NCSBN – Lesson 8A: Cardiovascular System Study Guide,100% CORRECT

NCSBN – Lesson 8A: Cardiovascular System Study Guide Leukocytes or White Blood Cells (WBCs) Leukocyte levels increase with infections or inflammation. Leukocyte Type Granulocyte Increases in Response to Infection by bacteria or fungus Neutrophil Leukocyte Type Agranulocyte Increases in Response to Viral infection or tumor Lymphocyte Leukocyte Type Granulocyte Increases in Response to Inflammation from allergies Eosinophil Leukocyte Type Granulocyte Increases in Response to Inflammation from allergies Basophil Leukocyte Type Agranulocyte Increases in Response to Infections – nonspecific Monocyte Heart Infections Heart infections are caused by an infectious agent that invades the heart. The following section reviews disorders such as pericarditis, myocarditis, endocarditis and rheumatic endocarditis. Pericarditis – Heart Infections • Etiology o Pericarditis is an inflammation of the pericardial sac. o Pericarditis is usually viral, but it can also be a bacterial or fungal disease, autoimmune disorder, e.g., systemic lupus erythematosus (SLE), or an inflammatory response after acute myocardial infarction or malignant neoplastic disease. • Epidemiology o Pericarditis may be acute or chronic and may occur at any age. Pericarditis occurs in up to 15% of persons with a transmural infarction. o The severe chest pain is caused by the inflamed pericardium rubbing against the heart. • Assessment Findings o Sharp chest pain that is often relieved by sitting upright and leaning forward. ▪ The pain is worse with coughing and lying in supine position. ▪ The client cannot lie flat without severe chest pain or SOB o Other findings include fever, sweating, chills (with infectious causes) and dysrhythmia. o Pulsus paradoxus (fall in systolic BP with inspiration > 10 mm Hg) will be seen as well. o Scratchy, grating or squeaking sound o Listen using the bell of stethoscope over the left lateral sternal border to hear one systolic sound and two diastolic sounds • Diagnostic Studies o A history and physical exam will be performed as well as serum studies: ▪ Increase in WBC (with infectious causes) ▪ Increased sedimentation rate (marker for inflammation) • Positive blood cultures if infection is present • Positive antinuclear antibody (ANA) if due to connective tissue (autoimmune) disease o There will be widespread echocardiograph (ECG) changes in the ST segment. o An EEG will be ordered to determine if there is a pericardial effusion or cardiac tamponade. • Management o Pharmacological: ▪ Anti-inflammatory medications: NSAIDS, corticosteroids to treat inflammation and pain ▪ Antibiotics if caused by an infection ▪ Avoid anticoagulants – may increase the possibility of cardiac tamponade from bleeding risk ▪ Oxygen if hypoxia is present o Surgical intervention may be necessary. o An emergency pericardiocentesis will be performed if cardiac tamponade develops. o For recurrent constrictive pericarditis; a partial pericardiectomy (pericardial window) or total pericardiectomy will be performed. • Nursing Interventions o The nurse will manage the client's pain and anxiety. o Position the client in a semi-Fowler's or high-Fowler's position for comfort. o Administer analgesics as ordered to keep pain at 0-2 (on a scale of 1-10). ▪ Also, administer medications as ordered to treat the cause. o Assess respiratory, cardiovascular and renal status every 1-2 hours in the acute phase. ▪ Monitor for pericarditis complications such as dysrhythmias, cardiac tamponade and heart failure. o Be sure to have a pericardiocentesis set at the client's bedside in case of cardiac tamponade. Teach the client and family the Cardio Five. ▪ Cardio 5 Teaching Plan TDD DS Topic Tests and Treatments Nursing Action Explain tests and treatments in simple, culturally sensitive ways T TDD DS Topic Drugs Nursing Action Write out names and explain the reason for medications, their side effects and how long the client will take them D TDD DS Topic Diet Nursing Action Good nutrition and restrictions, i.e., low sodium, whole grains, a variety of fruits and vegetables (DASH diet) D TDD DS Topic Disease Nursing Action Explanation of the disorder and treatment plan D TDD DS Topic Smoker? Nursing Action Encourage to stop smoking S Myocarditis – Heart Infections Myocarditis is an inflammatory condition of the myocardium which can be caused by a viral, bacterial or fungal infection, serum sickness, rheumatic fever, chemical agent or a complication of collagen disease like SLE. • Etiology o Myocarditis is usually an acute and self-limited virus, but it may lead to acute or chronic heart failure and can occur at any age. • Assessment Findings o The assessment findings will depend on the type of infection, degree of myocardial damage, and the capacity of the myocardium to recover and host resistance. ▪ May be minor or unnoticed, i.e., fatigue and dyspnea, palpitations, occasional precordial discomfort manifested as a mild chest soreness and persistent fever ▪ History of recent upper respiratory infection with fever, viral pharyngitis or tonsillitis ▪ Fatigue and dyspnea ▪ Possible signs of congestive heart failure include peripheral edema, weight gain and crackles in lungs ▪ Tachycardia disproportionate to the degree of fever ▪ Joint pain or swelling o Heart Sounds ▪ Systolic • Aortic stenosis - mild o Loud murmur early in systole (musical murmur) o Caused by turbulent blood flow into the aorta o Listen using the diaphragm of the stethoscope with the client in a supine position ▪ Diastolic • Aortic regurgitation - mild o Caused by a bicuspid (thickened) aortic valve o Listen using the diaphragm of the stethoscope over Erb’s point with the client in a sitting position, leaning forward • Mitral stenosis - mild o Commonly due to rheumatic heart disease o Listen using the bell of the stethoscope over the mitral valve, with the client in a left lateral position ▪ The first heart sound is increased in intensity ▪ The second heart sound is normal and unsplit ▪ S3 • Low frequency sound heard in early diastole • Cadence is similar to "Kentucky" • Results from increased atrial pressure, as seen in congestive HF; also associated with dilated cardiomyopathy • Listen using bell of stethoscope at the cardiac apex with the client in a supine position ▪ Gallop • Low frequency sound • Cadence is similar to "Tennessee" • Associated with coronary heart disease, aortic stenosis, ischemic or hypertrophic cardiomyopathy • Listen using the bell of stethoscope pressed lightly on the skin of the chest with the client in a supine position ▪ Friction Rub • Pericardial friction rub: o A sign of pericardial inflammation, heard in infective endocarditis (IE), myocardial infarction (MI) and rheumatic fever (RF) o Scratchy, grating or squeaking sound o Listen using the bell of stethoscope over the left lateral sternal border to hear one systolic sound and two diastolic sounds • Diagnostic Studies o An ECG will detect cardiac changes and arrhythmias. o Labs: ▪ There will be an increase in erythrocyte sedimentation rate (ESR) ▪ There will be an increase in myocardial enzymes, such as troponin and creatine kinase (CPK-MB) o An endomyocardial biopsy (EMB) and myocardial imaging may also be performed. • Management o Pharmacological Interventions: ▪ Administer antibiotics as ordered (with infectious cause) and/or corticosteroids to decrease inflammation. Analgesics will also be given for pain. ▪ Administer cardiovascular medications as ordered to treat heart failure (e.g., ACE inhibitors, beta blockers, vasodilators and digoxin). ▪ Administer diuretics as ordered to treat fluid overload (furosemide) and titrate oxygen to maintain oxygen saturation goal. • Nursing Interventions o The nurse will monitor the client's cardiovascular status. Notify the health care provider and provide