CARDIOVASCULAR

NCLEX REVIEW
PART TWO

2- CARDIOVASCULAR DISORDERS
 Insufficiency (or regurgitation),
incompetence
 Definition and related terms
 a damaged mitral valve allows blood from the left ventricle to flow back
into the left atrium during ventricular systole
 to handle the backflow, the atrium enlarges. So does the left ventricle,
in part to make up for its lower output of blood
 Epidemiology / etiology
 follows birth defects such as transposition of the great arteries

 in older clients, the mitral annulus may have become calcified

 cause unknown; may be linked to a degenerative process

 occurs in 5-10% of adults

 Marfan's Syndrome

 papillary muscle dysfunction or rupture

 trauma

 mitral valve prolapse, also called Barlow's Syndrome or floppy mitral

valve syndrome
 Insufficiency (or regurgitation),
incompetence
 Findings
 client may be asymptomatic

 orthopnea, dyspnea, fatigue, weakness, weight loss

 chest pain and palpitations

 findings of RVHF

 jugular vein distention

 peripheral edema
 hepatomegaly
 Diagnostics
 EKG for dysrhythmias and changes of left atrial enlargement

 echocardiogram - to visualize regurgitant jets and flail chordae /

leaflets
 cardiac catheterization - shows regurgitation of blood from left ventricle
to left atrium and increased pressures
 chest x-ray - shows cardiomegaly, pulmonary congestion

  
 Insufficiency (or regurgitation),
incompetence
 Management
 low-sodium diet - to control
underlying heart disease
 oxygen as needed - to
prevent tissue hypoxia
 antibiotics - to treat
infection
 prophylactic antibiotics - to
prevent infection
 surgery - mitral
valvuloplasty or valve
replacement

 Nursing interventions
 the Cardio-Care Six
 monitor The Cardio Seven
 monitor for left-sided heart
failure, pulmonary edema,
adverse reactions to drug
therapy, and cardiac
dysrhythmias - especially
Continue Nursing Intervention

 if client has surgery, monitor postoperatively for hypotension,

arrhythmias and thrombus formation
 reinforce client and family teaching regarding:
 diet restrictions and drugs

 explanation of tests and treatments

 long-term antibiotic and follow-up care

 the need for prophylactic antibiotics during routine dental

care as cleaning, or for any invasive procedure

 need to report findings of heart failure: dyspnea and

hacking, nonproductive cough

 Tricuspid stenosis

 Definition: narrowing of the blood flow through the tricuspid valve

between the right atrium and right ventricle
 Epidemiology
 relatively uncommon
 usually associated with lesions of other valves
 caused by rheumatic fever, IV drug abuses

 Findings
 dyspnea, fatigue, weakness, syncope
 peripheral edema
 jaundice with severe peripheral edema and ascites can mean that
tricuspid stenosis has led to right ventricular failure
 may appear malnourished
 distended jugular veins

 Diagnostics
 EKG - for dysrhythmias
 echocardiogram - right ventricular dilation and paradoxic septal
motion
 Management: surgery - valvulotomy or valve replacement;
Tricuspid stenosis

 Nursing interventions
 the Cardio-Care Six
 monitor the Cardio Seven
 monitor for findings of right heart failure
and adverse reactions to the drug therapy
 post valve surgery, monitor client for
hypotension, dysrhythmias and thrombus
formation
 when client sits, elevate legs - to prevent
dependent edema
 reinforce client and family teaching
regarding:
 the Cardio Five

 client must comply with long-term

antibiotic and follow up care

 the need for prophylactic antibiotics

during dental care or other invasive

procedures
Tricuspid insufficiency (regurgitation)

 Definition - tricuspid valve lets blood leak from the right ventricle
back into the right atrium during ventricular systole
 Epidemiology
 results from dilation of the right ventricle and tricuspid valve
ring
 most common in late stages of heart failure from rheumatic,
congenital heart disease, pulmonary fibrosis
 Findings
 dyspnea, fatigue, weakness and syncope
 peripheral edema may cause discomfort

 Diagnostics - echocardiogram for abnormal valve movement

 Management: surgical - valve replacement
 Nursing interventions

 Nursing interventions
 the Cardio-Care Six
 monitor for Cardio Seven
 monitor for signs of heart
failure and adverse
reactions to the drug
therapy
 post-op: monitor client for
hypotension, dysrhythmias
and thrombus formation
 when sitting, client should
raise legs - to prevent
dependent edema
 reinforce client and family
teaching regarding:
 the Cardio Five
 the need for
prophylactic antibiotics
during dental care or
other invasive
procedures
 the need to raise legs
when sitting - to
prevent dependent
edema
 Pulmonic stenosis

