Cardiovascular

COMMON LAB TESTS FOR CARDIOVASCULAR DISORDERS

1.
2.
3.
4.

Serum Chemistry
Serum Electrolytes
Alanine aminotransferase (AST) 5-40 IU/L
Creatine kinase CK
Male 55-170U/L
Female 30-135 U/L
5. CK - MB (isoenzyme) 0-7 U/L
6. Lactic dehydrogenase (LDH)
LDH1 22%-36%
LDH2 35%-46%
LDH313%-26%
LDH4 3%-10%
LDH5 2%-9%
7. CBC
8. Lipid levels
9. Prothrombin time
10. Alkaline phosphatase
11. ESR
12. Arterial Blood Gases
13. Troponin
COMPLETE BLOOD COUNT
1. Red blood cell count
a. Men 4.7-6.1 million/mm3
b. Women 4.2-5.4 million/mm3
c. Infants and children 3.8-5.5 million/mm3
d. Newborns 4.8-7.1 million/mm3
2. White blood cell count
a. Adults and children greater than two years of age 5,000-10,000/cm3
b. Children less than two years 6,200-17,000/mm3
c. Newborns 9000-30,000/mm3
3. Hematocrit
a. Men 42-52%
b. Women 37-47% (pregnancy>33%)
c. Children 31-43%
d. Infants 30-40%
e. Newborns 44-64%
4. Hemoglobin
a. Men 13.5-18.0 g/dl
b. Women 12-16 g/dl (pregnancy >11 g/dl)
c. Children 11-16 g/dl
d. Infants 10-15 g/dl
e. Newborns 14-24 g/dl
5. Erythrocyte indices
a. Mean corpuscular volume (MCV) 86-98 (m3/cell)
b. Mean corpuscular hemoglobin (MCH) 27-32 pg/RBC
c. Mean corpuscular hemoglobin concentrate. (MCHC) 32-36%
6. Differential white cell count
a. Neutrophils 55-70%
b. Lymphocytes 20-40%
c. Monocytes 2-8%
d. Eosinophils 1-4%
e. Basophils 0.5-1.0%
7. Examination of peripheral blood cells: examination of size and shape of individual RBCs and platelets

Electrocardiogram (ECG or EKG):

1. records electromechanical activity of myocardium, electrical axis of the

heart
2. the ECG records two basic events: depolarization and repolarization

3. the ECG records electrical activity as specific waves

a. P-wave: sinus node generates impulse; atria depolarize
b. PR interval: time for impulse to travel from sinus node through atria
to atrioventricular node, the Bundle of His, the bundle branches and
the ventricles; range: 0.12-0.20 seconds
c. QRS complex: ventricle depolarizes and contracts (systole)
d. T wave: ventricle repolarizes, ready for next systole
e. ST segment: time between ventricular depolarization and
repolarization
4. used to determine presence of ischemic cardiac disease and cardiac
conduction disturbances

Exercise stress test

1. records myocardial response to exercise
2. used to determine ischemic heart disease and cardiovascular fitness before
exercise programs
3. exercise level is progressively raised while ECG is monitored
4. blood pressure and blood gases may be measured
5. nursing interventions
a. encourage client to immediately report any symptoms during and
after test
b. client should dress for exercise and bring a change of clothing

Ambulatory electrocardiography (Holter monitor)

1.
2.
3.
4.

records myocardial activity continuously for 24 or 48 hours

portable device
used to detect cardiac rhythm disturbances over time
correlated with client's activity

5. specific nursing intervention: client must keep a diary that records both
activity and any symptoms during test

Electrophysiology studies
1. an invasive measure of cardiac electrical activity
2. electrical catheter is inserted into right atrium via a peripheral vein
3. an ECG records each electrical stimulation of heart and how the heart
responds
4. used to determine cardiac dysrhythmias

