BOOK TO FIND: Luckmann and Sorensen's Medical-Surgical Nursing: A Psychophysiologic
Approach
OR NURSING
CLASSIFICATION OF SURGICAL PROCEDURES
According to purpose
1
Diagnostic- to verify a suspected diagnosis.

Biopsy

Aspiration of fluid samples (amniocentesis, thoracentesis)
2
Exploratory- to establish the extent of disease at the same time, to confirm a diagnosis.

Exploratory laparotomy is surgery to open up the belly area (abdomen)
o
Multiple injury
o
Vehicular accident
o
Status post (S/P) - refer to a treatment (often a surgical
procedure), diagnosis or just an event, that a patient has
experienced
previously,
for
example,
"status
post
cholecystectomy", "S/P vaginal delivery."
3
Curative - removes or repairs damaged, diseased or congenitally malformed organs/tissues.

ablative- removal of a diseased organ. (appendectomy)

reconstructive- the partial or complete restoration of a damaged organ/ tissue to its
original appearance and function (skin graft)

constructive- repairs of a congenitally defective organ to improve its function and/or
appearance. (cheiloplasty- cleft lip repair)
4
Palliative- relieves symptoms but does not cure the underlying disease.
According to degree too risk
1.
major surgery
o
general anesthesia
2.
minor surgery
o
regional or local anesthesia
It could be a minor or major surgery depending on patients.
1.
Status
2.
Tolerance to pain
3.
Condition
According to urgency
1.
Emergency- immediate surgery
2.
Imperative- requires surgical intervention within 24-48 hrs.
3.
Planned required- necessary for the person’s well- being but is not urgent.
4.
Elective- performed for the person’s well- being but is not necessary.
5.
Optional- surgery is requested by the person, generally for aesthetic or psychosocial
reasons.
Delay in wound healing, probability of stress in the suture line (prone to
dehiscence and evisceration)
Fluid, electrolyte and nutritional dehydration and malnutrition
o
↓ blood flood - ↓tissue perfusion - ↓oxygenation - ↓ tissue repair
o
Viscous blood – cannot circulate well – delay in wound repair.
Electrolytes
o
2.
o
o
↓electrolytes – delay tissue repair
Nutritional dehydration
o
Protein, carbohydrates, magnesium, copper, zinc
o
Vitamin C, B complex, A, K
3.
Very young and very old patients
o
Very young – underdeveloped immune system
o
Very old – fragile, overdeveloped immune system.
4.
Presence of disease
o
Diabetes – viscous blood -> delay in wound healing
o
Treat first the disease before undergoing surgery.

Cardio-Pulmonary clearance
5.
Concurrent or prior pharmacotherapy
o
Polypharmacy – multiple drug

If the patient is receiving maintenance medication or
multiple medication, WITHHOLD THE MEDICATION AT
THE MOMENT to prevent overlapping of medication
(contraindication and side-effects)
OTHER FACTORS WHICH INFLUENCE SURGICAL RISK
1.
Nature of condition
2.
Location of the condition
3.
Magnitude and urgency of the surgical procedure
o
Extent
4.
Mental attitude of the person toward surgery
5.
Caliber of the professional staff and health care
EFFECTS OF SURGERY TO THE PATIENT AND THEIR IMPLICATIONS
1.
Stress response is elicited.
o
stress- a collective term for the many psychophysiologic factors that
cause neurochemical changes within the body.
1.
Defence against infection is lowered.
2.
Vascular system is disrupted.
o
Vascular system analysis – skin color (pallor)
3.
Organ functions are disturbed.
4.
Body image may be disturbed.
o
Body image may be disturbed for life (amputation)

Prosthesis
5.
Lifestyles may change.
o
Occupational Theraphy
PERIOPERATIVE NURSING
1.
Preoperative phase- from the time the nurse admits the person to the surgical unit
to the transfer of the patient to the operating room.
2.
Intraoperative phase- from the time the patient is received in the Operating room
until he/she is admitted in the recovery room.
3.
Post operative phase- from the time of admission to the recovery room (postanesthesia care unit).to the follow up home/clinic evaluation.
Wound Dehiscence and Evisceration.

Wound dehiscence (disruption of surgical incision or
wound)

Evisceration (protrusion of wound contents)
To prevent Dehiscence and Evisceration – use interlacing hand,
pillow or abdominal binder to act as a splint while performing
Valsalva (pag-ire)
No proper wound care ->admitted with Septicemia (blood poisoning by bacteria)
Four major Types of pathological processes requiring surgical intervention.
1.
Obstruction- Primarily affects hollow structures and ducts.
2.
Perforation- rupture of an organ, artery or bleb
3.
Erosion- Break in the continuity of tissue surface
4.
Tumors- abnormal growths of tissue that serve no physiologic function in the body.
GENERAL SURGICAL RISK FACTORS
1.
Obesity
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Physiologic Assessment of the patient undergoing surgery- to ensure less surgical risk,
quick recovery and prevent complications.
1.
Age
2.
Presence of pain
o
Patient-controlled analgesia (PCA) is a type of pain management that
allows you to decide when you will get a dose of pain medicine.
o
Pain medications
3.
Nutritional status
4.
Fluid and electrolyte balance
5.
Infection
o
Risk for hospital acquired infection (nosocomial infections)
6.
Cardiovascular function
Cardio-Pulmonary clearance
o
“Patients are assessed for cardiac comorbidities including congestive
heart failure, shortness of breath upon movement, and arrythmias.”
o
“Pre-operatively, patients may receive chest x-ray and ECGs to rule out
any undiagnosed cardiac conditions.”
7.
Pulmonary function
o
“Patients with underlying respiratory diseases like asthma or COPD are
assessed carefully for current threats to their pulmonary function.”
o
Treat all underlying respiratory conditions before surgery because it
may hamper the process.

If the patient cannot perform independent breathing, the
patient will be supported with via oxygenation (venturi
mask). They can be potentiated with intubation,
endotracheal tube connected to mechanical ventilation in
order to maintain respiration.
8.
Renal function
o
Kidneys – excrete anesthetic medications and metabolites therefore,
surgery is contraindicated for patients with acute nephritis, acute renal
insufficiency with oliguria or anuria or any acute renal problem.

Nursing management post op – encourage to drink water
to excrete anesthetic agents.
9.
Gastrointestinal function
Before surgery, clean the bowel. NPO prior surgery
Bowel elimination via laxative or enema are advisable for patients to be
able to remove feces or food particles they may have in their
gastrointestinal track.
o
ENEMAS ARE NOT COMMONLY PRESCRIBE pre-operatively unless
the patient will undergo abdominal or pelvic surgery.

In this case, a cleansing enema or laxative may be
prescribed the EVENING BEFORE SURGERY and may
be repeated in the morning before the surgery.
10.
Liver function
o
The liver is important in BIOTRANSFORMATION of anesthetic
compounds. Disorder of the liver will substantially affect how anesthetic
agents metabolize. Acute liver disease is associated with high surgical
mortality. Pre-operative improvement of liver function is a go
o
Assess the liver function.

Evaluate the biomarkers by determining SGPT and SGOP

Also found in heart. SGPT is predominantly found in the
liver.
o
Liver profile to evaluate liver sufficiency.
11.
Endocrine function
o
Overproduction or underproduction of hormones
o
Patients who received corticosteroids are risk for ADRENAL
INSUFFICIENCY and the use of corticosteroids for any purpose during
the proceedings must be recorded.

STERIODS RENDER PATIENTS IMMUNOCOMPRIMISE
o
Patients with uncontrolled thyroid disorders are risk for thyroid toxicosis,
hyper thyroid disorders or respiratory failure. The same thing with
patients with diabetes mellitus undergoing surgery is at risk for both
hypoglycemia and hyperglycemia.

Threat the thyroid problem first prior surgical procedure
12.
Neurologic function
o
Anxiety
o
During surgery, any medication that can alter the mental status should
be withhold because it can alter the assessment of mental status during
surgery.

Boost non-invasive approach such as therapeutic
communication, positive imagery, puppetry, progressive
muscle relaxation to treat anxiety.
13.
Hematologic function
o
Nursing consideration: BLEEDING

Check the prothrombin time (PT)
and partial
thromboplastin time (PTT) - blood test that looks at how
long it takes for blood to clot

Anticipate the administration of anticoagulant treatment
and the corresponding ANTIDOTE TREATMENT
14.
Use of medications
o
If the medications overlap with the medications given during the surgery,
withhold.
15.
Presence of trauma
o
Nursing consideration: Trauma

Aggressive
approach
such
as
psychotherapy,
administration of medication to ease the traumatic
experiences and allow acceptance of the situation.
Psychosocial assessment- the person who fears surgery is more at risk than one who’s accepts
the surgery and focuses on its benefit.

FEAR – related to the unknown lack of control, death or may be influenced by
anesthesia, peri complication, cancer, or prior surgical experiences.
o
Include the family in the treatment of the patients.
o
o
NURSING INTERVENTIONS TO MINIMIZE ANXIETY
1.
Explore patient’s feelings.
2.
Give accurate information regarding surgery.
o
Explain the patient’s bill of rights.

Right to Appropriate Medical
Treatment.

