1. CIRCULATION Susan Hench, RN, MSN Assistant Professor of Nursing N102

2. The Heart  Mid Chest  3 Layers  Double Pump

3. 3 Layers Of The Heart  Endocardium  Myocardium  Epicardium

4. Pericardium  Sac-like membrane that contains the heart  Has visceral and parietal portions  Between the portions is a very minute space into which pericardial fluid is secreted  Fluid between spaces allows the heart to move easily

6. Myocardial Blood Supply  Right Coronary Artery  Left Coronary Artery  Circumflex Artery

7. Cardiac Output  Volume of blood pumped out by the left ventricle in one minute Ejection Fraction  Percentage of the blood in the left ventricle that is pumped out with each contraction

9. Although the fundamental beat of the heart originates within the heart, it can be influenced by other systems  Nervous System Parasympathetic Sympathetic  Movement Of Electrolytes

10. Frequent Health Problems Of The Cardiac System  Arteriosclerosis Hardening and loss of elasticity of the arteries  Atherosclerosis Accumulation of fatty deposits on the walls of the arteries

11. Hypertension  Types Essential Or Primary Secondary

12. Heart Failure  Heart is unable to increase cardiac output to meet body’s demands  Leads to congestion of many organs with blood and tissue fluid  Causes  Elderly implications

13. Heart Failure  Left-Sided and Right-Sided Describes the inability of either the left and/or the right ventricle to pump effectively and meets the needs of the body

14. Left-Sided Heart Failure  Produces Respiratory Effects Cough Dyspnea Orthopnea

15. Right-Sided Heart Failure  End result is fluid accumulation in extremities as well as in organs

16. Thrombophlebitis  Inflammation of a vein accompanied by a clot formation  Venous stasis predisposes  Factors contributing to venous stasis

17. End of review and start of new material.

18. Acute Coronary Syndrome Begins with CAD ACS is on the continuum of coronary artery disease and starts when symptoms begin to manifest  Angina  Changes in EKG

19. Angina Pectoris (or just angina)  Results from myocardial ischemia  Acute Chest Pain Manifested by a squeezing, substernal pain described as a feeling of tightness- retrosternal chest discomfort Fullness-sudden, radiating, left side

21. Types of Angina  Stable Angina  Variant or Prinzmetal’s Angina  Unstable Angina Silent Ischemia  Some clients have myocardial ischemia without any symptoms of pain Many times are older, may also have hypertension and/or be diabetic

22. Angina  Not always described as pain  Dyspnea, pallor, diaphoresis, faintness with pain  Usually lasts less than 5 minutes  Often precipitated by activity  Subsides with rest or vasodilator SL Nitroglycerin vasodilator of choice

23. Angina  Treatment Depends on cause Usually use nitrates either to prevent or relieve attack During attack take SL Nitro q 5 minutes x 3, if no relief call EMS (911)  Key points for using SL Nitro in Williams and Hopper Lifestyle changes

24. Myocardial Infarction  MI, heart attack  Obstruction of a coronary artery or one of its branches  Results in prolonged ischemia to the myocardium with irreversible cell damage and muscle death

25. Myocardial Infarction  The most common cause is atherosclerosis.  Almost always occur in the left ventricle.  Results from a sudden decrease in coronary perfusion or an increase in myocardial oxygen demand without adequate coronary perfusion.

26. MI  Right coronary artery = posterior MI  Left coronary artery = anterior MI  These are most common sites  Circumflex artery is least common site, but most deadly (called the “widow maker”)

28. Symptoms Of An MI VVary – usually a sudden, severe chest pain, may radiate to either shoulder, either arm, teeth, jaw, neck (usually left-sided) MMen, women, and diabetics may have different symptoms PPain may be more severe and longer than anginal pain (silent MI has little or no pain) PPallor, sweating, hypotension, n/v, weak, rapid pulse MMay feel like indigestion PPatient has apprehension and denial

29. Diagnosis of MI  History  EKG – not always conclusive  Labs CBC and Sed Rate (increased in response to tissue death) Serum enzymes and isoenzymes  LDH, AST, SGOT (increased due to enzymes being released from cardiac cell death)  Total CPK and CPK-MB (brain enzymes that elevate)  Serum cardiac troponin (specific to cardiac injury – test of choice)

31. Myocardial Infarction  Treatment Immediate needs-treat pain, shock, correct dysrrhythmias Meds  Usually administer Nitroglycerin, ASA, maybe morphine for pain  May use thrombolytics to dissolve clot Administer oxygen Start IV Admit to CCU

32. Myocardial Infarction  Overall nursing goal is to decrease myocardial oxygen demand Rest, decreased activity  Keep comfortable and calm, decrease stress NPO initially with advancing diet  Ultimately to LFLC, Low Na, minimal caffeine Maintain glucose control Stool softeners  To prevent straining Medications Teaching/Discussion  Meds, diet, lifestyle changes, sexual concerns

