Cardiovascular System

1. Cardiovascular System

2. Cardiovascular Objectives Discuss the basic structure and function of the heart and peripheral vasculature. Analyze factors that affect cardiac output Discuss physiologic changes that occur in the cardiovascular system with aging. Differentiate common manifestations of altered cardiac functioning. Discuss the collaborative care management of patients with heart failure.

3. Objectives cont�. Discuss the pathophysiology of arterial and venous disease. Prepare a nursing care plan for a patient with primary hypertension. Discuss the risk factors, signs and symptoms, diagnosis, treatment, and complications of hypertension. Discuss tests and procedures used to diagnose peripheral vascular disorders. Assist in developing a plan of care for patients with peripheral vascular disorders.

4. Assessment of the Cardiovascular System

5. The Cardiovascular System Anatomy and physiology Heart�its structure and function Valves, arteries Cardiac output, cardiac index, heart rate Stroke volume Preload Afterload Vascular system Contractility Cardiac output is the amount of blood pumped by the left ventricle in 1 minute. It is determined by multiplying stroke volume by pulse. Cardiac index is calculated to adjust for the difference in body size. Cardiac index can be determined by dividing the CO by the body surface area. Stroke Volume is the amt of blood ejected by the left ventricle in one beat and averages 60-80 ml. Preload is the amt of blood in the LV at the end of diastole or the pressure generated at the end of diastole. Increased preload results in increased stroke volume and therefore increased cardiac output. Afterload is the amt of pressure the ventricles must overcome to eject the blood volume. It is determined primarily by the pressure in the arteries. Contractility is the ability of cardiac muscle fibers to shorten and produce a muscle contraction. Cardiac output is the amount of blood pumped by the left ventricle in 1 minute. It is determined by multiplying stroke volume by pulse. Cardiac index is calculated to adjust for the difference in body size. Cardiac index can be determined by dividing the CO by the body surface area. Stroke Volume is the amt of blood ejected by the left ventricle in one beat and averages 60-80 ml. Preload is the amt of blood in the LV at the end of diastole or the pressure generated at the end of diastole. Increased preload results in increased stroke volume and therefore increased cardiac output. Afterload is the amt of pressure the ventricles must overcome to eject the blood volume. It is determined primarily by the pressure in the arteries. Contractility is the ability of cardiac muscle fibers to shorten and produce a muscle contraction.

6. Blood Pressure Blood pressure is the force of blood exerted against the walls of the blood vessels. - systolic pressure is normally 90 to 135 mm Hg and diastolic is normally 60 to 85 mm Hg.

7. Blood Pressure Regulation Autonomic nervous system Baroreceptors Chemoreceptors Renal system Endocrine system External factors also affect BP Baroreceptors are stimulated when the arterial walls are stretched by an increased BP. Chemoreceptors are stimulated by hypercapnia. Chemoreceptors are sensitive to hypoxia. The kidneys are of great importance to the regulation of BP. If the blood flow to the kidneys decrease, renal filtration decreases and urinary output decreases to preserve blood volume. Decrease BP stimulates the kidneys to secrete renin, which initiates the renin-angiotension mechanism. Angiotension II causes vasocontriction and stimulates secretion of aldosterone, both of which raises blood pressure. Hormone, epinephrine, secreted by the adrenal medulla in stressful , is sympathomimetic in that it increases the heart rate and force of contraction and it dilates the coronary vessels. This in turn increases CO and systolic blood pressure. Baroreceptors are stimulated when the arterial walls are stretched by an increased BP. Chemoreceptors are stimulated by hypercapnia. Chemoreceptors are sensitive to hypoxia. The kidneys are of great importance to the regulation of BP. If the blood flow to the kidneys decrease, renal filtration decreases and urinary output decreases to preserve blood volume. Decrease BP stimulates the kidneys to secrete renin, which initiates the renin-angiotension mechanism. Angiotension II causes vasocontriction and stimulates secretion of aldosterone, both of which raises blood pressure. Hormone, epinephrine, secreted by the adrenal medulla in stressful , is sympathomimetic in that it increases the heart rate and force of contraction and it dilates the coronary vessels. This in turn increases CO and systolic blood pressure.