appropriate emergency care if the client's status is unstable or worsening, including: ▪ Changes in pulse, respirations, blood pressure, oxygen saturation and heart rhythm ▪ Signs of fluid overload: orthopnea (inability to breathe when lying flat), peripheral edema, increase in daily weight, crackles in lungs, jugular venous distention and worsening heart murmur ▪ Monitor for indicators of cardiac output, e.g., signs of lightheadedness, activity intolerance, fatigue or dyspnea with exertion ▪ Monitor arterial blood gas (ABG) levels as needed to ensure adequate oxygenation • Client & Family Teaching o Client and family teaching will include when the client should increase activity level (as tolerated) and how to monitor and record daily weight. o The client will contact the provider if there is a weight gain greater than three pounds in 1-2 days or greater than five pounds (1.36 kg) in one week. o The client should also report if they experience an abnormally rapid heartbeat. o Counsel female clients to avoid pregnancy, alcohol and competitive sports until approved by their health care provider. o The nurse will teach the client about anti-infective drugs and stress the importance of taking drugs as ordered. If the client is taking digoxin at home, they will: ▪ Check their pulse for one full minute before taking the dose. • If their heart rate falls below 60 beats/minute, withhold the drug and call their provider. ▪ Monitor for findings of digitalis toxicity, e.g., anorexia, nausea, vomiting, blurred vision and cardiac arrhythmias Endocarditis – Heart Infections Endocarditis is an infection of the endocardium, heart valves or heart valve prosthesis resulting from bacterial or fungal invasion. Infection can lead to growth of valvular vegetation that can break off (embolize), travel in the blood stream and lodge in distal areas (lungs, bowel or extremities). The embolization can lead to tissue ischemia and necrosis in areas perfused by the blocked blood supply. • Etiology o The infection is most likely to "seed" in damaged or prosthetic heart valves – this is especially problematic for people with heart murmurs and those using illicit IV drugs. Infective agents include group B streptococci, Staphylococcus aureus and fungi. o With proper treatment, the majority of clients recover. The prognosis is worse when endocarditis severely damages valves or involves a prosthetic valve. • Assessment Findings o Cardiac murmurs appear in 85-90% of clients (usually a murmur that changes suddenly or a new murmur that develops in the presence of a fever) o The nurse will assess the client's history of damage to a heart valve, i.e., rheumatic fever, murmur or heart valve prosthesis o Fever, chills, night sweats with no identifiable source of infection, a "fever of unknown origin" o Pericardial friction rub o Fatigue, malaise or anorexia o Neurologic sequelae of embolus o Petechiae of the skin, splinter hemorrhage under the nails o Signs of infarction related to an embolization include: ▪ Infarction of spleen or abdominal organs – abdominal pain, rigidity or signs of ileus ▪ Infarction in kidney – hematuria, pyuria, flank pain and decreased urine output ▪ Infarction in brain – hemiparesis, aphasia and other neurologic deficits ▪ Infarction in lung – cough, pleuritic pain, pleural friction rub, dyspnea and hemoptysis ▪ Peripheral vascular occlusion – numbness, tingling and cyanosis in an arm, leg, finger, toe, or a blackened area • Diagnostic Studies o Diagnosis begins with a health history. o Laboratory data will show elevated WBCs and positive blood cultures. o Elevated ESR o A transesophageal echocardiogram will show vegetation on the valve, which indicates endocarditis. The ECG will be used to detect arrhythmias. • Management o Pharmacologic Interventions include IV antibiotics which are administered typically for six weeks or until infection resolves, guided by culture and sensitivity. Antipyretics are used to control fever. o Oxygen is administered to prevent tissue hypoxia. o A surgical intervention may be necessary to replace the valve or if a prosthetic valve infection does not respond to antibiotics. • Nursing Interventions o The nurse will monitor the client's response to antibiotics (fever resolution, WBCs return to normal) and arrange for long term venous access for IV antibiotics (such as a peripherally inserted central line). Plan for home IV therapy after discharge. o The nurse will explain to the client and family the need for long-term IV antibiotic therapy and for prophylactic antibiotics prior to dental work and other invasive procedures. The client will report fever, tachycardia, dyspnea and shortness of breath. Rheumatic Endocarditis - Heart Infections Rheumatic heart disease (rheumatic endocarditis) is damage to the heart caused by one or more episodes of rheumatic fever, which can also affect the joints, skin and brain. The pathogen is a group A streptococcus. Rheumatic endocarditis results in damage to the heart, particularly the valves, resulting in valve leakage and/or stenosis; heart chambers compensate by enlarging. • Epidemiology o Rheumatic endocarditis is fairly rare in developed countries. It is more common in developing countries where malnutrition and crowded living conditions are common. It appears in children aged 5-15 years. Prevention incudes the identification and treatment of streptococcal pharyngitis. o Malfunction of valves due to rheumatic damage can lead to heart failure. • Assessment Findings o Clients will report a history of streptococcal pharyngitis (sudden sore throat, tonsillar exudate, swollen lymph nodes, headache and fever). o Polyarthritis will be manifested by numerous warm and swollen joints (usually the elbows, wrists, knees and ankles). They may also report high fever, chills, malaise, shortness of breath and chest pain will be reported. o Common findings include chorea (emotional instability, muscle weakness with quick, uncoordinated jerky movements usually in the face, feet and hands), erythema marginatum (a ring-like or snake-shaped rash on the trunk or extremities), subcutaneous nodules and a temperature to 104° F (40° C). o Heart Sounds ▪ Systolic • Aortic stenosis - mild o Loud murmur early in systole (musical murmur) o Caused by turbulent blood flow into the aorta o Listen using the diaphragm of the stethoscope with the client in a supine position ▪ Diastolic • Aortic regurgitation - mild o Caused by a bicuspid (thickened) aortic valve o Listen using the diaphragm of the stethoscope over Erb’s point with the client in a sitting position, leaning forward • Mitral stenosis - mild o Commonly due to rheumatic heart disease o Listen using the bell of the stethoscope over the mitral valve, with the client in a left lateral position ▪ The first heart sound is increased in intensity ▪ The second heart sound is normal and unsplit ▪ Friction Rub • Pericardial friction rub: o A sign of pericardial inflammation, heard in infective endocarditis (IE), myocardial infarction (MI) and rheumatic fever (RF) o Scratchy, grating or squeaking sound o Listen using the bell of stethoscope over the left lateral sternal border to hear one systolic sound and two diastolic sounds • Diagnostic Studies o Antistreptolysin O (ASO) titer – increased o Erythrocyte sedimentation rate – increased o Throat culture – positive for streptococci o WBC count – increased • Management o Pharmacological: Analgesics will be administered as ordered for pain and inflammation, as well as antibiotics for the infection. Oxygen will be provided to prevent tissue hypoxia. o Surgical procedures such as commissurotomy, valvuloplasty or a prosthetic heart valve may be necessary. • Nursing Interventions o The nurse will monitor for cardiac complications, assist with the resolution of the infection and help clients with chorea to grasp objects and