NURSING MANAGEMENT OF PATIENTS WITH ALTERATIONS IN CARDIOVASCULAR FUNCTIONING

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NURSING MANAGEMENT OF PATIENTS WITH ALTERATIONS
IN CARDIOVASCULAR FUNCTIONING

• DEBORAH PEPPER HOOVER, RN, MSN

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OXYGENATION

• A BASIC HUMAN NEED!!!

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Blood Flow In the Heart

• VENOUS SYSTEM
• RIGHT ATRIUM
• TRICUSPID VALVE
• RIGHT VENTRICLE
• PULMONIC VALVE
• PULMONARY ARTERY
• LUNGS

• PULMONARY VEINS
• LEFT ATRIUM
• MITRAL VALVE
• LEFT VENTRICLE
• AORTIC VALVE
• AORTA
• BODY

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See page 533
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See page 534
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CORONARY CIRCULATION

• RIGHT CORONARY ARTERY
• LEFT MAIN CORONARY ARTERY LEFT ANTERIOR
  DESCENDING LEFT CIRCUMFLEX

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See page 534
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See page 536
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Cardiac Output HR x SV

• THE ABSOLUTE BOTTOM LINE FOR ASSESSMENT IS
  CARDIAC OUTPUT!!!!!

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Stroke Volume - amt. of blood pumped per beat

• PRELOAD - stretch on the heart before
  contraction Frank-Starling Law of the heart
• CONTRACTILITY - forcefulness of contraction of
  ventricular fibers Positive INOTROPIC
  - increase
• AFTERLOAD - peripheral resistance against which
  the left ventricle must pump (press. that must be
  exceeded)

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Sympathetic Stimulation of the Heart

• Mediated by Beta adrenergic receptors
• Releases norepinephrine
• Causes 1. Inc. heart rate. 2. Inc. in speed of
  impule conduction in the AV node 3. Inc. in
  force of atrial ventricular contraction

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Parasympathetic Stimulation of the Heart

• Mediated through the vagus (X) nerve
• Releases acetylcholine
• Decreases heart rate
• Decreases speed of conduction through AV node

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Adrengeric Receptors in the Blood Vessels

• ALPHA STIMULATION- causes vasoconstriction
• BETA STIMULATION- causes vasodilitation

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HISTORICAL DATA

• Question about hx of chest pain, shortness of
  breath ( esp. paroxysmal nocturnal dyspnea ),
  alcoholism, anemia, rheumatic fever, congenital
  ht. dz., stroke, HTN, thrombophlebitis,
  intermittent claudication, varicosities, edema
• ? Risk factors - Inc. Lipids ? Smoking
  (see page 544 for risk factors)

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Inspection Palpation of the C-V System

• Overall view of skin color, hair distribution,
  edema, abnormal pulsations
• Gauge capillary filling time (within 3 sec.)
• Palpate pulses for normal, bounding, thready, or
  absent (0-3)
• ? Thrill ? Homans sign ? Bruit

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Assessing Jugular Venous Pressure (see page 547)
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Inspection Palpation of the Thorax for Cardiac
Status

• Inspection for abnormal thoracic structures
  vibrations
• Palpate auscultatory areas for thrills
• Note any heaves
• Locate the PMI

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Auscultation of the Heart

• Listen in the auscultatory areas starting with
  diaphragm then bell
• Concentrate on identifying S1, S2, systole
  versus diastole
• Feel for carotid pulse to determine first heart
  sound (S1) or lub
• Check for pulse deficit by listening to apical
  impulse while counting radial pulse

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HEART SOUNDS

• LUB or S1 - ASSOCIATED WITH CLOSURE OF THE
  TRICUSPID MITRAL VALVES
• DUB or S2 - ASSOCIATED WITH CLOSURE OF THE
  PULMONIC AORTIC VALVES

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Auscultation

• Third heart sound (S3) - extra, heard in early
  diastole (rapid filling of ventricle), associated
  with left ventricular failure
• Fourth heart sound (S4) - extra, heard in late
  diastole (atrial contraction), associated with
  resistance to ventricular filling like
  hypertension
• Normal physiologic splitting of S2 - split at
  pulmonic area with inspiration

