dysrhythmia can occur in any part of
the conduction system.
 Specialized cells in the heart muscle have the ability
to generate an electrical impulse. Under certain
conditions these cells start sending impulses to other
cells in the heart causing irregular beats called
ectopic beats.
 Causes of dysrhythmias:
 Coronary artery disease (CAD).
 Congestive heart failure (CHF).
 Myocardial infarction (MI).
 Electrolyte imbalances and drug toxicity.
15
Types of Arrhythmias:
1.
Sinus bradycardia/sinus Tachycardia
2.
Atrial flutter
3.
Atrial Fibrillation
4.
Premature Atrial Contraction
5.
SupraVentricular Tachycardia (SVT)
6.
Premature ventricular contraction
7.
Ventricular tachycardia
8.
Ventricular fibrillation
9.
Ventricular Asystole
16
Definitions
Flutter: Rapid, regular contraction of atria or
ventricle reaching upto 250/300 beats per
minute.

Fibrillation: Rapid, random, irregular 
contraction reaching upto 350-400 beats per
minute.
17
Management of Arrythmias
1. Cardioversion:
is the delivery of a synchronized (coordinated) electrical shock to
change a dysrhythmia to a rhythm
Uses: used mainly in ventricular tachycardia (VT)
Electrodes are placed to the right of the sternum below the
clavicle and at the apex of the heart. The electrodes are
lubricated with a special gel.
18
2. Defibrillation
is the delivery of an unsynchronized high-energy electrical shock
(up to 360 or more joules) during an emergency situation
Note:
•
Lubricate the electrodes and place them as in cardioversion.
•
When the electrical shock delivered to the client, everyone
stands clear (avoid touching) of the bed to prevent them from
receiving the electrical shock.
19
3. Cardiac Pacemaker Therapy:
 Pacemaker is a high-tension wire, highvoltage electrical generators used to generate
an impulse on the heart.
20
21
Complication:






Perforation of the myocardium wall by electrodes
(cardiac tamponade → distended neck vein).
Pacemaker malfunction (fails or rapid).
Thrombus formation.
Infections.
Hemorrhage.
Lower chest wall and abdominal discomfort
related to impulses for there muscle →spasm.
22
Nursing care of patient with pacemaker:
Preoperative
1.
2.
3.
4.
Assess V/S especially the pulses, mental status, ECG, and other lab and
diagnostic test ).
Obtain the consent form.
Recognize that the pacemaker is functioning
Provide psychological support and allow client to express his feelings
and answer his question (explanation mostly done by physician).
Postoperative
1.
2.
3.
4.
5.
6.
Check the operation site for complication and apply dressing as
ordered.
Assess V/S especially the pulse (rate, regularity, force)
Cover the external wires by gauze
Ask client to avoid close contact with large electrical motors
Advice client to inform any health professional referred to them
(Magnetic resonance imagining (MRI) may cause pacemaker
malfunction) and air port personnel that he has had a pacemaker.
The client should wear a medical identification tag indicating the
presence of a pacemaker.
23
ATHEROSCLEROSIS
Definition:
Abnormal accumulation of lipid or fatty
substances and fibrous tissues in vessel wall
Clinical manifestations:
Acute onset chest pain, ECG changes,
dysrhythmias & death
24
ATHEROSCLEROSIS
1.
Nonmodifiable