prevent falls. Encourage family and friends to spend time with the client and fight boredom during the long, tedious convalescence. • Client & Family Teaching o An explanation of all tests and treatments o Proper nutrition o Proper hygienic practices o Resume activities of daily living slowly, schedule rest periods o Report penicillin reaction, e.g., rash, fever or chills o Report findings of streptococcal infection: ▪ Sudden sore throat ▪ Diffuse throat redness and oropharyngeal exudate ▪ Swollen and tender cervical lymph glands ▪ Pain on swallowing ▪ Temperature of 101-104° F (38.3-40° C) ▪ Headache ▪ Nausea o Avoid exposure to people with respiratory infections o Explain the necessity of long-term antibiotics o Arrange for a visiting nurse if necessary o Help the family and client cope with temporary chorea Valve Disorders The four valves keep blood flowing in the correct direction. In some cases, one or more of the valves don't open or close properly. This can cause the blood flow through your client's heart to their body to be disrupted. The following section reviews different valve disorders that can affect the heart. • Epidemiology o Two-thirds of clients with mitral stenosis are female. In most cases, mitral stenosis is caused by rheumatic fever. • Assessment Findings o The client will present with a mild asymptomatic heart murmur. o Moderate to severe stenosis will present with symptoms of left-sided heart failure, due to blood backing up into lungs and poor cardiac output. o Common findings include: exertion, cough, orthopnea (dyspnea when supine), a recent history of propping up with pillows to sleep or sleeping in recliner and paroxysmal nocturnal dyspnea (sudden waking due to shortness of breath). o Crackles, weakness, fatigue, palpitations and mild weight gain are additional findings. • Diagnostic Studies o A history and physical exam o ECG – findings of left atrial enlargement and right ventricle enlargement o Echocardiogram – reduced mitral valve area o Cardiac catheterization – coronary arteries normal if no other heart disease o Chest X-ray – cardiac enlargement (cardiomegaly) • Management o Surgery to repair the mitral valve or replacement for severe or recurrent episodes of heart failure may be necessary. • Nursing Interventions o If your client has had valve surgery, watch for hypotension and arrhythmias, administer and titrate anticoagulants, using PTT for heparin and INR for warfarin. • Client & Family Teaching o If the client is on long-term anticoagulation therapy, periodic lab testing of INR for warfarin is necessary. Instruct your client to maintain steady dietary vitamin K levels and report signs of bleeding. o There may be a need for antibiotics before dental care or invasive procedures. Mitral Valve Insufficiency – Valve Disorders Mitral valve insufficiency (or regurgitation) occurs when a damaged mitral valve allows blood from the left ventricle to flow back into the left atrium during ventricular systole. To handle the back flow, the atrium enlarges; the left ventricle also enlarges, in part to make up for its lower cardiac output. • Epidemiology o Mitral valve insufficiency is often a result of a birth defect. • Assessment Findings o Clients often are asymptomatic. If they do present with symptoms, you may see the following: ▪ Orthopnea, dyspnea, fatigue, weakness and weight loss ▪ Chest pain and palpitations ▪ Systolic murmur at the apex; high pitched, blowing murmur; may radiate to axilla ▪ Jugular vein distention ▪ Peripheral edema ▪ Hepatomegaly • Diagnostic Studies o An ECG will be performed to check for arrhythmias and changes of left atrial enlargement. An echocardiogram will show regurgitant blood flow at the mitral valve. o A cardiac catheterization will show regurgitation of blood from the left ventricle to the left atrium and increased pressures. A chest X-ray will detect cardiomegaly and pulmonary congestion. • Management: DOABLE o Surgery may be necessary to repair or replace the valve for clients with severe, recurrent episodes of heart failure. • Nursing Interventions: CARDIAC LEVELS/DOABLE o If the client has had valve surgery, watch for hypotension and arrhythmias. Administer and teach about long-term anticoagulation therapy. The nurse will teach the client and family the REAL keys for self-care. o If the client is on long-term warfarin, periodic lab testing of INR is necessary as well as regulating vitamin K levels (contraindicated with warfarin). The client will report signs of bleeding. o Explain the potential need for antibiotics before dental care or invasive procedures. Tricuspid Stenosis – Valve Disorders Tricuspid stenosis is the narrowing of the tricuspid valve between the right atrium and right ventricle. • Etiology o Tricuspid stenosis is relatively uncommon and usually associated with lesions of other values. It can also be caused by rheumatic fever. • Assessment Findings o Client may report dyspnea, fatigue, weakness and syncope o Peripheral edema o Jaundice with severe peripheral edema and ascites can mean that tricuspid stenosis has led to right ventricular failure o Client may appear malnourished o Distended jugular vein • Diagnostic Studies o An ECG will detect arrhythmias and the echocardiogram will show tricuspid stenosis. • Management: DOABLE o Surgery may necessary to repair or replace the valve for severe, recurrent episodes of heart failure. • Nursing Interventions: REAL o If the client has had valve surgery, watch for hypotension and arrhythmias. Administer and teach the client about long-term anticoagulation therapy. • If the client is on long-term anticoagulation therapy, periodic lab testing of INR for warfarin is necessary. The client will also maintain steady dietary vitamin K levels (contraindicated in warfarin) and report signs of bleeding. • Explain the potential need for antibiotics before dental care or invasive procedures. Tricuspid Valve Insufficiency – Valve Disorders Tricuspid valve insufficiency (regurgitation) is when the tricuspid valve does not close properly during ventricular systole, allowing blood to leak from the right ventricle back into the right atrium. • Etiology o Tricuspid valve insufficiency is relatively uncommon. It results from dilation of the right ventricle and tricuspid valve ring and is usually associated with lesions of other valves. o It is most common in late stages of heart failure from rheumatic or congenital heart disease, or with IV drug abuse. • Assessment Findings o Tricuspid valve insufficiency is asymptomatic in early stages but, when severe, it can lead to right heart failure and poor cardiac output. o The client may present with: ▪ Dyspnea, fatigue, weakness and syncope ▪ Distended jugular veins ▪ Peripheral edema, ascites and pulmonary edema as blood is backing up from right side of heart into the venous system • Diagnostic Studies o An echocardiogram will show the abnormal tricuspid valve movement and regurgitation. • Management: DOABLE o Surgical-valve replacement or repair may be necessary if this condition is severe, with recurrent exacerbations and hospitalizations. • Nursing Interventions: CARDIAC LEVELS/REAL o If client has had valve surgery, watch for hypotension and arrhythmias. Administer and teach about long-term anticoagulation therapy. o If the client is on long-term anticoagulation therapy, periodic lab testing of INR for warfarin is necessary. Encourage your client to maintain steady dietary vitamin K levels (contraindicated in warfarin) and report signs of bleeding. o Explain the potential need for antibiotics before dental care or invasive procedures. Pulmonary Stenosis – Valve Disorders Pulmonary stenosis takes place when the narrowing of the pulmonic valve between the right ventricle and pulmonary artery obstructs right ventricular outflow, leading to right ventricular hypertrophy and right heart