Hemodynamic monitoring: invasive cardiac catheter

a. reflects left ventricular end diastolic pressure
b. use of a balloon-tipped, flow-directed catheter to provide continuous
monitoring

c. catheter introduced via subclavian vein or by cutdown and passed through

right side of heart to pulmonary artery
d. may be inserted at the bedside or under fluoroscopy
e. normal parameters

f.

complications of hemodynamic monitoring

i.
pneumothorax
ii.
dysrhythmias

iii.
infection, sepsis, thrombophlebitis
g. nursing interventions: monitor values, assess and change dressings,
maintain patency with fluids, calibrate equipment, remove lines, obtain
specimens, strict asepsis, standard precautions

Intra-arterial pressure
a.
b.
c.
d.
e.

f.

catheter in a major artery and attached to transducer

most common site: radial artery
usually inserted at bedside
also used to obtain arterial blood gas samples and other diagnostic studies
normal parameters
i.
peak systolic: 100 mm Hg
ii.
end diastolic: 60-80 mm Hg
iii.
mean 70-90 mm Hg
complications: clot formation, decreased or absent pulse, hematoma,
infection, hemorrhage

Cardiac output (CO)

a.
b.
c.
d.

volume of blood heart beats per minute

thermodilution technique using blood temperature changes
known volume of solution is injected at a specific rate into the right atrium
temperature-sensitive probe measures temperature of blood as it passes
through catheter
e. contraindications: bleeding disorders, immunosuppression
f. cardiac output (CO) (heart rate x stroke volume) 4-8L/min
g. nursing care of client with cardiac catheter
i.
explain procedure to client
ii.
obtain baseline vital signs and rhythm strip
iii.
place client in supine position
iv.
calibrate pressure monitor
v.
obtain chest x-ray to guide catheter placement
vi.
obtain arterial blood gases as ordered
vii.
change dressings and tubing as ordered
viii.
maintain patency of catheter
ix.
monitor and record vital signs and pressures as ordered
x.
observe for complications

Intraaortic balloon pump (IABP)

a. device that helps blood circulate after myocardial failure
1. sausage-shaped balloon is threaded via femoral artery into
aorta
2. balloon inflates with diastole and deflates with systole
b. used to treat cardiogenic shock
c. contraindications:
1. aortic regurgitation
2. dissection
3. abdominal aortic aneurysm
d. complications
1. insertion site:
1. infection
2. bleeding
3. hematoma
4. diminished or absent pulse
5. thrombus
2. generalized
1. aortic dissection or perforation
2. thrombocytopenia
3. dysrhythmias

4. myocardial failure
e. nursing interventions
1. explain procedure to client
2. obtain informed consent
3. take baseline vital signs, hemodynamic parameters and
ECG
4. monitor vital signs, hemodynamic status and ECG as
ordered
5. monitor client's level of consciousness (LOC)
6. obtain arterial blood gases as ordered
7. asepsis
8. provide emotional support to client and family
9. monitor intake and output
10. client must not bend leg in which balloon was inserted
11. monitor for complications

Pacemakers
a. a battery-powered pulse generator that stimulates the heart via electrodes
that touch myocardium
b. use:
1. hemodynamic and life support
2. to correct dysrhythmias
c. types
1. atrial pacing
2. ventricular pacing
3. atrioventricular sequential and physiologic pacing
d. three kinds of pacemakers
1. asynchronous (fixed rate): pace at a preset rate, regardless
of persons rhythm
2. demand (standby): pace only if intrinsic rate declines below
rate set on pacemaker
3. synchronous: sensing circuit detects atrial and ventricular
activity
e. indications for pacing
1. symptomatic bradyarrhythmia
2. symptomatic tachyarrhythmia
3. asystole
4. prophylaxis in persons with high risk bradycardia
5. diagnosis of dysrhythmias during electrophysiologic testing
f.