8. Venous System Structure: a series of veins located adjacent to the arterial system Function: completes the circulation of blood by returning blood from the capillaries to the right side of the heart Cardiovascular changes in the older adult: only evident when the person is active or under stress. Heart muscle becomes less efficient and there is a decrease in the maximum cardiac output and heart rate. Arteriosclerosis narrows the coronary artery.

9. Assessment Techniques Health History Demographic data Family history and genetic risk Personal history Diet history Medication history Socioeconomic status Cardiovascular history also include assessing level of consciousness (LOC), dyspnea, palpitations, fatigue, edema, paresthesia/paralysis.Cardiovascular history also include assessing level of consciousness (LOC), dyspnea, palpitations, fatigue, edema, paresthesia/paralysis.

10. Modifiable Risk Factors Cigarette smoking Physical inactivity Obesity Psychological factors Chronic disease

11. Pain or Discomfort Pain or discomfort can result from ischemic heart disease, pericarditis, and aortic dissection. Chest pain can also result from noncardiac conditions such as pleurisy, pulmonary embolus, hiatal hernia, and anxiety. (Continued)

12. Pain or Discomfort (Continued) Terms such as discomfort, heaviness, pressure, indigestion, aching, choking, strangling, tingling, squeezing, constricting, or vise-like are all used to describe pain. Women often do not experience pain in the chest but rather feelings of discomfort or indigestion.

13. Pain Assessment Onset Manner of onset Duration Frequency Precipitating factors Location Radiation (Continued)

14. Pain Assessment (Continued) Quality Intensity, which can be graded from 0 to 10, associated symptoms, aggravating factors, and relieving factors

15. Dyspnea Can occur as a result of both cardiac and pulmonary disease Difficult or labored breathing experienced as uncomfortable breathing or shortness of breath Dyspnea on exertion (DOE) Orthopnea: dyspnea when lying flat Paroxysmal nocturnal dyspnea after lying down for several hours

16. Other Manifestations Fatigue Palpitations Weight gain Syncope Extremity pain

17. Physical Assessment General appearance Integumentary system Skin color Skin temperature Extremities Blood pressure Venous and arterial pulses: central and jugular venous pressures, and jugular venous distention

18. Precordium Assessment of the precordium (area over the heart) involves: Inspection Palpation Percussion Auscultation Normal heart sounds Paradoxical splitting Gallops and murmurs Pericardial friction rub

19. Serum Markers of Myocardial Damage Troponin Creatine kinase Myoglobin Serum lipids Homocysteine C-reactive protein Blood coagulation tests Troponin is a protein involved in the contraction of striated muscle. Troponin T specifically from cardiac muscle can be identified and measured Elevated in pt with MI. Creatine kinase is an enzyme found in three tissue in high concentration: brain, heart, and skeletal muscle. Elevation indicates damage to myocardial cells. Myoglobin is a proteinfound in cardiac muscle and is the earliest marker detected within 2 hrs after an MI. Pg 695 � Lab Profile chart 36-4 Homocysteine is an amino acid produced when protein is broken down and is elevate in the blood in the development of CVD. C-Reactive protein is the most studied marker of inflammation. Elevation seen in hypertension, infection, and smoking.Troponin is a protein involved in the contraction of striated muscle. Troponin T specifically from cardiac muscle can be identified and measured Elevated in pt with MI. Creatine kinase is an enzyme found in three tissue in high concentration: brain, heart, and skeletal muscle. Elevation indicates damage to myocardial cells. Myoglobin is a proteinfound in cardiac muscle and is the earliest marker detected within 2 hrs after an MI. Pg 695 � Lab Profile chart 36-4 Homocysteine is an amino acid produced when protein is broken down and is elevate in the blood in the development of CVD. C-Reactive protein is the most studied marker of inflammation. Elevation seen in hypertension, infection, and smoking.