2.
Family history
Age
Gender
race
Modifiable






High blood cholesterol
Smoking
Hypertension
Diabetes mellitus
Obesity
Physical inactivity
25
PREVENTION
Control cholestrol level, LDL less than normal
Dietary control decrease fat & increase fiber
Medication to decrease serum fat & cholesterol
Quit smoking
Early detection & control hypertension
Control DM
Gender & estrogen level
Behavior pattern
26
Acute coronary syndrome
1.
2.
3.
Angina pectoris
Myocardial infarction (MI)
Sudden cardiac arrest
27
Angina Pectoris
(most common types of Coronary Artery Disease):
is a condition in which decrease blood and
oxygen supply to the heart muscles related to
narrowing of the coronary arteries
(Arteriosclerosis).
Arteriosclerosis is a narrowing and hardening of
the arteries due to fatty deposit
28
Types of angina:
1.
2.
Unstable angina: occurs at rest or with minimal exertion and
is not relieved with nitroglycerin. Client is at risk for
myocardial infarction and sudden death.
Stable angina: occurs with physical exertion, emotional
stress, smoking, exposure to extreme cold, and heavy meals.
S&S of angina:
1. Squeezing pain under the sternum, which radiates to
the Lt or Rt shoulder, jaw, or ear.
2. Shortness of breath with increased respiratory rate
3. Physical or mental fatigue and dizziness.
4. Changes in sleep patterns and mental alertness.
29
Risk factors of angina:
1.
Hereditary factors.
2.
Hypertension.
3.
Diabetes mellitus.
4.
Obesity.
5.
Sedentary life-styles.
6.
High LDL level.
Diagnoses by:




Stress test: the heart is placed under stress through increasing physical
activity on a treadmill or exercise bicycle. The increased oxygen demand of
the body puts an extraload on the heart causing electrocardiogram changes
and sometimes pain.
Coronary arteriogram: shows narrowing or occlusion of the vessels of the
heart.
Reviewing the client's history and lifestyle.
Laboratory tests: Cholesterol, low-density lipoprotein (LDL), and highdensity lipoprotein (HDL) levels.
30
Management of angina:
A.
Medical: Goal is to increase the blood supply to the
affected area by:
Pharmacological

Vasodilators: such as nitroglycerin

Analgesic medication.

Beta-adrenergic blockers and calcium channel blockers slow
the heart rate and decrease the oxygen demand of the heart.

Calcium channel blockers dilate vessels and decrease
spasms of the coronary vessels.
D. Diet and Activity:
1.
low-fat, low-cholesterol, salt-restricted diet.
2.
Bed rest may be need in the first time and then moderate
exercise was allowed.
31
2. B. Surgical
1-Percutaneous trans luminal coronary angioplasty
(PTCA): the atherosclerotic matter is pressed against
the wall of the coronary vessels to improve
circulation.
Complications: Occlusion of the vessel because of a
vascular spasm or vessel rupture.
2. Intracoronary stent.
3. Atherectomy cutter shaves the plaque away from the
artery wall.
4. Coronary Artery Bypass Graft (CABG) surgery is
performed by grafting a vein or artery from aorta to
the blood vessel after occlusion.
32
Percutaneous transluminal coronary
angioplasty (PTCA)
33
34
Coronary artery bypass graft
(CABG)
35
ATHERECTOMY
Rotational
Atherectomy

Directional
Coronary
Atherectomy
Extraction
Atherectomy
36
Nursing care:
1.
2.
3.
4.
5.
6.
7.
8.
Ask client to describe the pain (type, radiation, onset, duration,
and precipitating factors) frequently.
Assess vital signs
Observe the client on an EKG monitor and observed for any
dysrhythmias.
Give medication as ordered and monitor client's response.
Administer oxygen.
Teach the client to avoid situations that may produce angina
(stressful situations, sleep in a warm room, eat smaller meals)
Inform the client to carry nitroglycerin at all times.
Observe for side effect of nitroglycerin: (orthostatic
hypotension and headache).
37
Myocardial Infarction (MI)
Myocardial infarction (MI)
is caused by an obstruction in a coronary artery
resulting in necrosis (death) to the tissues. MI
is the leading cause of sudden death in men
and women.
Cause:
 Atherosclerotic plaque
 Thrombus
 Embolism.
38
Non modifiable risk factor
1.
2.
3.
Age
Gender
Family history
39
Modifiable risk factor
1.
2.
3.
4.
5.
Elevated serum lipids
Hypertension
Cigarette smoking
Obesity
Stress/anxiety
40
41
Clinical manifestation:
A. with symptoms:
 Chest heaviness or tightness that progresses to a severe
gripping pain (not relieved by rest or nitroglycerin) in the
lower sternal area. Upper abdominal pain.
 Shortness of breath.
 Diaphoretic.
 Anxious.
 Nausea and vomiting.
 Fatigue.
 Skin will be pale and then turn cyanotic.
 Confusion.
B. without symptoms: general symptoms:


Fatigue.
Frequent hiccups.
42
Complications:
1.
Heart failure.
2.
Stroke.
3.
Cardiogenic shock.
4.
Thrombosis.
Diagnosis by:
1.
2.
3.