 Definition - obstructed right ventricular outflow during ventricular

systole resulting in right ventricular hypertrophy

 Epidemiology
 usually congenital, often with other birth defects such as
tetralogy of Fallot
 rare among the elderly
 may result from rheumatic fever, pulmonary hypertension, or
fibrosis

 Findings
 dyspnea, fatigue, chest pain and syncope
 peripheral edema may cause discomfort, impaired skin integrity

 Diagnostics - echocardiogram for abnormal valve or blood

movement

 Management: surgical - replace the valve via balloon and cardiac

 Nursing interventions

 Nursing interventions
 Same as tricuspid stenosis and tricuspid insufficiency
 monitor for signs of heart failure, pulmonary edema, and
adverse reactions to the drug therapy
 post-op: monitor client for hypotension, dysrhythmias and
thrombus formation

 monitor the Cardio Seven

 reinforce client and family teaching - same as tricuspid stenosis
and tricuspid insufficiency
Pulmonic insufficiency (regurgitation)

 Definition - pulmonary valve fails to close, so that blood flows back

into the right ventricle during ventricular diastole
 Epidemiology
 a birth defect, or a result of pulmonary hypertension
 rarely, result of prolonged use of a pressure-monitoring catheter
in the pulmonary artery
 Findings
 dyspnea, fatigue, chest pain and syncope
 peripheral edema may cause discomfort
 if advanced: jaundice with ascites and peripheral edema
 possible malnourished appearance
 Diagnostics - echocardiogram for abnormal blood or valve
movement
 Management
 diuretics - to mobilize edematous fluid to reduce pulmonary
venous pressure
 sodium-restricted diet - to control underlying heart disease
 anticoagulants - to prevent blood clots
 digitalis - to increase the force or strength of cardiac
contractions
Pulmonic insufficiency (regurgitation)

 Nursing interventions

 the Cardio-Care Six

 monitor the Cardio Seven
 monitor for findings of heart failure and adverse reactions to
drug therapy
 post-op: monitor client for hypotension, dysrhythmias and
thrombus formation
 provide frequent rest periods
 reinforce client and family teaching: (same as tricuspid stenosis,
tricuspid insufficiency, and pulmonic stenosis)
 Aortic stenosis

 Definition - aortic valve stiffens to narrow opening.

left ventricle must work harder, so needs more
oxygen, and may suffer ischemia and heart failure
 Epidemiology
 Most significant valvular lesion seen among
elderly people. It usually leads to left-sided
heart failure, left ventricular hypertrophy, and
cardiomyopathy
 incidence increases with age
 occurs in 1% of the population
 about 80% of these people are male
 20% of them die suddenly, around age of 60
years
 Findings
 classic triad: dyspnea, syncope, angina (see
Clients with Cardiovascular Disorders )
 fatigue
 palpitations
 left-sided heart failure may bring on orthopnea,
paroxysmal nocturnal dyspnea, and peripheral
edema
 Diagnostics: echocardiogram for abnormal blood
flow movement
 Aortic stenosis

 Management
 nitroglycerin - to relieve chest pain
 low-sodium diet - to control underlying heart disease
 diuretics - to mobilize fluid and to reduce pulmonary venous
pressure
 digitalis - to increase the force or strength of cardiac
contractions
 oxygen - to prevent hypoxia
 surgery - percutaneous balloon valvuloplasty, then valve
replacement
 Nursing interventions
 the Cardio-Care Six
 monitor the Cardio Seven
 monitor for findings of heart failure, pulmonary edema, and
adverse reactions to the drug therapy
 post-op: monitor client for hypotension, dysrhythmias and clots
 reinforce client and family teaching: (same as tricuspid stenosis,
tricuspid insufficiency, pulmonic stenosis and pulmonic
insufficiency)
Aortic insufficiency (regurgitation)

 Definition
 blood flows back into the left ventricle during ventricular diastole
overloading the ventricle and causing it to hypertrophy
 extra blood also overloads the left atrium and, eventually, the
pulmonary system
 Epidemiology
 by itself, most common among males
 with mitral valve disease, more common among females
 may accompany Marfan's syndrome, ankylosing spondylitis,
syphilis, essential hypertension or a defect of the ventricular
septum
 Findings
 uncomfortable awareness of heartbeat
 palpitations along with a pounding head
 dyspnea with exertion
 paroxysmal nocturnal dyspnea, with diaphoresis, orthopnea and
cough
 fatigue and syncope with exertion or emotion
 anginal chest pain unrelieved by sublingual nitroglycerin
 heartbeat that seems to jar the client's entire body
 client's nailbeds may appear to be pulsating when fingertip is
pressed (Quincke's sign)
Aortic insufficiency (regurgitation)

