Chapter 47
Care of the Patient with a
Cardiovascular or a Peripheral
Vascular Disorder
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The Heart
About the size of a fist
Located within the mediastinum
Pumps approximately 1000 gallons of blood
every day
Divided into four chambers
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2
Chambers of the Heart
deoxygenated
Right atrium
oxygenated
Left atrium
Receives deoxygenated
blood from the body
Pumps blood to the right
ventricle
Right ventricle
Pumps blood into the
pulmonary artery
Receives oxygenated
blood from the pulmonary
vein
Pumps blood to the left
ventricle
Left ventricle
Pumps oxygenated blood
to the body through the
aorta
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3
Valves of the Heart
The tricuspid valve is located between the right atrium and right
ventricle
The pulmonary semilunar valve is located between the right
ventricle and the pulmonary artery
The bicuspid valve is located between the left atrium and left
ventricle
The aortic semilunar valve is located between the left ventricle
and the aorta
The opening and closing of the AV valves creates the
characteristic “lubb,” first heart sound
The opening and closing of the semilunar valves creates the
characteristic “dubb,” or second heart sound
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4
The Conduction System of the Heart
Sinoatrial (SA) node—the pacemaker of the
heart
Atrioventricular (AV) node slows the impulse
to allow the atria to fill the ventricles
The AV node also serves as a secondary
pacemaker
The bundle of His
Purkinje fibers
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5
Coronary Blood Flow
Blood enters
coronary blood flow
through the right
and left coronary
arteries
Flows through
coronary circulation
Returns to systemic
circulation via
coronary veins
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Diagnostic Tests (PTEC 150 Obj.#1)
A number of diagnostic tests are used to evaluate
coronary function
Diagnostic imaging
Cardiac catheterization and angiography
Electrocardiography
Cardiac monitors
Thallium scanning
Echocardiography
Positron emission tomography
MUGA scan
Laboratory tests
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7
Diagnostic Imaging
Radiography
Angiogram
Aortogram
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8
Cardiac Catheterization
and Angiography
An invasive procedure used to visualize the
heart’s chambers, valves, great vessels, and
coronary arteries
Used to measure
Pressure within the heart
Blood-volume relationship to cardiac competence
Valvular defects, arterial occlusion, and
congenital anomalies are determined
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Electrocardiography
ECG or EKG
A graphic study of the electrical activities of
the myocardium to determine transmission of
cardiac impulses through the muscles and
conduction tissue
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Cardiac Monitors
Telemetry
Exercise stress ECG, or stress test
Thallium scanning
Echocardiography
PET scan
MUGA scan
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Laboratory Tests
CBC
PT/INR
Erythrocyte sedimentation rate
Serum electrolytes
Serum lipids
Arterial blood gases
Serum cardiac markers
B-type natriuretic peptide (BNP)
Homocysteine
C-reactive protein
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12
Risk Factors for
Cardiovascular Disease
PTEC 150 Obj.#4
Non-modifiable Risk Factors
Family
Gender
Age
Ethnicity
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Risk Factors for Cardiovascular
Disease cont’d
Modifiable Risk Factors
Smoking
Hyperlipidemia
Hypertension
Diabetes mellitus
Obesity
Sedentary lifestyle
Stress
Psychosocial
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PTEC 150 Obj. #3
Describe at least 5 common DO of the heat
and related nursing care
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Cardiac Dysrhythmias
A dysrhythmia (or arrhythmia) refers to any cardiac
rhythm that deviates from normal sinus rhythm
Normal sinus rhythm
Rate: 60-100 bpm
P waves: precede each QRS complex (atrial depolarization)
P-R interval: interval between atrial and ventricular
repolarization
QRS complex: ventricular depolarization
T wave: ventricular repolarization
Rhythm: regular
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Cardiac Dysrhythmias cont’d
Sinus tachycardia
Sinus bradycardia
Supraventricular tachycardia
Atrial fibrillation
Atrioventricular block
Premature ventricular contractions
Ventricular tachycardia
Ventricular fibrillation
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Angina Pectoris
Table 8-3 p. 334
Refers to thoracic pain or choking caused by
decreased oxygen of the myocardium
Atherosclerosis of the coronary arteries is the
most common cause
Pain is the characteristic symptom of angina
pectoris
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Angina Pectoris cont’d
Assessment
Subjective data
Patient reports of pain
Feeling of impending doom
Objective data
Signs of pain
Increased pulse
Increased blood pressure