20. Cardiac Catheterization Client preparation Possible complications: myocardial infarction, stroke, thromboembolism, arterial bleeding, lethal dysrhythmias, and death Follow-up care: Restricted bedrest, insertion site extremity kept straight Monitor vital signs Assess for complications

21. Other Diagnostic Tests Electrocardiography Electrophysiologic study Exercise electrocardiography Echocardiography Pharmacologic stress echocardiogram Transesophageal echocardiogram Imaging Pgs 698, 699, 700, 701 Pgs 698, 699, 700, 701

22. Interventions for Clients with Cardiac Problems

23. Heart Failure Also called pump failure, general term for the inadequacy of the heart to pump blood throughout the body; causes insufficient perfusion of body tissue with vital nutrients and oxygen Left-sided heart failure Right-sided heart failure High-output failure

24. Compensatory Mechanisms Sympathetic nervous system stimulation Renin-angiotensin system activation Other neurohumoral responses Myocardial hypertrophy

25. Etiology Heart failure is caused by systemic hypertension in 75% of cases. About one third of clients experiencing myocardial infarction also develop heart failure. Structural heart changes, such as valvular dysfunction, cause pressure or volume overload on the heart. Heart Failure is a syndrome that occurs as a result of the progressive inability of the heart to pump enough blood to meet the body�s oxygen and nutrients needs. Hypertension is as indicated one of the major causes of left-sided heart failure because it increases the pressure within the arteries. Increased pressure in the aorta makes the left ventricle work harder to pump blood into the aorta. Overtime the strain caused by the increased workload causes the left ventricle to weaken and fail. Other causes of heart failure include coronary heart disease, myocardial infarction, cadiomyopathy, heart valve problems, and hypertension. In the elderly, the most common cause of heart failure is cardiac ischemia.Heart Failure is a syndrome that occurs as a result of the progressive inability of the heart to pump enough blood to meet the body�s oxygen and nutrients needs. Hypertension is as indicated one of the major causes of left-sided heart failure because it increases the pressure within the arteries. Increased pressure in the aorta makes the left ventricle work harder to pump blood into the aorta. Overtime the strain caused by the increased workload causes the left ventricle to weaken and fail. Other causes of heart failure include coronary heart disease, myocardial infarction, cadiomyopathy, heart valve problems, and hypertension. In the elderly, the most common cause of heart failure is cardiac ischemia.

26. Left-Sided Heart Failure Manifestations include: Weakness Fatigue Dizziness Confusion Pulmonary congestion Shortness of breath (Continued) Left �Sided Heart Failure Left �Sided Heart Failure

27. Assessments Laboratory assessment Radiographic assessment Electrocardiography Echocardiography Pulmonary artery catheters S&PS&P

28. Left-Sided Heart Failure (Continued) Oliguria Organ failure, especially renal failure Death Assess blood pressure, mental status, breath sounds

29. Right Sided Heart Failure The major cause of Right-Sided Heart Failure is Left-Sided Failure. - when the left side fails, fluids backs up into the lungs and pulmonary pressure is increased. The right ventricle must continually pump blood against this increased fluid and pressure in the pulmonary artery and lungs. Other causes include pulmonary hypertension, Cor pulmonale, pulmonary stenosis, and atrial septal defect.

30. Right-Sided Failure cont�. Jugular vein distension Enlarged liver and spleen Swollen hands and fingers Dependent edema (legs and sacrum) Anorexia and nausea Distended abdomen Polyuria at night Weight gain Increased Blood Pressure

31. Impaired Gas Exchange Interventions include: Ventilation assistance Hemodynamic regulation Energy management, diet therapy, drug therapy

32. Decreased Cardiac Output Interventions include: Optimization of cardiac output: stroke volume (determined by preload, afterload, and contractility) and heart rate (Continued)

33. Decreased Cardiac Output (Continued) Drug therapy including: Angiotensin-converting enzyme ACE inhibitors Diuretics Human B-type natriuretic peptides Nitrates Inotropics Beta-adrenergic blockers

34. Hemodynamic Regulation Interventions include: Reduce afterload. Reduce preload. Improve cardiac muscle contractility. Administer drugs as prescribed. Monitor for therapeutic and adverse effects. Teach client and family drug therapy.