Clinical symptoms
Electrocardiogram (ECG): elevation of ST segment and inversion
of T wave.
Cardiac enzymes.
LDH.
CPK.
Cardiac tropinin I: protein found in cardiac cells. When cardiac cells are
damaged, this protein is released resulting in elevated levels (<0.6 mg) for 7
days.
Cardiac myoglobin: blood levels elevate within an hour of an MI, peak in 4
to12 hours, and return to normal in 18 hours.

Radioactive isotope scan.
43
Management:
Medical:
Aim of management:
1.
Reduce oxygen demands.
2.
Increase oxygen supply to the myocardium.
3.
Relieve pain.
4.
Improve tissue perfusion.
5.
Prevent complications.
A.Medical management:
1.
Oxygen administration.
2.
Complete bed rest.
3.
Analgesia.
4.
Coronary artery vasodilators (Nitrates).
5.
Decrease stress and anxiety.
B. Surgical:
1.
PTCA (balloon compression).
2.
CABG.
44
CABG
Harvested vessels are connected to the blocked arteries. Several
medical centers are now offering minimally invasive coronary artery
45
surgery. Less invasive technique for 1 or 2 clogged arteries.
C. Pharmacological
1.
Morphine sulfate.
2.
Nitrates.
3.
Sedatives.
4.
Thrombolytic therapy: streptokinase (Streptase)
and Activase. These medications may cause
bleeding.
5.
Heparin therapy inhibits further clotting.
6.
Aspirin or ticlopidine (Ticlid) is given to prevent
vasoconstriction and platelet aggregation.
D. Diet: liquid diet is progressed to a regular low-fat,
low-cholesterol, low-salt diet (small frequent
feedings).
E. Activity: physical, mental, and emotional rest.
46
Nursing care:
1.
Assess pain, vital signs (peripheral pulses), skin changes,
breath sounds, mental status, and EKG rhythm strips.
2.
Administer medication.
3.
Observe for complication and side effect of medication
4.
Provide all care for client while is in complete bed rest.
5.
Prevent visits.
6.
Provide oxygen.
7.
Provide a quiet, calm environment.
8.
Reassurance and provide of psychological support.
9.
Monitor I&O.
47
Heart Failure (HF)
or Congestive Heart Failure (CHF)
Heart Failure is the inability of the heart muscle to contract
well to eject blood for the body parts. The muscles are
hypertrophied (increases muscle mass) and ventricles are
enlarged.
Types of heart failure:
1.
2.
Left-sided heart failure Pulmonary edema
Right-sided heart failure. Peripheral edema
Causes:
1.
2.
Coronary artery disease.
MI and other cardiac diseases.
48
Heart Failure
49
Clinical manifestations OF Left
Ventricular Failure
Signs and Symptoms:
Tachycardia (early sign)
Exertional and nocturnal dyspnea
Orthopnea
Dry Cough with frothy sputum
Nocturia
Crackles in the lungs→ Pulmonary Edema
S3 and S4 heart sounds
↑ HR (early sign)
Fatigue
•








50
Right Ventricular Failure
Tachycardia (early sign)
By itself usually from pulmonary disease
Most often occur 2nd-ary to Left Heart Failure
Ascites, GI Disorders (nausea), abd. pain
Jugular Vein Distention (JVD)
Liver and Spleen engorgement
JVD
Dependent bilateral pitting edema
Weight Gain
Murmurs
Anxiety
Anorexia
Nocturia
Fatigue












