Chapter 8 Care of the Patient with a Cardiovascular or a Peripheral

Chapter 8 Care of the Patient with a Cardiovascular or a Peripheral
Vascular Disorder Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Key Terms Aneurysm Hypoexmia Angina pectoris Intermittent claudication
Arteriosclerosis Ischemia Atherosclerosis Myocardial infarction (MI) Bradycardia Occlusion BNP (B-type natriuretic peptide) Orthopnea Cardioversion Peripheral Coronary artery disease (CAD) Pleural Effusion Defibrillation Polycythemia Dysrhythmia Pulmonary Edema Embolus Tachycardia Endarterectomy Heart failure

Overview of Anatomy and Physiology
Heart Four-chambered, hollow, muscular organ, not much bigger than a fist Lies in the mediastinum Lower border is called the apex Heart wall: three layers Epicardium (pericardium): double, serous membrane on the outside of the heart Myocardium: constructed of cardiac muscle Endocardium: lines the inner surface of the chambers of the heart The cardiovascular system has the awe-inspiring responsibility of providing sustenance to all of the cells and systems within the body. What phrases can be used to describe the functions of the cardiovascular system?

Heart and major blood vessels viewed from front (anterior).
Figure 8-1 The heart carries 1,000 gallons of blood each day. With each heartbeat, blood is circulated throughout the body. How many times per day do you estimate the heart beats? (from Thibodeau, G.A. & Patton, K.T. [2007]. Structure and function of the human body. [13th ed.]. St. Louis: Mosby. ) Heart and major blood vessels viewed from front (anterior).

Septum (divides right and left halves) Heart chambers Right atrium—receives deoxygenated blood Left atrium—receives oxygenated blood Right ventricle—pumps deoxygenated blood Left ventricle—pumps oxygenated blood Heart valves Atrioventricular valves Tricuspid and bicuspid (mitral) valves Semilunar valves Pulmonary and aortic semilunar valves Chordae tendineae A structure known as the septum divides the heart into halves. Each half functions as a unique and separate pumping station. The ventricles are separated by valves. What role is played by the valves?

Figure 8-2 Interior of the heart.
(From Thibodeau, G.A., Patton, K.T. [2007]. Anatomy and physiology. [6th ed.]. St. Louis: Mosby.) Interior of the heart.

Electrical conduction system Automaticity An inherent ability of the heart muscle tissue to contract in a rhythmic pattern Irritability The ability to respond to a stimulus Impulse pattern Sinoatrial node to AV node to bundle of His to right and left bundle branches to Purkinje fibers * Hormones, ion concentration, and changes in body temperature can effect conduction, rhythm, and coordination of heart beat* A muscle, the heart performs by contracting in a rhythmic manner. Failure to contract as designed will result in illness or death. What factors may influence the ability of the heart to demonstrate synchronicity between the contracting structures?

Conduction system of the heart.
Figure 8-3 (From Thibodeau, G.A., Patton, K.T. [2007]. Anatomy and physiology. [6th ed.]. St. Louis: Mosby.) Conduction system of the heart.

Cardiac cycle A complete heartbeat Atria contract while ventricles relax Ventricles contract while atria relax Systole Phase of contraction Diastole Phase of relaxation Period between contraction of the atria or ventricles during which the blood enters the relaxed chambers *Lubb-longer and lower pitch Dubb-shorter and sharper pitch* *Murmur (swishing) can be normal or abnormal* When the heart is functioning as designed, there is coordination between contraction of the atria and ventricles. With each heartbeat cycle, there are the characteristic “lubb and dubb” sounds. What actions are responsible for these tones? What explanations could explain a heartbeat cycle without these tones or with modifications in these tones?

Blood flow during systole.
Figure 8-4 During systole, there is relaxation of the ventricles during which the atria contract. Where does the blood distributed by the contraction travel? (From Canobbio, M. [1990]. Cardiovascular disorders, Mosby’s clinical nursing series. St. Louis: Mosby.) Blood flow during systole.

Blood flow during diastole.
Figure 8-5 A complicated network is responsible for carrying blood to and from the heart in the body. To what could this vast network be compared? (From Canobbio, M. [1990]. Cardiovascular disorders, Mosby’s clinical nursing series. St. Louis: Mosby.) Blood flow during diastole.

Blood vessels Capillaries Tiny blood vessels joining arterioles and venules Arteries Large vessels carrying blood away from the heart arterioles Veins Vessels that convey blood from the capillaries to the heart venules

Circulation Coronary blood supply Right and left coronary arteries
Branch off of the aorta Encircle the heart like a crown Supply the myocardium with blood Coronary veins Return the unoxygenated blood to the coronary sinus, then to the right atrium

Arterial coronary circulation (anterior).
Figure 8-6 (From Canobbio, M. [1990]. Cardiovascular disorders, Mosby’s clinical nursing series. St. Louis: Mosby.) Arterial coronary circulation (anterior).

Circulation Systemic circulation Pulmonary circulation
Circulates blood from the left ventricle to all parts of the body and back to the right atrium Carries oxygen and nutritive materials to all body tissues and removes products of metabolism Pulmonary circulation Circulates blood from the right ventricle to the lungs and back to the left atrium of the heart Carries deoxygenated blood to the lungs to be reoxygenated and removes the metabolic waste product, carbon dioxide

Laboratory and Diagnostic Examinations
Number of diagnostic test available to evaluate cardiovascular function Nursing responsibilities Physically prepare patient for test or procedure Explain examination to patient

Radiographic examination Film record of heart size, shape and position and outline of shadows Lung congestion also shown (Heart failure) Diagnostic imaging Fluoroscopy (action picture radiograh; pacemaker placement, intracardial catheter (Swan) placement Angiogram-series of radiographs after contrast injected; picture of circulating process Aortogram-x-ray visual of abdominal aorta and leg arteries Cardiac catheterization and angiography Measures heart pressures, ejection fraction, visual of valves, arteries and structure Sterile procedure; contrast contains iodine; assess circulation post-operatively (pulses, vitals, EKG, puncture site) Diagnostic studies of a cardiovascular disorder can be divided into categories: visualization, assessment of conduction, and serum values. Describe the use of imaging in providing diagnostic information about the heart. Which of the tests listed will require a signed consent from the patient?

Electrocardiography (ECG/EKG) Graphic recording of electrical activity of myocardium 3 distinct waves (deflections); P, QRS, T Contraction-depolarization Relaxation-repolarization 12 leads Supine, exercise stress, Holter Cardiac monitors Similar to EKG; preset alarms; telemetry monitors Monitor wires, battery, connection, gel pads, etc.

Normal ECG deflections.
Figure 8-7 An electrocardiogram involves the use of electrodes to assess cardiac impulses with the heart’s conduction. Identify the three distinct waves in the electrocardiogram. Discuss placement of the electrodes during the test. Normal ECG deflections. 19

Thallium scanning Intracellular ion actively transported into normal cells If cell is ischemic, thallium not picked up Thallium concentrates in tissue with normal blood flow Inadequately perfused areas appear dark on scan (cold spots) Sestamibi in place of thallium diminishes artifact in females Persantine (dipyridamole) given prior to thallium for patients who cannot tolerate activity Echocardiography-high frequency ultrasound EF: normal >60% PET (positron emission tomography)-inhaled/injected radioactive substance displaying color coded images related to metabolic function

Laboratory tests: CBC (rbc, wbc, platetets, H&H) High WBC Low Hgb High RBC (polycythemia) d/t hypoexmia blood cultures coagulation studies Chronic afib, cardioversion, MI d/t thrombus PT, INR PTT ESR-inflammatory infective conditions (MI, endocarditis, rheumatic fever) Electrolytes; Na, K+, Ca, Mg Lipids; LDL, HDL, VLDL arterial blood gases; PaO2, PaCO2, pH

cardiac markers Proteins released into blood from necrotic heart muscle after infarction Cardiac serum enzymes CK(creatine kinase CK-MB (creatine phosphokinase)-gold standard also found in skeletal muscle Can be elevated from surgery, trauma, diease Not specific for MI Rise within 2-3 hours of injury, peak 24 hours, return to normal hours Troponin I Myocardial muscle protein released after MI Not influenced by skeletal muscle injury Rises 3 hours, peaks hours, normal 5-7 days

B-type Natriuretic Peptide (BNP) Neurohormone secreted by the heart in response to ventricular expansion Elevated in heart failure; higher the number, more sever the HF Homocysteine Amino acid produced during protein digestion Elevated levels may act as independent risk factor for heart disease Deficiency in B6, B12, and folate most common cause

Disorders of the Cardiovascular System
Major health concern Normal aging patterns Risk factors Nonmodifiable factors Family history Age Sex (gender) Race Risk factors leading to the increased incidence of cardiovascular disease have been studied. Nonmodifiable risk factors are those which cannot be changed by patient intervention. Why does aging influence the onset of cardiovascular disease? Compare and contrast the risk factors of men and women.