Increased respiratory rate
Anxiety
Diaphoresis
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Angina Pectoris cont’d
Diagnostic Tests
ECG may reveal ischemia and rhythm changes
Exercise stress test may show ischemic changes
Coronary angiography may show changes
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Angina Pectoris cont’d
Medical Management and Surgical
Interventions
Antiplatelets
Vasodilators
Beta blockers
Calcium channel blockers
Nitrates
Coronary artery bypass graft
Percutaneous transluminal angiography
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Angina Pectoris cont’d
PTEC 150 Obj.# 2
Nursing Interventions
Promote comfort
Promote tissue perfusion
Promote rest
Reduce anxiety
Promote feelings of well-being
Provide patient education
**** Reduce the workload of the heart****
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Myocardial Infarction
Table 8-3 p 334
An occlusion of a major coronary artery or
one of its branches with subsequent necrosis
of myocardium caused by atherosclerosis or
an embolus
An asymptomatic MI may occur
Pain is the leading symptom of MI
Pain not relieved by nitroglycerin or rest
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Myocardial Infarction cont’d
Assessment
Pain (OPQRST)
Tachycardia
Weak pulse
Hypotension
Diaphoresis
Vomiting
Pale skin
Labored respirations
Cardiac dysrhythmias
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Referred pain - MI
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MI - Women
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Myocardial Infarction cont’d
Diagnostic Tests
Troponin T
Troponin I
ECG
12-lead ECG
Echocardiogram
PET scan
MUGA scan
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Myocardial Infarction cont’d
Medical Management
Focuses on preventing further tissue injury
MONA: Morphine, oxygen, nitroglycerine, aspirin
Beta blockers
Calcium channel blockers
Fibrinolytics
PTCA
CABG
“Time is muscle”
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Myocardial Infarction cont’d
Nursing interventions
Administer medications
Avoid excess fatigue
Assist with ADLs
Encourage and provide education about cardiac diet
Prevent complications
Encourage patient to discuss feelings
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Heart Failure
When the heart has become unable to meet
the metabolic demands of the body
Patient may have
Left ventricular failure
Right ventricular failure
PE
CHF
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Heart Failure cont’d
Assessment
Dyspnea
Orthopnea
Jugular venous distention (JVD)
Fluid retention
Ascites
Peripheral edema
Weight gain is the most sensitive indicator
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Heart Failure cont’d
Diagnostic Tests
CBC – complete blood count
BMP – basic metabolic panel – electrolytes,etc
BNP - B type natriuretic peptide hormone
ABGs - Arterial blood gasses
ECHO- sonogram of the heart
ECG – electrical conduction
MUGA scan – cardiac function, ejection fraction
BUN - Blood Urea Nitrogen – decreased glomerular
filtration
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Heart Failure cont’d
Medical Management
Loop diuretics
Thiazide diuretics
Diuretics work to reduce fluid build up – treat edema & pulmonary
congestion
Nitrates: medications used for treating or preventing chest pain
(angina) caused by heart disease, usually of the arteries in the
heart. Nitrates are vasodilators (dilators of blood vessels that
increase their diameter) that allow blood to flow more easily.
Digoxin – increase cardiac efficiency
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ACE inhibitors: Angiotensin-converting enzyme
(ACE) inhibitors help relax blood vessels. ACE
inhibitors prevent an enzyme in your body from
producing angiotensin II, a substance in your
body that affects your cardiovascular system by
narrowing your blood vessels and releasing
hormones that can raise your blood pressure.
This narrowing can cause high blood pressure
and force your heart to work harder.
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Beta blockers: also known as beta-adrenergic
blocking agents, are medications that reduce your
blood pressure. Beta blockers work by blocking
the effects of the hormone epinephrine, also
known as adrenaline. When you take beta
blockers, the heart beats more slowly and with less
force, thereby reducing blood pressure
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ARBs: Angiotensin II receptor blockers (ARBs)
are medications that block the action of
angiotensin II by preventing angiotensin II from
binding to angiotensin II receptors on the
muscles surrounding blood vessels. As a
result, blood vessels enlarge (dilate) and blood
pressure is reduced.
Diet
Fluid restriction
Oxygen
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Heart Failure cont’d
Nursing Interventions
Monitor vital signs
Monitor fluid status
Assess lung sounds
Monitor urinary output
Assess edema – lower extremity - sacrum
Assess for signs and symptoms of pulmonary edema
Daily weight 1Liter fluid = 1 kg or 2.2 lbs.