51

Diagnosis:
1.
Chest x-ray: visualize the ventricles and check for evidence of
lung congestion.
2.
EKG.
3.
Arterial blood gases.
4.
Oxygen saturation.
Management:
A. Medical
Goals for treating CHF:
1.
Improve circulation to the coronary arteries
2.
Decrease the workload of the left ventricle.
Intervention:
1.
2.
3.
Use medication.
Administer oxygen.
Keep client in bed rest.
52
B. Pharmacological
1.
Diuretics.
2.
Digitalis preparation to increase the strength and contractility of the heart
muscle.
3.
Vasodilators such as nitroglycerin are given to dilate the veins → blood
will stay in the peripheral vessels and decrease blood return to the right
side of the heart→ decreasing the workload on the heart.
4.
ACE (angiotensin-converting enzyme inhibitors; Capoten): to reduce blood
pressure and peripheral arterial resistance and improve cardiac output.
5.
Morphine: to control pain and decrease anxiety.
C. Diet: Fluid intake may be limited and the client is generally on a lowsodium diet.
D. Activity: Activity may range from complete bed rest to allowances of some
activity according to the client condition.
53
E. Surgical:
1. Intra-aortic balloon pump.
2. Ventricular assist device (VAD).
3. A cardiomyoplasty.
54
Intra-Aortic Balloon Pump
Procedure:
Catheter is inserted
into femoral artery
Advanced into
descending Aorta
Balloon inflates
during Diastole
Balloon deflates
during Systole
55
Ventricular Assist Devices
(VAD)
Purpose: Provides longer term support for a 
decompensated heart
Assist or replace the action of the ventricle 
May be implanted or external 
Indications: 
Ventricular failure associated with an MI 
Waiting for a donor or artificial heart 
56
Nursing care:
1. A daily weight and strict intake and output are
necessary to assess fluid retention.
2. Restrict fluid and provide diet as ordered
3. Provide bed rest.
4. Elevate the head of the bed to 45°.
5. Administer medication as prescribed.
6. Provide oxygen.
Continue
57
7.Monitor the electrolytes: potassium and
sodium level.
8.Take the apical pulse before giving a digitalis
preparation (If the heart rate is below 60,
withhold the medication and notify the
physician).
9. Assess of peripheral pulses and capillary refill:
check the level of circulation to the
extremities.
10. Assessment for edema in extremities and
abdomen.
58
Inflammatory Disorders of the Heart
Infective endocarditis.
2.
Myocarditis.
3.
Pericarditis.
Other Disorders
1.
Valvular heart disease.
2.
Rheumatic heart disease.
1.
59
Rheumatic Heart Disease:
Is inflammation on the heart which results as a complication
of rheumatic fever and is linked to group "A betahemolytic streptococcus" following an upper respiratory
infection (mainly pharyngitis).
Symptoms of rheumatic fever:
1.
2.
3.
4.
5.
Mild fever
Polyarthritis
Carditis.
Chorea (abnormal movement in hands).
Rash.
Once the person is affected with rheumatic fever, he is
more susceptible to having it again.
60
Sites of inflammation on the heart:
1.
2.
Three heart layers: endocardium, myocardium, and epicardium.
Mitral valve (stenosis: thickening and stenosis).
Management:
Types of management:
1.
2.
3.
4.
Antibiotics.
Anti-inflammatory agents
Corticosteroids
Strict bed rest.
Main goal of treatment:
1.
Treat the inflammation.
2.
Prevent cardiac complications.
3.
Prevent the recurrence of the disease.
61
Infective Endocarditis
It is an inflammation or infection (bacteria, fungi, or virus) of
the inside lining of the heart, particularly the heart
valves→ scar tissue on the valves → become hard, weak,
and do not close properly.
Symptoms of endocarditis:
1.
Symptoms of a systemic infection.
2.
Tachycardia, pallor, and diaphoresis.
3.
Dyspnea, peripheral edema, and pulmonary congestion.
Management of Infective endocarditis:
1.
Surgical repair or replacement of a valve is done in severe
cases.
2.
Pharmacological:Antibiotics such as penicillin1 V,
vancomycin, and gentamycin sulfate.
3.
Activity: he client is placed on bed rest.
62
Myocarditis:
It is the inflammation of the myocardium of the heart.
diagnosis of myocarditis can be confirmed with an
endomyocardial biopsy.
Management
1.
2.
Medical: Oxygen is administered as needed.
Pharmacological:
1.
2.
3.
4.
Digitalis preparations are given to try to prevent congestive heart failure.
Antibiotics.
Anti-inflammatory agents: to reduce the inflammation.
Activity: bed rest on semi-Fowler's position
63
Pericarditis:
is the inflammation of the membranous sac surrounding the heart mainly by
virus, bacteria, fungal, and parasites or idiopathic (meaning no known
cause).
Symptoms:



Severe precordial pain (anterior surface of the chest over the heart).
Pericardial friction rubs (noisy sound heard when 2 layers of the pericardial
surfaces are rubbing during heart contraction.
Cardiac tamponade (excess fluid in pericardial space) may develop.

Management:
1.
Pericardiocentesis: aspiration the excess fluid from the pericardial sac.
Pharmacological
2.


Antipyretics, analgesics, anti-inflammatory agents, and antibiotics.
Digitalis and diuretics
64
Nursing care for Inflammatory Disorders of the
Heart patient:
1.
2.
3.
4.
5.
6.
7.
Administer medication and monitor for their action and side
effect.
Encourage bed rest.
Administer oxygen.
Assist in procedure and preparing for procedural treatment and
surgery.
Monitor vital signs.
Monitor EKG for dysrhythmias.
Put client in a comfortable position.
65
Valvular Heart Disease
66
Understanding Terms
Stenosis = Constriction or narrowing of orifice
Regurgitation = Retrograde or backflow of 
the flow of blood from one chamber back into
another
Prolapse = valve leaflets billow back or 
buckle back into the atrium

67
Mitral Stenosis
Mitral valve becomes narrow and constricted 
Causes : -↑ L. Atrial pressure and volume 
Most are due to Rheumatic Heart disease 
Symptoms: murmur at 5th Inter Costal Space 
(ICS) , Extended dyspnea and fatigue
68
Mitral Valve Prolapse
Valve billows back into L. Atrium 
Cause is unknown 
Heard as a murmur 
Can be familial due to connective tissue
disorder
Most people asymptomatic, benign 
Most common valve disorder 
May lead to Mitral Valve Regurgitation
Diagnosed by ECHO 


69
Mitral Regurgitation
Retrograde blood flow from L. Ventricle to 
L. Atrium
Etiology R/T: MI, Rheumatic heart disease, 
MVP
Symptoms R/T acute or chronic murmur 
Heard best at 5th ICS
May feel a thrill 

More common in women than men

70
71
Aortic Stenosis
Blood flow restricted from L. Ventricle to
Aorta
Results in LVH, & ↑myocardial oxygen
consumption
Causes: congenital, Rheumatic Fever,
atherosclerosis
Symptoms - ↓ S1 or S2 sound
Murmur
S4






72
Aortic Regurgitation
Retrograde blood flow from the Ascending
Aorta into L. Ventricle
Results in: L. Ventricle dilation & LVH,
leading to ↓contractility of the heart
murmur
Soft S1, S3 or S4
Causes: Congenital, Rheumatic Heart Disease
May have Orthopnea, Exertional dyspnea,
paroxysmal nocturnal dyspnea






73
Tricuspid Valve Disease
Stenosis & Regurgitation
Tricuspid Stenosis is uncommon
R. Atrium enlargement & ↑systemic venous 
pressure
Tricuspid Regurgitation
Volume overload in R. Atrium and 
Ventricle occurs
Causes: R. Ventricular dysfunction, or 
pulmonary HTN