Risk factors (continued) Modifiable factors Smoking Hyperlipidemia Hypertension Diabetes mellitus Obesity Sedentary lifestyle Stress Oral contraceptives Psychosocial factors Modifiable factors are those in which the patient can make life adjustments to reduce the incidence of heart disease. Assess the risk factors for the students in the class.

Cardiac dysrhythmias Any cardiac rhythm that deviates from normal sinus rhythm Sinus tachycardia Sinus bradycardia Supraventricular tachycardia Atrial fibrillation Atrioventricular block Premature ventricular contractions Ventricular tachycardia Ventricular fibrillation The deviation from the normal sinus rhythm can cause physiological manifestations that are individualized by types. Review the characteristics of each of the identified dysrhythmias.

Cardiac Arrest The sudden cessation of cardiac output and circulatory process Cause: ventricular tachycardia, ventricular fibrillation, and ventricular asystole Signs and symptoms: abrupt loss of consciousness with no response to stimuli; gasping respirations followed by apnea; absence of pulse and blood pressure; pupil dilation; pallor and cyanosis Treatment: cardiopulmonary resuscitation (CPR) and advanced cardiac life support (ACLS) pacemaker When cardiac arrest occurs, immediate intervention is needed to revive the individual and to prevent permanent damage to the body’s organs. The initiation of CPR involves the establishment and maintenance of the critical ABCs. What do the ABCs stand for? How much time can elapse between cardiac arrest and resuscitation before damage to vital organs and the accompanying loss of function result? Outline the parameters of ACLS.

Disorders of the Heart Coronary atherosclerotic heart disease
Coronary artery disease (CAD) A variety of conditions that obstruct blood flow in the coronary arteries Atherosclerosis A common arterial disorder characterized by yellowish plaques of cholesterol, lipids, and cellular debris in the inner layers of the walls of the arteries; the primary cause of atherosclerotic heart disease (ASHD) Coronary artery disease is a growing health concern in the United States. What factors are associated with its development? What influence does race and ethnicity have on the development of coronary artery disease?

Progressive development of coronary atherosclerosis.
Figure 8-10 The arteries of the heart can be likened to hoses. It is the responsibility of these hoses to carry blood and nutrients to areas of the body. Certain behaviors and groups of people can experience a narrowing in the pipes. See the figure illustrated. Each subsequent artery represents a reduction in diameter, thus increasing the level of compromise to the body. (From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2007]. Medical-surgical nursing: assessment and management of clinical problems. [7th ed.]. St. Louis: Mosby.) Progressive development of coronary atherosclerosis.

Disorders of the Heart Angina pectoris Etiology/pathophysiology
Cardiac muscle is deprived of oxygen Increased workload on the heart Clinical manifestations/assessment Pain (usually relieved by rest) Dyspnea Anxiety; apprehension Diaphoresis Nausea The presence of angina can be a wakeup call to millions. The onset of the characteristic discomfort is an indication the body is unable to successfully supply the heart with oxygen and blood. The onset of an angina attack should be followed by seeking medical care. What factors can be associated with an episode of angina?

Disorders of the Heart Angina pectoris (continued)
Medical management/nursing interventions Correct cardiovascular risk factors Avoid precipitating factors Pharmacological management Dilate coronary arteries and decrease workload of heart Nitroglycerin Beta-adrenergic blocking agents Calcium channel blockers When a patient presents with an episode of suspected angina, what data should be collected by the nurse? What subjective data might the patient report? What diagnostic tests will be ordered to determine the cause of the patient’s complaints?

Disorders of the Heart Angina pectoris (continued)
Medical management/nursing interventions Surgical interventions Coronary artery bypass graft (CABG) Percutaneous transluminal coronary angioplasty (PTCA) Stent placement At times, surgical intervention can be indicated in conjunction with or in lieu of pharmacological therapies. What patients are candidates for the procedures? Discuss the education that is needed for the patient undergoing CABG or PTCA.

Disorders of the Heart Myocardial infarction Etiology/pathophysiology
Occlusion of a major coronary artery or one of its branches with subsequent necrosis of myocardium Most common cause is atherosclerosis Ability of the cardiac muscle to contract and pump blood is impaired A myocardial infarction can result from atherosclerosis, an embolus, or a thrombus. The loss of blood flow results in ischemia and damage to the affected tissues. What factors will determine the degree of damage or loss of function experienced by the patient?

Four common locations where myocardial infarctions occur.
Figure 8-16 (From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2007]. Medical-surgical nursing: assessment and management of clinical problems. [7th ed.]. St. Louis: Mosby.) Four common locations where myocardial infarctions occur.

Disorders of the Heart Myocardial infarction (continued)
Clinical manifestations/assessment Asymptomatic (silent MI) Pain (not relieved by rest, position, or nitroglycerin) Nausea SOB; dizziness; weakness Diaphoresis Pallor—ashen color Sense of impending doom The onset of discomfort is often met with denial by the patient. What types of explanations do patients frequently use to “explain away” the manifestations? Once the patient enters the health care system, prompt, accurate assessment by the team is vital to the patient’s survival. What manifestations can be anticipated in the patient’s vital signs?

Sites to which ischemic myocardial pain may be referred.
Figure 8-11 (From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2007]. Medical-surgical nursing: assessment and management of clinical problems. [7th ed.]. St. Louis: Mosby.) Sites to which ischemic myocardial pain may be referred.

Disorders of the Heart Myocardial infarction (continued)
Medical management/nursing interventions Oxygen Fibrinolytic agents Percutaneous transluminal coronary angioplasty (PTCA) Coronary artery bypass graft surgery Pharmacological management Vasopressors, analgesics, nitrates, beta-adrenergic blockers, calcium channel blockers, antidysrhythmics, diuretics, inotropic agents, diuretics, stool softeners The immediate priority for the management of care is to reduce cardiac ischemia and limit damage. What outcomes will be desired by the therapies? The role of the nurse in the care of a patient after a myocardial infarction is important. Describe nursing interventions and assessments that will be performed.

A, Saphenous vein. B, Saphenous aortocoronary artery bypass.
Figure 8-12 Physicians can determine surgical intervention is needed to manage ASHD or CAD. Surgeons can use grafts to bypass occluded arteries and provide blood flow to the heart. Graft surgeries have an anticipated lifespan. How long can grafts from the saphenous vein be expected to last? (A, from Urden LD, et al [2006]. Thelan’s critical care nursing: Diagnosis and management. [5th ed.]. St. Louis: Mosby. B, from Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2007]. Medical-surgical nursing: assessment and management of clinical problems. [7th ed.]. St. Louis: Mosby.) A, Saphenous vein. B, Saphenous aortocoronary artery bypass.

Coronary artery bypass graft.
Figure 8-13 (from Monahan, F.D., et al. [2007]. Phipps’ medical-surgical nursing: health and illness perspectives. [8th ed.]. St. Louis: Mosby. ) Coronary artery bypass graft.

Disorders of the Heart Heart failure Etiology/pathophysiology
Abnormal condition characterized by circulatory congestion resulting from the heart’s inability to act as an effective pump Left ventricular failure Most common Right ventricular failure Usually caused by left ventricular failure Cardiac insufficiency results when the heart is no longer able to adequately provide perfusion to the entire body. This condition was once known as congestive heart failure. This term is now considered somewhat antiquated. Why has this term been replaced in the medical community? Heart failure can result from chronic neurohormonal conditions or result from other medical conditions. What are examples of medical conditions associated with the development of heart failure?

Disorders of the Heart Heart failure (continued)
Clinical manifestations/assessment Decreased cardiac output Fatigue Angina Anxiety; restlessness Oliguria Decreased GI motility Pale, cool skin Weight gain In addition to the objective clinical manifestations, the nurse is also responsible for assessing subjective patient reports. What questions can the nurse ask to facilitate the exchange of information?