Right to Informed Consent
Care
and
Humane

In case the patient is incapable of giving consent, the
following persons, in the order of priority stated
hereunder, may give consent:
i. spouse.
ii. son or daughter of legal age.
iii. either parent.
iv. brother or sister of legal age,
v. guardian

Right to Privacy and Confidentiality.

Right to Information

The Right to Choose Health Care Provider and Facility

Right to Self-Determination

Right to Religious Belief

Right to Medical Records

Right to Leave

Right to Refuse Participation In Medical Research

Right to Correspondence and to Receive Visitors

Right to Express Grievances

Right to be Informed of His Rights and Obligations as a Patient
Emancipated minor: if not married, the parents should be the one who will
give consent.
i.
Parents
ii.
Siblings
3.
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Give empathetic support.
o
If someone is available to talk to who experienced the same procedure
as the patient who will undergo that same procedure, let them talk to
them. Give much clearing view about the procedure and coping after
surgery.
4.
Consider the person’s religious references.
o
Before surgery – there will be a blood typing and cross matching in
anticipation of blood loss (hemorrhage) during the surgery.
INFORMED CONSENT- a form signed by the patient and significant others, granting
permission to have the operation performed as described by the patient’s physicians.
The patient signs 2 consent
o
Upon admission
o
Prior the surgery
Purposes:
1.
To ensure that the patient understands the nature of the treatment including the
potential complications and disfigurement.
o
The reason why we give antimicrobial medication after surgery – as a
prophylactic against hospital acquired infections.


2.
3.
4.
Example: Central Line-associated Bloodstream Infections
(CLABSI) - bloodstream infection in a patient with a central line at the
time of (or within 48-hours prior to) the onset of symptoms and the
infection is not related to an infection from another site.
(Staphylococcal Infection)

IF the IV line is not used: change every 48 hours.

IF the IV bag and IV line is used: change every 24
hours

Change the cannula for the next 72 hrs.
Catheter-associated UTI (CAUTI) - prolonged use of the urinary
catheter

Exposing an individual to a foreign object increases
the risk of infection.

Should change daily.
To indicate that the patient’s decision was made without pressure.
o
Independent decision of the patient
To protect the patient against unauthorized procedure
To protect the surgeon and hospital against legal action by a patient who claims that
an unauthorized procedure was performed.
Language
barrier:
Interpreter
Deaf: Sign language
Blind: Braille
No patient should be urged or coerced to give informed consent. Refusing to undergo a
surgical procedure is a person’s legal right and privilege.
CIRCUMSTANCES REQUIRING A PERMIT
1.
Any surgical procedure where scalpel, scissors, suture, haemostat or electro
coagulation may be used.
2.
Entrance into a body cavity
o
Use of scope, no surgical incision (endoscopy, colonosopy)
3.
General anaesthesia, local infiltration or regional block
REQUISITES FOR VALIDITY
1.
Written permission is best and is legally acceptable.
2.
Signature is obtained with the patient’s complete understanding of what is to occur.
3.
A witness is desirable.
4.
In an emergency, permission via telephone or telegram is acceptable.
5.
For minor (below 18 years old), unconscious irresponsible permission is required from
responsible family member.
6.
If patient is unable to write, a thumb mark to indicate his signature and 2 signed
witnesses to his mark is acceptable.
PHYSICAL PREPARATIONS
1.
Teaching pre op exercises
the best time to give instruction is in the afternoon or evening before surgery.

Deep breathing exercises (Diaphragmatic Breathing) - deep breathing exercise
that fully engages the diaphragm and increases the efficiency of the lungs.
o
Lying supine – making It difficult for the lungs to expand due to
pressure of the diaphragm pushing the lungs upward.

Position in SEMI-FOWLERS POSITION (30-60
degrees) to maximize lung expansion to increase
oxygen.

Deep breathing – inhale through the nose, exhale
through the mouth 15 TIMES TWICE A DAY

To prevent build-up of secretions in the pulmonary
tree.

Accumulation of secretions ->
pulmonary congestion -> pulmonary
edema -> atelectasis
o
Ambulation improves circulation.

Initiate of return of peristalsis (normal
gastrointestinal function returned)

Incentive spirometry
o
Spirometry – also used to boost the amount of oxygen a person
can utilize.
o
Nursing consideration: provide instructions on what is the
purpose of spirometry.

Coughing exercises
o
Done after EXPIRATION
o
Nursing consideration: instruct the patient to deep breath and
cough.
o
To expulse the secretions

Turning exercises
o
Buerger-Allen exercises (BAE) – some patients cannot ambulate
so we can use this. Buerger-Allen exercise includes set of
activities like elevation, movement and rest of the lower
extremities.
Let the patient sit on the edge of the bed, dangle
feet to promote movement.
Turn the patient every 2 HOURS in the count of 3.
LOG ROLL TECHNIQUE to maintain the integrity of the
spinal column. (3 manpower: 1 head, 1 trunk, 1
extremities)

Turn the patient left lateral position.

Turn the patient supine position.

Turn the patient right lateral position.

Turn the patient supine position.

o

2.
3.
Foot and leg exercises
o
Prevent thrombus and embolus formation.
o
Prevent the stagnation of fluids in the lower extremities.
Preparing the person, the evening before surgery

preparing the skin
o
Sponge bath or warm bath (hypo-allergenic solution) – to prevent
irritation.
o
Warm water

preparing the gastrointestinal tract
Upper GI preparation
o
Endoscopy – utilization of tranquilizer, NPO
Lower GI preparation
o
Colonoscopy – NPO, laxative or enemas

preparing for anaesthesia

promoting rest and sleep
o
sleeping – cellular repair
o
When taking vital signs if the patient is sleeping, do not wake up.
As long as the cardiovascular is not compromised, allow the
patient to rest.
Prone - the patient lies on the abdomen with their head turned to one side and the
hips are not flexed. Indication for patients with spinal injury
5.
Lateral - the patient lies on one side of the body with the top leg in front of the bottom
leg and the hip and knee flexed. This flexion reduces lordosis and promotes good
back alignment. Kidney procedure.
Preparing the person on the day of surgery

early A.M. care
o
head preparation and gowning (tali depending on procedure)

preoperative medications/ pre anaesthetic drugs
o
To facilitate the administration of any anaesthetic
o
To minimize respiratory tract secretions and change in heart rate.
o
To relax the patient and reduce anxiety.
We give tranquilizers and antihistamine solutions prior surgery as a standard
procedure.
o
One ampule of lidocaine
o
One ampule of Benadryl/Antihistamine solution for possible
hypersensitivity reactions
COMMONLY USED PRE-OPERATIVE MEDICATIONS
1.
Tranquilizers - downer
2.
Sedatives – sedation/down
3.
Analgesics – for pain (lidocaine)
4.
Anticholinergics – in case the patient would have dysrhythmia.
5.
Antiistamine – in case of hypersensitivity reactions (Benadryl)
Transporting patient to O.R.

Free from noise and jarring movement
Patient’s family
Positions during surgery
1.
Dorsal recumbent - the patient lies flat on the back with head and shoulders slightly
elevated using a pillow unless contraindicated.
2.
Trendelenburg- lowering the head of the bed and raising the foot of the bed of the
patient. Requires for patients who need circulation in upper extremities.
3.
Lithotomy - a patient position in which the patient is on their back with hips and knees
flexed and thighs apart. Position of choice for surgery involving the reproductive or
perineal area
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4.
TYPES OF ANAESTHESIA
Anesthesia is a state of narcosis (severe central nervous system depression produced by
pharmacologic agents), analgesia, relaxation, and reflex loss.
1.
2.
GENERAL- total loss of consciousness and sensation

not arousable

lose the ability to maintain ventilatory function.

Cardiovascular function may be impaired as well.
REGIONAL- reduce all painful sensation in one region of the body without inducing
unconsciousness.

anesthetic agent is injected around nerves so that the region supplied by these
nerves is anesthetized.
STAGES OF ANESTHESIA
1.
Onset / induction stage- from the administration of anaesthetic agents to loss
of consciousness; pupil size is normal and reacts to light irregular or, normal
blood pressure.
2.
Excitement stage- from the loss of consciousness to the loss of lid reflex
characterized by struggling, shouting and talking; pupils dilated but reactive to
light, pulse is rapid, irregular respiratory rate.
3.
Surgical stage- from the loss of lid reflex to loss of most reflexes; pupils are
small and reactivate to light RR is regular and BP normal; unconscious; muscle
relaxed.
4.
Medullary/Stage of danger- vital functions too depressed to respiratory and
circulatory failure, reached when too much anesthesia has been administered.
o
if too much anesthesia has been given. Respirations become
shallow, the pulse is weak and thready, and the pupils become
widely dilated and no longer constrict when exposed to light. It is
not a planned stage.
Complications and discomforts of spinal anesthesia
1.
Hypotension | post anesthesia hypotension: risk for falls

Nursing consideration: make sure that the anesthesia is wore off before
ambulation.
2.
Nausea and vomiting

Nursing consideration: Kidney basin prepared.
3.
Headache

Nursing consideration: monitor the extent and severity of headache.
4.
Respiratory paralysis
5.
Neurologic complications

Nursing consideration: Cranial nerve assessment, reflex response
Transport of patient from O.R. to R.R.
1.
Avoid exposure.