74
Diagnosing Valve Disease
History and Physical Exam
Echocardiography
Cardiac Catheterization
ECG




75
Collaborative Care for Valvular
Disease
Ask about history of Rheumatic Heart Disease
Use of antibiotic prophylaxis
Digitalis
Diuretics
Anticoagulation (ASA, Coumadin)
Surgical repair or replacement






76
REPAIR PROCEDURES
Balloon valvuloplasty:- A balloon catheter is passed
thru the femoral vein to enlarde the valvular orifice.
Mitral Annuloplasty:- Tightening and suturing the
malfunctioning valve annulus to eliminate or greatly
reduce regurgitation
Commissurotomy / valvotomy:- The valve is
visualised, thrombi removed from the atria, fused
leaflets incised and calcium is removed to widen the
orifice thru open heart surgery
VALVE REPLACEMENT Procedures
Mechanical prosthetic vaves
Bioprosthetic valves





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
Shock
 It is a condition of profound hemodynamic and
metabolic disturbance characterized by
inadequate tissue perfusion and inadequate
circulation to the vital organs.
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Types of shock
Type
cause
Signs and
symptoms
Emergency care
Hypovolemic
Hemorrhage, burns or fluid
loss
Increased
HR;
hypotension; cold,
clammy
skin;
thirst
Replace fluids
Cardiogenic
MI, HF
Increased
HR;
hypotension; cold,
clammy skin
Initiate drug therapy for
myocardial infarction;
replace fluids; possible
emergency coronary
bypass surgery
Toxic
infection
Hot, dry, flushed skin;
hypotension;
increased
heart
rate
Locate source of infection,
treat
with
broadspectrum
antibiotic;
replace fluids.
Anaphylactic
Medications, insect bites or
stings, foods
Throat edema with
increasing
difficulty
breathing; hypotension; increased
heart rate
Manage ABCs; administer
epinephrine
(Adrenalin);
Neurogenic
Spinal cord injury.
Slow
HR
hypotension
Replace fluids, administer
drugs to increase blood
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pressure and heart rate
and
Management:
A. Medical
1.
Initiate resuscitation: maintenance of the ABCs
(Airway, Breathing, and Circulation).
2.
Stop active bleeding.
3.
Blood can be administered.
4.
Identify and treat the underlying cause of shock
(after the client is stabilized).
B. Pharmacological:
1.
Administration of oxygen.
2.
Insertion of two large intravenous (IV) lines; fluids
may be administered.
3.
Administration of epinephrine, ( to improve
circulation).
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Nursing care:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Maintenance of the ABCs (airway, breathing, circulation).
Administration of oxygen.
Stop active bleeding.
Evaluate vital signs.
Initiate and maintain fluid replacement with two large IV
access lines.
Administer medication.
Administer blood as ordered.
Evaluate client for paleness, diaphoretic, and clammy skin.
Monitor intake and output.
The client should be asked to describe any pain with
regard to intensity, location, and duration.
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VASCULAR DISORDERS
82
Hypertension
Hypertension (HTN): known as high blood pressure. A systolic blood
pressure above 140 or a diastolic pressure above 90 is indicative of
hypertension.
Cause: the cause of HTN is unknown but there are many Risk factors e.g.:
1.
2.
3.
4.
5.
6.
Family history of hypertension.
Smoking.
Hyperlipidemia.
Obesity and lack of exercise.
Diabetes mellitus.
Low education and low socioeconomic status.
Classification of HTN:
1.
2.
Primary hypertension: the cause is unknown
Secondary hypertension: is due to another condition within the body such
as renal diseases and Arteriosclerosis disease.
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Classification of hypertension
Bp classification SBP
MM of HG
DBP
MM of HG
Normal
And <80
<120
Prehypertentsion 120-139
80-89
Stage 1
HTN
Stage 2
HTN
140-159
90-99
≥160
≥100
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Complications of HTN:
1.
2.
3.
4.
cerebral vascular accident (stroke)
myocardial infarction
congestive heart failure
Renal failure.
Sings and symptoms:
The hypertensive client may not be experiencing any symptoms
or may complain of the following symptoms:
1.
2.
3.
Headache.
Blurred vision.
Fatigue.
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Management:
A. Medical: Main goal is to keep blood pressure within normal limits.
1.
The first step (3-6 months) is to encourage the client to change the diet and
lifestyle. If the BP still remains high (>140/90) →the second step.
2.
The second step (2 months) adding a diuretic or a beta blocker to the client's care
regimen.
3.
Trying another drug, or adding a second antihypertensive drug from another class
of drugs.
4.
The last step would be implemented by adding a second or third antihypertensive
drug.
B. Pharmacological:
1.
Diuretics (increase the renal excretion of sodium and water).
2.
Beta-adrenergic blocking agents are given to block the epinephrine and
norepinephrine receptor sites: Inderal.
3.
Alpha-receptor blockers: cardura.
4.
Angiotensin-converting enzyme (ACE) inhibitors: Capoten.
5.
Calcium channel blockers: isoptin.
6.
Direct vasodilators: hydrolazine hydrochloride (Apresoline).
C. Diet: Low fat, low-cholesterol, and low-sodium diet (6 grams sodium chloride).
D.Activity: A regular aerobic exercise (Walking and swimming) regimen (30 to 45
minutes 3 to 5 times / week) assists in lowering blood pressure
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Nursing care:
1. Assess BP accurately and repeat blood
pressure (if it is high) after 15 minutes later
and compared to previous readings. Report
any abnormal readings.
2. Assess height and weight.
3. Assess life-styles.
4. Educate client about dietary and lifestyle
changes.
5. Assess for complication.
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Disorders of Peripheral Arteries
Acute arterial occlusion:
Causes:


External compression.
Thrombosis (blood clots) or embolus (foreign mass such as air, fat, and
cancerous cell).
Signs and symptoms ( 5 Ps):
1.
2.
3.
4.
5.
Pain (intermittent caludication): relived by rest.
parastheasia or Numbness or burning sensation (more at
night) and worsen progressively.
Pulselesness: Weak or absent peripheral pulses. Compare
between 2 legs. If pulse is deep Doppler flowmeter may be
used.
Pallor.
Paralysis.
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Treatment:
Aim of treatment:
1.
Prevent enlargement of clots
2.
Prevent other clots formation.
3.
Prevent transmission to the vital organs.
Types of treatment:



Thrombolytic therapy.
Anticoagulant to prevent new cases.
Bypass surgery.
Nursing responsibility:
1.
2.
3.
4.
5.
Identify persons at risk and early detection by frequent assessment of the
circulation (establish baseline assessment of the pulses, skin color, and
temperature) and report abnormal findings to the physician.
Observe for complication.
Administer medication.
Provide skin care because client may be in bed rest.
Monitor client for signs of bleeding
89
Deep vein thrombosis (DVT):
DVT is the formation of a blood clot (thrombus) inside
a blood vessel.
Causes:




Injury to the inner lining of a blood vessel
Blood disorders that result in thickened blood and an
increased tendency toward clotting.
Restricted blood flow, caused by such problems as
obesity.
Atherosclerosis.
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DVT → Thrombophlebitis (swelling and
inflammation where the clot develops in the vein).
Treatment:
1.
2.
Administration of anticoagulants and thrombolytic
drugs.
Surgical techniques for removing particularly
threatening clots.
An important nursing intervention
is to assess the improvement of the condition and the early signs
of complication (movement of the clots to the brain, lung,
or the heart).
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Chronic peripheral vascular problems
Varicose Vein:
mean is dilated and tortuous (unstraight) vein.
Causes:
1.
Increased resistance to its forward movement (upright
position, compression, long standing, obesity, and
pregnancy) →valve become incompetent and may be
damaged→ blood stasis.
2.
Hereditary weak vein.
Signs and symptoms:
1.
2.
3.
4.
5.
Dilated, tortuous vein, and discolored vein area (blue color).
Local edema → necrosis.
Cramp pain.
Heavy feeling of affected tissue.
Swelling of the ankles and ulcerations on the skin.
92
93
Dilated, tortuous vein, and discolored vein area (blue color).
94
Common sites:
1.
2.
3.
4.
Legs (most commonly) →venous thromboses.
Anus (hemorrhoids)
Esophagus
Testes in males (varicocele)
.
Treatment:




Applying elastic stocking.
Avoid conditions that increase the resistance to movement of blood in to the
vein.
Sclerosing agent.
Surgical: ligation under general anesthesia.
Nursing care:
1.
2.
3.
4.
5.
Assess for adequate circulation (color, temp, sensation, capillary refill).
Inspect site of surgery for bleeding, infection, and make a dressing as ordered.
Apply elastic stocking.
Elevate leg.
Encourage mobilization in the first day of operation.
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Aneurysms
is a localized dilation of an artery's medial layer.
Causes of aneurysms:
1.
Atherosclerosis and HTN.
2.
Hereditary: lack of elastin in the arterial wall.
3.
Congenital conditions.
4.
Acquired: trauma to the vessel wall, infection and/or inflammation, and
syphilis.
Symptoms of an aneurysm: Aneurysms are often asymptomatic until they start
leaking or pressing on other structures.
Rupture of an aneurysm is an emergency. Signs of rupture:
1.
2.
3.
Hypotension, tachycardia, pallor, cool and clammy skin.
Intense abdominal, back, or groin pain.
Diaphoresis and loss of consciousness.
96
97
Diagnoses: may be discovered by X-ray and ultrasound done for other conditions.
1.
Doppler ultrasound.
2.
Cardiac catheterization.
3.
Angiogram.
4.
CT scan.
Main types:
A. Abdominal Aortic Aneurysm (AAA): Signs:
1.
Abdominal, back, or flank pain.
2.
The client may feel a pulse in the abdomen when in a supine position.
3.
Tender pulsating mass may be palpated slightly left of the umbilicus.
B. Thoracic Aorta Aneurysm (TAA):
1.
2.
3.
Thoracic aneurysm may press on surrounding structures causing dull upper
back pain or deep, scattered chest pain.
Pressure on the trachea and bronchus may cause dyspnea, coughing, wheezing,
and hoarseness.
The client experiences dysphagia from pressure on the esophagus.
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Management of the Aneurysm:
A. Medical


Control of the hypertension.
Monitor Aneurysms for enlargement & for Thrombi formation.
B. Surgical
Replacement of the aorta by grafting with a saphenous vein or a synthetic
vein.
1.
Administer blood (4 to 8 units) before surgery.
2.
Nasogastric tube may be inserted: to decrease pressure on the aneurysm repair site
and incision.
3.
After surgery, the client kept with mechanical ventilator assistance in breathing.
Complications of surgery:
Myocardial infarctions &Strokes.

Renal damage.

Occlusion of the Vessels below the repaired aneurysm.
C. Pharmacological
1.
Inderal: to decrease the pressure of the blood coming from the heart to the affected
vessel.
2.
Antihypertensive medications and diuretics.
3.
Analgesics.
D. Activity: avoid any activity that increases blood pressure

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Nursing care:
1.
2.
3.
4.
5.
Palpate abdomen for a pulsating mass or other parts
of the body according to the site of aneurysm.
Check vital signs.
Assess capillary refill.
Take antihypertensive medication regularly .
Monitor for symptoms of vessel occlusion (pain,
paleness, cyanosis, and coldness).
Continue
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6. Check the operative site and under the client's
body frequently for hemorrhage.
7. Measure the abdomen for increasing
abdominal girth (internal bleeding).
8. Assess for edema which could indicate fluid
overload or a vessel occlusion.
9. Measure output to make sure the client has at
least 25 to 30 cc of urine/ h.
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Thank you
102