Clinical manifestations/assessment (continued) Left ventricular failure Pulmonary congestion Dyspnea Paroxysmal nocturnal dyspnea Cough; frothy, blood-tinged sputum Orthopnea Pulmonary crackles Pleural effusion (x-ray) The left side of the heart is responsible for pumping oxygenated blood to the body. When the left side of the heart is unable to meet the body’s demands, decreased cardiac output results. What are the implications of untreated left-sided heart failure?

Clinical manifestations/assessment (continued) Right ventricular failure Distended jugular veins Anorexia, nausea, and abdominal distention Liver enlargement Ascites Edema in feet, ankles, sacrum; may progress up the legs into thighs, external genitalia, and lower trunk Right ventricular failure most commonly results from effects of the failing left ventricle. What additional causes can be associated with the right-sided failure?

Medical management/nursing interventions Pharmacological management Increase cardiac efficiency Digitalis Vasodilators ACE inhibitors (decrease blood pressure) Bed rest, HOB elevated Oxygen Treat edema and pulmonary congestion Monitor fluid retention (weigh daily; strict I&O) Diagnosis of heart failure uses the presenting clinical manifestations and confirming tests. Chest radiographs, electrocardiograms, and echocardiography can be used. What findings will support a heart failure diagnosis? Laboratory testing is also common. What serum tests can be anticipated? What prognosis is associated with the diagnosis of heart failure?

Disorders of the Heart Pulmonary edema Etiology/pathophysiology
Accumulation of fluid in lung tissues and alveoli Complication of congestive heart failure (CHF) Clinical manifestations/assessment Restlessness Agitation Disorientation Diaphoresis Dyspnea and tachypnea Pulmonary edema is an acute and life-threatening event. It is caused by left-sided heart failure. The affected patient can literally drown in his/her own secretions.

Disorders of the Heart Pulmonary edema (continued)
Clinical manifestations/assessment (continued) Tachycardia Pallor or cyanosis Cough—large amounts of blood-tinged, frothy sputum Wheezing, crackles Cold extremities When pulmonary edema is suspected, what diagnostic tests can be used to confirm diagnosis?

Disorders of the Heart Pulmonary edema (continued)
Medical management/nursing interventions Pharmacological management Morphine sulfate Nitroglycerin Diuretics Inotropic agents Vasodilators High Fowler’s or orthopneic position Oxygen The goals of management seek to increase oxygenation, improve cardiac output and reduce congestion. What will occur if the condition continues to progress unchecked? What nursing diagnoses would be appropriate for the care of the patient diagnosed with pulmonary edema? Discuss nursing implications/considerations for the medications that may be administered to the patient diagnosed with pulmonary edema. What manifestations will indicate that the medication therapies are having the desired effects?

Disorders of the Heart Valvular heart disease Etiology/pathophysiology
Heart valves are compromised and do not open and close properly Stenosis Insufficiency Causes may be: Congenital Rheumatic fever Heart valves have the job of maintaining the direction of the blood flow through the right and left atrium and ventricles. How do the heart valves know when to open and close? Identify the names of the heart valves and their locations.

Disorders of the Heart Valvular heart disease (continued)
Clinical manifestations/assessment Fatigue Angina Oliguria Pale, cool skin Weight gain Restlessness Abnormal breath sounds Edema Dysfunction of the valves can occur due to stenosis or a history of valvular heart disease. What can cause stenosis of the valves? Discuss populations at risk for the development of valvular heart disease.

Disorders of the Heart Valvular heart disease (continued)
Medical management/nursing interventions Pharmacological management Diuretics Digoxin Antidysrhythmics Restrict activities Sodium-restricted diet Surgery Open mitral commissurotomy Valve replacement Diagnostic tests used to confirm the presence of valvular heart disease include radiographs, ECG, echocardiogram, and cardiac catheterization. Initial management options focus on noninvasive interventions such as medications, diet, and activity restrictions. When these treatment modalities are no longer helpful, surgical intervention might be indicated. Outline the types of surgical intervention that can be undertaken.

Disorders of the Heart Rheumatic heart disease
Etiology/pathophysiology Rheumatic fever Inflammatory disease that is a delayed childhood reaction to inadequately treated childhood upper respiratory tract infection of beta-hemolytic streptococci Causes scar tissue in the heart Rheumatic heart disease occurs after an individual has had rheumatic fever. The time span between the two disorders can be many years. Since the 1980s, rheumatic fever has become increasingly uncommon in the United States. To what can this decline be attributed?

Disorders of the Heart Rheumatic heart disease (continued)
Clinical manifestations/assessment Elevated temperature Elevated heart rate Epistaxis Anemia Joint pain and stiffness Nodules on the joints Specific to valve affected Heart murmur Explain the changes in the heart’s valves in response to the disease process. There is no specific diagnostic test. Diagnosis is made by combining the clinical manifestations with supportive data from the test results. Tests include scanning studies and laboratory tests. An echocardiogram and ECG can be ordered. What laboratory tests can be ordered?

Disorders of the Heart Rheumatic heart disease (continued)
Medical management/nursing interventions Pharmacological management NSAIDs Prevention Treat infections rapidly and completely Bed rest Application of heat Dietary recommendations Well-balanced diet Supplement with vitamins B and C Encourage fluids Commissurotomy or valve replacement The best cure for rheumatic heart disease is prevention. This can be accomplished by successful treatment of the originating disease process. If the disease results, treatment is largely supportive. What is the role of the nurse in providing care to the patient diagnosed with rheumatic heart disease? What is the prognosis for the patient diagnosed with rheumatic heart disease?

Disorders of the Heart Pericarditis Etiology/pathophysiology
Inflammation of the membranous sac surrounding the heart May be acute or chronic Bacterial, viral, or fungal Noninfectious conditions Azotemia, MI, neoplasms, scleroderma, trauma, systemic lupus erythematosus (SLE), radiation, drugs Inflammation of the pericardium of the heart results in thickening and constriction of the structure. What alterations in functioning of the heart result from this process?

Disorders of the Heart Pericarditis (continued)
Clinical manifestations/assessment Debilitating pain Dyspnea Fever Chills Diaphoresis Leukocytosis Pericardial friction rub Pericardial effusion An accurate assessment of the patient presenting with clinical manifestations of pericarditis is important. Both the subjective and objective data will need to be reported. What questions concerning the characteristics and precipitating the pain’s onset are indicated? Provide examples of questions that can be used by the nurse to obtain additional information.

Disorders of the Heart Pericarditis (continued)
Medical management/nursing interventions Pharmacological management Analgesics Salicylates Antibiotics Anti-inflammatory agents Corticosteroids Oxygen IV fluids Surgery: pericardial window, pericardial tap If caught early, pericarditis can have a fair prognosis. As the disease progresses, there are increasing complications and death can result. Prompt diagnosis and treatment will determine the patient’s final outcomes. What diagnostic tests are used to support the diagnosis of pericarditis? When is surgical intervention indicated?

Disorders of the Heart Endocarditis Etiology/pathophysiology
Infection or inflammation of the inner membranous lining of the heart Clinical manifestations/assessment Influenza-like symptoms Petechiae on the conjunctiva, mouth, and legs Anemia Splinter hemorrhages under nails Weight loss Heart murmur Endocarditis can involve the innermost part of the heart or the heart’s valves. The disease process is classified by the cause. What events might precede the onset of endocarditis? What populations are at an increased risk for the development of the disorder? Discuss changes in populations previously at increased risk for the development of endocarditis. Why have these changes occurred?

Disorders of the Heart Endocarditis (continued)
Medical management/nursing interventions Bed rest Antibiotics IV for 1 to 2 months Prophylactic antibiotics for “high-risk” patients Surgical repair of diseased valves or valve replacement Endocarditis can present in a rapid, acute manner, or it could be a slower onset. When the presentation does occur, diagnostic tests are indicated to pinpoint the cause to begin treatment. Diagnostic tests used are ECG, chest radiography, complete blood count, erythrocyte sedimentation rate, and blood cultures. What results will support an endocarditis diagnosis? What prognosis is associated with endocarditis?

Disorders of the Heart Myocarditis Etiology/pathophysiology
Inflammation of the myocardium Rheumatic heart disease Viral, bacterial, or fungal infection Endocarditis Pericarditis A variety of causes can be to blame for the development of myocarditis. The clinical manifestations can also vary. The signs and symptoms presented will differ based upon the site of cardiac involvement. Identify clinical manifestations that can be associated with endocarditis. Why do dysrhythmias result with this disease process?