Avoid exposure of the areas that are not necessarily need to expose.
2.
Avoid rough handling.

Jarring can cause dizziness, vertigo or headache.
3.
Avoid hurried movement and rapid changes in position.
NURSING ASSESSMENT AND INTERVENTION
ASSESSMENT
1.
Appraise air exchange status and note skin colour.: help to assess circulation.
2.
Verify identity, operative procedure and surgeon.
3.
Assess neurologic status.
4.
Determine vital signs and skin temperature.

Tissue injury can cause Malignant hyperthermia.
5.
Examine operative site and check dressings.
6.
Perform safety checks.

Side rails up
7.
Require briefing on problems encountered in O.R.
The Aldrete score is used to determine the patient’s general condition and readiness for transfer
from the PACU. The Aldrete score is usually between 7 and 10 before discharge from the PACU.



2.
CIRCULATORY COMPLICATIONS

hemorrhage- copious escape of blood from the bloody vessel

femoral phlebitis/deep thrombophlebitis- often occurs after operations on
the lower abdomen or during the course of septic conditions as ruptured ulcer
or peritonitis.
3.
PULMONARY COMPLICATIONS

Atelectasis- collapse of pulmonary alveoli

Bronchitis- inflammation of the bronchi

Bronchopneumonia/ lobar pneumonia

Hypostatic pulmonary congestion- stagnation of secretions at the base of
the lungs

Pleurisy-knife-like pain in the chest especially during inspiration
4.
PULMONARY EMBOLISM

embolism has become dislodged from the original site, carried to the heart and
forced into the pulmonary artery.
URINARY DIFFICULTIES

Retention- caused by spasm of the bladder sphincter.

Incontinence- loss of tone of the bladder sphincter
5.
Acceptable score for Aldrete scoring is 7 - 8.
Below 7 – 8 means the patient is not candidate to relieved from PACU
Bawal itransfer yung unconscious patients mula sa PACU to ward
INTERVENTIONS (RR)
1.
Ensure maintenance of patient airway and adequate respiratory function
2.
Assess status of circulatory system
3.
Promote comfort and maintain safety.

Wag na wag nyo iiwan ang patient nyo ng walang side rails!
4.
Continuous constant surveillance of the patient until he/she is completely out of
anesthesia
5.
Recognize stress factors that may affect the patient in R.R.
PARAMETERS FOR DISCHARGE FROM R.R.
1.
Activity – able to move all extremities
o
0 – cannot move extremities
o
1 – can move 2 extremities
o
2 – can move 4 extremities
2.
Respiration
o
0 – Fully reliant on ventilator
o
1 - Reliant on oxygen via nasal cannula
o
2 - Independent function
3.
Circulation – excretion
o
0 – unable to urinate even with foleycath
o
1 – with help of foleycath
o
2 – without use of foleycath
4.
Consciousness
o
Level or consciousness and responsiveness
5.
Color
NURSING CARE OF PATIENT DURING THE EXTENDED POST OP PERIOD
1.
Self-care activities – can do ADL
2.
Activity limitations – use of assistive devices
3.
Diet and medications at home – type of diet and compliance in medication regimen
4.
Possible complications
5.
Referrals, follow up check-up. – include in post-op management
POSTOPERATIVE COMPLICATIONS
1.
SHOCK- response of the body to a decrease in the circulating blood volume, which
results to poor tissue perfusion and inadequate tissue oxygenation resulting to
impaired tissue metabolism causing cell/ organ death.
CLASSIFICATIONS
1.
Hypovolemic shock- due to inadequate circulating volume
2.
Cardiogenic shock- due to inadequate pumping action of the heart because
of myocardial dysfunction or mechanical obstruction to blood flow
3.
Vasogenic shock- due to changes in the blood vessels tone that increase the
size of the vascular space.
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anaphylactic shock- generalized allergic reaction
septic/toxic shock- associated with generalized infection and released
of vasoactive substances.
neurogenic shock - interference with nervous control of the blood
vessels; severe reactions due to pain or psychic trauma (under stress,
increase ICP)
GASTROINTESTINAL COMPLICATIONS
6.
HICCUPS (SINGULTUS)

intermittent spasms of the diaphragm that results from vibration of the closed
vocal cards as air rush to the lungs.
7.
WOUND COMPLICATIONS

infection, hemorrhage/hematoma, wound dehiscence and evisceration
8.
PSYCHOLOGICAL DISTURBANCE

delirium and acute confusional states
PAIN
It is defense mechanism when the normal functioning of the body is threatened by internal or
external sources.
TYPES OF RECEPTORS
1.
Nociceptors- found in skin, meninges, periosteum and some internal organs.
2.
Thermoreceptors- heat and cold
3.
Mechanoreceptors- stretching, cutting, and tearing.
PAIN THEORIES
1.
Specificity theory- holds that there are certain specific nerve receptors that responds
to noxious stimuli and that these are always interpreted as pain.
2.
Pattern theory- any stimulus could be perceived as painful if the stimulation were
intense enough.
o
Based on severity of pain
3.
Gate control theory- there is a specialized system that modulates sensory input
before evoking perception and response to the stimuli.
o
Nerve block – prevent the perception of pain sensation
PAIN THRESHOLD- refers to the intensity of the stimulus required to cause an
individual to experience.
PAIN TOLERANCE- refers to the point at which the individual reacts to the pain with
verbal or other responses, each individual has a different pain tolerance, which can
be influenced by culture, age, pain experience, level of consciousness, gender and
time
TYPES OF PAIN
1.
ACUTE PAIN- indicates that damage or injury has occurred. Acute pain usually
decreases as healing occurs.
2.
3.
PATTERNS

Constant pain- occurs continuously.

Intermittent pain- occurs periodically.

Intractable pain- not relieved by ordinary measures
LOCATIONS

Superficial- usually produces sharp pain behavior

Deep- involves tendons, ligaments, bones, nerves, and blood vessels.

Visceral- involves internal organs.
DURATION

Acute

Chronic
SOURCES OF PAIN

Physical

Environmental

Psychological
TYPES OF BEHAVIORAL RESPONSES TO PAIN

Verbal

Non- verbal

Motor response
NURSING CARE FOR CLIENTS EXPERIENCING PAIN
ASSESSMENT

characteristics of pain
1.
Localized
2.
Projected
3.
Radiated
4.
Referred
PLANNING

Factors
1.
Age
2.
development stage of the client,
3.
measures used previously by the client.
4.
client’s choice of relief
IMPLEMENTATION

Removal of noxious stimuli

Postural change

Electrical stimulation

Cutaneous stimulation

Counterirritation

Touch

Acupuncture

Pharmacological agents

Environmental control and

Nutrition and rest
SURGICAL DESTRUCTION OF PAIN STIMULI
1.
RHIZOTOMY- a division of the anterior or posterior spinal nerve roots
2.
NERVE BLOCK- injection of anesthetic close to the nerve trunk
3.
CONTINUOUS EXTRAVASCULAR INFUSION- infusion of analgesic or
anesthetic to block nerve fibers
4.
NEURECTOMY- division of cranial and peripheral nerves to eliminate localized
pain.
measures to alter perception - distraction, behavior modification,
narcotics, placebos, hypnosis.
5|P a g e
CHRONIC PAIN- constant or intermittent pain that persist beyond the expected
healing time and that can seldom be attributed to a specific cause or injury.
CANCER RELATED PAIN- so ubiquitous that when CA patients are asked
about possible outcomes, pain is reported to be the most feared outcome.
FACTORS INFLUENCING PAIN RESPONSE