 Diagnostics:
 chest x-ray
 echocardiogram
 cardiac catherization
 Management
 digitalis - increases the heart's
contractility
 diuretics - to mobilize
edematous fluids and to reduce
pulmonary venous pressure
 sodium-restricted diet - to
control underlying heart
disease
 anticoagulant agents - to
prevent blood clots
 ACE inhibitors decrease cardiac
workload and assist to increase
oxygenation
 surgical - valve replacement
(however, aortic insufficiency
often damages the ventricle
before it is detected)
Aortic insufficiency (regurgitation)

 Nursing interventions

 same as all other valve disorders - The Cardio-Care Six except

don't need to elevate head unless pulmonary problems have
begun
 monitor the Cardio Seven
 monitor for signs of heart failure, pulmonary edema, and drug
reactions
 post-op: monitor client for hypotension, arrhythmias and clots
 reinforce client and family teaching regarding:
 same as all other valve disorders - The Cardio Five
 Failures of the Heart Muscle
Myocardial infarction (MI)

 Definition - insufficient oxygen supply kills (causes necrosis of)

myocardial tissue. Process of infarction may take from one to six
hours.

 Epidemiology / etiology
 client history of smoking, obesity, high cholesterol/low density
lipoprotein diet, physical/emotional stress
 may be cocaine induced
 factors affecting mortality:
 age

 number of occluded vessels

 previous history of MI

 presence of cardiogenic shock

 females have twice the mortality of males; may be related

to the fact that they tend to be older and have more
significant risk factors
  
Myocardial infarction (MI)
 Myocardial infarction (MI)
 Diagnostics
 history and physical
 EKG - monitor for changes in the 12 lead,
dysrhythmias
 serum markers - elevated
 isoenzymes - CK-MB, LDH, LDH2
 muscle proteins - troponin, myoglobin   myocardium - usually given first
 Management
 cardiac monitoring for dysrhythmias
 supplemental oxygen - to prevent tissue
hypoxia
 bed rest - to decrease the workload of the
heart, often with bathroom privileges
 stool softeners - to decrease the workload
of the heart caused by straining, which can
cause vagal stimulation producing
bradycardia and dysrythmias
 narcotic analgesics - to reduce pain,
anxiety, fear, and decrease the workload of
the heart
Continue Managment :
 antidysrhythmic - to prevent
dysrythmias, which are the most
common complications after an
MI
 thrombolytic agents - to dissolve
the thrombus in the coronary
artery and reperfuse the
 nitrates - to decrease pain and
decrease preload and afterload
while increasing the myocardial
oxygen supply
 anticoagulants - to prevent blood
clots
 Swan-Ganz catheter to monitor
pressure in pulmonary artery
(measure functioning of left
ventricle)
 intra-aortic balloon
counterpulsation may be used
for cardiogenic shock
 cardiac catheterization may be
performed for PTCA or stent
insertion
 Myocardial infarction (MI)

 Nursing interventions
 the Cardio-Care Six plus monitor the
following to identify early heart failure,
infections and complications
 temperature
 daily weight
 intake and output
 respiratory rate
 breath sounds
 blood pressure
EKG readings
EKG MEASURES ELECTRICAL ACTIVITY OF
HEART
 Electrocardiogram = (ECG) = (EKG)
Do not confuse with Echocardiogram (Echo)
 An EKG is a graphic recording of the
electrical currents of the heart. It may be a
one-lead, which is used for continuous
monitoring, or a 12-lead, which is used for
diagnostic purposes.
 The EKG records two basic events -
depolarization and repolarization as a series
of waves:
 Nursing interventions

 monitor pain management and give analgesics as needed, and record

the severity, location, type, duration of pain, and effectiveness of
medications
 monitor for cough, tachypnea, and crackles, which may predict left
ventricle is failing
 as ordered apply antiembolism stockings and intermittent pneumatic
compression devices to prevent venostasis and thrombophlebitis
 assist with range-of-motion exercises
 reinforce client and family teaching regarding:
 the Cardio Five