Disorders of the Heart Myocarditis (continued)
Medical management/nursing interventions Bed rest Oxygen Antibiotics; anti-inflammatory agents Assessment and correction of dysrhythmias Clinical manifestations/assessment Vary according to site of infection Cardiac enlargement Murmur; gallop; tachycardia The management of myocarditis is symptomatic. What prognosis can be anticipated? Are there long-range complications with this disorder?

Disorders of the Heart Cardiomyopathy Etiology/pathophysiology
A group of heart muscle diseases that primarily affects the structural or functional ability of the myocardium Not associated with CAD, hypertension, vascular disease, or pulmonary disease Primary—unknown cause Secondary—infective, metabolic, nutritional, alcohol, peripartum, drugs, radiation, SLE, rheumatoid arthritis Cardiomyopathy is classified by cause. It can be primary or secondary. Primary cardiomyopathy is a disease of the heart muscle with an unknown underlying cause. It is further subdivided by the type of damage. These subdivisions are dilated cardiomyopathy, hypertrophic cardiomyopathy, and restrictive cardiomyopathy. Explain the differences among the types.

Disorders of the Heart Cardiomyopathy (continued)
Clinical manifestations/assessment Angina Syncope Fatigue Dyspnea on exertion Severe exercise intolerance Signs and symptoms of left- and right-sided CHF The signs and symptoms are similar to those seen in heart failure. Why does this similarity exist? The most common symptom is severe exercise intolerance.

Disorders of the Heart Cardiomyopathy (continued)
Medical management/nursing interventions Pharmacological management Diuretics ACE inhibitors Beta-adrenergic blocking agents Treat underlying cause Internal defibrillator Cardiac transplant Diagnosis is based upon both the clinical presentation and the results from supportive diagnostic tests. What diagnostic tests can be anticipated? What results will support a cardiomyopathy diagnosis? What actions are desired from the medication classifications used in the management of cardiomyopathy? When the condition is no longer able to respond to conventional treatment options, a heart transplant could be considered. If transplantation is being considered, which patients are viewed as suitable candidates? Which candidates are not eligible for a heart transplant?

Disorders of the Peripheral Vascular System
Arterial assessment PATCHES P = Pulses A = Appearance T = Temperature C = Capillary refill H = Hardness E = Edema S = Sensation Arterial blood circulation refers to the blood being transported from the heart to the body. What signs and symptoms are associated with insufficiencies?

Venous assessment First symptom is usually edema Dark pigmentation Dryness and scaling Ulcerations Pain, aching, and cramping Usually relieved by rest or elevation Venous circulation involves the transportation of blood from the body’s tissues en route to the lungs. This excess fluid remains in the tissues and manifests as characteristic edema. Another common symptom involves changes in skin appearance. What pathophysiology is responsible for this? What differences exist between arterial and peripheral disorders?

Diagnostic tests Noninvasive procedures Treadmill test Plethysmography Digital subtraction angiography (DSA) Doppler ultrasound Invasive procedures Phlebography or venography 125I-fibrinogen uptake test Angiography Numerous tests are available to evaluate peripheral vascular status. The treadmill test is used to evaluate blood flow in the extremities after exercise. What education will need to be provided to the patient prior to the completion of the test? A Doppler ultrasound can be used to evaluate the blood flow in blood vessels. What types of disorders can be detected by using this test? Invasive tests include the phlebography, 125I-fibrinogen uptake test, angiography, D-dimer, and duplex scanning tests. What responsibilities does the nurse have before an invasive test is performed?

Arteriosclerosis Thickening, loss of elasticity, and calcification of arterial walls, resulting in decreased blood supply Atherosclerosis Narrowing of the artery due to yellowish plaques of cholesterol, lipids, and cellular debris in the inner layers of the walls of large- and medium-sized arteries A type of arteriosclerosis The terms “arteriosclerosis” and “atherosclerosis” are often used interchangeably. Despite similarities, there are differences. Pinpoint the differences between the two conditions. What similarities do they have?

Hypertension Etiology/pathophysiology A sustained elevated systolic blood pressure greater than 140 mm Hg and/or a sustained elevated diastolic blood pressure greater than 90 mm Hg. Vasoconstriction (increases blood pressure ) Essential (primary) hypertension 90% to 95% of all diagnosed cases Secondary hypertension Attributed to an identifiable medical diagnosis A diagnosis of hypertension requires elevations in readings that meet the set criteria and are taken at different times. Risks for the development of hypertension exist for individuals who have what is termed as “prehypertension.” Prehypertension is defined as a systolic blood pressure reading of 120 to 139 mm Hg or 80 to 89 mm Hg diastolic. The risk for the development of hypertension by these individuals doubles. Explain what encompasses the systolic reading. What is meant by the diastolic reading?

Hypertension (continued) Clinical manifestations/assessment Headache; blurred vision Epistaxis Angina Medical management/nursing interventions Pharmacological management Antihypertensive medications; diuretics Dietary recommendations Weight control, reduction of saturated fats, and low sodium No smoking There are two types of hypertension. Primary hypertension is most common. There is no exact cause for its development. What theories are available to explain this type? Secondary hypertension is identified with a specific medical diagnosis. Discuss the concept of malignant hypertension. What risk factors are associated with the development of hypertension? What is the long-range picture for the individual with hypertension?

Arteriosclerosis obliterans Etiology/pathophysiology Narrowing or occlusion of the blood vessel with plaque formation—little or no blood flow to the affected extremity Clinical manifestations/assessment Pain—intermittent claudication Pulselessness Pallor Paresthesia Paralysis When performing an assessment of the patient suspected of having arteriosclerosis, what questions should the nurse ask to collect data? What diagnostic tests will be employed to support the diagnosis?

Arteriosclerosis obliterans (continued) Medical management/nursing interventions Anticoagulants Fibrinolytics Surgery Embolectomy Endarterectomy Arterial bypass Percutaneous transluminal angioplasty Amputation The goals of treatment focus on the prevention of total arterial occlusion. Pharmacological agents used include anticoagulants, fibrinolytics, and vasodilators. What is the mode of action that aids in the management of this disease? When administering these medications, what are the nursing implications?

Arterial embolism Etiology/pathophysiology Blood clots in the arterial bloodstream May originate in the heart Foreign substances Clinical manifestations/assessment Pain Absent distal pulses Pale, cool, and numb extremity Necrosis The presence of arterial emboli is a potentially life-threatening condition. When the emboli lodge in the vessels, pain is a chief symptom. What is the cause of the pain? Data collection is necessary to make a timely diagnosis. What questions will the nurse need to ask to facilitate the collection of data?

Arterial embolism (continued) Medical management/nursing interventions Pharmacological management Anticoagulants Fibrinolytics Endarterectomy Embolectomy Diagnostic testing will include Doppler ultrasonography and angiography testing. Once a diagnosis is made, management will include medications and possibly surgery. Identify nursing diagnoses applicable for the care of the patient experiencing arterial emboli.

Arterial aneurysm Etiology/pathophysiology Enlarged, dilated portion of an artery Causes: arteriosclerosis; trauma; congenital Clinical manifestations/assessment Asymptomatic Large pulsating mass Pain, if large enough to press on other structures Although aneurysms can occur in any vessel, there are vessels having an increased incidence of the phenomena. What sites are more commonly associated with the development of an aneurysm?

Types of aneurysms. A, Fusiform. B, Saccular.
Figure 8-20 (From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2007]. Medical-surgical nursing: assessment and management of clinical problems. [7th ed.]. St. Louis: Mosby.) Types of aneurysms. A, Fusiform. B, Saccular. C, Dissecting.

Arterial aneurysm (continued) Medical management/nursing interventions Assess for signs and symptoms of rupture, thrombi, ischemia Control hypertension Surgery Ligation Grafts Although aneurysms are largely asymptomatic, diagnostic tests are available to aid in the diagnostic process. What diagnostic tests will be anticipated if an aneurysm is suspected?

Thromboangitis obliterans (Buerger’s disease) Etiology/pathophysiology Occlusive vascular condition in which the small and medium-sized arteries become inflamed and thrombotic Clinical manifestations/assessment Pain; sensitivity to cold Skin cold and pale Ulcerations on feet or hands; gangrene Superficial thrombophlebitis The cause of thromboangiitis obliterans is not completely understood. What population is most likely to be affected by this disorder? What is the possible relationship between tobacco use and this disease?