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Gallops (see page 549)
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Murmurs

• Produced by turbulent blood flow
• Graded on a scale from I - VI I - soft,
  faint VI - heard without a
  stethoscope
• Record timing, location, pitch, characteristics
• Associated with valve disorders or abnormal blood
  flow patterns

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Diagnostic Studies

• EKG - 12 lead, telemetry, ambulatory (Holter),
  treadmill exercise test (GXT)
• Echocardiogram - ultrasound waves
• Nuclear cardiology - MUGA, Thallium imaging,
  Technetium scan, PET scan
• Serum enzymes - CK-MB fraction, myoglobin
• Cardiac catheterization (arteriography)

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ECG or EKG (Electrocardiogram) Monitoring (see
page 553)
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Echocardiogram (see page 555)
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CORONARY ARTERY DISEASE

• ATHEROSCLEROSIS ANGINA

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Normal Atherosclerotic Artery (see page
594)
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CORONARY ARTERY DISEASE (CAD)

• Progressive obstruction of blood flow through one
  or more coronary arteries
• Disease progresses for many years before symptoms
  develop
• Nonmodifiable risk factors - AGE, SEX, FAMILY
  HISTORY
• Modifiable risk factors - SMOKING,
  HYPERLIPIDEMIA, HTN, Diabetes, Obesity, Lack of
  Exercise, Stress, The Pill

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Angina Pectoris - Choking of the Chest

• STABLE ANGINA PECTORIS - occurs when physical
  exertion or emotional stress causes an increase
  in myocardial O2 demand beyond the ability of
  coronary arteries to increase blood supply
• UNSTABLE ANGINA PECTORIS - coronary arteries are
  unable to meet the O2 demands of the myocardium
  at rest

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Other Types of ANGINA

• INTRACTABLE - chest pain that is refractory to
  interventions such as meds
• PRINZMETALS OR VARIANT - severe, prolonged chest
  pain in the absence of precipitating factors
  thought to develop from coronary artery spasm
• NOCTURNAL - chest pain that occurs only at night
• See page 597 SILENT ISCHEMIA

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Cardiac Markers

• CPK-MB 3-6hrs 12-24hrs 2-3dys Can rule out MI
  Other disorders can elevate like trauma, surgery,
  exercise
• Myoglobin 1-2hrs 3-15hrs 20-24h Levels rise
  quickly with MI other disorders can cause
  elevation value ends 24
• Troponin T 2-4hrs 4-6hrs weeks Useful in ruling
  out MI for up to one wk Angina uremia can
  elevate
• Troponin I 4-6hrs 14-18hrs 6-7dys Very cardiac
  specific costly

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NITRATES

• Nitroglygerin is most common
• Side effects from vasodilation - headache,
  hypotension, syncope
• Need nitrate-free interval
• Sudden withdrawal may result in death

• Causes a generalized vasodilation throughout the
  body
• Decreases venous return (preload) BP
  (afterload) thus decreasing the O2 demands of
  heart

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INNOVATIONS IN CAD

• PERCUTANEOUS TRANSLUMINAL ANGIOPLASTY (PTCA)
• INTRACORONARY STENTS
• LASER ANGIOPLASTY
• ATHERECTOMY
• CORONARY ARTERY BYPASS GRAFT SURGERY (CABG)

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Percutaneous Transluminal Coronary Angioplasty
PTCA (see page 602)
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Intracoronary Artery Stent (see page 603)
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Three Coronary Artery Bypass Grafts (see page 604)
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NURSING DIAGNOSES

• PAIN RT MYOCARDIAL ISCHEMIA
• ANXIETY RT PAIN FEAR OF DEATH
• POTENTIAL DISTURBANCE IN SELF CONCEPT
• KNOWLEDGE DEFICIT ABOUT DISEASE PROCESS,
  THERAPIES METHODS TO AVOID COMPLICATIONS