failure. • Epidemiology o Pulmonary stenosis takes place when usually congenital, often occurring with other birth defects, such as tetralogy of Fallot. It is rare among the elderly and may result from rheumatic fever. • Assessment Findings o Cyanosis dyspnea, fatigue, syncope and findings of right heart failure o Cyanosis, failure to thrive • Diagnostic Studies • An echocardiogram will show the valve abnormalities and increased right heart pressure. • Management o Surgery may be needed to repair or replace the valve for severe, recurrent episodes of heart failure. • Nursing Interventions o If the client has had valve surgery, watch for hypotension and arrhythmias. Administer medication as ordered and teach the client about long-term anticoagulation therapy. o If the client is on long-term anticoagulation therapy, periodic lab testing of INR for warfarin is ne o cessary. The client will also maintain steady dietary vitamin K levels (contraindicated in warfarin) and report signs of bleeding. o Explain the potential need for antibiotics before dental care or invasive procedures. Pulmonary Valve Insufficiency – Valve Disorders Pulmonary valve insufficiency (regurgitation) occurs when the pulmonary valve fails to close, so that blood flows back into the right ventricle. • Epidemiology o Pulmonary valve insufficiency may be a result of a birth defect or of pulmonary hypertension. o Rarely, it is a result of prolonged use of a pressure-monitoring catheter in the pulmonary artery. • Assessment Findings o Dyspnea, fatigue, chest pain and syncope o Peripheral edema may cause discomfort o Possible malnourished appearance o If advanced, the client will present with jaundice with ascites and peripheral edema. • Diagnostic Studies o An echocardiogram will detect abnormal blood or valve movement. • Management: DOABLE/ M DOG o Surgery may be needed to repair or replace the valve for severe, recurrent episodes of heart failure • Nursing Interventions: CARDIAC LEVELS/REAL o If the client has had valve surgery, watch for hypotension and arrhythmias. Administer medication as ordered and teach the client about long-term anticoagulation therapy. o If the client is on long-term anticoagulation therapy, periodic lab testing of INR for warfarin is necessary. The client will also maintain steady dietary vitamin K levels (contraindicated in warfarin) and report signs of bleeding. o Explain the potential need for antibiotics before dental care or invasive procedures. Aortic Stenosis – Valve Disorders • Aortic stenosis occurs when the aortic valve narrows, causing poor cardiac output and increasing left heart pressures. • Etiology o Aortic stenosis is the most significant valvular lesion seen among elderly people. It usually leads to left-sided heart failure, left ventricular hypertrophy and cardiomyopathy. Incidence does increase with age but only occurs in 1% of the total population. 20% of these patients may die suddenly, around the age of 60. • Assessment Findings o Classic triad: dyspnea, syncope, angina o Fatigue, palpitations and left-sided heart failure may occur with orthopnea, paroxysmal nocturnal dyspnea and crackles in the lungs o Systolic murmur that radiates into the carotid arteries and the apex of the heart ▪ Loud murmur early in systole (musical murmur) ▪ Caused by turbulent blood flow into the aorta ▪ Listen using the diaphragm of the stethoscope with the client in a supine position o An ECG will show findings of left ventricular hypertrophy o Fourth heart sound ▪ Low frequency sound ▪ Cadence is similar to "Tennessee" ▪ Associated with coronary heart disease, aortic stenosis, ischemic or hypertrophic cardiomyopathy ▪ Listen using the bell of stethoscope pressed lightly on the skin of the chest with the client in a supine position Assessing Cardiovascular Disorders Pathophysiological Basis Ischemia to myocardium Potential Assessment Questions Where is your pain? What does the pain feel like? How severe is it on a scale of 0-10? What causes the pain? Does anything relive it? Does it spread to your arms, neck, jaw, shoulders or back? Finding Chest pain Pathophysiological Basis Pulmonary congestion in recumbent position (left-sided heart failure) Potential Assessment Questions Do you have a cough? If yes, what do you cough up? If yes, do you cough more at night? Finding Coughing at night Pathophysiological Basis Severe congestion of pulmonary capillaries (left-sided heart failure) Finding Coughing up blood Pathophysiological Basis Ischemia to myocardium Potential Assessment Questions Where is your pain? What does the pain feel like? How severe is it on a scale of 0-10? What causes the pain? Does anything relive it? Does it spread to your arms, neck, jaw, shoulders or back? Finding Chest pain Pathophysiological Basis Right ventricular heart failure Potential Assessment Questions Have you noticed any weight gain or swelling in your feet, ankles, legs or abdomen (sacrum if bedridden)? Do your shoes feel tight? Do your clothes feel tight around your waist? Finding Dependent edema Pathophysiological Basis Poor perfusion of skeletal muscles Potential Assessment Questions How would you describe your usual activity level? What is your current activity level and has it changed? What activities can you no longer do because of fatigue? Do you feel rested when you wake up in the morning? Can you rest during the day? How often do you awaken at night? Finding Fatigue/weakness Pathophysiological Basis Obstruction of arterial vessels in legs Potential Assessment Questions Do you have pain, achiness, fatigue, burning, or discomfort in the muscles of your feet, calves or thighs? Do these symptoms occur during exercise or at rest? Do you have an numbness or tingling in your feet or toes? What do you do to relieve the pain? Finding Intermittent claudication Finding Pathophysiological Basis Heart failure, either right- or left- sided Potential Assessment Questions Do you have to get up at night to urinate? Have you noticed an increase or decrease in the amount you usually Nocturia Pathophysiological Basis Ischemia to myocardium Potential Assessment Questions Where is your pain? What does the pain feel like? How severe is it on a scale of 0-10? What causes the pain? Does anything relive it? Does it spread to your arms, neck, jaw, shoulders or back? Finding Chest pain urinate? Pathophysiological Basis Left-sided heart failure Potential Assessment Questions Do you ever wake up at night with shortness of breath? Is it relieved by sitting or standing? How many pillows do you use under your head at night? Do you ever have to sleep sitting up? Finding Orthopnea Pathophysiological Basis Cardiac dysrhythmias Potential Assessment Questions Do you ever feel your heart racing, skipping beats or pounding? Do you feel lightheaded or dizzy? Are there any other symptoms that occur at the same time? How much caffeine do you consume? Do you use any nutritional supplements or herbs? Have there been any changes in the amount of stress you experience? Do you use tobacco? Finding Palpitations Pathophysiological Basis Decreased left ventricular pumping ability; some degree of left-sided heart failure Potential Assessment Questions Do you sleep in your bed, or do you breathe easier sleeping in a chair? How many pillows do you use to sleep? Has this changed recently? Finding Paroxysmal nocturnal dyspnea Finding Pathophysiological Basis Left-sided heart failure (LHF) Potential Assessment Questions When did you first notice feeling short of breath? What makes you short of breath? What activities are you no longer able to do because you are short of breath? Do you ever wake up at night feeling Shortness of breath Pathophysiological Basis Ischemia to myocardium Potential Assessment Questions Where is your pain? What does the pain feel like? How severe is it on a scale of 0-10? What causes the