Thromboangitis obliterans (Buerger’s disease) (continued) Medical management/nursing interventions No smoking Exercise to develop collateral circulation Surgery Amputation of gangrenous fingers and toes Sympathectomy When providing care to the patient diagnosed with thromboangiitis obliterans, what is the role of the nurse? Discuss the prognosis of the patient diagnosed with thromboangiitis obliterans.

Raynaud’s disease Etiology/pathophysiology Intermittent arterial spasms Primarily affects fingers, toes, ears, and nose Exposure to cold or emotional stress Clinical manifestations/assessment Chronically cold hands and feet Pallor, coldness, numbness, cyanosis, and pain during spasms; erythema following a spasm Ulcerations on the fingers and toes The intermittent episodes of Raynaud’s disease result from attacks of ischemia. The cause is unknown. The condition may be primary or associated with other diseases including scleroderma, rheumatoid arthritis, systemic lupus erythematosus, drug intoxication, and occupational trauma. What populations are more likely to develop this condition?

Raynaud’s disease (continued) Medical management/nursing interventions Pharmacological management Vasodilators Calcium antagonists Muscle relaxants Surgery: sympathectomy No smoking Avoid exposure to cold Amputation for gangrene Diagnosis of Raynaud’s disease includes a cold stimulation test. What is involved in a cold stimulation test? The goals of therapy are geared at prevention. Pharmacological interventions often include calcium channel blockers. How do these medications work? What education will assist the patient to avoid episodes?

Thrombophlebitis Etiology/pathophysiology Inflammation of a vein in conjunction with the formation of a thrombus Risk factors: venous stasis, hypercoagulability, trauma of a blood vessel, immobilization after surgery Clinical manifestations/assessment Pain Edema Positive Homans’ sign Erythema, warmth, and tenderness along the vein

Deep vein thrombophlebitis.
Figure 8-23 The assessment of extremities affected by thrombophlebitis requires close observation. What observations can be charted in the permanent medical record? (From Kamal, A., Brockelhurst, J.C. [1991]. Color atlas of geriatric medicine. [3rd ed.]. St. Louis: Mosby-Year Book —Europe.) Deep vein thrombophlebitis.

Thrombophlebitis (continued) Medical management/nursing interventions Superficial Pharmacological management NSAIDs Bed rest Moist heat Elevate extremity Thrombophlebitis can be superficial or deep. How do these types differ? What diagnostic tests will be used to confirm the presence of thrombophlebitis?

Thrombophlebitis (continued) Medical management/nursing interventions Deep Pharmacological management Anticoagulants Fibrinolytics Bed rest Elevate extremity Antiembolism stockings Surgery: thrombectomy; vena cava umbrella (Greenfield filter) Anticoagulant therapies are often prescribed to manage thrombophlebitis. When given, what are patient safety considerations? Discuss the role of the nurse.

Varicose veins Etiology/pathophysiology Tortuous, dilated vein with incompetent valves Clinical manifestations/assessment Dark, raised, tortuous veins Fatigue; dull aches Cramping of the muscles Heaviness or pressure of extremity Edema, pain, changes in skin color, and ulcerations with venous stasis Varicose veins impact approximately 15% of the population. What gender is most likely affected? Identify factors that can promote this problem. Varicose veins may be primary or secondary. Compare and contrast these types.

Varicose veins (continued) Medical management/nursing interventions Elastic stockings Rest Elevate legs Sclerotherapy Surgery Vein ligation and stripping The management of milder varicose veins employs special stockings, rest, and leg elevation. Surgical intervention might be indicated in more serious presentations. Outline the safety precautions that are indicated when elastic stockings or bandages are used for these patients.

Venous stasis ulcers Etiology/pathophysiology Ulcerations of the legs from chronic deep vein insufficiency and stasis of blood in the venous system of the legs Open necrotic lesion due to an inadequate supply of oxygen-rich blood to the tissue Causes Varicose veins, burns, trauma, sickle cell anemia, diabetes mellitus, neurogenic disorders, and hereditary factors

Venous stasis ulcers (continued) Clinical manifestations/assessment Pain Ulceration with dark pigmentation Edema Medical management/nursing interventions Diet: increased protein; vitamins A and C and zinc Debridement of necrotic tissue Antibiotics Unna boot Venous stasis ulcers present a challenge to manage. The reduced blood flow to the area makes healing prolonged. Further, the populations most likely affected frequently have comorbid conditions adding to this dilemma. Diet therapies are useful. What specific foods will promote healing? Discuss the types of debridement.

Scale for pitting edema depth.
Figure 8-17 An assessment of edema is needed for both cardiovascular and peripheral vascular disorders. How is edema documented? (From Canobbio, M. [1990]. Cardiovascular disorders, Mosby’s clinical nursing series. St. Louis: Mosby.) Scale for pitting edema depth.

Nursing Process Nursing diagnoses Activity intolerance Anxiety
Decreased cardiac output Ineffective coronary tissue perfusion Fluid volume excess Impaired gas exchange Knowledge, deficient Pain

Cardiovascular and Renal Medications
Chapter 15 Cardiovascular and Renal Medications Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 91

Learning Objectives Identify the approved way to give different forms of antianginal therapy Discuss the uses and general actions of cardiac drugs used to treat dysrhythmias Describe the common treatment for various types of lipoprotein disorders Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Cardiovascular System: Major Arteries
Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Question 1 Arteries move blood from the heart to tissues using smaller branches called: Arterioles. Bronchioles. Nerves. Venules. Correct Answer: 1 Rationale: Arteries move blood from the heart to tissues using smaller branches called arterioles. Veins move blood from tissues back toward the heart, beginning with their smaller branches called venules. Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Cardiovascular System: Major Veins

Antianginals and Peripheral Vasodilators
Nitrates: “Universal Vasodilators” Directly cause vascular smooth muscle to relax in arterial and venous circulation Decrease myocardial oxygen use Increase collateral-vessel circulation to the heart Calcium Channel Blockers Dilate coronary arteries and arterioles Reduce response of electrical conduction system Narrowing or constriction of smooth muscle in the coronary arteries and peripheral vascular system reduces the amount of blood flow to the heart. This lack of blood supply results in diminished oxygen and nutrient flow to the heart, causing chest pain, or “angina,” and peripheral vascular disease. Arterial relaxation reduces the pressure the heart has to pump against. Venous relaxation causes blood pooling and decreases venous return to the heart. Nitrates are readily absorbed under the tongue, through the skin, and orally. Nitroglycerin is a nitrate. The half-life of nitroglycerin is only 1 to 4 minutes. Calcium is an electrolyte that helps move electrical impulses through cardiac tissue. Calcium channel blockers are drugs that help slow down the flow of calcium ions across the cell membrane, which reduces the amount of calcium available to move electrical impulses. There are many actions of these drugs. Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Question 2 Which are the best drugs for treating coronary artery disease? Beta blockers Calcium channel blockers Diuretics Nitrates Correct Answer: 4 Rationale: Nitrates are the best drugs for treating coronary artery disease, whereas vasodilating agents (agents to open up the vessels) are used for peripheral vascular disease. The use of beta blockers in treating angina has also increased over the years, even though there is not agreement about their effectiveness. Calcium channel blockers may also play a role in treating angina, although concern about their possible role in changes in the heart (which may lead to chronic heart failure) in patients who have had a myocardial infarction (heart attack) has limited their use. Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Main Components of Microcirculation

Antianginals and Peripheral Vasodilators (cont.)
Action and Uses Nitrates Acute and chronic anginal attacks Reduce the workload of the heart Peripheral Vasodilators Relax the smooth muscles of peripheral arterial vessels to increase peripheral circulation Used to treat leg pain caused by vasoconstriction Patients with occlusive arterial disease have blockages in peripheral arteries. This causes swollen, painful feet and ulcers around the ankles. Peripheral vasodilators have been used with limited success. Patients who may benefit from peripheral vasodilators include those with intermittent claudication, arteriosclerosis obliterans, Raynaud disease, nocturnal leg cramps, and vasospasm caused by blood clots. Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Site of Action of Peripheral Vasodilators

