CARDIOVASCULAR DISEASES

Overview of function & structure of the heart

HEART - Muscular, pumping organ of the body - Left mediastinum - Weigh 300 400 grams - Resembles a closed fist - Covered by serous membrane pericardium Pericardium Parietal layer Pericardial Fluid prevent Friction rub Visceral layer

Layer 1. Epicardium outermost 2. Myocardium inner responsible for pumping action/ most dangerous layer - cardiogenic shock 3. Endocardium innermost layer Chambers 1. Upper collecting/ receiving chamber - Atria 2. Lower pumping/ contracting chamber - Ventricles Valves 1. Atrioventricular valves - Tricuspid & mitral valve Closure of AV valves gives rise to 1st heart sound or S1 or lub 2. Semi lunar valve a.) Pulmonic b.) Aortic Closure of semilunar valve gives rise to 2nd heart sound or S2 or dub Extra heart Sound S3 ventricular Gallop CHF S4 atrial gallop MI, HPN

Heart conduction system 1. Sino atrial node (SA node) (or Keith-Flock node) Loc junction of SVC & Rt atrium Fx- primary pace maker of heart -Initiates electric impulse of 60 100 bpm 2. Atrioventicular node (AV node or Tawara node) Loc inter atrial septum Delay of electric impulse to allow ventricular filling 3. Bundle of His location interventricular septum Rt main Bundle Branch Lt main Bundle Branch 4. Purkenjie Fiber Loc- walls of ventricles-- Ventricular contractions SA node

AV

Purkenjie Fibers Bundle of His Complete heart block insertion of pacemaker at Bundle Branch Metal Pace Maker change q3 5 yo Prolonged PR atrial fib ST segment depression angina ST elev MI T wave inversion MI widening QRS arrhythmia

CAD coronary artery dse or Ischemic Heart Dse (IHD) Atherosclerosis Myocrdial injury Angina Pectoris Myocardial ischemia MI- myocardial necrosis ATHEROSCLEROSIS - Hardening or artery due to fat/ lipid deposits at tunica intima. Artery tunica adventitia outer - Tunica intima innermost - Tunica media middle ATHEROSCLEROSIS Predisposing Factor 1. Sex male 2. Black race 3. Hyperlipidemia 4. Smoking 5. HPN 6. DM 7. Oral contraceptive- prolonged use 8. Sedentary lifestyle 9. Obesity 10. Hypothyroidism Signs & Symptoms 1. Chest pain 2. Dyspnea 3. Tachycardia 4. Palpitations 5. Diaphoresis Treatment P percutaneous T tansluminar C coronary A angioplasty Obj: 1. 2. 3. To revascularize the myocardium To prevent angina Increase survival rate ARTERIOSCLEROSIS - Narrowing or artery due to calcium & CHON deposits at tunica media.

PTCA done to pt with single occluded vessel . Multiple occluded vessels C coronary A arterial B bypass A and G graft surgery Nsg Mgt Before CABAG 1. Deep breathing cough exercises 2. Use of incentive spirometer 3. Leg exercises

ANGINA PECTORIS- A clinical syndrome characterized by paroxysmal chest pain usually relieved by REST
or NGT nitroglycerin, resulting fr temp myocardial ischemia. Predisposing Factor: 1. sex male 2. black raise 3. hyperlipidemia 4. smoking 5. HPN 6. DM 7. oral contraceptive prolonged 8. sedentary lifestyle 9. obesity 10.hypothyroidism Precipitating factors 4 Es 1. Excessive physical exertion 2. Exposure to cold environment - Vasoconstriction 3. Extreme emotional response 4. Excessive intake of food saturated fats. Signs & Symptoms 1. Initial symptoms Levines sign hand clutching of chest 2. Chest pain sharp, stabbing excruciating pain. Location substernal -radiates back, shoulders, axilla, arms & jaw muscles -relieve by rest or NGT 3. Dyspnea 4. Tachycardia 5. Palpitation 6.diaphoresis Diagnosis 1.History taking & PE 2. ECG ST segment depression 3. Stress test treadmill = abnormal ECG 4. Serum cholesterol & uric acid - increase. Nursing Management 1.) Enforce CBR 2.) Administer meds NTG small doses venodilator Large dose vasodilator 1st dose NTG give 3 5 min