33. Myocardial Infarction  Complications Arrhythmias Heart failure Thrombus Pulmonary embolus Aneurysm, especially ventricular

34. Aneurysm  A sac formed by the localized dilation of the wall of an artery, a vein or the heart  Three kinds – fusiform, saccular, dissecting  Causes Congenital Trauma (for example – MI) Infections Arteriosclerosis Syphilis

36. Aneurysm  With MI – ventricular site  Another common site – abdominal aorta (AAA)  Also occur in brain  Danger with any aneurysm but especially with the AAA Blood clot formation which may cause blockages Rupture with massive bleeding – emergency situation Slow leak

39. Carotid Stenosis  Leading cause of TIA and CVA  Blood flow to brain is decreased or interrupted  Diagnosis by Doppler and arteriogram  If stenosis is 70% or greater, surgery is indicated  If less, may use anticoagulants to prevent worsening or emboli

42.  Carotid Stenosis Surgical Treatment Carotid Endarterectomy

43. Complications of Carotid Endarterectomy:  Numbness in face due to damage to the many nerves that are close to the carotid artery  Hoarseness  Fatigue  Drooling  Risk of emboli causing CVA (remember the S/S of a CVA)

44. Post-Operative Carotid Endarterectomy  Nursing implications Neuro checks Patient safety Meds-ASA and other anticoagulants Observe for bleeding along the suture line & for the development of a hematoma Observe for neck/airway swelling Cranial nerve checks

45. Inflammatory disorders of the heart  Acute or chronic  Inflammation of any one of the layers of the heart  Usually caused by infections – bacterial or viral  Examples Rheumatic carditis Infective endocarditis Pericarditis Myocarditis

46. Rheumatic Carditis A serious complication of rheumatic fever  All layers of the heart become inflamed  With healing, the myocardium becomes scarred and fibrotic  The mitral valve is usually most affected End result is mitral valve regurgitation S/S  Tachycardia, heart murmur, pericardial friction rub, heart enlargement, EKG changes

47. Rheumatic Carditis Prevention  Prevent rheumatic fever by detecting and treating strep infections Nursing Management  History and physical assessment  Relieve pain and anxiety  Education about disease, acute and lifelong prophylactic treatment, and other meds

48. Infective Endocarditis Infection of the endocardium that can be fatal Organisms that cause enter bloodstream from IV drug use, gingival gum disease, infections of the skin, GI or GU tracts, or any type of invasive procedure Risk factors include compromised immune system, congenital or valvular heart disease, IV drug use

49. Infective Endocarditis S/S – fever, new murmur, petechiae, Janeway lesions, Osler’s nodes Complications include vegetative emboli and heart structure damage such as valvular stenosis or regurgitation Heart failure may also occur Prevention includes good dental care especially for those at risk Nursing Care includes education, IV antibiotics, proper hygiene and dental care, lifestyle changes

52. Mitral valve vegetation

53. Pericarditis Inflammation of the sac surrounding the heart that causes a problem for the expansion and fill of the heart Cardiac output and blood pressure are decreased Caused by infections, drug reactions, connective tissue disorders, neoplastic disease, cardiac surgery, kidney disease S/S – chest pain most common, pericardial friction rub most classic

54. Pericarditis Echocardiogram shows pericardial effusion Pericardiocentesis is done to examine the fluid for causative factors Treated with bedrest, antibiotics, NSAIDs, corticosteroids  May also get a pericardial window or, as a last resort, a pericardiectomy Complication is cardiac tamponade

56. Pericarditis Nursing Management  History  Vital signs  Focus on relieving pain and anxiety and maintaining normal cardiac function  Observe for cardiac tamponade and heart failure

57. Myocarditis Rare condition that usually follows a viral infection S/S vary from none to severe cardiac manifestations Diagnosed with presentation and biopsy Treated with oxygen, rest, antibiotics, and meds to strengthen the heart contractility and slow the rate Nursing care – vital signs, meds, reduce fatigue, reduce anxiety, increase knowledge

59. Cardiomyopathy Enlargement of the heart muscle Three types  Dilated  Hypertrophic  Restrictive Currently no cure All lead to left ventricular function impairment and heart failure

60. Cardiomyopathy

61. Valvular Disorders Mitral Valve Prolapse Mitral Stenosis Mitral Regurgitation Aortic Stenosis Aortic Regurgitation

63. Heart Valve Repairs  Can be done to improve closure or to loosen stenosis Heart Valve Replacement  Aortic and mitral valves most common  Usually for mitral valve regurgitation  Chest incision  Usually replaced with synthetic valve

