Care of Patient with Problems on Cardiovascular System Lecturer

that receives systemic venous blood through the superior vena cava, inferior

  

vena cava and coronary sinus Overview b. Right ventricle a low-pressure chamber Structures of the heart that receives blood from the right atrium through the tricuspid valve during

A hollow, muscular organ, the heart lies in the mediastinum ( space between the two lungs ) ventricular diastole. It then ejects and rest on the diaphragm. deoxygenated blood through the a. Pericardium a thin, membranous sac that pulmonic valve into the pulmonary has visceral layer in contact with the heart artery and into pulmonary circulation and an outer parietal layer. The space during ventricular systole between the pericardial layers, contains 20 to 30 ml. of serous fluids, which protects c. Left atrium a low pressure chamber the heart from trauma and friction. that receives blood from the left atrium 2. Heart wall through the mitral valve during a. Epicardium the thin, serous outer ventricular diastole. It then ejects layer oxygenated blood the aortic valve into b. Myocardium the thick, muscular middle layer c. Endocardium the smooth, inner layer that comes in contact with blood 3. Heart chambers a membranous muscular septum divides the heart into distinct sides. Each sides contains two chambers: an atrium and a ventricle a. Right atrium a low pressure chamber the aorta and into systemic circulation during ventricular systole d. Left ventricle a high- pressure chamber that receives blood from the left atrium through the mitral valve during ventricular diastole. It then ejects oxygenated blood through the aortic valve into the aorta and into systemic circulation during ventricular diastole.

4. Heart valves - it connects the chambers and outflow tracts a. Atrioventricular valves separates the atria and ventricles 1. Tricuspid valve ( contain three cusps or leaflets ) located between the right atrium and ventricle 2. Bicuspid valve ( contain two cusps) located between the left atrium and ventricle

specialized cardiac cells that initiate or propagate electrical impulses throughout the myocardium as precursor to cardiac muscle contraction A. Electrical pathways 1. Sinoatrial node located at the junction of the right atrium and superior vena cava, functions as the pacemaker of the myocardium, initiating the rhythmic electrical impulses at a rare of 60 to 100 impulses per minute

b. Semilunar valves ( each containing three cusps) located between each ventricle and corresponding artery 1. Pulmonic valve located between the right ventricle and pulmonary artery 2. Aortic valve located between the left ventricle and aorta 3. Papillary muscles muscle bundles on the ventricular walls and chordae tendinae, fibrous bands extending from the papillary muscles to the valve cusps, keep the valves closed during systole. This maintains the unidirectional blood flow through the AV valves and prevents backflow of blood 5. Conduction system consist of

2. Atrioventricular node located in the septal wall of the right atrium, receives impulses from the SA node and relays them to the ventricles 3. Bundle of His a bundle of specialized muscle fibers in the myocardial septum, conducts impulses from the AV node. The Bundle of His divide into right and left branches a. right bundle branch conducts impulses down to the right side of the septum b. left bundle branch conducts impulses into right and left fascicles that fan out into the left ventricular muscle

c. RBB and LBB terminate in the Purkinje fibers which propagate electrical impulses into the endocardium and myocardium B. Electrical impulses activity electrical

- Rhythm is regular with no abnormal delay   CORONARY ARTERIES Supply the heart with blood from branches

that originate in the right or left sinus of the aortic valve cusps a. right coronary arteries supplies blood

impulses traveling through the cardiac to the right heart wall conduction system can be measured and b. left main coronary arteries divides recorded by electrocardiography. into the left anterior descending coronary and circumflex artery, supplies most of the blood to the left heart wall  PHASES OF ELECTROCARDIOGRAM  Functions of the heart: it has electrophysiologic, mechanical and neurologic properties that coordinate to a. P wave represents atrial depolarization b. PR interval represents the time from the beginning of atrial depolarization to the beginning ventricular depolarization c. QRS complex represents ventricular depolarization d. T wave represents ventricular repolarization   Normal Sinus Rhythm Characteristics of electrical impulse activity

produce effective myocardiac contraction and pumping of blood 1. Cardiac output defined as the volume of blood ejected by each ventricle per minute CO = stroke volume x heart rate a. Stroke volume is the amount of blood ejected by the left ventricle with each heartbeat