2nd dose NTG 3 5 min 3rd & last dose 3 5 min Still painful after 3rd dose notify doc. MI! 55 yrs old with chest pain: 1st question to ask pt: what did you do before you had chest pain. 2nd question: does pain radiate? If radiate heart in nature. If not radiate pulmonary origin Venodilator veins of lower ext increase venous pooling lead to decrease venous return. Meds: A. NTG- Nsg Mgt: 1. Keep in a dry place. Avoid moisture & heat, may inactivate the drug. 2. Monitor S/E: orthostatic hypotension dec bp transient headache dizziness 3. Rise slowly from sitting position 4. Assist in ambulation. 5. If giving NTG via patch: i. avoid placing it near hairy areas-will dec drug absorption ii. avoid rotating transdermal patches- will dec drug absorption iii. avoid placing near microwave oven or during defibrillation-will burn pt due aluminum foil in patch B. Beta blockers propanolol C. ACE inhibitors captopril D. Ca antagonist - nefedipine Administer O2 inhalation Semi-fowler Diet- Decrease Na and saturated fats Monitor VS, I&O, ECG HT: Discharge planning: a. Avoid precipitating factors 4 Es b. Prevent complications MI c. Take meds before physical exertion-to achieve maximum therapeutic effect of drug d. Importance of follow-up care.

3.) 4.) 5.) 6.) 7.)

MI MYOCARDIAL INFARCTION hear attack terminal stage of CAD

Types: Characterized by necrosis & scarring due to permanent mal-occlusion

1. Trasmural MI most dangerous MI Mal-occlusion of both R&L coronary artery 2. Sub-endocardial MI mal-occlusion of either R & L coronary artery
Most critical period upon dx of MI 48 to 72h - Majority of pt suffers from PVC premature ventricular contraction.

Predisposing factors

Signs & symptoms

Diagnostic Exam

1. 2. 3. 4. 5. 6. 7.

sex male black raise hyperlipidemia smoking HPN DM oral contraceptive prolonged 8. sedentary lifestyle 9. obesity 10. hypothyroidism

1. chest pain excruciating, vice like, visceral pain located substernal or precodial area (rare) - radiates back, arm, shoulders, axilla, jaw & abd muscles. - not usually relived by rest r NTG 2. dyspnea 3. erthermia 4. initial increase in BP 5. mild restlessness & apprehensions 6. occasional findings a.) split S1 & S2 b.) pericardial friction rub c.) rales /crackles d.) S4 (atrial gallop)

1. cardiac enzymes a.) CPK MB Creatinine Phosphokinase b.) LDH lactic acid dehydrogenase c.) SGPT (ALT) Serum Glutanic Pyruvate Transaminase- increased d.) SGOT (AST) Serum Glutamic Oxalo-acetic - increased 2. Troponin test increase 3. ECG tracing ST segment increase, widening or QRS complexes means arrhythmia in MI indicating PVC 4. serum cholesterol & uric acid increase 5. CBC increase WBC

Nursing Management 1. Narcotic analgesics Morphine SO4 to induce vasodilation & decrease levels of anxiety. 2. Administer O2 inhalation low inflow (CHF-increase inflow) 3. Enforce CBR without BP a.) Bedside commode 4. Avoid valsalva maneuver 5. Semi fowler 6. General liquid to soft diet decrease Na, saturated fat, caffeine 7. Monitor VS, I&O & ECG tracings 8. Take 20 30 ml/week wine, brandy/whisky to induce vasodilation. 9. Assist in surgical; CABAG 10. Provide pt HT a.) Avoid modifiable risk factors b.) Prevent complications: 1. Arrhythmias PVC 2. Shock cardiogenic shock. Late signs of cardiogenic shock in MI oliguria 3. thrombophlebitis - deep vein 4. CHF left sided 5. Dresslers syndrome post MI syndrome -Resistant to medications -Administer 150,000 450,000 units of streptokinase c.) Strict compliance to meds - Vasodilators 1. NTG 2. Isordil - Antiarrythmic 1. Lydocaine blocks release of norepenephrine 2. Brithylium - Beta-blockers lol 1. Propanolol (inderal) - ACE inhibitors - pril 1. Captopril (enalapril) - Ca antagonist 1. Nifedipine - Thrombolitics or fibrinolytics to dissolve clots/ thrombus S/E allergic reactions/ uticaria

1. Streptokinase 2. Urokinase 3. Tissue plasminogen adjusting factor

Monitor for bleeding: - Anticoagulants 1. Heparin PTT If prolonged bleeding

2. Caumadin delayed reaction 2 3 days PT prolonged bleeding

Antidote antidote Vit K Protamine sulfate - Anti platelet PASA (aspirin) d.) Resume ADL sex/ activity 4 to 6 weeks Post-cardiac rehab 1.)Sex as an appetizer rather then dessert Before meals not after, due after meals increase metabolism heart is pumping hard after meals. 2.) Position non-weight bearing position. When to resume sex/ act: When pt can already use staircase, then he can resume sex. e.) Diet decrease Na, Saturated fats, and caffeine f.) Follow up care.