35. Drugs That Reduce Afterload Angiotensin-converting enzyme (ACE) inhibitors Human B-type natriuretic peptides Pg 756 Vasotec, Monopril, Capoten. Pg 756 Vasotec, Monopril, Capoten.

36. Interventions That Reduce Preload Diet therapy Drug therapy Diuretics Venous vasodilators

37. Drugs That Enhance Contractility Digitalis Digitalis toxicity includes anorexia, fatigue, changes in mental status. Monitor heart rate and electrolytes. Other inotropic drugs including dobutamine, milrinone, and levosimendan Beta-adrenergic blockers S&PS&P

38. Other Nonsurgical Options Continuous positive airway pressure Cardiac resynchronization therapy Investigative gene therapy

39. Surgical Management Newer surgical therapies include the following: Partial left ventriculectomy Endoventricular circular patch Acorn cardiac support device Myosplint

40. Activity Intolerance Interventions include: Ventilation assistance Hemodynamic regulation Energy management Interdisciplinary interventions, which regulate energy to prevent fatigue and optimize function Sentence and phrasesSentence and phrases

41. Potential for Pulmonary Edema Interventions include: Assess for early signs, such as crackles in the lung bases, dyspnea at rest, disorientation, and confusion. Rapid-acting diuretics are prescribed, such as Lasix or Bumex. Oxygen is always used. Strictly monitor fluid intake and output. Sentences and phraseSentences and phrase

42. Interventions for Clients with Vascular Problems

43. Arteriosclerosis and Atherosclerosis Arteriosclerosis: thickening or hardening of the arterial wall Atherosclerosis: type of arteriosclerosis involving the formation of plaque within the arterial wall Etiology and genetic predisposition Factors related to atherosclerosis include obesity, lack of exercise, smoking, and stress. Arterioslerosis is a term used to describe conditions that affect arteries and may lead to occlusive cardiovascular disease.Arterioslerosis is a term used to describe conditions that affect arteries and may lead to occlusive cardiovascular disease.

44. Laboratory Assessment Lipid level, including cholesterol and triglycerides, is elevated in atherosclerosis clients. High serum levels of homocysteine can allow cell walls to become vulnerable to plaque buildup. Homocycysteine � an amino acid produced by catabolism. This level is elevated in the blood and increases the risk for atheriosclerosis. Homocycysteine � an amino acid produced by catabolism. This level is elevated in the blood and increases the risk for atheriosclerosis.

45. Interventions Evaluation of total serum cholesterol levels and lifestyle changes Diet therapy Smoking cessation Exercise Drug therapy

46. Hypertension Hypertension: systolic blood pressure = 135 mm Hg and/or diastolic blood pressure = to 85 mm Hg (not including diabetics) Malignant hypertension: elevated blood pressure that progresses rapidly to systolic pressure > 200 mm Hg and diastolic pressure > 130 mm Hg

47. Nonmodifiable Risk Factors Family History of Hypertension Age Race and ethnicity Diabetes Mellitus

48. Modifiable Risk Factors Weight Reduction Stress Management Meal Planning Alcohol Consumption Exercise Smoking

49. Diseases Diseases that commonly cause secondary hypertension: Renal vascular Renal parenchymal Dysfunction of the adrenal medulla or the adrenal cortex Primary aldosteronism (Continued) Renovascular is associated with narrowing of one or more of the main arteries carrying blood directly to the kidneys. Renal parenchymal diseases related to infection, inflammation, and changes in kidney structure and function. Primary aldosteronism excessive causes hypertension and hypokalemia.Renovascular is associated with narrowing of one or more of the main arteries carrying blood directly to the kidneys. Renal parenchymal diseases related to infection, inflammation, and changes in kidney structure and function. Primary aldosteronism excessive causes hypertension and hypokalemia.