Antianginals and Peripheral Vasodilators (cont.)
Adverse Reactions Nitrates: Flushing, postural hypotension, tachycardia, confusion, dizziness, fainting, headache, lightheadedness, vertigo, weakness, drug rash, localized pruritus, skin lesions, eye and mouth edema, local burning in mouth, nausea and vomiting Peripheral Vasodilators: Headache, weakness, tachycardia, flushing, postural hypotension, dysrhythmias, confusion, severe rash, nervousness, tingling, and sweating Some nitrates contain tartrazine, a chemical that may cause an asthmatic type of allergic reaction. Peripheral vasodilating agents have a stronger action when taken with antihypertensives and alcohol. This leads to hypotension. What are the nursing implications for the LPN/LVN regarding these drugs? What patient teaching should be done for nitrates? (Storage? Expiration date?) For peripheral vasodilating agents? How should patients be taught to use nitroglycerin during an acute anginal attack? What are some drug interactions with nitrates or peripheral vasodilators? Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Antidysrhythmics Four Classes
Class I: disopyramide, procainamide, quinidine Lengthen the refractory period Decrease cardiac excitability Class II: acebutolol, esmolol, propranolol Reduce sympathetic excitation (reduce loading) Class III: amiodarone Lengthen the time it takes for one cell to fire and recover Class IV: verapamil Blocks calcium entry into the myocardium, prolongs resting phase People with heart disease or other problems that affect the heart muscle are at risk of developing irregular heartbeats, or cardiac dysrhythmias. Dysrhythmias may be fast or slow, with an irregular or regular pattern. The most common causes of dysrhythmias are an irritation to the heart tissue after a myocardial infarction, fluid and electrolyte imbalances, diet, hypoxia, and drug reactions. Dysrhythmias vary in patients in regularity and intensity. An electrocardiogram is needed to determine the type of dysrhythmia a patient is experiencing. Halter monitors are portable ECG machines that take an ongoing tracing of the heart’s electrical function. Antidysrhythmics act on each individual cell of the heart. Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Conduction System of the Heart

Antidysrhythmics (cont.)
Action and Uses Quinidine and Procainamide Treat rapid and irregular dysrhythmias by decreasing the excitability of myocardial cells Bretylium Slows conduction rate in the ventricles, slows norepinephrine release in the myocardium Disopyramide Slows the depolarization of cardiac cells The exact type of irregular rhythm can only be determined by taking an ECG. It is important to find the cause of the dysrhythmia. Most dysrhythmias are caused by (1) increased sensitivity of the electrical cells in the heart, resulting in irregular or early ectopic beats and (2) electrical activity moving through abnormal conduction pathways, triggering myocardial cells to fire improperly. Depolarization is the movement of electrolytes in and out of the cell as it gets ready to send another electrical impulse. Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Antidysrhythmics (cont.)
Lidocaine Increases the strength of electrical impulses Adenosine Stops the heart for several seconds to allow it to convert to normal sinus rhythm Beta-adrenergic blockers (propranolol) Decrease the heart’s beta-receptor response to epinephrine and norepinephrine Many patients refuse to continue taking adenosine after experiencing its effects. Many of the antidysrhythmics are so powerful they should only be used in critical care units. What are some of the medication-specific adverse effects of these drugs? Antidysrhythmics often cause or worsen heart failure or urinary retention. Patients with a past history of heart failure should be watched closely. Drug interactions: the effect of quinidine is increased by potassium and decreased by hypokalemia. The action of verapamil is stronger if the patient is taking digitalis and beta blockers. Beta blockers have many drug-specific interactions. How can the steps of the nursing process be applied here? Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Antihyperlipidemics Types of Lipoproteins
Chylomicrons (mostly triglycerides) Formed from absorption of dietary fat in intestine Very low-density lipoproteins (VLDLs) Made up of large amounts of triglycerides that were made in the liver (pre-beta lipoproteins) Low-density lipoproteins (LDLs) Breakdown of VLDLs linked with cholesterol and protein High-density lipoproteins (HDLs) Clear out excess cholesterol from tissue Lipoproteins are described by how thick or dense they are. Chylomicrons are usually present for 1 to 8 hours in the plasma after the last meal. Nearly all the triglycerides in plasma that are not in chylomicrons are considered to be VLDLs. About 75% of plasma cholesterol is moved in the form of LDLs. High LDL levels indicate cholesterol levels that are higher than the body needs. Patients are at high risk for developing atherosclerosis. HDLs block the uptake of LDL cholesterol by the vascular smooth muscle cells and may prevent atherosclerotic activity. Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Path of Lipid Metabolism

Antihyperlipidemics (cont.)
HMG-CoA Reductase Inhibitors Highly effective for lowering LDL levels Fibric Acid Derivatives Highly effective for lowering triglyceride and increasing HDL levels Bile Acid Sequestrants Form an insoluble compound with bile salts to reduce serum cholesterol levels Niacin Effective at lowering LDL levels and increasing HDLs Research suggests high LDL levels can lead to coronary artery disease. Evaluation of LDL and HDL levels is of primary importance, because research has shown that lowering serum lipids or cholesterol can reduce the risk of atherosclerotic heart disease. HMG-CoA reductase inhibitors (statins) are extremely costly but highly effective. Liver function tests should be closely monitored when taking these drugs. Fibric acid derivatives are not as effective as HMG-CoA reductase inhibitors in lowering LDL levels. Gemfibrozil and fenofibrate are well tolerated but can cause liver toxicity and gallstones. The liver uses cholesterol to replace the bile excreted by bile acid sequestrants. These drugs increase triglyceride levels. Adverse GI side effects include constipation, nausea, and bloating. Niacin is highly effective. Its use is limited by the side effect of flushing in the face and neck. What are some significant points for the LPN/LVN to include in patient teaching? Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Learning Objectives List the general uses and actions of cardiotonic drugs Explain the actions of different categories of drugs used to treat hypertension Identify indications for electrolyte replacement Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Internal Anatomy of the Heart