 the ICU or Coronary Care Unit, the associated routines and

machinery, and communication methods to client and family
 encourage client to join the cardiac rehab exercise program, if
ordered
 reinforce education for the gradual resumption of sexual activity -
taking nitroglycerin before sex may prevent chest pain
 advise the client when to report typical or atypical chest pain to
care provider
 reinforce information about postmyocardial infarction syndrome;
and to report it to care provider
 stress that client must modify risky life-style behaviors

 assist with dietary consultation as indicated

 Heart failure

 Findings: earliest to latest

 Diagnostics - the primary goal is to determine the underlying cause
of the heart failure
 history and physical exam
 CXR - to determine heart size and pleural effusions
 EKG for changes and dysrhythmias
 echocardiogram to measure valvular abnormalities
 nuclear imaging - to determine myocardial contractility,
myocardial perfusion, and acute cell injury
 hemodynamic monitoring of arterial blood pressure, pulmonary
artery pressure, pulmonary artery wedge pressure and cardiac
output
 Management
 goal is to restore balance between the myocardial oxygen
supply and the demand
 treatments include oxygen, digitalis, vasodilators, nitrates,
antihypertensives, cardiac glycosides, diuretics, intra-aortic
balloon counterpulsation, ventricular assist pumping, etc.
Heart failure
 Cardiac tamponade

 Definition /etiology
 Fluid quickly fills pericardial sac and minimizes cardiac output. Cardiac
tamponade is a medical emergency.

PRINCIPLES OF CARDIOPULMONARY RESUSCITATION (CPR) -

ADVANCED CARDIAC LIFE SUPPORT
 Early access
 Early CPR
 Early defibrillation
 Early advanced cardiac life support
 Give drugs after defibrillation (in the adult)
 For drug delivery, antecubital veins are first choice because central-line
placement would interrupt CPR
 Endotracheal tube placement
 Intraosseous route for drugs is alternative (in children)
 Cardiac tamponade

 Etiology
 acute pericarditis
 post-op after cardiac surgery
 pericardial effusions
 chest trauma
 myocardial rupture
 aortic dissection
 anticoagulant therapy
 malignancy
 Findings: classic triad of symptoms
 hypotension with
 muffled heart sounds with
 high jugular venous pressure: increased CVP, increased jugular vein
distention if no hypovolemia
 Diagnostics
 chest x-ray
 echocardiogram
 computerized tomogram of chest
 Management
 pericardiocentesis: needle aspiration of pericardial sac
 Cardiac tamponade

 Nursing interventions

 bed rest with elevated

head of bed 35 to 45
degrees
 prepare client for
pericardiocentesis
 provide emotional
support
 prepare for surgery if
pericardiocentesis is
ineffective
 monitor for complications
of procedure
 pneumothorax

 dysrhythmias

 hypotension
 Disorders of the Circulatory System
Hypertension
EIGHT FACTORS THAT AFFECT ARTERIAL BLOOD
PRESSURES
 Cardiac output
 Resistance in peripheral vessels (arterioles)
 Arterial elasticity: Elastic vessels let blood flow at lower
pressures; rigid, sclerotic vessels require higher
pressures.
 Viscosity
 Too many red blood cells (RBCs) or plasma proteins
increases pressure
 Lower viscosity, from anemia or lack of RBCs,
decreases pressure
 Age: newborns have low blood pressure, which
increases with age
 Weight: the higher the weight, the higher the blood
pressure
 Exercise: faster heart rates mean higher systolic blood
pressure
 Autonomic Nervous System: The sympathetic nervous
system speeds the heart rate; the parasympathetic
 Hypertension

 Definitions
 hypertension - systolic blood pressure of 140 mm Hg or greater,
diastolic blood pressure of 90 mm Hg or greater, on at least
three separate occasions
 pregnancy induced hypertension (PIH) - high blood pressure
present before week 20 of gestation
 accelerated hypertension - a hypertensive crisis: blood pressure
rises very rapidly
 threat of immediate vascular necrosis and end-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