So, a weight gain of 2.2 lbs. means the patient
has a liter of excess fluid
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Valvular Heart Disease
Stenosis – definition?
Insufficiency
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Valvular Heart Disease cont’d
Assessment
Fatigue
Weakness
Pain
Nocturnal dyspnea
Orthopnea
Crackles
Edema
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Valvular Heart Disease cont’d
Medical Management and Nursing
Interventions
Commissurotomy is an open-heart surgery that repairs a
mitral valve that is narrowed from mitral valve stenosis. During
this surgery, a person is put on a heart-lung bypass machine.
The surgeon removes calcium deposits and other scar tissue
from the valve leaflets.
Valve replacement
Assist with ADLs
Administer prescribed medications
Assess oxygenation status – O2 Sat
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Patient Teaching for
Cardiac Disorders
Diet
Medications
Procedures
Rest
Smoking cessation
Exercise
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Cardiac Rehabilitation
Cardiac rehabilitation has two major parts
Exercise training to help the patient learn how to
exercise safely, strengthen muscles, and improve
stamina
Education, counseling, and training to help the
patient understand his or her heart condition and
find ways to reduce the risk of future heart
problems
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Pulmonary Edema
The accumulation of extravascular fluid in
lung tissues and alveoli, most often caused
by heart failure (HF)
An acute and extensive life-threatening
complication of HF caused by severe left
ventricular dysfunction
See blue box 8-5 & 8-6 & green table 8-7
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Pulmonary Edema cont’d
Clinical Manifestations and Medical
Management
Severe respiratory distress
Pink sputum
Frothy sputum
For assessment see Box 47-5
Diagnosed by radiograph of the chest
Medical management involves simultaneous
interventions to promote oxygenation, improve
cardiac output, and reduce pulmonary congestion
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Pulmonary Edema cont’d
Nursing Interventions
Promote oxygenation
Promote venous return to the heart
Promote adequate respiration
Monitor I&O
Monitor electrolytes
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Rheumatic Heart Disease
Is a result of rheumatic fever
Arises from group A or group B streptococcus
infection – strep throat!
Characterized by fever, epistaxis, tachycardia, and
nodules on joints
Assessment will reveal joint pain, chest pain, or other
manifestations associated with complications
Valvular manifestations will mimic valvular disease
It is diagnosed through signs and symptoms and lab
values
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Rheumatic fever
Sydenham chorea is a major
sign of acute rheumatic fever.
The person may currently or
recently have had the disease.
may be the only sign of
rheumatic fever in some
patients.
occurs most often in girls before
puberty, but may be seen in
boys.
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Erythema marginatum – rheumatic fever
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Rheumatic Heart Disease cont’d
Medical Management
Prevention is the best management
NSAIDs
Antibiotics
If needed, valve repair or replacement
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Rheumatic Heart Disease cont’d
Nursing Interventions
Promote rest as indicated by patient’s condition
Administer prophylactic antibiotics as prescribed
Provide patient education regarding dental
procedures
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Pericarditis
Inflammation of the pericardium caused by bacteria, fungus, or
virus
Characterized by retrosternal chest pain that is worse when
lying supine
Chest pain should be thoroughly assessed
Patient should be assessed for general aches and fatigue
Diagnosis made through careful assessment and lab values
The nurse should evaluate the patient and monitor vital signs
Supportive care should be provided
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Endocarditis
Inflammation of the endocardium
IV drug abusers are the most frequently affected
Patient complains of flulike symptoms and chest pain,
and may have splinter hemorrhages or petechiae
Treatment involves rest and antibiotics
Surgery may be required
Nursing interventions are aimed at symptom control
and promoting rest and comfort
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Cardiomyopathy
Cardiomyopathy is a term used to describe a
group of heart muscle diseases that primarily
affect the structural or functional ability of the
myocardium
Dilated
Hypertrophic
Restrictive
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Cardiomyopathy cont’d
Causes
Infection
Metabolic disorders
Severe nutritional disorders
Alcohol abuse
Peripartal disorders
Drugs
Radiation therapy
Lupus
Rheumatoid arthritis
Cocaine abuse
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Cardiomyopathy cont’d
Clinical Manifestations
The patient may have symptoms of heart failure,
edema, or hepatic dysfunction
Medical management includes ACE inhibitors,
antidysrhythmics, or beta blockers
Heart transplantation
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Effects of Aging on the Heart
Blood vessels become thicker and less