Past experience

Anxiety and depression

Culture

Gerontological considerations

Gender

Genetics

Placebo effect
CHARACTERISTICS OF PAIN

Intensity

Timing

Location

Quality

Personal meaning

Aggravating and alleviating factors

Pain behaviors
CARDIOVASCULAR DISEASES AND IT'S MANAGEMENT
TABLE OF CONTENTS
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
IX.
X.
XI.
XII.
Rheumatic Fever
Rheumatic Endocarditis
Infective Endocarditis
Myocarditis
Hypertension
Arteriosclerosis
Peripheral Vascular Disease (PVD)
Angina Pectoris
Myocardial Infarction
Congestive Heart Failure
Cardiomyopathy
Abdominal Aortic Aneurysm
DISEASE OF THE HEART
RHEUMATIC FEVER
●
Professor’s Notes:
●
Rheumatic Fever is a symptom.
●
There’s a possibility of recurrence infection with Rheumatic Fever simply because of
frequent exposure from the causative microorganism.
Usual people having Rheumatic Fever:
●
In terms of predisposition:
○
Individuals living in low socio-economic status/ under privilege are
susceptible to Rheumatic Fever.
■
Poor hygiene
■
Exposed to overcrowding.
■
Exposure to BETA- HEMOLYTIC STREPTOCOCCAL
infection
●
At a certain extent for those individuals who had been infected by this particular
infection and had several bouts of Rheumatic fever,
○
They can be given antibiotics for prophylactic purposes before they
reach the age of 21 if the recurrence is frequent.
○
This is not given continuously but administered before reaching 21 to
prevent recurrence.
■
But unfortunately, it can happen again because even if we
are given prophylactic treatment, this will not serve as a
body shield.
●
For this particular condition,
○
Narrowed mitral valve causing heart murmur.
○
Erythema marginatum which is very typical for this kind of patient.
○
Painful joints
○
Fever
●
●
●
Why Rheumatic fever occurs:
○
Via the upper respiratory tract infection, when the streptococcal
infection reaches the throat (itchy, difficulty in swallowing) this
infection actually goes downward affecting the heart.
■
That’s why systemic infection could develop.
○
This systemic involvement, in Erythema Marginatum (non-itchy
rash), discoloration of the skin could also happen:
■
Discoloration of the skin is attributed to inadequate tissue
perfusion in the integumentary system causing the
presence of rashes.
○
For those individuals who have self-consciousness and altered body
image: Board exam question: “What will you do to a child who is
anxious and experiencing alteration of body image secondary to
skin rashes due to Rheumatic fever?”
■
Nurses’ primary considerations:
●
Covering with long-sleeves clothes
●
Boost the confidence of the child via
therapeutic communication.
Painful joints is again attributed with poor tissue perfusion and attributed by the
spread of infection in the systemic circulation.
○
We could provide topical application of pain relievers, lotion, and
ointment in order to ease the pain.
○
The problem is because of painful joints, the person may exhibit
immobilization.
■
Unable to walk.
■
The dexterity of the hands becomes poor.
Fever. This particular infection in its pathophysiology is proliferative —many parts of
the body.
Based on the Pathophysiology of Rheumatic Fever:
1.
Streptococcal Infection
○
It could proliferate in tissue, joints, and integumentary.
2.
Abnormal Humoral and Cell Mediated Response
○
Blood analysis can reveal the presence of blood dyscrasias because
the patient appears to have abnormal blood values, particularly when it
comes to complete blood count (CBC).
3.
Diffuse, Proliferative and Executive Inflammatory Process of the CNS, Heart,
Subcutaneous Tissue, Gastrointestinal, Joints, and Skin.
○
Because it is the heart and blood, it is diffuse. The throat infection travels
to the heart.
○
CNS involvement can result in class 2 signs of involuntary joint
movement called St. Vitus Dance or Sydenham’s Chorea.
○
The heart suffers by way of developing aschoff bodies.
■
Aschoff Bodies - parang mga kulugo “vegetation” that
should not be in the heart.
■
Cross Sectional Analysis - can detect and diagnose
aschoff bodies. (the heart is cut, which is only possible
during an autopsy.)
■
The anatomy of the heart has its own special purpose,
especially when it comes to contractions. The natural
6|P a g e
4.
Diffuse inflammatory disease that involves a delayed response to infection such as
group BETA- HEMOLYTIC STREPTOCOCCUS
5.
6.
7.
8.
9.
10.
pacemaker of the heart is the SA node, it initiates the initial
contraction of the heart. From the SA node, it goes down
to the purkinje fibers down to the bundle of his.
■
Vegetation alters the contraction and rhythmicity of the
cardiovascular system. As a result, when we auscultate
patients with this condition, we detect a heart murmur
because the heart produces these abnormal heart
sounds.
■
Typically, only two heart sounds are produced by the
heart: the S1 (LUB) and S2 (DUB). However, since
vegetation is present, S3 and S4 are produced. Once this
is found out, it comes together with dysrhythmias,
abnormal heart rhythm.
○
Subcutaneous Tissues are involved, such as the skin discoloration
that is not superficial but deeply rooted in the skin.
■
Skin involvement is not superficial, it does not only involve
the epidermis and the dermis but also, at the same time,
it includes the subcutaneous area.
○
Gastrointestinal involvement. Patients experience stomach upset
○
Joints. Difficulty of moving the joints and painful joints.
○
Skin involvement as rheumatic fever includes skin discoloration.
Affects pericardium, epicardium, myocardium, and endocardium by developing
aschoff bodies.
○
Due to the presence of an infection, there is a possibility of infection or
inflammation in the heart's layers, such as myocarditis or
endocarditis.
Valves Dysfunction
○
Includes the mitral and tricuspid valves.
○
The valves of the heart become looser than they should be. Although
dilated valves can aid in the smooth flow of blood, they should be
constricting because there is no movement when there is no
constriction.
○
It is only via vasoconstriction that there is forward movement of the heart
towards the pulmonary artery, which is the only artery that carries
deoxygenated blood.
○
There is movement of blood from the pulmonary vein, the only vein that
carries deoxygenated blood, towards the left atrium, towards the left
ventricle, towards the aorta, towards the systemic circulation.
Small Bacterial Vegetations Form on the Valve Tissue
Valves Lose Elasticity
Increasing Cardiac Workload
○
If there is a deficiency in terms of the oxygenation of the heart, it will
pump more.
○
The failure of the heart to forward oxygenated blood towards the
systemic circulation results in an extra effort of the heart to pump more
to compensate.
■
Since the heart is a muscle, as it pumps blood and exerts
more effort, it will get bigger which can result in
cardiomyopathy or cardiomegaly.
1.
Cardiomyopathy is any disease of the
heart muscle in which the heart loses its
ability to pump blood effectively.
2.
Cardiomegaly – enlargement of the heart
Blood Regurgitates
○
The blood should move, if there is no movement, there is backward flow.
○
If the blood does not move forward, there is stagnation. The blood will
remain inactive in either the systemic or pulmonary circulation.
○
If deoxygenated blood remains in the systemic circulation, fluid will
escape the cell and enter the third space shift, resulting in edema.
○
If inadequate oxygenation prevents the blood from moving forward in
the lungs, it will just stay in the lungs.
○
Almost all cardiovascular conditions, such as untreated hypertension or
angina, can be a precursor to cardiac failure.
Vascular Disorder, Disorder Cardiomyopathy, CHF
DIAGNOSTIC EXAMINATIONS
1.
Positive throat culture of group A Beta-Hemolytic streptococci
Note: Conventional mouth and throat gurgles are not advisable or allowed for patients.
Allow for evaluation and diagnosis of specific bacterial infection present.
2.
Elevated cell count (WBC), Erythrocyte Sedimentation Rate (ESR), C-Reactive
Protein
Note: Everytime that the body is affected by any form of infection, there is an elevation
of WBC and ESR. The presence of infection also escalates C-Reactive protein as it
is very sensitive to infection.
MANAGEMENT
1.
Penicillin or Erythromycin: Administration of penicillin serves well in terms of
relieving infection, however, if the patient has hypersensitivity or allergy to penicillin,
erythromycin is given.
2.
Salicylates: Aspirin or salicylates facilitates in relieving pain.

Aspirin is an OTC blood thinner drug; thus, these drugs induce further bleeding.
3.
Corticosteroids: (steroids e.g Prednisone) Steroids are stress hormones that are
naturally produced in the body in conditions of stress, reducing exacerbation of
symptoms particularly inflammatory processes.

Intake of steroids causes immunosuppression hence, strict adherence to
treatment regimen is advised.
4.
Cardiac Glycosides: (Digoxin, Lanoxin) : Cardiac glycosides are given to maintain
heart rate and cardiac contraction. Nursing consideration on its intake includes
monitoring and checking for heart rate prior to medication administration to prevent
digoxin toxicity.

Do not administer when heart rate is lesser or greater than 60 as the bodily
system is confused given that it does not appreciate the mechanism of action
of cardiac glycosides. It can induce (tachycardia) or reduce (bradycardia)
cardiac heart rate.
5.
Diuretics: Diuretics are administered for the management of edema due to fluid
retention in the third space as blood cannot move forward towards the heart. The
lungs’ bowman’s capsule, which is the semipermeable membrane of the kidney
responsible for the filtration processes of all nitrogenous waste products in the body,
fails to receive adequate blood to function.

As the amount of blood is being reduced, leading to reduction in tissue
perfusion, diuretics are used to induce the patient’s natural urine production,
thus increasing urine output. This is to prevent the occurrence of azotemia,
which can result from the escalation of nitrogenous waste products in the body.