- rate is 60 to 100 beats per minute - P waves precede each QRS complex - PR interval is 0.12 to 0.20 seconds - QRS complex is 0.40 to 0.1 seconds 1. Preload the end diastolic filling volume of - Conduction is forward and cyclical through the conduction system ventricle, increases by increased returning volume  Factors that influence cardiac output indirectly affects stroke volume

to ventricle

pulmonic valve closure c. S3 known as ventricular gallop, is often

2. Afterload the resistance to left ventricular normal in persons younger than age ejection, increases by increased systemic arterial pressure b. Heart rate is the number of heartbeats per minute Normal heart rate = 60 to 100 beats per minute 30 but pathologic in older persons and occurs during the rapid ventricular filling stage of diastole d. S4 known as atrial gallop, is liked to resistance to ventricular filling, as in hypertrophy or 2. Cardiac cycle Phases: a. Systole is the contraction phase which is triggered by depolarization of cardiac muscles which involves transient change in potassium and sodium ion concentration inside and outside the cell injury of the ventricular wall 4. Neurologic factors regulating heart function a. SNS stimulation releases norepinephrine which results into arteriolar vasoconstriction, increased heart rate b. PNS stimulation releases acetylcholine which results in decreased heart rate and slowed AV conduction b. Diastole is the relaxation phase, this happens immediately after depolarization is completed, the process reverse itself which results in repolarization and return to resting state 3. Heart sounds results from vibrations caused by valve closure and ventricular filling a. S1 is associated with tricuspid and mitral valve closure b. S2 is associated with aortic and c. The response of chemoreceptors located in the carotid and aortic bodies, any changes on oxygen and carbon dioxide will affect the heart rate Example: decreased O2 but increased CO2 will result to increase heart rate d. The response of baroreceptors located in the aortic arch, carotid sinus, vena cava, pulmonary arteries and atria

- any changes in heart rate will result in blood pressure changes   1. Nursing Process ASSESSMENT Health history

- associated symptoms may include ECG changes and arrhythmias 2. Palpitations characterized by rapid irregular, pounding hear beat, racing, fluttering or skipping hear beat - it can occur as a result of decreased cardiac output due to cardiac rhythm disturbances such as sinus tachycardia, atrial fibrillation and premature beats - may be associated with arrhythmia or ischemia

a. Elicit a description of present illness and chief complaints - onset - course - duration - location - precipitating and alleviating factors - cardinal signs and symptoms indication altered cardiovascular function  Cardinal signs and symptoms

3.Intermittent claudication characterized by pain in the extremity with exercise - this may indicate peripheral vascular disease 4. Dyspnea characterized by difficult in breathing 0r shortness of breath with activity ( dyspnea on exertion) in supine position (orthopnea), 0r sudden onset at night ( paroxysmal nocturnal dyspnea) can occur as the myocardial need for oxygen increases - commonly associated with compromised cardiac function - it may be a sign of early congestive heart failure due to alveolar swelling 5. Fatigue with or without activity

1. Pain felt on the lower sternal region and upper abdomen characterized by heavy vicelike, belt-squeezing pain that may radiate to shoulders, neck and down arms - dullness, heaviness or a sensation of pressure in the chest associated with

- associated with myocardial ischemia which results from insufficient blood supply to the muscle cells of the heart - chest pain commonly occurs when the myocardial need for oxygen is greater than the supply decreased cardiac output 6. Syncope with or without dizziness - transient loss of consciousness which result from insufficient blood flow to the brain

- it can occur as a result of decreased cardiac output due to cardiac rhythm disturbances, valvular disease, and carotid hypersensitivity 7. Diaphoresis associated with clamminess and cyanosis - this reflects decreased cardiac output and decreased cardiac perfusion 8. Edema/weight gain is accumulation of excess fluids in the body tissues that occurs when the pressure in the vascular space is high - the extent and depth of edema indicate the severity of the condition - > 3 lb. in 24 hours may indicate heart failure 9. Abnormal heart sounds - sounds produced by turbulent blood flow from onechamber to another (S3 or S4) or across heart valves (murmurs) 10.Crackles - produced by passing through an accumulation of fluid in the alveoli cells, this occurs when pressure in the vascular space is high 11.ECG changes - certain changes occurring along the ECG waves can represent myocardial problems or conduction defects - ST depression indicate ischemia - T wave inversion represents myocardial ischemia - ST elevation indicates myocardial injury - development of large Q waves signifies necrosis