compliant
Peripheral vascular resistance increases,
causing a rise in blood pressure
Atherosclerotic changes in the blood vessels
increase
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PTEC 150 obj #6
Describe at least 4 Dos of the blood vessels
ad discuss related nursing care
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Arterial Disorders Assessment
Intermittent claudication
Strength of pulses
PATCHES mnemonic
Pulses
Appearance
Temperature
Capillary refill
Hardness
Edema
Sensation
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Arterial DOs
Atherosclerosis
Arteriosclerosis
Sometimes used interchangeably
Thickened narrowed arteries
Plaques,
Hardened calcified vessel walls
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PAD: peripheral arterial dz
5 P’s
Pain
Pulselessness
Pallor
Paresthesia
Paralysis
Pp. 362-363 clinical manifestations
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Venous Disorders Assessment
Chronic edema
Stasis ulcers
Peripheral pulses are present
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Hypertension
Essential
Secondary
Malignant
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Hypertension cont’d
Essential hypertension (HTN)—there is no
underlying cause
Accounts for 90-95% of HTN cases
Secondary HTN occurs as the result of a
comorbidity
Malignant HTN is a severe, rapidly
progressive elevation in blood pressure that
causes damage to the small arterioles in
major organs
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Hypertension cont’d
Medical management
Medications
Lifestyle modification
Diet
Smoking cessation
Stress management
Treat underlying causes of secondary HTN
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Arterial Aneurysm
An aneurysm is an enlarged, dilated portion
of an artery that exceeds 3 cm
Aneurysms may be the result of
arteriosclerosis, trauma, or a congenital
defect
Aortic aneurysms are most common in men in
their 60s and 70s
Other risk factors are smoking, hypertension,
atherosclerosis, family history of aortic
aneurysm, infarction, and trauma
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Arterial Aneurysm cont’d
Clinical Manifestations and Diagnostic
Exams
Palpating mass in the abdomen
Chest pain
Shortness of breath
Dysphagia
Pain in lower back or anus
Diagnosed with CT scan, X-ray, Aortograph, MRI
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Arterial Aneurysm cont’d
Medical Management and Nursing
Interventions
Control hypertension
Graft
Removal of aneurysm
The nurse should monitor patient status and report
changes quickly
Treat anxiety
Treat pain
Report sudden changes to the provider rapidly
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Buerger’s Disease
Thromboangiitis obliterans (Buerger’s disease) is an
occlusive vascular condition in which the small- and
medium-sized arteries become inflamed and
thrombotic
Most often affects men ages 25-40 who smoke
Characterized by pain and sometimes ulceration
There are no specific tests for this condition
Treatment focuses mainly on modifying risk factors
and stopping smoking
Nursing interventions focus on managing risk factors
and promoting circulation
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Buerger’s disease
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Raynaud’s Disease
Caused by intermittent arterial spasms
Raynaud’s is either primary or secondary
Primary—the cause is not known and the condition is usually
mild
Secondary—when symptoms occur as a result of other
conditions
The patient typically complains of cold hands and feet
and may have discoloration
Medical management is aimed at prevention
Nursing interventions focus on promoting comfort and
preventing the disease
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Thrombophlebitis
Inflammation of the vein with formation of a thrombus
Pain and edema occur when the vein is occluded
Active dorsiflexion of the foot may result in calf pain
Diagnosed via ultrasound
Treatment is anticoagulant therapy
Nursing interventions are aimed at controlling pain
and administering prescribed medications
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Varicose Veins
Tortuous, dilated veins with incompetent valves
Poor posture, prolonged standing, and constrictive clothing are
risk factors
Often the only symptom is the appearance of darkened veins on
the patient’s legs
Patient should be assessed for predisposing factors and
varicosities
Controlled with elastic stockings, rest periods, and leg elevation
Sclerotherapy
Nursing interventions focus on care of the patient after a
surgical procedure
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Stasis Ulcer
Ulcers occur from chronic deep vein insufficiency and
stasis of blood in the venous system of the leg
Patient may report varying levels of pain
Obvious stasis ulcer on the leg
Pedal pulses are present
Diagnosis made via venography and ultrasound
Management focuses on promoting wound healing
and preventing infection
Nursing interventions are aimed at promoting wound
healing and providing patient education
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4 stages of a CVA:
cardiovascular accident
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Stages of CVA
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The end
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