6.
Anticipate for the insertion of the indwelling foley catheter. However, once the
patienurination;natural urination, it is removed to prevent Catheter-Associated
Urinary Tract Infection (CAUTI).
Bedrest: We have to reduce metabolic demands for the pt as they are exhibiting
symptoms of joint pain. Bedrest induces sleep which involves cellular repair needed
for patients exhibiting infection.
RHEUMATIC ENDOCARDITIS
●
●
●
There is a specific involvement of one layer of the heart which is the endocardium.
is not infectious in the sense that the tissues are not invaded and directly damaged
by the streptococci.
Patients with this condition are usually with medical histories and the exacerbation of
symptoms are a result of their decreased immune system.
CLASSIFICATION
1.
Subacute Bacterial Endocarditis
○
This is a kind of endocarditis that does not develop immediately.
2.
Acute Bacterial Endocarditis
○
develops immediately.
3.
Native Valve Endocarditis
○
are those patients with frequent bouts of endocarditis ( frequent bouts
of infection) leading to native valve involvement
4.
Prosthetic Valve Endocarditis
○
When a foreign material from certain procedures especially for cardiac
repair such as synthetic valves and stent affects (foreign object) the
heart in the long run.
5.
Non-Bacterial Thrombotic Endocarditis
○
This results from a blood clot that stays called a thrombus. It happens
when there is a subsequent narrowing/ thrombus in one of the coronary
arteries.
○
Non-bacterial because it results from a thrombus.
○
Example Diagnosis: Coronary Artery Disease (CAD) secondary to
rheumatic endocarditis
CLINICAL MANIFESTATIONS
1.
Arthritis - joint pain
2.
Carditis - inflammation of the heart
3.
Fever - increased metabolic demand (administration of antipyretic medication)
4.
Subcutaneous Nodules - nodular formation in the subcutaneous areas developed
when there is an accumulation of fluid of fat due to inadequate circulation.
5.
Erythema Marginatum - development of skin lesion
6.
Chorea (St. Vitus Dance) - there is an involuntary movement of joints, attributed to
CNS involvement.
7.
Abdominal Pain - it is near the heart, so it is being affected due to stress. When the
human body is experiencing infection or inflammatory conditions, the natural tendency
is to produce extra hydrochloric (HCL) acid, so the patient has the potential to feel
frequent stomach upset.
8.
Weakness, Malaise, Anorexia, and Weight Loss
DIAGNOSTIC FINDINGS:
1.
History - family may also have the same condition.
2.
Throat Cultures - do not let the patient gargle for the accuracy of the result.
3.
Rapid Antigen Detection Test - it is not conclusive since it is an addition to
conclusiveness of the result.
4.
ECG - there are 12-lead ECG and 3-lead ECG, but 12-lead ECG is the most
conventional among the two.
3-lead ECG (salt, pepper, and ketchup) - salt is white, pepper is black,
ketchup is red.
Salt and pepper is positioned in the upper chest, while the
ketchup is positioned in the 5th intercostal space,
midclavicular line.
12-lead ECG - can provide you a clear view or angle of the heart.
5.
Elevated Erythrocyte Sedimentation Rate (ESR) or Serum C-Reactive Protein
Level
ESR and C-Reactive Protein elevates when there is an infection.
MEDICAL MANAGEMENT:
1.
One-time intramuscular injection of penicillin or a 10-day course of oral
penicillin is prescribed.
If there is a hyper-sensitivity, we give erythromycin.
2.
Anti-inflammatory medications
NSAIDS (acetylated salicylate)
Don’t give if the patient is bleeding since NSAIDS are said
to be blood thinner.
3.
Symptoms of heart failure are treated accordingly.
Dysrhythmia (abnormal heart rhythm)
Arrhythmia (irregular heartbeat)
We introduce cardiovascular medications in the form of
inotropes, epinephrine, dopamine, dobutamine, or
isoproterenol (isoprenaline), which is the same with
nitroglycerin.
There are nitroglycerin patches and one of
the nursing considerations is do not touch
the patch (wear gloves) since you are also
absorbing the medication.
Nitroglycerin in drip form is photosensitive
as it can decrease its potency. Thus, it is
covered by carbon paper in its packaging.
Cardioversion is where we utilize defibrillation to regain
normal heart rhythm.
When a patient exhibits asystole or flat line,
the patient should be assessed first before
proceeding with cardioversion. Check for
the patency, location, and position of the
leads.
4.
Prophylactic Antibiotics
Especially for those individuals who frequently acquired infection.
7|P a g e
NURSING MANAGEMENT
1.
Teaching patients about the disease, its treatment, and the preventive steps needed
to minimize recurrence and potential complications.
Teach the patient about the disease for them to understand the disease
process and the recurrence of infection.
2.
Long-term cardiac evaluation
The susceptibility of the individual to acquire infection is affected by its
social environment and compliance to the treatment regimen.
3.
The nurse monitors the patient for signs and symptoms of valvular disease, heart
failure, pulmonary hypertension, thromboemboli, and dysrhythmias.
Monitoring can be done using ECG, Echocardiogram, and evaluation of
biomarkers.
Your heart releases cardiac enzymes (cardiac
biomarkers) when there's heart damage or stress due to
low oxygen. Troponin and creatinine phosphokinase
(CPK) levels rise after a heart attack. Elevated heart
enzyme levels can also indicate acute coronary syndrome
or ischemia.
Types of cardiac marker:
1.
CPK MB (creatinine phosphokinase) - most
sensitive and the most specific indicator
available for the diagnosis of an acute
myocardial infarction.
CPK – MB – heart
CPK – MM – muscle
CPK – BB – bone
2.
SGOT is AST (serum glutamic-oxaloacetic
transaminase
(SGOT)
or
aspartate
transferase (AST))
3.
SGPT is ALT (Serum glutamic pyruvic
transaminase or Alanine Aminotransferase
(ALT)) - an enzyme that is normally present
in liver and heart cells. SGPT is released
into blood when the liver or heart are
damaged.
1.
Liver involvement
4.
Cardiac troponin, (TnI, TnT), and lactate
dehydrogenase (LDH).
-
Check the level of cholesterol through serum triglyceride.

For evaluation of blood cholesterol level – NPO for 6hrs prior to
serum extraction

For triglyceride – NPO for 10 – 12 hours prior to serum extraction
Preferably collected in the morning as the patient should be on NPO
status for 10 hours before the serum extraction.
INFECTIVE ENDOCARDITIS
●
●
A microbial infection of the endothelial surface of the heart
Classifications:
1.
Staphylococcal Endocarditis- primary staphylococcal infection
2.
Hospital - Acquired Infective Endocarditis- acquired from prolonged
hospitalization.
3.
Fungal Endocarditis- caused by fungal infection.
4.
Bacterial Endocarditis- caused by bacterial infection except for
staphylococci.
PATHOPHYSIOLOGY
●
Deformity or injury of the pericardium (injury in a specific layer of the heart) ->
Accumulation of fibrin and platelets and clot formation. (Vegetation in the heart,
fibrinous accumulation. and thrombosis) -> Infectious organisms invade the clot
and endocardial lesion develops (Embolus such as pulmonary embolus can disrupt
filtration thus preventing osmosis and diffusion therefore decreases oxygenation) ->
Platelets, fibrin, blood vessels, and microorganisms cluster as vegetations on
the endocardium develop.
MYOCARDITIS
●
●
an inflammatory process involving the myocardium.
○
Viral infection
○
Rickettsial infection
○
Fungal infection
○
Parasitic infection
○
Protozoal infection
○
Spirochetal infection

immunosuppressed patients; infective endocarditis, pharmacologic or radiation
Almost the same on the clinical manifestation of endocarditis
involvement determines degrees of hemodynamic effect (involvement of the blood)
CLINICAL MANIFESTATIONS
1.
Fatigue - because of insufficient oxygenation; pagod yung puso to pump blood;
insufficient oxygenation can lead to:

respiratory acidosis (no inspiration + accumulation of carbon dioxide in the
lungs)