50. Diseases (Continued) Pheochromocytomas Cushing�s syndrome Coarctation of the aorta Neurogenic disturbances, such as brain tumors, encephalitis, and psychiatric disturbances Pheochromocytomas is a benign adenomas of the adrenal cortex that causes excessive secretion of catecholamines. Cushing Syndrome is excessive glucocorticoids. Coarctation of the aorta is congenital narrowing of the aorta that may cause hypertension. Pheochromocytomas is a benign adenomas of the adrenal cortex that causes excessive secretion of catecholamines. Cushing Syndrome is excessive glucocorticoids. Coarctation of the aorta is congenital narrowing of the aorta that may cause hypertension.

51. Knowledge Deficit Interventions include: Sodium restriction Weight reduction Moderation of alcohol intake Exercise Relaxation techniques Tobacco and caffeine avoidance

52. Drug Therapy Diuretics Calcium channel-blocking agents ACE inhibitors Angiotensin II receptor antagonists Aldosterone receptor antagonists Beta-adrenergic blockers Central alpha agonists Alpha-adrenergic agonists

53. Risk for Ineffective Therapeutic Regimen Management Interventions include: Teach medication compliance, usually for the rest of life. Discuss goals of therapy, potential side effects, and how to identify potential problems. Assist client to understand therapeutic regimen. Discuss consequence of noncompliance.

54. Peripheral Arterial Disease Disorders that alter the natural flow of blood through the arteries and veins of the peripheral circulation Manifestation of systemic atherosclerosis: a chronic condition in which partial or total arterial occlusion deprives the lower extremities of oxygen and nutrients

55. Physical Assessment Intermittent claudication Pain that occurs even while at rest; numbness and burning Inflow disease affecting the lower back, buttocks, or thighs Outflow disease causing cramping in calves, ankles, and feet (Continued) Sentences and phrasesSentences and phrases

56. Physical Assessment (Continued) Hair loss and dry, scaly, mottled skin and thickened toenails Ulcers: arterial ulcers, diabetic ulcers, venous stasis ulcers

57. Diagnostic Assessments Segmental systolic blood pressure measurements Exercise tolerance testing Plethysmography

58. Nonsurgical Management Exercise Positioning Promoting vasodilation Drug therapy Percutaneous transluminal angioplasty Laser-assisted angioplasty Atherectomy

59. Surgical Management Preoperative care Operative procedures (Continued)

60. Surgical Management (Continued) Postoperative care Assessment for graft occlusion Promotion of graft patency Treatment of graft occlusion Monitoring for compartment syndrome Assessment for infection

61. Acute Peripheral Arterial Occlusion Embolus: the most common cause of occlusions, although local thrombus may be the cause Assessment: pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia Drug therapy Surgical therapy Nursing care

62. Aneurysms of Central Arteries Aneurysm: a permanent localized dilation of an artery, enlarging the artery to twice its normal diameter Fusiform aneurysm Saccular aneurysm Dissecting aneurysm (aortic dissections) Thoracic aortic aneurysms

63. Assessment of Abdominal Aortic Aneurysm (AAA) Pain related to AAA is usually steady with a gnawing quality, is unaffected by movement, and may last for hours or days. Pain is in the abdomen, flank, or back. Abdominal mass is pulsatile. Rupture is the most frequent complication and is life threatening. Sentences and phrasesSentences and phrases

64. Assessment of Thoracic Aortic Aneurysm Assess for back pain and manifestation of compression of the aneurysm on adjacent structures. Assess for shortness of breath, hoarseness, and difficulty swallowing. Occasionally a mass may be visible above the suprasternal notch. Sudden excruciating back or chest pain is symptomatic of thoracic rupture. S&PS&P

65. Diagnosis and Management X-rays Computed tomography scan to assess size and location of aneurysm Aortic angiography Ultrasonography Goal of nonsurgical management: monitor growth of the aneurysm and maintain blood pressure at normal level S&PS&P

66. Abdominal Aortic Aneurysm Resection Preoperative care Operative procedure Postoperative care Monitor vital signs. Assess for complications. Assess for signs of graft occlusion or rupture.