12. Dysrhythmias are disturbances in the heart rate or rhythm that result from either analteration in the cardiac cells automaticity or conductivity - Ischemia or injury to cardiac cells typically causes dysrhythmias as well as electrolyte disorders, hypoxia or medication - can be significant or life threatening 13. Abnormal cardiac enzymes - necrosis of the myocardial cells results in the release of enzymes into the blood - CPK/CPK-MB/LDH 14.Decreased cardiac output - can produce tachycardia, weak peripheral pulses, altered level of consciousness, oliguria, shortness of breath and cool, pale skin 15.Hyperlipidemia an abnormal accumulation of lipid in the blood, commonly occurs with a high fat diet but can also be familial b. Explore the client s health history for risk factors associated with cardiovascular disease - Positive family history for cardiovascular disease - Age: incidence of cardiovascular disease increases after the age of 40 - Gender: cardiovascular disease is greater in men; however differences decreases after menopause - Race: mortality is greater for nonwhites

than whites - Smoking: the risk of cardiovascular disease is two or four times greater for cigarette

anxiety, and altered level of consciousness - Inspect lips and buccal mucosa for central cyanosis which reflects hypoxia

smokers than nonsmokers - Hypertension particularly elevated systolic pressure - Hyperlipidemia: the ratio of HDL to LDL is - Assess the jugular venous pressure and the best predictor - Obesity: contributes to the severity of other risk factors - Sedentary lifestyle - Diabetes: uncontrolled elevated blood glucose level increases risk - Stress: may contribute to developing coronary artery diseases - Use of oral contraceptives 2.Physical examination a. Vital signs - pulse rate - blood pressure - respirations ANY changes or increased in blood pressure and respirations may indicate cardiovascular disease b. Techniques b.1 Inspection - Observe the general appearance for signs of distress, b.3 Auscultation - systematically auscultate the heart sounds, murmurs and friction rub, covering the four main areas: aortic area, pulmonary area, mitral area and tricuspid observe for venous distention b.2 Palpation - Palpate all peripheral pulses including carotid, brachial, radial, femoral, popliteal, dorsalis pedis and anterior tibia - using the grading system - 0: no pulse - 1+: weak - 2+: thready - 3+: normal - 4+: bounding - Palpate the precordium to locate the point of maximal impulse or the apical pulse - Inspect the peripheral extremities for cyanosis and capillary refill time of less than 3 seconds

area c. Respiratory assessment - cough: possibly reflecting pulmonary congestion - crackles or wheezing: reflecting airway narrowing, atelectasis or left ventricular failure

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Sleep pattern disturbance Anxiety Knowledge deficit Altered family processes Planning and outcome identification Enhancement of cardiopulmonary status Increased gas exchange and activity intolerance Prevention of pain and infection Improved sleep pattern Reduction of anxiety Adherence to a self-care program and understanding of disease process and management Improved family functioning Implementation Assess the cardiopulmonary status

- hemoptysis: possibly pointing to acute pulmonary edema

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3. - cheyne stokes respiration: possibly associated with with severe left ventricular failure d. Abdominal assessment - liver enlargement and ascites: which may indicate decreased venous return secondary to right ventricular failure - bladder distention: may indicate decreased cardiac output - bruits just above the umbilicus: may indicate or reflects abdominal aortic obstruction or aneurysm 3. Laboratory and Diagnostic studies  1. 2. 3. 4. 5. Nursing Diagnoses Decreased cardiac output Impaired gas exchange Activity intolerance Pain Risk for infection 7.  1. 4. 5. 6.

- Assess level of consciousness, heartrate and rhythm, heart sounds blood pressure, peripheral pulses, peripheral edema, skin color and temperature, respiratory rate and lungs - Monitor ABGs and pulse oximetry - Monitor ECG and telemetry - MIO and maintain 30 ml /hour urinary output 2. Enhance cardiac output - Establish patent IV line to administer fluids 3. Promote gas exchange - Collaborate with the respiratory therapist and administer 02 to maintain

oxygen saturation level of 95% to 100% if no other disease present - Encourage the client to maintain in semi-fowler position while resting in bed - Keep the client on bed or chair rest to decrease oxygen myocardial consumption - Instruct the client to cough, breathe deeply, and turn frequently which can decrease pooling of fluid in the lungs

in clients after surgery and those requiring bed rest 7. Promote adequate sleep -Attempt to cluster nursing interventions to provide the client with several hours of uninterrupted sleep 8. Minimize anxiety - Encourage to ventilate feelings - Develop a trusting and caring relationship with client and client s family 9.Provide client and family teaching