respiratory alkalosis (increase inspiration/ rapid breathing; decrease carbon
dioxide). Use brown paper bag to induce balance between alkalosis and
acidosis.
2.
Dyspnea - mechanical failure of the heart
3.
Palpitations - attributed to poor tissue perfusion and poor oxygenation in the heart.
4.
Occasional discomfort in the chest and upper abdomen – type of pain:
retrosternal pain tagos hanggang rib HAHAHAAHAHAH
5.
Flu - like - increased metabolic demands = induce hypothalamic reactions by
increasing the body temperature of the patient
●
DIAGNOSTIC FINDINGS:
1.
Endocardial biopsies - small amount for determination of the extent
2.
Dysrhythmias - evident in ECG
3.
Faint heart sounds - slow heart sounds
4.
Elevated WBC and ESR - elevated when there is infections
MEDICAL MANAGEMENT:
1.
Penicillin
2.
Bed rest
3.
Physical Activity is increase slowly - improve circulation but do not put pressure
and more fatigue to the patient.
4.
Corticosteroids
5.
NSAIDs - aspirin is the most common; Caution: Full meal before drinking these meds
because it causes stomach upset and ulceration if taken on an empty stomach.
HYPERTENSION (HPN)
Abnormal condition of the small vessels of the arterial system in which the systolic and diastolic BP
is elevated.
●
A symptom (resulting from underlying conditions)
●
A pathological condition (Primary Hypertension) – only high blood pressure
Pay attention to sudden elevation.
●
May develop to hypertrophy (enlargement of heart muscle) resulting to cardiomegaly
if left untreated.
●
Can’t deny it because it can be a prelude to a more severe heart condition.
120/80 - Prehypertension for a typical Filipino stature
●
110/70 should be the normal
Nursing consideration:
●
Ask usual BP for point of reference.
●
Health Teaching: BP can be lowered with healthy lifestyle.
●
Hypertension will never be normal even though it’s your normal BP.
SIGNS AND SYMPTOMS
●
Dizziness - there is CNS involvement.
○
Dizziness: “Para akong umiikot”
○
Vertigo: “Parang ang paligid ko ay umiikot” - problem in the state of
balance and vestibulocochlear.
●
Irregular heartbeat - also called dysrhythmia. The “sinus” from the normal sinus
rhythm came from the Sinoatrial (SA) node, which is the primary pacemaker of the
heart.
○
Normal: First contraction is in SA to Purkinje fiber to bundle of his
■
P wave - atrial depolarization (initial contraction)
■
T wave - ventricular repolarization (resting)
○
Abdominal Aortic Aneurysm
■
Abnormal ST segment
■
Heart doesn’t know if it will rest.
■
SA node doesn’t initiate contraction.
●
Nausea and vomiting - whenever our body is under stress, there is an increase in
metabolic demand.
●
Fainting - another CNS involvement.
○
Always be with your patient, do not leave your patient to prevent
accidental falls. Letting your patient lie on the floor is more therapeutic
than sitting them up.
●
Low blood pressure - This is a rebound effect of hypertension. Erratic low blood
pressure is dangerous.
●
Fatigue - Due to poor tissue perfusion, making it harder for the heart to pump enough
blood and deliver oxygen. [Check O2 Sat]
○
malaise is generalized weakness.
CLASSIFICATION OF HYPERTENSION
1.
Primary or essential - Sustained elevation of diastolic pressure
2.
Secondary - Elevation of BP is secondary to some known cause.
Treatment
1.
2.
3.
8|P a g e
Supportive or intensive psychotherapy
a.
a lot of them feel anxious regarding their condition.
Diet Modification - low fat low salt diet; low carbohydrates
Drugs
a.
Rauwolfia alkaloids - controversial but serves well as antihypertensive
drug.
b.
Saluretics - or your diuretics in order to reduce third space shift or to
reduce cardiac overload decreases overwhelming contraction in the
heart.
c.
Aldosterone - blocking agents or diuretics, similar to saluretics;
decreases overwhelming contraction in the heart.
d.
Hydralazine HCL (Apresoline HCl) - works well in combination with
diuretics.
e.
Sympatholytic agents - to reduce hypercontractility of the heart such
as paroxysmal supraventricular tachycardia (PSVT). In PSVT, the atrial
chambers lost their control resulting in the ventricles becoming more
erratic.
i.
Sympathetic Stimulation (Natural Elements in the body)
●
natural drug
●
Sympathetic stimulation that induces the
production
of
epinephrine
and
norepinephrine
●
adrenaline rush
ii.
Sympathomimetic - injectable sympathetic; it mimics
sympathetic.
f.
g.
h.
i.
j.
k.
Sympatholytic counter the effect of
sympathomimetics or sympathetic.
iii.
Parasympathomimetic ●
Parasympatholytic
counters
the
parasympathomimetic or parasympathetics.
Decarboxylase inhibitors - inhibits overexcitations of the heart.
Anti renin agents - induce or boost renal function, the kidney and renal
system acts as a buffering system.
●
Buffer system - Acid base balance
Beta-adrenergic blocking agents - blocks cells to prevent over
excitation of the heart muscles (beta-blockers – olol)
Prazosin (Minipress) - reduces both systolic and diastolic pressures.
Hypertensive drugs for HTN crisis - calcium channel blockers
Carry ID card.
Nursing Implications in Giving Drugs
1.
Observe side effects and promptly report them.
2.
Febrile Illness or dehydration tends to enhance the potency of antihypertensive drugs.
a.
Malignant hyperthermia, whenever our body tissues are injured or
inflamed, this takes place (flu like sensations) Similar to a patient that
have overstretched tissues.
3.
Measure intake and output
a.
This is important since anuria is the implication of problems in terms of
filtration.

Accumulation of nitrogenous wastes in the body is called
azotemia which is exhibited by proteinuria.