Cardiotonics Actions Increase the contraction strength or force (positive inotropic action) Slow the heart rate Uses Treatment of CHF and rapid or irregular heartbeats (atrial fibrillation, atrial flutter, frequent PVCs or paroxysmal atrial tachycardia) Cardiotonics, often referred to as cardiac glycosides, make the heart beat slower and stronger. The digitalis preparation digoxin is the major cardiac glycoside. It has been used for many decades. All cardiotonic drugs have the same basic drug action. They differ only in the speed and duration of action. Chronotropic drugs affect the rate or rhythm of the heart. Dromotropic drugs influence the speed of the electrical impulse as it passes through the nerve or cardiac muscle fibers. PVCs are premature ventricular contractions. Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Cardiotonics (cont.) Adverse Reactions Drug Interactions
Digitalis toxicity: serum digoxin levels verify The amount of medication that is helpful (therapeutic) and the amount that is harmful (toxic) are not very different. Don’t confuse the sound-alikes digoxin and digitoxin Drug Interactions Nursing Implications and Patient Teaching Cardiotonics are powerful and can be toxic to the heart. The symptoms of digitalis toxicity may begin slowly and are easy to overlook; however, toxicity can occur quickly, especially in the elderly. Symptoms include bradycardia, dysrhythmia, tachycardia, apathy, confusion, delirium, disorientation, drowsiness, mental depression, headache, visual changes (blurred vision, yellow/green vision, halos around dark objects), anorexia, diarrhea, nausea, vomiting, severe weakness. Nursing implications include taking an apical pulse for a full minute prior to administering the dose of digoxin. If the apical pulse is less than 60, the medication is held (not given) and the physician immediately notified. What patient and family teaching will the LPN/LVN be expected to give? Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Antihypertensives, Diuretics, and Other Drugs Affecting the Urinary Tract
Indirectly reduce blood pressure by producing sodium and water loss and lowering the tone or rigidity of the arteries Types Thiazide and sulfonamide diuretics Loop diuretics Potassium-sparing diuretics Hypertension is a disorder in which the patient’s blood pressure is elevated above normal limits for age. Blood pressures above 150/90 mm Hg are associated with accelerated vascular damage of the heart, brain, and kidneys, which leads to increased risk of death. Primary hypertension affects 80% to 90% of people with high blood pressure; the cause is unknown. The other 10% to 20% have secondary hypertension, in which elevated blood pressure is the result of another disease process or problem. Loop diuretics block the active transport of chloride, sodium, and potassium in the thick ascending loop of Henle. These drugs work well in patients with impaired renal function. Potassium-sparing diuretics increase the excretion of water and sodium by saving potassium. These drugs are used in patients with kidney disease or who are at risk for potassium imbalance. Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Antihypertensives, Diuretics, and Other Drugs Affecting the Urinary Tract (cont.)
Adrenergic Inhibitors Beta-adrenergic blockers Nonselective; block beta1 and beta2 sites Selective; block beta1 sites Central adrenergic inhibitors Cause vascular relaxation and lower blood pressure Peripheral adrenergic antagonists Limit norepinephrine release, prevent vasoconstriction The elderly population are more susceptible to developing adverse reactions (hypotension, impaired mental activity, hypokalemia, increased serum glucose levels) when using diuretics. Lower doses are advised in this population, and the drug is gradually discontinued to avoid a rebound effect. The various adrenergic inhibitors block the transmission of epinephrine and norepinephrine at the alpha and/or beta sites. Nonselective beta blockers reduce the heart rate and force of contraction, prevent renin release, and slow the outflow of sympathetic nervous system messages from the brainstem to the vasomotor center, which tells the body to constrict the blood vessels and increase heart rate. Central adrenergic inhibitors stimulate peripheral alpha-adrenergic receptors, causing brief vasoconstriction, and then stimulate alpha2-adrenergic receptors in the brainstem that coordinate cardiac function. Peripheral adrenergic antagonists decrease total peripheral resistance to blood flow by relaxing smooth muscle. Most of these medications are no longer available in the United States. Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Antihypertensives, Diuretics, and Other Drugs Affecting the Urinary Tract (cont.)
Alpha1-adrenergic inhibitors Lower peripheral resistance and blood pressure Combined alpha- and beta-adrenergic blockers Angiotensin-Related Agents Angiotensin-converting enzyme inhibitors Angiotensin II receptor antagonists Vasodilators Calcium Channel Blocking Agents The renin-angiotensin mechanism directly increases blood pressure. ACE inhibitors (angiotensin-converting enzyme inhibitors) inhibit the conversion of angiotensin I to angiotensin II in the liver and lungs. Angiotensin II receptor antagonists interfere with angiotensin II acting on the adrenal cortex to increase aldosterone secretion. Vasodilators reduce systolic and diastolic blood pressure by direct relaxation of smooth muscle, which lowers vascular resistance. Calcium channel blocking agents limit the passage of extracellular calcium ions through specific ion channels of the cell membrane in cardiac, vascular, and smooth-muscle cells. This lowers peripheral resistance and decreases blood pressure. Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

High Blood Pressure Stage I: Lifestyle Changes Stage II: Drug Therapy
Adverse Reactions Drug specific Drug Interactions What lifestyle changes may help a patient reduce hypertension risk factors? (Losing weight, increased physical activity, reduction of fat, salt, and calories in the diet, smoking cessation, and reducing alcohol intake) The initial drug of choice is an oral thiazide or adrenergic beta blocker. The drug is started in low dosage and increased as needed until maximum dosage is reached. Loop diuretics are used when hypertension is severe, and blood pressure must be brought down quickly. Antiadrenergic agents may be added if the maximum diuretic or beta-blocker dose is not effective. Vasodilators are most effective when used with a beta-adrenergic blocking agent. Adrenergic-inhibiting agents are powerful and are used only when necessary because of their high risk of side effects. Refer to Table for adverse reactions of these drugs. What are some of the nursing implications and patient-teaching issues for these medications? Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Drugs Useful in Treating Urinary Problems
Urinary incontinence Treatment: anticholinergics/antispasmodics, alpha-adrenergic agonists, estrogens, cholinergic agonists, and alpha-adrenergic antagonists Benign prostatic hyperplasia Treatment: alpha1-adrenergic receptor blockers Analgesia Treatment: phenazopyridine There are a variety of drugs to treat urinary symptoms related to incontinence, benign prostatic hyperplasia (BPH), and urinary tract pain secondary to infections. Anticholinergic agents used for urinary incontinence stop bladder contraction and decrease the response of some bladder muscles. Antispasmodic drugs directly cause smooth-muscle relaxation. Estrogens may help restore urethral mucosa and increase vascularity, tone, and the ability of the urethral muscle to respond. Benign prostatic hyperplasia (BPH) is a noncancerous growth of the prostate gland that can cause voiding problems. Tamsulosin (Flomax) and finasteride are two drugs specifically used for this problem. What are some of the nursing implications and patient teaching issues for these medications? Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Question 3 ___________ is an electrolyte that helps move electrical impulses through cardiac tissue. Calcium Iron Hemoglobin Oxygen Correct Answer: 1 Rationale: Calcium is an electrolyte that helps move electrical impulses through cardiac tissue. Calcium channel blockers are drugs that help slow down the flow of calcium ions across the cell membrane, thus reducing the amount of calcium available for electrical impulse movement. The electrical message directing the heart to contract depends on a special balance of electrolytes (such as calcium and sodium) in the cardiac tissues and on good function of the cardiac conduction system. This electrical message is what is recorded on the electrocardiogram (ECG). Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Lesson 19.1: Cardiovascular Disease
Cardiovascular disease is the leading cause of death in the United States. Several risk factors contribute to the development of coronary heart disease and hypertension, many of which are preventable by improved food habits and lifestyle behaviors. Other risk factors are nonmodifiable, such as age, gender, family history, and race. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 125

Introduction (p. 379) Coronary heart disease
Leading cause of death in the United States More than 615,000 deaths each year Similar in other Western developed nations More than 1 million live with various forms of rheumatic and congestive heart disease What are the primary underlying disease processes of cardiovascular disease? (Atherosclerosis and hypertension) Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 126

Atherosclerosis (p. 379) Major cause of CVD
Fatty fibrous plaques develop into fatty streaks on inside lining of major blood vessels Plaques largely composed of cholesterol Narrows interior part of the blood vessel If affected vessel is major artery supplying heart muscle, result could be myocardial infarction Local area of dead tissue is an infarct What may eventually happen if this narrowing continues or a blood clot develops? (Blood flow is cut off, causing tissue to die) What is the common name for a myocardial infarction? (Heart attack) Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 127

Atherosclerosis (cont’d) (p. 379)
If affected vessel is major artery supplying brain, result could be cerebrovascular accident The common name for a cerebrovascular accident is stroke. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 128

Atherosclerosis (cont’d) (p. 379)
Identified as coronary heart disease Common symptom is angina pectoris, chest pain usually radiating down the arm, sometimes brought on by excitement or physical effort From where does the term “coronary” heart disease originate? (The major arteries and their many branches serving the heart are called “coronary” arteries because they cross the brow of the heart muscle and resemble a crown.) Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 129

Key Terms Related to Atherosclerosis (p. 380)
Myocardial infarction Cerebrovascular accident Coronary heart disease Angina pectoris Lipids Ask individual students to define each of these terms. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 130

Atherosclerotic Plaque (p. 381)
Illustration of atherosclerotic plaque in an artery The top view shows a moderate buildup of atherosclerotic plaque. The bottom view shows a more progressed form of plaque buildup, with a thrombus forming between the plaques that could cut off blood flow. If the thrombus blocked the blood vessel, what would happen? (Myocardial infarction or stroke) Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 131

Relation to Fat Metabolism (p. 381)
Elevated blood lipids associated with coronary heart disease Triglycerides: Simple fats in body or food Cholesterol: Fat-related compound produced in body; also in foods from animals Lipoproteins: “Packages” wrapped with protein that carry fat in the bloodstream To what does the term lipids refer? (Class name for all fats and fat-related compounds) Cholesterol is important for cell functioning, but an excess amount of cholesterol is associated with heart disease. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 132

Types of Lipoproteins (p. 381)
Chylomicrons Lipoprotein particles that carry absorbed dietary triglycerides to fat and tissues Very-low-density lipoproteins (VLDLs) Carry large load of fat to cells Intermediate-density lipoproteins (IDLs) After VLDLs deposit triglycerides, IDLs remain in circulation Low-density lipoproteins (LDLs) Carry two thirds of total plasma cholesterol to body tissues High-density lipoproteins (HDLs) Carry less total fat and more protein Which cholesterol is considered the “good cholesterol”? (HDL) Why is HDL called “good cholesterol”? (Protects against cardiovascular disease) HDL cholesterol is not found in food; it is produced in the body. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 133