 Hypertension

Etiology and epidemiology

HOW THE BODY CONTROLS BLOOD PRESSURE
Arterial blood pressure (BP): increases with increase in: cardiac output , peripheral resistance or
blood volume.
 Intrinsic control: hour by hour, chemoreceptors control blood flow according to the tissues' use of
oxygen and the amount of carbon dioxide in the brain.
 Extrinsic control: overrides intrinsic control when necessary.
 For rapid, short-term adjustments, the body monitors blood pressure via stretch receptors
(baroreceptors) in the walls of the carotid sinus and the aortic arch .  
 Control of blood pressure begins in vasomotor centers in medulla oblongata, through the
autonomic nervous system, the kidneys, and hormones such as epinephrine and angiotensin.
 If arterial pressure increases above normal, the body lowers BP by decreasing heart rate
(mediated by acetylcholine , the neurotransmitter of the parasympathetic nervous system.)
 If arterial pressure falls, BP is raised by increasing cardiac output (mediated by epinephrine,
the neurotransmitter of the sympathetic nervous system)
 Slow, long-term control of blood pressure is achieved through:
 excretion of sodium and water by the kidney
 by the activity of the renin-angiotensin system
 by the atrial natriuretic factor - a hormone released from the right atrium in response to
increased atrial stretch
 and antidiuretic hormone ( ADH )
Hypertension
 Hypertension

 Diagnostics

 based on the average of three or more blood pressure readings,

two minutes apart, at each of three or more visits after an initial
screening visit
 classification of adult hypertension
 hypertension is classified according to its cause:
 primary or essential hypertension (about 90% of clients)

 secondary hypertension (results from another disease;

about 5% to 10% of clients)

 PIH - associated with pregnancy

 accelerated hypertension - a hypertensive crisis

 Hypertension

 Management

 pharmacological
 initial therapy - for uncomplicated hypertension, it is

recommended to start with a diuretic or Beta-adrenergic

blocking agent
 oxygen prn in acute crisis

 angiotensin-converting enzyme (ACE) inhibitors are used to

treat left-sided heart failure and preferred if client is diabetic

 antilipemics

 other: weight loss, regular exercise, limit sodium intake

 goals of treatment
 blood pressure < 140/90 mm Hg, or after cardiac surgery

blood pressure < 120 / 80

 control dyslipidemia, obesity, inactivity

 control diabetes mellitus, if indicated

 Hypertension

 Nursing interventions: reinforce client and family teaching

regarding:
 client to use self-monitoring blood pressure cuff
 client to record readings at least twice weekly in a
journal or calendar for review by care provider during
visits
 client to set up routine for taking antihypertensive
medications
 the need to warn against high-sodium antacids, and
cold or sinus remedies with vasoconstrictors such as
antihistamines
 diet low in sodium, cholesterol and saturated fat

 when client is to report extremely high blood pressure

readings
 lifestyle modifications
 optimize body weight
 drink alcohol based on current guidelines
 moderate dietary sodium (2-gm sodium diet)
 exercise: regular moderately intense aerobic
activity
 avoid tobacco products
 manage stress triggers and responses to
triggers
 Coronary artery disease

 Coronary artery disease (CAD)

 Definition - Fatty deposits in coronary arteries (atheroma or
plaque) narrow the artery (by 75% or more) and cut flow of blood
and oxygen to the heart muscle.
 Coronary artery disease

 Epidemiology and etiology

 CAD is epidemic in the western world
 more than 30% of men age 60 or older show signs of CAD on
autopsy
 most common cause: atherosclerosis
 risk factors:
 gender: over 40 white male ; women after menopause

 family history of CAD

 uncontrolled high blood pressure

 high cholesterol , triglycerides

 smokers are twice as likely to have a myocardial infarction and

four times as likely to die suddenly - this risk drops sharply

within one year after smoking ceases
 obesity (waist predominance); [added weight increases the

risk of diabetes, hypertension and high cholesterol]

 physical inactivity

 stressed lifestyle
 Findings: Angina

TYPES OF ANGINA
 Angina, especially after physical exertion, is the classic finding of coronary
artery disease.
 Angina appears commonly with nausea, vomiting, fainting, sweating, and
cool extremities
 Angina may follow excitement, a large meal, or exposure to extreme cold
or heat.
 Types of angina
 Nocturnal angina - occurs during sleep to wake client
 Angina predictable and relieved by nitroglycerine: stable angina.
 More frequent and lasting angina: unstable angina.
 Effort-induced pain that occurs more and more often: crescendo angina
 Severe angina at rest: Prinzmetal's angina - associated with coronary
artery spasm
 Angina

 Diagnostics
 serum elevations
 homocysteine levels

 C-reactive protein

 LDH cholesterol

 triglycerides

 cardiac catherization

 Management
 pharmacology
 nitrates such as nitroglycerin,

isosorbide dinitrate (Isordil), or

beta-adrenergic neuron-blocking
agents
 oxygen - to prevent hypoxia

 diuretics and beta-adrenergic

blocking agents
 antiplatelet agents: aspirin (8/mg

daily), the most commonly used,

reduces platelet aggregation
 Antilipemics - to decrease circulating
lipids
Angina