4. Increased activity intolerance - Balance periods of rest and exercise - Assist as needed with activities of daily living and self-care 5. Promote comfort - Assess the client s description of chest discomfort, including location, duration of pain, and what precipitated pain 6.Prevent infection - Monitor skin integrity of lower extremities and incisions from cardiac surgery - Assess insertion sites from invasive procedures for signs of redness, warmth, edema and pain - Monitor vital signs, especially for fever - Assess breath sounds for changes associated with pneumonia - Teach the client measures to reduce modifiable risk factors to include the importance of low sodium diet, smoking cessation and adequate amount of exercise - Teach energy conservation measures - Discuss medication, including possible adverse effects and interaction - Discuss danger signs and symptoms requiring prompt medical attention including chest pain, increased shortness of breath, sudden onset of fever, irregular hear beat and weight gain of more than 2 pounds in less than 24 hours 10.Enhance family functioning - Assist with adaptation to role changes caused by disease-related limitations and activity restrictions  1. Outcome evaluation The client demonstrates stable cardiac rhythm, vital signs, hemodynamic parameters and urinary output - Teach family members or significant others about the pathophysiology of the underlying disease process

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The client demonstrates stabilization of cardiac rhythm with proper pacemaker pacing and sensing The client responds to cardiopulmonary resuscitation The client demonstrates clear lung sounds, capillary refill time less than 3 seconds and no central or peripheral cyanosis The client limits activities to a level that permits the heart to rest The client verbalizes factors and events that precipitate pain The clientr eports no pain during normal activities and

disease  Overview of Pathophysiologic Processes

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A. Ischemic diseases - Includes disorders in which impaired coronary circulation causes imbalance between coronary blood flow and myocardial oxygen needs - these disorders begin with anginalchest pain if left untreated can lead to myocardial infarction - Angina pectoris is classified as an ischemic disorder as this process continues, MI develops, resulting into irreversible cell death - Risk factors for ischemic diseases includes: - Family history of heart disease - High-fat diet - Sedentary lifestyle - History of hypertension - Smoking B. Cardiac failure

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report relief of anginal pain with nitrate administration 8. The client demonstrate stabilization of the inflammatory process The client is free of systemic and local infection

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10. The client sleeps at least 6 hours each night uninterrupted 11. The client and significant others displays decreased anxiety 12. The client can verbalize an understanding, preventive measures and treatment of the disease process and the signs and symptoms that should be reported to tge health care provider 13. Family members or significant others verbalize an understanding of CPR and the pathophysiology of underlying - Cor pulmonale may be present as right sided cardiomegaly evolves due to obstructive respiratory disease - becomes cardiogenic shock as tissue perfusion ceases; this results to pulmonary edema life threatening complication - refers to the inability of the heart to pump enough blood to meet the metabolic demand needs of body tissues - it can occur when the heart is diseased or when the heart is normal but is placed under excessive demands - incidence increased due to increased rate of survival from MI

- Pulmonary embolism life threatening complication - Cardiac arrest is the worse case scenario that can result from MI or cardiogenic shock - the major risk factor for cardiac failure includes history of heart disease C. Valvular heart disease - occurs when the heart valves are unable to fully open (stenotic) or fully close (regurgitant) - Stenotic heart disease decreases forward flow of blood from one chamber to another - Regurgitant valvular disease causes some blood flow backward into the chamber it came from - Risk factors for valvular heart disease: - congenital valve defects - valvular damage Example: endocarditis in cases of intravenous drug abuse and rheumatic heart disease D. Electrophysiologic disorders - The specialized cells of the heart have

impulses - Refractoriness: inability of the cardiac muscles to respond to a second stimulus that might occur after contraction - an alteration in any of these properties can produce dysrhythmia , or abnormal heart rhythm, which interferes with the heart s pumping ability - Risk factors for electrophysiologic disorders - ischemic disorders - ingestion of certain drugs (all cardiac drugs and antihistamines) - electrolyte disorders E. Infectious disorders - These kinds of disorders can - Infectious cardiac disorders can alter the structure and function of the heart, rendering contractions ineffective be caused by viruses, bacteria, or inflammation - Pericarditis, infective endocarditis and myocarditis are classified as infectious cardiac disorders - Risk factors for infectious cardiac disorders:

electrophysiologic properties: - immunosuppression - Automaticity: ability to generate - intravenous drug abuse spontaneous action potential without F. Cardiomyopathies stimulus - Rhythmicity: regular generation of an action potential by the heart s conduction system - Conductivity: ability to conduct electrical - are group of heart diseases that affect only the heart muscle and not other structures, such as coronary arteries - these disorders can be primary with unknown cause; secondary as a result from infections, nutritional deficits, connective tissue diseases and muscle wasting states

- can be classified as hypertrophic, congestive or restrictive - Risk factors for cardiomyopathies: - severe nutritional deficits ( anorexia ) - connective tissue diseases ( scleroderma ) - cardiac infectious disease ( myocarditis 0