Risk Factors (p. 382) Gender: CVD more common in men until women reach menopause Age: risk increases with age Family history Heredity: certain ethnic groups Compounding diseases: type 2 diabetes, hypertension, metabolic syndrome Blood cholesterol profile: high total and LDL and low HDL cholesterol Ask students whether cardiovascular disease is common in their families. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 135

Case Study Mr. Elliott is a 68-year-old male who is referred to the dietitian for a fat-controlled meal plan. Mr. Elliott is 5 feet 10 inches tall and weighs 250 lbs. His blood pressure is 155/95. Recent labs reveal a total cholesterol of 245 mg/dL, LDL 171 mg/dL, HDL 36 mg/dL, and TG 200 mg/dL. Case Study: Mr. Elliott is a 68-year-old male who is referred to the dietitian for a fat-controlled meal plan. Mr. Elliott is 5 feet 10 inches tall and weighs 250 lbs. His blood pressure is 160/95. Recent labs reveal a total cholesterol of 245 mg/dL, LDL 171 mg/dL, HDL 36 mg/dL, and TG 200 mg/dL. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 136

Case Study (cont’d) List Mr. Elliott’s risk factors for heart disease.
Which risk factors can be modified? What additional information would be helpful to look at risk factors? Risk Factors include: Gender: more often in men (until women reach menopause) Age Compounding factors: hypertension, overweight Elevated blood cholesterol levels: total cholesterol, LDL, TG and low HDL Risk Factors that can be modified: Compounding factors Cholesterol profile Additional Information: heredity, family history glomerular filtration rate, activity, whether or not he smokes, dietary history Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 137

Case Study (cont’d) What other lab value and assessment data would you consider in assessing Mr. Elliott? Why? May want to look at serum fasting glucose level to see if he fits criteria for metabolic syndrome. Mr. Elliott already has elevated TG, reduced HDL and elevated blood pressure. Weight circumference is also part of the diagnostic criteria for metabolic syndrome. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 138

Dietary Recommendations (p. 383)
Dietary recommendations for reduced risk Reduce fat and cholesterol National Cholesterol Education Program (NCEP): reduce high blood cholesterol Therapeutic Lifestyle Changes (TLC): Total energy intake equals energy expenditure Exercise to expend at least 200 kcal/day Total fat no more than 25% to 35% of intake Avoid trans-fatty acids Carbohydrates equal 50% to 60% of energy intake Protein equals about 15% of energy intake Total cholesterol intake less than 200 mg/day These recommendations reflect a life habit intervention: appropriate weight, diet, physical activity, and other controllable risk factors. Individuals with metabolic syndrome or diabetes can increase intake of unsaturated fats in place of carbohydrates. What types of protein are people encouraged to eat as a low-fat alternative to animal products? (Soy protein) Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 139

Drug Therapy (p. 386) NCEP ATP III guidelines: drug therapy initiated depending on risk factors TLC guidelines should be continued as adjunct therapy The NCEP guidelines consider both the LDL cholesterol level and the number and severity of other risk factors before initiating drug therapy. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 140

Case Study (cont’d) Discuss interventions that could assist Mr. Elliott in reducing his cardiovascular risk. Following the dietary guidelines National Cholesterol Education Program guidelines Therapeutic Lifestyle Changes interventions that focuses on appropriate weight, diet, physical activity, and other controllable risk factors to reduce cholesterol Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 141

Acute Cardiovascular Disease (p. 387)
Acute cardiovascular disease: myocardial infarction Cardiac rest: analgesics Principles of medical nutrition therapy Energy intake reduced to reduce load on heart Soft or easily digested foods Fat: Mediterranean-type diet Limited sodium When cardiovascular disease cuts off blood supply to the major coronary arteries, a myocardial infarction may occur. Why is cardiac rest important? (Allows the damaged heart to return to normal functioning; reduces the metabolic workload) How can metabolic activities be decreased? (Eat small amounts throughout the day.) Early meals after a heart attack include relatively soft, easily digested foods to avoid gas discomfort or excess effort. How can a restricted sodium diet be achieved? (Use salt lightly in cooking, add no salt when eating, and avoid salty processed foods.) Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 142

Heart Failure (p. 388) Objective: control of pulmonary edema
Fluid shift mechanism Hormonal alterations Principles of diet therapy Sodium restriction Fluid restriction Texture Nutritional adequacy Little or no alcohol The main source of dietary sodium is common table salt, sodium chloride. A large amount of salt is used in food processing. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 143

Lesson 19.2: Hypertension Hypertension, or chronically elevated blood pressure, may be classified as essential (primary) or secondary hypertension. Hypertension damages the endothelium of blood vessels. Early education is critical for the prevention of cardiovascular disease. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 144

Essential Hypertension (p. 389)
Incidence and nature 31% of American adults have high blood pressure (hypertension) Injury to inner lining of blood vessel wall appears to be underlying link to cause Secondary hypertension is symptom or side effect of another primary condition Hypertension called the “silent disease” In what demographic group is the incidence of hypertension highest? (Older African-American women) Why is “hypertension” used instead of “high blood pressure”? (Hypertension is the term for essential hypertension; i.e., chronic elevated blood pressure. High blood pressure may be a temporary condition from overexertion or stress.) Hypertension is usually an inherited disorder. What other factors may contribute to hypertension? (Obesity, smoking, lack of exercise, chronic stress, certain drugs, caffeine) Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 145

Hypertensive Blood Pressure Levels (p. 390)
Prehypertension: focus on lifestyle modifications Stage 1 hypertension: diet therapy and drugs as needed Stage 2 hypertension: diet therapy and vigorous drug therapy Blood pressure measurements indicate the pressure of the blood surge in the upper arm and are measured in millimeters of mercury (mm Hg). What two numbers are used in measuring blood pressure? (Systolic measures the force of the blood surge when the heart contracts [top number]. Diastolic measures the pressure remaining in the arteries when the heart relaxes [bottom number].) Normal (or prehypertensive) adult blood pressure is recorded as <140/<90 mm Hg. If diuretics are used to control stage 2 hypertension, dietary replacement by increased use of potassium-rich foods is important. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 146

Principles of Medical Nutrition Therapy (p. 391)
Weight management: lose excess weight and maintain healthy weight Sodium control: limit sodium to 1500 to 2400 mg/day DASH diet: lower blood pressure through diet alone Additional lifestyle factors: limit alcohol, stop smoking, reduce saturated fat, increase aerobic activity A well-planned personal program of weight reduction and physical activity is essential in hypertension therapy. What does “DASH” stand for? (Dietary Approaches to Stop Hypertension) DASH diet followers, on average, decrease systolic blood pressure 6 to 11 mm Hg. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 148

Case Study (cont’d) Discuss additional nutrition factors that may assist Mr. Elliott in controlling his blood pressure. Weight management: Lose weight and maintain appropriate weight for height Sodium control Other minerals: Calcium, magnesium DASH diet: Lower blood pressure through diet alone Additional lifestyle factors Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 149

Education and Prevention (p. 393)
Food planning and purchasing Control energy intake; read labels Eat fresh foods with small selection of processed foods Food preparation Use less salt and fat Use seasonings instead (herbs, spices, lemon, onion, garlic, etc.) Special needs Personal desires, ethnic diets, food habits The Dietary Guidelines for Americans, 2020 provide a basic outline for sound food habits (see Chapter 1). See Exchange Lists for Meal Planning in Appendix E for food groups with fat and sodium modifications discussed in this chapter. All processed food manufacturers making any health claim must follow strict labeling guidelines provided by the Food and Drug Administration. What are some other factors in food preparation? (Less meat in smaller portions combined with complex carbohydrates; whole-grain breads and cereals; more fish; variety of vegetables) Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 150

Education Principles (p. 396)
Start early Prevention begins in childhood, especially with children in high-risk families Focus on high-risk groups Direct education to people and families with risk of heart disease and hypertension Use variety of resources National organizations, community programs, registered dietitians What organizations and individuals provide valuable information on prevention and control of hypertension and coronary heart disease? (American Heart Association, American Dietetic Association, National Institutes of Health, Centers for Disease Control and Prevention, community programs, registered dietitians, cooking “light” classes, bookstores, public libraries, health education libraries, and health care centers) Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 151

Chapter 8 Care of the Patient with a Cardiovascular or a Peripheral

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Chapter 8 Care of the Patient with a Cardiovascular or a Peripheral

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