pain? Does anything relive it? Does it spread to your arms, neck, jaw, shoulders or back? Finding Chest pain short of breath? Pathophysiological Basis Transient reduction of blood flow to brain or postural hypotension Potential Assessment Questions Do you ever feel dizzy or lightheaded? Do you ever pass out or have fainting spells? Do you strain while having a bowel movement or when urinating? Do you have headaches? Finding Syncope Pathophysiological Basis Right ventricular heart failure Potential Assessment Questions What is your usual weight? Have you had a recent weight gain (or weight loss)? Finding Weight loss or weight gain • Diagnostic Studies o An echocardiogram will show a small aortic valve area and abnormal blood flow. • Management: DOABLE o Surgery may be needed to repair the valve or replacement for severe, recurrent episodes of heart failure. • Nursing Interventions: CARDIAC LEVELS/REAL o If the client has had valve surgery, watch for hypotension and arrhythmias. Administer medication as ordered and teach the client about long-term anticoagulation therapy. o If the client is on long-term anticoagulation therapy, periodic lab testing of INR for warfarin is necessary. Instruct your client to maintain steady dietary vitamin K levels (contraindicated in warfarin) and report signs of bleeding. o Explain the potential need for antibiotics before dental care or invasive procedures. Aortic Insufficiency – Valve Disorders Aortic insufficiency (regurgitation) occurs when blood flows back into the left ventricle during diastole, overloading the ventricle and causing it to hypertrophy. Extra blood also overloads the left atrium and, eventually, the pulmonary system. • Epidemiology o Aortic insufficiency may accompany Marfan's syndrome, ankylosing spondylitis, syphilis, essential hypertension or a defect of the ventricular septum. • Assessment Findings o Uncomfortable awareness of heartbeat o Palpitations o Dyspnea with exertion o Orthopnea, paroxysmal nocturnal dyspnea and cough o Fatigue and syncope with exertion or emotion o Anginal chest pain unrelieved by sublingual nitroglycerin o Nail beds appear to be pulsating o Quincke's sign – root of nail will flush and then pale when press nail tip o If the right ventricle fails – may show signs of right heart failure with peripheral edema, jugular vein distention and ascites o High pitched diastolic murmur at the third or fourth intercostal space, left sternal border o Widened pulse pressure o Pulsus bisferiens – a double-beat pulse, palpated over the carotid or brachial artery • Diagnostic Studies o A chest X-ray, echocardiogram and cardiac catheterization will be used to detect aortic insufficiency. • Management: DOABLE o Surgery may be needed to repair the valve or replace it if the client experiences severe, recurrent episodes of heart failure. • Nursing Interventions: CARDIAC LEVELS/REAL o If the client has had valve surgery, watch for hypotension and arrhythmias. Administer medication as ordered and teach the client about long-term anticoagulation therapy. o If the client is on long-term anticoagulation therapy periodic lab, testing of INR for warfarin is necessary. Instruct your client to maintain dietary vitamin K levels (contraindicated in warfarin) and report signs of bleeding. o Explain the potential need for antibiotics before dental care or invasive procedures. Disorders of the Heart Muscle Millions of cardiac muscle cells work together to pump all of the blood in the body through the heart in less than a minute. Disorders of the heart muscle can lead to life-threatening pump failure. The following section reviews some of the disorders that affect the heart muscle. • Etiology o The progression toward an MI includes: Atherosclerotic plaques that cause narrowing in arteries (coronary artery disease or CAD); sudden rupture of unstable plaque causes thrombotic event; suddenly worsening stenosis (acute coronary syndrome), leading to the occlusion of coronary blood flow to heart muscle distal to the blockage (myocardial infarction). • Epidemiology o MI is common killer in North America and Western Europe. o Clients are more at risk who have a history of cardiovascular risk factors, including smoking, obesity, diabetes, sedentary lifestyle, hyperlipidemia, physical/emotional stress and depression. o Factors affecting mortality include: ▪ Mortality about 25% – more than half of sudden deaths from MI happen within an hour ▪ Number of occluded vessels ▪ Previous history of MI ▪ Presence of cardiogenic shock ▪ Advanced age; females have twice the mortality of males • Assessment Findings o Classic findings include persistent, crushing, substernal chest pain. o Pain may radiate to the left arm, jaw, neck and shoulder blades, with a feeling of impending doom that will not resolve with rest. o Some clients report no pain or call their symptoms mild indigestion. o Clients with diabetes have an increased risk of MI and heart disease. o Clues that suggest a "silent" MI (acute or sudden) include heart failure, change in mental status, unexplained abdominal pain, dyspnea and fatigue. o Some clients (especially older women) report only fatigue, nausea or vomiting, shortness of breath or flu-like symptoms. • Diagnostic Studies o An ECG will show ST-segment changes (elevation) in the 12-lead ECG and arrhythmias. o Serum markers will be elevated. o CK-MB (creatine kinase) isoenzyme rises 4-6 degrees within 3-6 hours and peaks in 18-24 hours. (This returns to normal in 3-4 days.) o LDH (lactate dehydrogenase) appears 12-24 hours and peaks 48-72 hours. This lasts 6-12 days. o Troponin peaks in 4-12 hours and remains elevated for up to 3 weeks. • Management o For suspected or confirmed acute coronary syndrome/acute myocardial infarction: ▪ The nurse will rapidly assess symptoms, vital signs and 12-lead ECG. ▪ The nurse will immediately administer Morphine, Oxygen, Nitrates and Aspirin (M.O.N.A.). ▪ The nurse will resolve symptoms as quickly as possible – think "time is muscle." ▪ Emergency coronary angiogram with revascularization may be needed: • Cardiac catheterization may be performed for percutaneous transluminal coronary angioplasty (PTCA), i.e., stent insertion. • Thrombolytic agents such as tissue plasminogen activator (tPa) to dissolve the thrombus in the coronary artery and reperfuse the myocardium (this technique is used in centers without angioplasty capabilities). ▪ Coronary artery bypass graft surgery may be necessary. ▪ Perform cardiac monitoring for arrhythmias. ▪ Induce hypothermia (target temperature of 32-34° C) for cardiac arrest survivors, as soon as possible after the return of spontaneous circulation. ▪ Enforce bed rest (often with bathroom privileges) during an acute event or episodes of physiologic instability. • Bed rest will assist in decreasing the workload of the heart. • Activity can slowly increase when the client is stable. ▪ Administer pharmacologic agents to stabilize the heart and reduce the risk of complications and death. ▪ Administer antiplatelets and/or anticoagulants to prevent recurrent thrombosis. ▪ Administer nitrates to decrease pain and decrease preload and afterload while increasing the myocardial oxygen supply. ▪ Administer narcotic analgesics (for acute episodes of chest discomfort or pulmonary edema) to reduce pain, anxiety, fear and decrease the workload of the heart. ▪ Administer beta blockers to decrease myocardial tissue oxygen consumption and decrease the risk of arrhythmias. ▪ Administer ACE inhibitors to decrease pressures in the heart, reducing the risk of cardiac remodeling that leads to heart failure. ▪ Administer diuretics if pulmonary edema occurs. ▪ Administer sedatives to decrease anxiety and fear, and to decrease the workload of the heart. ▪ Administer antiarrhythmics to prevent or control arrhythmias, which are the most common complications