67. Thoracic Aortic Aneurysm Repair Preoperative care Operative procedure Postoperative care assessments: Vital signs Complications Sensation and motion in extremities Respiratory distress Cardiac dysrhythmias

68. Endovascular Repair of Abdominal Aortic Aneurysm Clients selected for endovascular repair are generally at high risk for major abdominal surgery. Various designs Benefits of endovascular repair Complications of endovascular repair Sentences and phrasesSentences and phrases

69. Aneurysms of the Peripheral Arteries Femoral and popliteal aneurysms Symptoms: limb ischemia, diminished or absent pulses, cool to cold skin, and pain Treatment: surgery Postoperative care: monitor for pain Surgery include excision of the femoral aneurysm and restoration of circulation using a dacron graft. Surgeons will bypass popliteal aneurysm. Monitor for lower limb ischemia. Palpate pulses below the graft for patency. Doppler ultrasonography may be needed. Monitor for pain. Surgery include excision of the femoral aneurysm and restoration of circulation using a dacron graft. Surgeons will bypass popliteal aneurysm. Monitor for lower limb ischemia. Palpate pulses below the graft for patency. Doppler ultrasonography may be needed. Monitor for pain.

70. Aortic Dissection May be caused by a sudden tear in the aortic intima, opening the way for blood to enter the aortic wall Pain described as tearing, ripping, and stabbing (Continued)

71. Aortic Dissection (Continued) Emergency care goals include: Elimination of pain Reduction of blood pressure Decrease in the velocity of left ventricular ejection Nonsurgical treatment Surgical treatment Nonsurgical tx include IV Nitoprusside or Fenoldopam by continuous drip initially to lower the blood pressure. If ineffective, Cardene may be used. Surgical tx include proximal dissection which require cardiopulmonary bypass (CPB)Nonsurgical tx include IV Nitoprusside or Fenoldopam by continuous drip initially to lower the blood pressure. If ineffective, Cardene may be used. Surgical tx include proximal dissection which require cardiopulmonary bypass (CPB)

72. Buerger�s Disease Thromboangiitis obliterans: relatively uncommon occlusive disease limited to the medium and small arteries and veins Often identified with tobacco smoking Nursing interventions to prevent progression of disease

73. Other Disorders Subclavian steal occurring from artery occlusion or stenosis Thoracic outlet syndrome resulting in arterial wall damage Popliteal entrapment

74. Raynaud�s Phenomenon Caused by vasospasm of the arterioles and arteries of the upper and lower extremities Drug therapy: Procardia, Cyclospasmol, and Dibenzyline Lumbar sympathectomy Reinforcement of client education; restriction of cold exposure

75. Venous Thromboembolism Thrombus: a blood clot Thrombophlebitis Deep vein thrombosis Pulmonary embolism High rate of death S&PS&P

76. Assessment Calf or groin tenderness or pain Sudden onset of unilateral swelling of the leg Positive Homans� sign Localized edema Venous flow studies

77. Nonsurgical Management Rest Drug therapy includes: Unfractionated heparin therapy Low�molecular weight heparin Warfarin therapy Thrombolytic therapy

78. Surgical Management Thrombectomy Inferior vena caval interruption Ligation or external clips

79. Venous Insufficiency Result of prolonged venous hypertension, stretching veins and damaging valves Stasis dermatitis, stasis ulcers Management of edema Management of venous stasis ulcers Drug therapy Surgical management

80. Varicose Veins Distended, protruding veins that appear darkened and tortuous Collaborative management includes: Elastic stockings Elevation of extremities Sclerotherapy Surgical removal of veins Radio frequency energy to heat the veins Sentences and phrasesSentences and phrases

81. Phlebitis Inflammation of the superficial veins Management: warm, moist soaks and elastic stocking Complications: tissue necrosis, infection, or pulmonary embolus S&PS&P

82. Pictures for Cardiac System Nur 105