CHF CONGESTIVE HEART FAILURE - Inability of heart to pump blood towards systemic
circulation. - Backflow 1.) Left sided heart failure: Predisposing factors: 1.) 90% mitral valve stenosis due RHD, aging RHD affects mitral valve streptococcal infection Dx: - Aso titer anti streptolysine O > 300 total units - Steroids - Penicillin - Aspirin Complication: RS-CHF Aging degeneration / calcification of mitral valve Ischemic heart disease HPN, MI, Aortic stenosis S/Sx Pulmonary congestion/ Edema 1. Dyspnea 2. Orthopnea (Diff of breathing sitting pos platypnea) 3. Paroxysmal nocturnal dysnea PNO- nalulunod 4. Productive cough with blood tinged sputum 5. Frothy salivation (from lungs) 6. Cyanosis 7. Rales/ crackles due to fluid 8. Bronchial wheezing 9. PMI displaced lateral due cardiomegaly

10. Pulsus alternons weak-strong pulse 11. Anorexia & general body malaise 12. S3 ventricular gallop Dx 1. CXR cardiomegaly PAP Pulmonary Arterial Pressure PCWP Pulmonary CapillaryWedge Pressure PAP measures pressure of R ventricle. Indicates cardiac status. PCWP measures end systolic/ diastolic pressure PAP & PCWP: Swan ganz catheterization cardiac catheterization is done at bedside at ICU (Trachesostomy bedside) - Done 5 20 mins scalpel & trachesostomy set CVP indicates fluid or hydration status Increase CVP decrease flow rate of IV Decrease CVP increase flow rate of IV Echocardiography reveals enlarged heart chamber or cardiomayopathy ABG PCO2 increase, PO2 decrease = = hypoxemia = resp acidosis

2.

3. 4.

2.) Right sided HF Predisposing factor 1. 90% - tricuspid stenosis 2. COPD 3. Pulmonary embolism 4. Pulmonic stenosis 5. Left sided heart failure S/Sx Venous congestion - Neck or jugular vein distension - Pitting edema - Ascites - Wt gain - Hepatomegalo/ splenomegaly - Jaundice - Pruritus - Esophageal varies - Anorexia, gen body malaise Diagnosis: 1. 2. CXR cardiomegaly CVP measures the pressure at R atrium Normal: 4 to 10 cm of water Increase CVP > 10 hypervolemia Decrease CVP < 4 hypovolemia Flat on bed post of pt when giving CVP Position during CVP insertion Trendelenburg to prevent pulmonary embolism & promote ventricular filling.

3. Echocardiography enlarged heart chamber / cardiomyopathy 4.Liver enzyme SGPT ( ALT) SGOT AST Nsg mgt: Increase force of myocardial contraction = increase CO 3 6L of CO 1. Administer meds: Tx for LSHF: M morphine SO4 to induce vasodilatation A aminophylline & decrease anxiety D digitalis (digoxin) D - diuretics O - oxygen G - gases a.) Cardiac glycosides Increase myocardial = increase CO Digoxin (Lanoxin). Antidote: digivine Digitoxin: metabolizes in liver not in kidneys not given if with kidney failure. b.) Loop diuretics: Lasix effect with in 10-15 min. Max = 6 hrs c.) Bronchodilators: Aminophillin (Theophyllin). Avoid giving caffeine d.) Narcotic analgesic: Morphine SO4 - induce vasodilaton & decrease anxiety e.) Vasodilators NTG f.) Anti-arrythmics Lidocaine 2. Administer O2 inhalation high! @ 3 -4L/min via nasal cannula 3. High fowlers 4. Restrict Na! 5. Provide meticulous skin care 6. Weigh pt daily. Assess for pitting edema. Measure abdominal girth daily & notify MD 7. Monitor V/S, I&O, breath sounds 8. Institute bloodless phlebotomy. Rotating tourniquet or BP cuff rotated clockwise q 15 mins = to promote decrease venous return 9. Diet decrease salt, fats & caffeine 10. HT: a) Complications :shock Arrhythmia Thrombophlebitis MI Cor Pulmonale RT ventricular hypertrophy b.) Dietary modifications c.) Adherence to meds