Uremia is also one manifestation. Having an elevated
concentrations of urea in the blood
4.
Take BP in desirable position and teach the patient to record own BP.
5.
Give in combination to obtain optimal effects while at the same time minimizing
the side effects of individual drugs.
a.
Any HPN medication should be taken in a regular time frame. Regularity
is important.
b.
Adherence on a regular basis to treatment is important.
6.
Many of these drugs are potentiated by alcohol, tranquilizers and other drugs
like cold and cough medications.
a.
A very good example is phenylpropanolamine wherein there is over
constriction in the heart. This then affects preload and afterload.
b.
Alcohol, tranquilizers, and other drugs induce vasoconstriction.
7.
Avoid pickled herring, chocolate, chicken liver, beer and aged cheese.
a.
Aged cheese- it has more salt; salt absorbs fluid. More salt= more fluid
absorbed. Where sodium goes, water follows.
i.
Sodium increases concentration of fluids. Sodium is
present in both extracellular and intracellular
compartments.
ii.
High sodium= shrinkage of cells
3 types of edemas
1.
Pitting Edema – lower extremities
2.
Ascites - abdomen
3.
Anasarca- Generalized edema
ARTERIOSCLEROSIS
Hardening of the arteries, which results in loss elasticity of the intimal layer of the artery.
●
Sclerosis - means hardening.
●
Atherosclerosis - accumulation in the arteries of fatty plaque made of lipids.
●
Coronary arteries are narrowed or obstructed by the accumulation of plaque, the
presence of an embolus or vasospasm.
○
Killer clots
■
Thrombus - blood clot na tambay huhu
■
Embolus - blood clot na gala
●
The narrowing or obstruction of the artery resulting in decreased perfusion and
inadequate myocardial oxygen supply.
Diagnostics
1.
ECG - determination of P, Q, R, S, and T waves to determine abnormal heart rhythms.
2.
Stress Test - Cardiac Electrocardiography, Treadmill with chest leads, to evaluate
cardiovascular vitality. The body in general will be gasping for air and demanding for
oxygen.
3.
Coronary Arteriography - Graphy means administration of radiopaque solution
which contains iodine solution, so you need to assess patients for sensitivity to iodine
or seafoods solutions.
4.
Blood Chemistry - Cardiovascular biomarkers
a.
CPK-MB (Creatinine-phosphokinase- MB)
b.
SGPT
c.
SGOT
d.
LIPID profile - cholesterol level and triglycerides
5.
Ambulatory Electrocardiography - Kind of ECG which measures the ECG pattern
of a patient while walking.
Medical Management
1.
Diet Therapy
2.
Arterial Line for Blood Pressure Monitoring
3.
Intra-Aortic Balloon Pump - not only improves circulation but also monitor blood
flow in the heart.
4.
Streptokinase Therapy - does not dissolve blood clot rather, it prevents blood clot
formation.
5.
Percutaneous Transluminal Coronary Angioplasty
a.
Plasty - repair, to repair a particular coronary artery.
6.
7.
8.
9.
10.
11.
Antihyperlipidemic Agents - the effect is hepatotoxicity, so you have to take care of
the patient's liver while taking this drug. determination of liver profile by determining
SGOT levels.
Nitrates- nitroglycerin
●
Spray, oral, SL, IV infusion (piggyback or side drip), patch (like
Salonpas, placed on chest)
●
Patch- good for 24 hours
○
Nursing Management- Don’t touch the patch for it contains
medication; might as well use gloves.
Beta-Adrenergic Blockers - to stop the B-cells.
Calcium Blockers- Amlodipine
Analgesics - for pain
Anti-Anxiety Agents - because anxiety adds to cardiovascular demand - When a
person is anxious, it adds to the excitation of the heart.
Nursing Interventions
1.
Maintain diet (LSLF Diet)
2.
Maintain ideal weight.
3.
Differentiate between pain of angina and pain of MI.
a.
Angina - trajectory (tingling, numbing of fingers, shoulder, jaw, down to
the heart)
b.
MI - retrosternal pain, sa spot talaga ng puso, subsequent pain
surrounding that area NO NUMBING AND TINGLING
4.
Limit alcohol intake to 2 ounces per day.
5.
Monitor blood pressure daily
6.
Follow dietary restrictions and recommendations.
PERIPHERAL VASCULAR DISEASE (PVD)
Inadequate blood flow in the extremities.
a.
Artery walls thicken and lose elasticity, narrowing the diameter of the
artery.
b.
Decreased perfusion and the formation of blood cause blockage and
ischemia
●
Problem is perfusion → dahil hindi masyado makapa-distribute ng oxygenated blood.
CLASSIFICATION
Differs only in etiology but have the same manifestations.
1.
Arteriosclerosis Obliterans (ASO) - primary hardening of arteries
2.
Raynaud's Phenomenon - due to extreme emotion, due to cold exposure
3.
Buerger's Disease - also referred to as Thromboangiitis obliterans (TAO);
may thrombus = there is clot.
Clinical Manifestations
1.
Intermittent Claudication - tumitigas na kamay, hindi magalaw
2.
Pain at rest - patient manifests persistence of pain despite rest
3.
Trophic Changes - kumakapal kuko/thickening of nails (insufficient oxygenation in
the blood), absence of hair, alopecia, skin is taut (shiny, kinis)
4.
Diminished or absent pulses - inadequate circulation
5.
Temperature changes in extremities - attributed to inadequate circulation.
6.
Color changes - also attributed to inadequate circulation.
7.
Homan’s Sign - (+) Pt is in supine position, flex the lower extremities and instruct the
patient to move the feet, and the patient would exhibit/experience pain in the calf
(cramps-like)
Diagnostic
1.
Arteriography - extent of insufficiency
2.
Doppler Studies - utilized to specifically identify blood flow.
3.
Blood Chemistry - to determine level of lipids (cholesterol, triglyceride)
●
Cholesterol Preparation: NPO for 6-8 hours prior to serum extraction
●
Triglyceride Preparation: NPO for 10 hrs before extraction
Homans Sign - is a screening test used to check for deep vein thrombosis (DVT) of the calf. It’s
sometimes called dorsiflexion sign. (Feels like cramping)
●
The patient is supine. The examiner lifts the affected leg and rapidly dorsiflexes the
patient’s foot with the knee extended. This maneuver is repeated with the patient’s
knee flexed while the examiner simultaneously palpates the calf.
●
Homans Sign is positive if pain is occurring upon dorsiflexion of the foot with
the knee extended and flexed indicating deep vein thrombosis (DVT).
b.
c.
d.
e.
Bishydroxycoumarin (dicumarol®) - suppresses the liver in the
formation of anti-clotting factors.
Warfarin Sodium (Coumadin®)- suppresses liver in producing
prothrombin.
Ethyl Biscoumacetate (Tromexan ®) -, acts quickly but only acts at a
short period of time compared to Bishydroxycoumarin, assess PT and
PTT
Lipid Reducers
Nursing Responsibilities
1.
Recognize signs of hemorrhage
●
check for hematuria.
2.
Acetylsalicylic acid or Aspirin (ASA) and steroid preparation can be potentially
dangerous.
●
(ASA)- blood thinner; prescribed for high blood.
3.
IM not Done.
●
Causes hematoma.
4.
Careful regulation as to amount and continuity of dosage
5.
Drugs that potentiate anticoagulants and adrenocorticosteroids also prolong
the anticoagulant effect.
6.
Drugs that inhibit anticoagulant effect
7.
When a patient is being switched to oral anticoagulant from IV administration,
the latter is decreased or maintained until the oral preparation has been fully
absorbed and has reached its peak level.
8.
Antidote
●
Nursing consideration: Antidotes: make sure they are around.
a.
Protamine sulfate to heparin
b.
Vitamin K (Synkavit or AquaMephyton) to dicumarol
Nursing Interventions
1.
Proper positioning
●
Semi Fowler's - to extend lungs for breathing.
2.
Assess peripheral circulation.
●
Pulse, solar, and sensation of extremities
3.
Encourage leg exercises and walking.
●
Buerger-Allen Routine- very important for patients with limited
movement; prevents exacerbation of signs and symptoms.
i.
Feet up from ½-3 minutes
ii.
Sit on edge of bed do feet exercise for 3 minutes.
iii.
Lie down for 5 minutes.
4.
Patient / family teaching goals
ANGINA PECTORIS
A clinical syndrome characterized by episode or paroxysm of pain or pressure in the anterior chest.
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.
●
What does Angina feel like?
○
Chest pain- trajectory is
from the hand.
○
Chest pressure
○
Squeezing sensation in
chest
○
Indigestion- that’s why
nausea and vomiting
also exist.
○
Pain that spreads to
your neck, jaw, arms,
back, or belly
Factors Associated with Typical Anginal Pain
1.
Physical exertion
2.
Exposure to cold
3.
Eating a heavy meal- that is why small frequent feedings is the most recommended.
4.
Stressor any emotion-provoking situation
Medical Management
1.
Diet Therapy- Low fat, low calorie
2.
Maintain Activity - Range of Motion Activity (flexion, extension)
3.
Vasodilators
●
Alcohol is said to be therapeutic because of the vasodilation effect.
●
30-60 mL- 3-4 times a day (acceptable amount)
4.
Anticoagulants- prevents clotting.
a.
Heparin- for immediate effect (Hepa drip); for consumption for the next
3-4 hours; not side drip; use soluset (100 cc)
●
Standard operating procedure after administration og
anticoagulant: Check PT (prothrombin time); PTT Partial
thromboplastin time Test to see if the medication is
effective.
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Types of Anginas
1.
Stable Angina- predictable
2.
Unstable angina (Crescendo angina)- pre-infarction, pain at rest, unpredictable
3.
Intractable or refractory angina - severe incapacitating chest pain, unresponsive to
medication
4.
Variant angina
●
Prinzmetal’s angina
●
Pain still persists even at rest.
●
ST segment elevation that is reversible.
5.
Silent ischemia- there is evidence of ischemia; seen in stress tests.
6.
Nocturnal angina- during sleep.
●
With rapid eye movement and accompanied by dreaming
7.
Angina decubitus- angina attack upon sitting/change position.
8.
Post infarction angina- characterized by residual ischemia.
●
Diagnostic
1.
2.
3.
4.
Usually occurs after MI.
ECG for the determination of dysrhythmias
Stress test
Radioisotope imaging - similar to administration of radiopaque solution
Coronary angiography
a.
“graphy” - imaging; visualization
Clinical Manifestations
1.
Sensation - Gas or Heartburn
a.
Initially it is mild, until there is heaviness when it comes to heartburn.
2.
Severity - Mild or moderate
a.
If untreated “feeling of impending doom”
3.
Location - 80-90% Retrosternal or slightly to the left of the sternum
4.
Radiation - left shoulder and upper arm, on the area of radiation, but to one single
small area
5.
Duration - 5 mins with heavy meal or 15-20 mins with extreme anger
6.
Relief - nitroglycerin and rest
●
Both interventional and diagnostic
●
If relieved - angina pectoris only
Medical Management
1.
Nitroglycerin - Dilates the veins and in higher doses also the arteries.
a.
Packaging comes with carbon paper (photosensitive)
2.
Beta-Adrenergic blocking agents - Reduction in heart rate, slowed conduction of
impulses through the conduction system, decreased BP, and reduced myocardial
contractility to balance the myocardial oxygen needs and the amount of oxygen
available.
●
Blocks Beta Cells
3.
Calcium Channel Blocking Agents (calcium ion antagonists) - Decrease
sinoatrial node automaticity and atrioventricular node conduction; relax the blood
vessels causing a decrease in blood pressure and an increase in coronary artery
perfusions; increase myocardial oxygen supply by dilating the smooth muscle wall of
the coronary arterioles.
●
Blocks calcium
4.
Antiplatelet And Anticoagulant - to prevent platelet aggregation and subsequent
thrombosis which impedes blood flow (Do not dissolve but prevent further
development of clot).
a.
Aspirin - relieving patients from coagulation since it is a blood thinner
b.
Glycoprotein llb / llla agents and ticlopidine
c.
Clopidogrel and Ticlopidine
d.
Heparin
●
Make sure to determine always the shelf life and storage; the drug expires when
exposed in high humidity environment.
Continuing Care
1.
Educate to avoid activities that precipitates - anger, exertion.
2.
Daily management of hypertension- adherence to maintenance
3.
Regular program of activities
4.
Quit smoking - causes sclerosis; cigarettes have a lot of carcinogenic contents.
5.
Weight reduction
6.
Counseling - to become optimistic when it comes to treatment options.
●
Patient preferences are important.
MYOCARDIAL INFARCTION
Reduced blood flow in a coronary artery due to rupture of an atherosclerotic plaque and subsequent
occlusion of the artery by a thrombus. Formation of localized necrotic areas within the myocardium,
usually follows the sudden occlusion of a coronary artery and the abrupt cessation of blood and
oxygen flow.
●
Zone of ischemia
●
Zone of hypoxic injury
●
Zone of infarction necrosis.
10 | P a g e
Nursing consideration during ECG procedure

Inform the client about the procedure and the purpose of procedure.