after an MI. ▪ Administer stool softeners to decrease the workload of the heart caused by straining, which can cause vagal stimulation producing bradycardia and arrhythmias. ▪ Apply pulmonary artery (Swan-Ganz) catheter to monitor pressure in pulmonary artery (measures functioning of left ventricle). ▪ Intra-aortic balloon counter pulsation may be used for cardiogenic shock. • Nursing Interventions o The cardio-care six plus monitor the following to prevent heart failure, infections and complications: ▪ Temperature ▪ Take daily weights ▪ Intake and output (I/O) ▪ Respiratory rate ▪ Breath sounds ▪ Blood pressure ▪ Serum enzyme levels ▪ ECG readings ▪ Peripheral pulses ▪ Abnormal heart sounds, especially S3 and gallop ▪ Chest discomfort or recurrent cardiac symptoms, especially findings similar to those that brought the client into the hospital; for recurrent cardiac symptoms, repeat 12-lead ECG and M.O.N.A. protocol ▪ Cough, tachypnea and crackles, which may indicate pulmonary edema due to left ventricular failure Cardio-Care 6 A Application Activities of daily living (ADLs) Nursing Action Help the client with ADLs Rationale It stresses the heart less B Application Bed rest Nursing Action Maintain bed rest Rationale To reduce the oxygen demands on the heart C Application Commode Nursing Action Commode at bedside Rationale Using a commode stresses the heart less than using a bedpan D Application Diversions Nursing Action Offer diversionary activities while on bedrest Rationale To engage client in activities that don't stress the heart E Application Elevate Nursing Action Elevate head of bed (semi-Fowler's) or sit client up Rationale To increase chest expansion and improve ventilation A Application Activities of daily living (ADLs) Nursing Action Help the client with ADLs Rationale It stresses the heart less F Application Feelings Nursing Action Listen to client's concerns; provide emotional support to reduce anxiety Rationale Anxiety increases oxygen demand o As ordered, apply antiembolism stockings and intermittent pneumatic compression devices to prevent venostasis and thrombophlebitis. Assist the client with range-of-motion exercises as appropriate for clients who are on bed rest. o Reinforce client and family teaching regarding: Cardio Five Teaching Plan ▪ The ICU, CCU or Telemetry units – inform the client and family about associated routines, machinery and communication methods. ▪ Explain nitroglycerin use for recurrent cardiac symptoms and when to seek emergency care. ▪ Advise the client when to report to the health care provider typical or atypical cardiac symptoms or chest discomfort controlled with nitroglycerin. ▪ Encourage client to join the cardiac rehab exercise program, if ordered. ▪ Reinforce education for the gradual resumption of sexual activity when client can walk up two flights of stairs without symptoms. ▪ Taking nitroglycerin before sex may prevent angina (but reinforce that drugs such as sildenafil are contraindicated in those taking nitrates because severe hypotension may occur). ▪ Reinforce information about post-myocardial infarction syndrome and what to report to care provider. Stress to the client that they should modify risky lifestyle behaviors to reduce likelihood of recurrent MI. Assist with dietary consultation as indicated. Cardio 5 Teaching Plan TDDDS T Topic Tests and Treatments Nursing Action Explain tests and treatments in simple, culturally sensitive ways TDDDS D Topic Drugs Nursing Action Write out names and explain the reason for medications, their side effects and how long the client will take them TDDDS Topic Nursing Action TDDDS T Topic Tests and Treatments Nursing Action Explain tests and treatments in simple, culturally sensitive ways Diet Good nutrition and restrictions, i.e., low sodium, whole grains, a variety of fruits and vegetables (DASH diet) D TDDDS Topic Disease Nursing Action Explanation of the disorder and treatment plan D TDDDS Topic Smoker? Nursing Action Encourage to stop smoking S Heart Failure – Disorders of the Heart Muscle Heart failure (HF) occurs when a damaged heart fails to pump enough blood to support the body's functions, leading to poor cardiac output and fluid overload. HF is a common cause of hospitalization and recurrent hospitalization in older adults. The type of HF depends on which part of the heart is abnormal, and the type of abnormality. The left heart receives blood from the lungs and pumps blood to the body (cardiac output) to perfuse tissue. The right heart receives blood from the venous system via the central vena cava, and pumps blood to the lungs. Heart muscle damage is called cardiomyopathy, which leads to heart failure syndrome. 1. Systolic heart failure: disorder of weakened left ventricle (LV) with reduced ability to contract characterized by reduced LV ejection fraction of ≤ 40% 2. Diastolic heart failure: left ventricle (LV) is unable to relax properly during diastole, usually due to hypertrophy; this prevents adequate filling of the LV, reducing stroke volume and is characterized by normal to high LV ejection fraction > 50% • Etiology o Coronary artery disease that causes ischemia and infarction – ischemic cardiomyopathy is most common type of HF o Infections of the heart (endocarditis, myocarditis) o Cardiac valvular disorders in moderate-to-severe stages o Infiltrative disorders, i.e., amyloidosis, tumors and sarcoidosis o Collagen-vascular disease: systemic lupus erythematosus, scleroderma o Arrhythmias that reduce cardiac filling time, i.e. atrial fibrillation o Disorders that increase cardiac workload: hypertension, anemia and hyperthyroidism o Cardiac tamponade • Assessment Findings o Heart failure symptoms listed in order of earliest findings to later findings: ▪ Right HF • Significant weight gain • Jugular vein distention • Bilateral dependent peripheral edema • Liver engorgement (hepatomegaly with abdominal pain, anorexia and nausea) • Ascites ▪ Left HF • Fatigue and activity intolerance • Cough (often dry initially) • Mild weight gain that leads to early pulmonary symptoms • Shortness of breath/orthopnea • Paroxysmal nocturnal dyspnea • Tachypnea • Crackles • Third heart sound • Cardiac cachexia and muscle weakness in advanced stage. • Acute pulmonary edema: o Frothy sputum (may be blood-tinged) o Restlessness, irritability, hostility, agitation and anxiety o Prominent crackles throughout lung fields o Diaphoresis o Cyanosis • Diagnostic Studies o The primary goal of these diagnostic studies is to determine the underlying cause of the heart failure, and to reduce the risk of complications: ▪ History and physical exam ▪ Echocardiogram to look for structural defects, heart movement, blood flow and ejection fraction ▪ Serum labs: complete blood count (CBC), electrolytes, brain (or B-type) natriuretic peptide (BNP) ▪ Chest X-ray to determine heart size and pleural effusions ▪ ECG for changes, arrhythmias ▪ Nuclear imaging to determine myocardial contractility, myocardial perfusion and acute cell injury, reversible causes of heart failure such as ischemia ▪ Hemodynamic monitoring in cardiogenic shock: arterial blood pressure, pulmonary artery pressure, pulmonary artery wedge pressure and cardiac output • Management: DOABLE o Pharmacologic treatments include digitalis, vasodilators, nitrates, antihypertensives, cardiac glycosides, diuretics, beta blockers, ACE inhibitors and inotropes. o Other treatments include oxygen, intra-aortic balloon counterpulsation, ventricular assist pumping and biventricular pacing. o The required surgery is partial left ventriculectomy. • Nursing Interventions: CARDIAC LEVELS o If the client has a prosthetic valve or atrial fibrillation, administer and titrate anticoagulants using PTT for heparin and INR for warfarin. • Client & Family Teaching: REAL o If the client is on long-term anticoagulation therapy, periodic