PERIPHERAL MUSCULAR DISEASE Arterial ulcers 1. Thromboangiitis Obliterans male/ feet 2. Reynauds female/ hands venous ulcer 1. Varicose veins 2. Thrombophlebitis

1.) Thromboangiitis obliterates/ BUERGER DISEASE- Acute inflammatory disorder affecting small to medium sized arteries & veins of lower extremities. Male/ feet Predisposing factors: - Male - Smokers

S/Sx 1. Intermittent claudication leg pain upon walking - Relieved by rest 2. Cold sensitivity & skin color changes White Pallor bluish cyanosis red rubor

3. Decrease or diminished peripheral pulses - Post tibial, Dorsalis pedis 4. Tropic changes 5. Ulcerations 6. Gangrene formation Dx: 1. 2.

3.
5.

Oscillometry decrease peripheral pulse volume. Doppler UTZ decrease blood flow to affected extremities. Angiography reveals site & extent of mal-occulsion.

Nsg Mgt: 1. Encourage a slow progression of physical activity a.) Walk 3 -4 x / day b.) Out of bed 2 3 x a / day 2. Meds a.) Analgesic b.) Vasodilator c.) Anticoagulant 3. Foot care mgt like DM a.) Avoid walking barefoot b.) Cut toe nails straight c.) Apply lanolin lotion prevent skin breakdown d.) Avoid wearing constrictive garments 4. Avoid smoking & exposure to cold environment 5. Surgery: BKA (Below the knee amputation) 2.)REYNAUDS Predisposing factors: 1. 2. 3. Female, 40 yrs Smoking Collagen dse a.) SLE pathognomonic sign butterfly rash on face

PHENOMENON acute episodes of arterial spasm affecting digits of hands & fingers

Chipmunk face bulimia nervosa Cherry red skin carbon monoxide poisoning Spider angioma liver cirrhosis Caput medusae leg & trunk umbilicus- Liver cirrhosis Lion face leprosy 4. S/Sx: b.) Rheumatoid arthritis Direct hand trauma piano playing, excessive typing, operating chainsaw 1. 2. Intermittent claudication - leg pain upon walking - Relieved by rest Cold sensitivity

Nsg Mgt: a. Analgesics b. Vasodilators c. Encourage to wear gloves especially when opening a refrigerator. d. Avoid smoking & exposure to cold environment

VENOUS ULCERS 1. VARICOSITIES / Varicose veins - Abnormal dilation of veins lower ext & trunk - Due to: a.) Incompetent valves leading to b.) Increase venous pooling & stasis leading to c.) Decrease venous return Predisposing factors: a. Hereditary b. Congenital weakness of veins c. Thrombophlebitis d. Heart dse e. Pregnancy f. Obesity g. Prolonged immobility - Prolonged standing S/Sx: 1. Pain especially after prolonged standing 2. Dilated tortuous skin veins 3. Warm to touch 4. Heaviness in legs Dx: 1. Venography Trendelenbergs test vein distend quickly < 35 secs

2.

Nsg Mgt: 1. Elevate legs above heart level to promote venous return 1 to 2 pillows 2. Measure circumference of leg muscles to determine if swollen. 3. Wear anti embolic or knee high stockings. Women panty hose 4. Meds: Analgesics 5. Surgery: vein sweeping & ligation Sclerotherapy spider web varicosities S/E thrombosis

THROMBOPHLEBITIS (deep vein thrombosis) - Inflammation of veins with thrombus formation

Predisposing factors: 1. Smoking 2. Obesity 2. Hyperlipedemia 4. Prolonged use of oral contraceptives 5. Chronic anemia 6. DM 7. MI 8. CHF 9. Postop complications 10. Post cannulation insertion of various cardiac catheters S/Sx: 1. 2. 3. Dx: Pain at affected extremities Cyanosis (+) Homans sign - Pain at leg muscles upon dorsiflexion of foot.

1. Angiography 2. Doppler UTZ Nsg Mgt: 1. Elevate legs above heart level. 2. Apply warm, moist packs to decrease lymphatic congestion. 3. Measure circumference of leg muscles to detect if swollen. 4. Use anti embolic stockings. 5. Meds: Analgesics. Anticoagulant: Heparin 6. Complication:

Pulmonary Embolism:
- Sudden sharp chest pain - Dyspnea - Tachycardia - Palpitation - Diaphoresis - Mild restlessness