Inform about proper positioning of the ECG led
Pathophysiology of MI
1.
Thrombus
2.
Complete or nearly complete coronary occlusion
3.
Anaerobic metabolism- potential to develop vegetation.
4.
Hemorrhage
5.
Plaque
6.
Development of necrotic areas within the myocardium
7.
Pain
8.
Severe dysrhythmia
9.
Congestive heart failure
10.
Cardiogenic shock
11.
Rupture of the heart
Clinical Manifestations
1.
Chest pain or discomfort, palpitations. Heart sounds may include S3, S4, and new
onset of a murmur (relieved by nitroglycerin)
2.
Increased jugular venous distension.
3.
Blood pressure may be elevated or decreased.
4.
Pulse deficit may indicate atrial fibrillation.
5.
In addition to ST-segment and T-wave changes, ECG may show tachycardia,
bradycardia, or dysrhythmias.
6.
Shortness of breath, dyspnea, tachypnea, and crackles
●
crackles- when heart fails to contract, pulmonary congestion develops.
7.
Nausea and vomiting
8.
Decreased urinary output.
●
Anuria-absence of urine output
●
Kidney is a buffer system-compensate by releasing nitrogenous
products from the body.
9.
Cool, clammy, diaphoretic, and pale appearance.
10.
Anxiety, restlessness, and lightheadedness
11.
Fear with feeling of impending doom, or patient may deny that anything is wrong.
Diagnostics
1.
Patient history - presenting symptom and history of illness
●
because of familial tendency
2.
Electrocardiogram - the location, evolution, and resolution of an MI can be identified
and monitored.
●
significant T wave inversion; ST elevation
3.
Echocardiogram - evaluate ventricular function.
4.
Laboratory test - Cardiac Biomarkers
a.
Creatinine Kinase and its isoenzymes - increases only when there
has been damage to these cells.
b.
Myoglobin - negative results are an excellent parameter for ruling out
an acute MI.
c.
Troponin - an increase in the level of troponin in the serum can be
detected within a few hours during acute MI.
Medical Management
1.
Diet therapy- Low Cholesterol, Low Fat, Low Sodium Diet
2.
Antiarrhythmics - Lidocaine and Procainamide serves the patient well in relieving
any form of arrhythmia.
3.
Anticoagulants - Like Aspirin to prevent coagulation.
4.
Antihypertensives - Hydralazine or Apresoline, Methyldopa or Aldomet
5.
Intra-aortic balloon pump (IABP) - improve coronary circulation.
6.
Thrombolytic therapy- to dissolve the thrombus.
a.
Antithrombotic therapy
b.
Streptokinase
c.
Tissue-type plasminogen activator
Nursing Interventions
1.
Bed rest - complete bed rest and avoid visitation.
2.
Positioning - semi-fowler’s position
3.
Rest periods
4.
Discharge planning - important especially in terms of instructions on self-care
5.
Sexual expressions - no sexual intercourse for 6-8 weeks, extreme temperature and
heavy meals should also be avoided during sexual intercourse since it can result to
easy fatigability.
6.
Cardiac Rehabilitation
a.
In-hospital rehabilitation - adhere to medications
b.
c.
Intermediate rehabilitation - requires support and guidance (lifestyle
modification)
Long-term rehabilitation - maintain patient stability and find out or
detect probable complications.
Complications
1.
Dysrhythmias - abnormal heart rhythm
2.
Cardiogenic shock - due to failure of heart to pump
3.
Heart failure and pulmonary edema - MI is a prelude to CHF.
4.
Pulmonary embolism - major consideration; considered a medical emergency.
5.
Recurrent myocardial infarction - like stroke, can be recurrent.
6.
Pericarditis Dressler’s syndrome - after MI attack; if you have history of MI there
will seem to be a pocket in the heart wall due to recurrent inflammation.
Phases of Cardiac Rehabilitation
1.
In-hospital
2.
Intermediate
3.
Long-term
CONGESTIVE HEART FAILURE
The inability of the heart to pump sufficient
blood to meet the needs of the tissues for
oxygen and nutrients, it is a clinical syndrome
characterized by signs and symptoms of fluid
overload or of inadequate tissue perfusion.
The main problem here is there is a forward
failure of moving oxygen in the blood from
pulmonary arteries and there is ejection
failure on the left ventricle to move
oxygenated blood to the aorta towards the
systemic circulation.
●
Left ventricular failure - first to
fail since it requires higher
pressure.
●
Right ventricular failure ●
Conditions that Precipitate or Exacerbate
○
Physical or emotional stress
○
Dysrhythmia - untreated dysrhythmia
○
Infection
○
Anemia - heart will compensate by pumping more blood.
○
Thyroid Disorder - hypothyroidism, potential to develop thyrotoxicosis.
○
Pregnancy - the problem is untreated hypertension.
○
Paget’s Disease - a kind of disease where ⅓ of skeletal structure of the
body is being reduced. Blood products are being produced by bone
marrow thus, depletion of circulating blood volume accompanied by
blood depletion in the body results in depletion of skeletal capacity.
○
Nutritional Deficiency - Thiamine or B1, these are important for the
development of blood components. In alcoholics, they don't get enough
thiamine and B1.
○
Pulmonary Disease - being paved way by the left ventricular
hypertrophy.
○
Hypovolemia - Poor renal function; an indication of excess amount of
sodium
●
Disease and unable to meet normal circulatory demands.
●
Intrinsically normal but unable to meet increased circulatory needs.
PATHOPHYSIOLOGY:
○
The left ventricle fails to eject enough blood.
○
The amount of blood remaining in the left ventricle at the end of the
diastolic increases
○
Decrease ventricles capacity to receive blood from the left atrium.
○
Subsequent pulmonary congestion, pulmonary edema, and respiratory
symptoms
○
The right ventricle dilation and hypertrophy because of the increase
pressure in the pulmonary vascular system
○
Engorgement of the venous system extends backward producing
congestion (gi. liver, viscera, kidneys, legs, and sacrum)
Left Ventricular Failure - Pulsus alternans herald the onset of LVF, pulmonary congestion can
eventually reduce the vital capacity of the lungs. The cough may produce large amounts of frothy,
blood-tinged sputum. On auscultation bilateral crackles may be heard, orthopnea develops because
when the client is in supine there is an increase amount of blood returning from the lower extremities
to the heart and lungs, paroxysmal nocturnal dyspnea resembles the frightening suffocation.
Cerebral hypoxia may aggravate fatigue.
Right Ventricular Failure - lobules of the liver become congested and become anoxic. This leads
to necrosis of the lobules, cardiac cirrhosis develops manifested by ascites and jaundice,
dependent edema is one of the early signs, usually occurs symmetric.
11 | P a g e
Diagnosis
1.
2.
3.
4.
5.
6.
Chest Radiography - to determine of the extent of anginal.
ABG - to determine compensation between the two buffering system which are lungs
and kidneys.
Liver Enzymes (SGPT, SGOT) - determination of extent of severity of liver
involvement
BUN and Creatinine - for kidney failure
ECG - to monitor extent of dysrhythmias.
Electrolyte (Replacement) - because at times the heart cannot pump anymore due
to insufficiency of levels of electrolytes.
Treatment and Nursing Care
1.
To reduce the cardiac load by lessening the tissue demand for blood and by
eliminating factors that tend to stimulate cardiac activity unnecessarily (No strenuous
exercises/activities)
2.
To reinforce the pumping action of the heart, improving its effectiveness as a pump
thereby delivering more blood (Tolerable and ideal exercises are much
recommended)
3.
Reduction of Na absorption and fluid retention
CARDIOMYOPATHY
A patient with cardiomyopathy has structural and/or functional abnormalities of the ventricular
myocardium that are idiopathic. It does not include end stage myocardial dysfunction related to
coronary artery disease,hypertensive heart disease,valvular heart disease or any other known
systemic disorder or physiologic state
Classification
1.
Dilated Cardiomyopathy - “Dilated” =
the problem is the degeneration of the
myocardial muscles’ kaya nagkakaroon
ng subsequent enlargement
2.
Hypertrophic Cardiomyopathy - also
known as “Idiopathic Hypertrophic
Subaortic
Stenosis
(IHSS),”
the
prominent problem is paroxysmal
nocturnal dyspnea.
3.
Restrictive/Obliterative
Cardiomyopathy - there is rapid
impulse and impacting impediment as
far as ventricular contraction is concern
is not very filling.
Diagnostic
1.
2.
3.
4.
ECG
Echocardiography
Chest radiography
Blood chem
Management
1.
Transplantation - only if available
2.
Vasodilator - d/t the enlarged muscles
3.
Rest - to decrease metabolic demand.
4.
Digitalis, diuretics, anti-arrhythmic, anticoagulant
●
Digitalis - maintains contraction of the heart.
○
Only given if heart rate is normal because it will not take effect
○
Do not give Digoxin or Lanoxin if the heart rate is below 60, or above 80
5.
Automatic cardiac defibrillator - to regulate the rhythmicity of the heart
6.
No alcohol; no sodium
ABDOMINAL AORTIC ANEURYSM
Dilation or localized weakness in the medial layer of an artery
“Walking time bomb” - it may rupture anytime.
ETIOLOGICAL FACTORS:
●
history of atherosclerosis
●
congenital defect
●
trauma (gunshot wounds,
stab wounds)
●
syphilis
●
hypertension
●
infection
Clinical Manifestations
1.
Asymptomatic
2.
Lower abdominal, lower back pain
3.
Abdominal mass left of midline.
4.
Abdominal pulsations - an indication of abdominal tension
5.
Bruit
6.
Diminished femoral pulses - because of inadequate oxygenation and circulation; d
7.
Systolic blood pressure is less low than systolic blood pressure in arms
Medical and Nursing Interventions
1.
Bed rest - reduce metabolic demand.
2.
Neurovascular monitoring - checking neurological function.
3.
Beta-adrenergic blockers - prevent over excitation of cardiac muscles.
4.
Antihypertensive
5.
Assess pain - continuous, intermittent pain.
6.
Recognize signs and symptoms of decreased peripheral circulation.
Abdominal Aneurysm Resection - removal of a portion of weakened arterial wall with and endto-end anastomosis to a prosthetic graft.
●
Pre-Operative: complete patient and family preoperative teaching, demonstrate
postoperative management.
●
Post-Operative: assess different body system; pain meds; lV therapy assess
dressing, Turn, Cough, Deep, Breathing (TCDB) and splinting incision; assess return
of peristalsis; maintain activity; administer oxygen; monitor and maintain position and
patency of tubes; measure abdominal girth; assess peripheral circulation.
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