lab testing of INR for warfarin is needed. Instruct the client to maintain steady dietary vitamin K levels and report signs of bleeding. Cardiac Tamponade – Disorders of the Heart Muscle Cardiac tamponade occurs when fluid quickly fills the pericardial sac and minimizes cardiac output, requiring emergency care to avoid cardiac arrest. It is a medical emergency! - Compression of the heart d/t fluid accumulation w/n the pericardium • Etiology o Acute pericarditis o Post-op after cardiac surgery o Pericardial effusions o Chest trauma o Myocardial rupture o Malignancy o Aortic dissection o Anticoagulant therapy • Assessment Findings o Classic triad of signs: ▪ Hypotension with ▪ Muffled heart sounds with ▪ Marked jugular vein distention if no hypovolemia o Additional findings: ▪ Pulsus paradoxus is when the client's systolic blood pressure is greater than 10 mm/Hg, lower on inspiration than expiration. ▪ Narrowed pulse pressure is the difference between systolic and diastolic blood pressure, an indicator of poor cardiac output. ▪ Tachypnea, tachycardia, restlessness, light-headedness or decreased level of consciousness – this person requires emergency care! • Diagnostic Studies o Echocardiogram will show a large pericardial effusion with poor heart movement and blood flow. • Management 1. Rapid response (or organization emergent system) will be called. 2. Emergency pericardiocentesis (needle aspiration of pericardial sac) will be performed. • Nursing Interventions o Continuous monitoring of cardiovascular status o Bedrest with the head of the bed elevated 35-45 degrees o Prepare the client for pericardiocentesis o Provide emotional support o Prepare the client for surgery if pericardiocentesis is ineffective o Monitor for complications such as pneumothorax, arrhythmias and hypotension upon completion of the pericardiocentesis Cardiomyopathy – Disorders of the Heart Muscle Dilated or congestive cardiomyopathy results from extensive damage to the myocardial muscle fiber. This disorder gives the heart a globular shape, interferes with myocardial metabolism and abnormally dilates every heart chamber. • Etiology & Pathophysiology o The onset of cardiomyopathy is gradual and subtle, but the effects are harmful and can progress to end-stage heart failure. All four chambers of the heart become dilated as a result of increased volumes and pressures. Blood can pool which can lead to thrombi and evolve into an embolism. o The cause is unknown, but several theories do exist. Metabolic and infectious agents have been associated with cardiomyopathy. Also muscle disorders such as myasthenia gravis and muscular dystrophy have a higher occurrence in developing cardiomyopathy. Infiltrative disorders, rheumatic fever (as a child), and the use of certain drugs also have a correlation. Finally, there are reports of an x-linked inheritance pattern. • Assessment Findings o There are many signs and symptoms associated with cardiomyopathy that tend to occur slowly over a long-period of time. Findings include: ▪ Shortness of breath ▪ Orthopnea ▪ Dyspnea (exertion and paroxysmal nocturnal dyspnea) ▪ Fatigue ▪ Dry cough (nighttime) ▪ Palpitations ▪ Peripheral edema ▪ Vague chest pain ▪ Narrow pulse pressure ▪ Irregular rhythms ▪ S3 and S4 gallop ▪ Murmur • Diagnostic Studies o Diagnostic studies include ECG and angiography to rule out ischemic heart disease. Chest X-ray will show cardiomegaly and an echocardiography can help identify any ventricular thrombi and the degrees of chamber dilation. A cardiac catheterization will also show left ventricular dilation and dysfunction, filling pressures and demisted cardiac output. Finally, the transvenous endomyocardial biopsy may be used to identify an underlying disorder. • Management o Management of cardiomyopathy will include controlling heart failure by improving the heart contractility and decreasing preload and afterload. Specific treatment will depend of the stage of the disease progression. o Pharmacologic Intervention: ▪ Nitrates to decrease preload ▪ Ace Inhibitors to reduce afterload ▪ Aldosterone antagonists to control neurohormal stimulation ▪ Antidysrhythmias ▪ Anticoagulation therapy to reduce the risk of thrombi ▪ Non drug therapy such as a ventricular assist device can allow the heart to rest and recover from acute heart failure ▪ In these cases, the client may not respond well to therapy: • Often admitted for infusions of dobutamine and aggressive diuresis • Terminal or end-stage CMP may qualify for a heart transplant • Nursing Interventions o Nursing interventions are critical to maintain quality of life for clients with CMP. The nurse will monitor for signs and symptoms of worsening heart failure, dysrhythmias, embolus formation, and drug effectiveness. The goal is to keep the client functioning without the need for consist return visits to the hospital. Encourage the caregiver to learn cardiopulmonary resuscitation if the client remains a full code. Home health or hospice can assist the client and family with palliative care. Disorders of the Circulatory System The circulatory system (cardiovascular/vascular system) permits blood to circulate and transport nutrients, oxygen, carbon dioxide, hormones and blood cells through the body. The following section reviews disorders of the circulatory system such as hypertension, CAD and hyperlipidemia. Hypertension – Disorders of the Circulatory System Hypertension occurs when the systolic blood pressure (SBP) is 140 mm Hg or greater and diastolic blood pressure (DBP) is 90 mm Hg or greater, on at least three separate occasions. Chronic hypertension of pregnancy is high blood pressure already present before week 20 of gestation. Accelerated (or malignant) hypertension is a hypertensive crisis when blood pressure rises very rapidly. Untreated hypertension may cause immediate vascular necrosis and target organ damage, particularly to the heart, kidneys, retina and brain. Blood pressure is usually greater than 180/120 mm Hg or a mean arterial pressure of more than 150 mm Hg. Blood Pressure Guidelines: Normal: systolic < 120 mm/Hg...and...diastolic < 80 mm/Hg Prehypertension: systolic 120 to 139 mm/Hg...or...diastolic 80 to 89 mm/Hg Hypertension (Stage 1): systolic 140 to 159 mm/Hg...or...diastolic 90 to 99 mm/Hg Hypertension (Stage 2): systolic ≥ 160 mm/Hg...or...diastolic ≥ 100 mm/Hg • Etiology & Epidemiology o Primary Hypertension ▪ In 90-95% of cases, the cause of primary hypertension is unknown but risk factors include: ▪ Family history – hypertension within immediate family, including mother, father, sister, brother ▪ Race – African Americans, Hispanics and Native Americans are more susceptible ▪ Stress levels ▪ Obesity – 20% more than ideal weight ▪ A diet high in sodium ▪ Use of tobacco ▪ Sedentary life/lack of exercise ▪ Age o Secondary Hypertension ▪ Secondary hypertension is high blood pressure from an identifiable cause including: ▪ Renal disease (renal artery stenosis, glomerulonephritis or end-stage kidney disease) ▪ Drugs (stimulants such as ephedrine-type decongestants and cocaine, certain immunosuppressants, such as cyclosporine, hormonal contraceptives and excessive alcohol consumption). ▪ Cushing's syndrome (increased levels of cortisol, a stress hormone) ▪ Pregnancy-related hormones ▪ Neurologic disorders, i.e, brain tumors, traumatic brain injury ▪ Coarctation of the aorta (congenital aortic narrowing) • Diagnostic Studies o Hypertension is diagnosed based on the average of three or more blood pressure readings, two minutes apart, at each of three or more visits, (not including the initial screening visit). o Hypertensive crisis: diagnostic testing to determine end-organ damage. • Assessment Findings o Usually asymptomatic unless end-organ damage is present or hypertensive crisis is occurring. o Findings that reflect the effect of hypertension