65. DIAGNOSTIC STUDIES Cardiac Catheterization  Used to make x-ray films called a coronary angiogram  Catheter threaded into the brachial or femoral artery until it reaches heart  Shows blood flow through the coronary arteries to locate blockages which might lead to MI  Invasive procedure

67. Cardiac Cath: Nursing Care Pre-op  Allergies to dye  NPO  Stop ASA/anti-platelet meds  Experience warm sensation in chest

68. Cardiac Cath: Nursing Care Post-op  Care depends on site Keep extremity straight Pressure or sealant to prevent bleeding Neurovascular checks  Monitor vital signs  Monitor for bleeding  Monitor for chest pain

72. Interventional Cardiac Cath Percutaneous Transluminal Coronary Angioplasty (PTCA)  (P)treatment done through a hole in the skin  (T)done inside a lumen of a diseased artery,  (C)done inside a coronary artery,  (A)the treatment itself which is a catheter with a tiny balloon at the tip of it which is threaded into a coronary artery, the balloon is inflated at the site of the blockage, pressure forces blockage against walls of the vessel

73. CARDIAC SURGERIES CAD Often Leads To Open Heart Surgery Cardiopulmonary Bypass Complications Of Surgery – thrombus/embolis formation, electrolyte imbalance, HF, tissue anoxia, arrhythmias, risk of Hepatitis and HIV

74. Coronary Artery Bypass Graft (CABG)  Corrects severe blockages  Two areas affected with incisions Chest Legs or arms  Veins from other parts of the body are grafted onto the diseased coronary artery above and below the blockage  Number of bypasses listed after CABG Example: CABG X 4

76. CABG – Pre-Op Care  Obtain baseline assessment data  Routine admission testing  Hold meds related to bleeding and diuresis  NPO 8-12 hrs – hold insulin and other oral hypoglycemic agents  Thorough teaching regarding what to expect after surgery, pain management, use of ISB, IV lines, foley catheter, etc.

77. CABG – Post-Op Care  Admitted to ICU  On heart monitor, pacer wires, IV  May be on ventilator  Chest tubes  Incisions

78. CABG – Nursing Implications  Supportive care to patient and family  Site care  SCDs/TED hose  ISB/Coughing and deep breathing exercises  Discharge teaching

79. Cardiac Transplantation  For end-stage cardiac disease  Strict donor criteria Younger than 40 No significant cardiac or malignant disease No active infections No severe HTN or DM Donor and recipient must weigh within 20 pounds of one another

81. Cardiac Transplantation  Must be on immunosuppressive therapy for life Cyclosporine (Neoral, Sandimmune) Azathioprine (Imuran) Steroids  Complications Rejection – to detect, biopsies are done Infection and malignancies

82. Nursing Care Post Transplantation  Physical care  Emotional support – grief for the donor and elation for the new heart  Education about rejection and meds – client and support persons  Exercise rehabilitation

83. Cardiac Rhythms Cardiac Pacemakers Defibrillation  External  Implantable Cardioversion Ablation  Mechanical, chemical, and radio frequency

84. Atrial or Supraventricular Start above the Bundle of HIS Atrial are not functioning properly and ventricles do not fill properly  Decreases cardiac output by about 1/3 Examples  Atrial flutter or atrial fibrillation  Premature atrial contraction  Sinus tachycardia or bradycardia  Paroxysmal SVT

85. Ventricular Starts below the Bundle of HIS Can be life-threatening because of the ineffective filling of the ventricles resulting in very decreased or absent cardiac output Examples  Premature ventricular contractions (PVCs)  Ventricular tachycardia  Ventricular fibrillation This is when CPR is necessary

86. Atrioventricular Blocks Blocked conduction at the A-V node Degrees  First degree is a partial block  Second degree is a partial block with an occasional totally blocked beat  Third degree is a total block and the atria and ventricles are functioning independently of each other

87. Clients with Arrhythmias Assessment  Heart rate and rhythm  SOA/Dyspnea  Lightheadedness  Dizziness/Syncope  Activity tolerance

88. Cardiac Pacemakers Electronic device that helps maintain adequate heart rate and cardiac output in clients with conduction or impulse-formation disorders. Consists of a pulse generator and one or two lead wires. Can automatically and routinely pace the heart or can be rate sensitive and only activate when the client’s own heart pacemaker fails to work.

91. Pacemakers Client teaching points  Regularly check pulse and inspect the incision site for evidence of infection  Persistent hiccups or “pacing” in the chest may indicate a lead wire dislodgement – notify the physician  Report lightheadedness, syncope, fever, skin discoloration or skin breakdown over the pacemaker site to the physician  Follow up with periodic transtelephonic monitoring.  Avoid high-output electrical generators, contact sports, and tight clothing worn over the pacemaker site.  Wear appropriate medical identification and inform all health care providers that one has a pacemaker.

92. CIRCULATORY SYSTEM ANY QUESTIONS