on organ systems include: ▪ Brain: occipital headache, blurred vision, dizziness, TIA or stroke ▪ Eyes: retinal arteriole abnormalities ▪ Heart: chest pain, palpitations, dyspnea or signs of heart failure; diagnostic tests showing LV hypertrophy, ischemia or infarction ▪ Peripheral vascular: intermittent claudication (leg pain with exercise, relieved by rest), vascular bruits or aneurysm ▪ Kidneys: elevated serum creatinine, urine positive for protein o Complications of an acute hypertensive crisis include: ▪ Brain: hypertensive encephalopathy (often first sign) severe headache, nausea, vomiting, seizures, confusion, coma or stroke-like symptoms ▪ Eyes: papilledema ▪ Heart: rapid development of angina or myocardial infarction or pulmonary edema ▪ Kidneys: new renal insufficiency or renal failure • Management o Initial treatment for pre-hypertension and uncomplicated stage 1 hypertension are lifestyle modifications such as: ▪ Weight reduction ▪ Regular physical activity (goal – 30 minutes total aerobic activity on most days) ▪ Dietary Approaches to Stop Hypertension (DASH) eating plan: fruits, vegetables, fat-free or low fat milk products, whole grains, fish, poultry, beans, seeds and nuts ▪ Limit dietary sodium ▪ Alcohol in moderation ▪ Smoking cessation ▪ Stress reduction o Pharmacological therapy is used if lifestyle changes fail to decrease the blood pressure to an acceptable level: ▪ Initial therapy for uncomplicated hypertension is to start with a diuretic or beta-adrenergic blocking agent ▪ Oxygen as needed within an acute crisis ▪ Angiotensin-converting enzyme (ACE) inhibitors are used to treat left- sided heart failure and is preferred if the client is diabetic (to protect kidneys) ▪ Anti-lipemics o If a client is in a hypertensive crisis, intensive care is required with rapid reduction of blood pressure using IV vasodilators. Take actions to prevent a hypertensive crisis; monitor for signs of end-organ damage. o The goals of treatment are to bring the blood pressure to less than 130/85 mm Hg and to have control of other cardiovascular risk factors. o Complementary and Integrative Health: ▪ Herbal remedies or dietary supplements (such as cocoa, coenzyme Q10, garlic and fish oil); there is limited evidence about their effectiveness in reducing blood pressure ▪ Mind and body practices such as meditation, yoga, biofeedback and transcendental meditation can help lower blood pressure • Nursing Interventions o Teach the client (and their caregiver) how to self-monitor their blood pressure, how to obtain and use the equipment, and how to properly record blood pressure readings for review during visits to their health care provider. Encourage your client to develop a routine for taking antihypertensive medications and to avoid OTC medications that can increase their BP, such as decongestants. o The nurse will reinforce the DASH eating plan and ask the client to report any extremely high blood pressure readings. ▪ A healthy heart lifestyle will include: ▪ Optimize body weight ▪ Moderate alcohol intake based on current guidelines ▪ Limit dietary sodium, e.g., 2 grams per day ▪ Participate in regular and moderately intense aerobic activity (at least 30 minutes total on most days) ▪ Avoid tobacco and secondary smoke ▪ Manage stress and responses to triggers Malignant Hypertension – Disorders of the Circulatory System Nursing interventions for hypertensive crisis will include monitoring for end stage organ damage, urine output and level of consciousness. It is important to monitor the client's BUN, creatinine, arterial blood gases and urinalysis. The client will be on continuous cardiac monitoring, and the nurse will monitor vital signs every 5-30 minutes (check the health care organization's policy), while titrating the IV vasodilators. Coronary Artery Disease (CAD) – Disorders of the Circulatory System Coronary artery disease (CAD) occurs when fatty deposits in coronary arteries (atheroma or plaque) narrow the artery by 75% or more, reducing flow of blood and oxygen to the heart muscle. • Epidemiology & Etiology o CAD is epidemic in the Western world and more than 30% of men aged 60 or older show signs of CAD on autopsy. o The most common cause is atherosclerosis. o Risk factors for CAD include: ▪ White males over age 40 and women after natural or surgical menopause ▪ Clients whose diabetes is poorly controlled ▪ Family history of CAD increases risk ▪ Uncontrolled high blood pressure ▪ Hyperlipidemia – high LDL and/or triglycerides, low HDL ▪ Tobacco smoke and second-hand smoke exposure ▪ Obesity (waist predominance) ▪ Physical inactivity ▪ Stressed lifestyle • Assessment Findings o In the early stages of CAD, clients are asymptomatic. o Anginal chest discomfort or cardiac symptoms occur when blockage significantly reduces cardiac blood flow (> 70% narrowing). o Chest discomfort or cardiac symptoms will occur with exertion and resolve with rest. o Women, clients with diabetes and older adults often have atypical symptoms, e.g., such as dyspnea, lightheadedness, GI complaints or pain/discomfort in atypical locations. • Diagnostic Studies o Clients will present with elevated labs with their homocysteine levels, C- reactive protein levels, LDH cholesterol and triglycerides. ▪ There will also be a reduction of HDL cholesterol. o Cardiac stress testing will show ST segment changes with exercise or pharmacologically-induced tachycardia. o Nuclear perfusion scanning will show areas of poor perfusion. o Cardiac catheterization with coronary angiography ("gold standard" for diagnosis) shows areas of narrowing in coronary arteries. • Management o Pharmacological ▪ Nitrates – Coronary Artery Vasodilators: • Short-acting nitroglycerin sublingual tablets or spray are used for relief of acute cardiac symptoms. • Oral isosorbide or transdermal nitroglycerin prevents anginal episodes. • All nitrates require a nitrate-free period during each 24-hour period to prevent tolerance. Administer nitrates during the active period of the day and take a break during sleep. ▪ Beta Blockers • Beta blockers reduce myocardial oxygen demand by decreasing heart rate and tachycardic response to stress and exercise. ▪ Antiplatelet Agents • Antiplatelet agents (81mg aspirin daily) reduce platelet aggregation and the likelihood of a thrombotic event. ▪ Antilipemics • Antilipemics are used to treat hyperlipidemia. HMG CoA reductase inhibitors ("statin" drugs) stabilize arterial endothelium, reducing risk of atherosclerotic plaque rupture, which is the cause of most myocardial infarction. ▪ Oxygen • In health care settings, administer oxygen during acute anginal events to improve myocardial oxygenation. o Prevention ▪ A well-balanced diet low in fat and cholesterol that includes several daily servings of fruits and vegetables ▪ Tobacco cessation ▪ Stress reduction techniques ▪ Interventional or surgical revascularization for significant coronary lesions ▪ Coronary angioplasty (PTCA) with stent ▪ Surgical treatment – coronary artery bypass graft (CABG) • Nursing Interventions o Place the client on bed rest during acute events. Monitor for symptoms as the client slowly resumes activity. o Reassure the client and explain all procedures and tests. Assess routinely for cardiac symptoms and chest discomfort. o When cardiac symptoms or chest discomfort occur, quickly assess pain, vital signs, administer a 12-lead ECG and treat with M.O.N.A. o Post cardiac catheterization and percutaneous transluminal coronary angioplasty/stent interventions: ▪ Maintain heparinization to reduce the risk of thrombosis in stent ▪ Monitor the client for chest pain, hypotension, coronary artery spasm and bleeding from the catheter site ▪ Observe for bleeding or hematoma at the puncture site ▪ Keep the affected leg straight and immobile for 6-12 hours ▪ Check for distal pulses to detect arterial occlus