types of pulse generators

i.
temporary pacemakers

transvenous approach is most common: Catheter electrode

inserted via peripheral vein and connected to external pulse
generator

transthoracic: used primarily during cardiac surgery; catheter

electrode is placed directly into heart
ii.
permanent pacemakers: transvenous

catheter electrode is passed through right heart and

connected to small generator

generator is implanted subcutaneously on chest wall, usually

in upper right quadrant

lithium-powered battery can last up to ten years

g.

complications of pacemakers
i.
infection
ii.
perforation of myocardium
iii.
pneumothorax
iv.
hemothorax
v.
dysrhythmias

vi.

h.

thrombosis
vii.
failure
viii.
syncope
ix.
hypotension
x.
pallor
xi.
hiccups
xii.
shortness of breath
nursing interventions
i.
explain procedure to client
ii.
initiate preoperative care
iii.
post-procedure

initiate post-anesthesia care

monitor vital signs and ECG as ordered

maintain bed rest as ordered

observe for signs of complications

iv.
teach client

pacemaker's set rate

how to take pulse (rate and rhythm)

findings of pacemaker failure, wound infection

activity limitations

hazards: high output electrical generators: welding

equipment, radar, microwaves, MRI

importance of carrying medical alert jewelry and

information

need for periodic battery replacement

avoidance of contact sports and those that involve

swinging arms (golf, hunting)

importance of medical follow-up

Automatic implantable cardioverter-defibrillator (AICD)

a. pulse generator implanted in subcutaneous pocket. When it detects
ventricular tachycardia or ventricular fibrillation, it delivers electrical shock
to heart
b. used to treat life-threatening ventricular dysrhythmias
c. complications
i.
ii.
infection
iii.
malfunction
iv.
battery failure
d. nursing interventions
i.
explain procedure to client
ii.
care of the surgical client
iii.
administer medications as ordered
iv.
monitor ECG as ordered
v.
provide emotional support and reassurance
vi.
teach client
findings of defibrillation discharge
importance of routine follow-up
findings of complications
limit activity as ordered
avoid strong magnetic fields
wear MedicAlert jewelry and information
assure client that no household appliance will affect
AICD
shock may be painful

I.

Anatomy and Physiology

A.

Anatomy
1.
Layers
a.
pericardium: fibrous
b.
epicardium: covers surface of heart
c.
myocardium: muscular portion of the heart
d.
endocardium: lines cardiac chambers and covers surface
of heart valves
2.
Chambers of heart
a.
right atrium: collecting chamber for incoming systemic
venous system
b.
right ventricle: propels blood into pulmonary system
c.
left atrium: collects blood from pulmonary venous system
d.
left ventricle: thick-walled, high-pressure pump that propels
blood into system
3.
Heart valves: membranous openings that allow one way blood
flow
a.
atrioventricular valves: prevent backflow from ventricles to
atria during systole
b.
tricuspid - right heart valve
c.
mitral - left heart valve
d.
semilunar valves prevent backflow from aorta and
pulmonary arteries into ventricles during diastole
i.
pulmonic
ii.
aortic

Think:
Mighty (or Big) left side of the heart Mitral (or Bicuspid) valve.
In Contrast: Tiny right side of the heart Tricuspid valve.
4.

Blood supply to heart

a.

b.

5.

arteries
i.
right coronary artery supplies right ventricle and
part of left ventricle
ii.
left coronary artery supplies mostly left ventricle
veins
i.
coronary sinus veins
ii.
thebesian veins

Conduction system
a.
SA (sinoatrial) node
b.
junctional tissue
c.
bundle branch Purkinje system

B.

Physiology

1.
2.

3.

4.
5.

Function of the heart is the transport of oxygen, carbon dioxide,

nutrients and waste products
Cardiac cycle consists of:
a.
systole - the phase of contraction during which the
ventricles eject blood
b.
diastole - the phase of relaxation during which the
chambers fill with blood. When heart pumps, myocardial
layer contracts and relaxes.

Blood flow:
a.
deoxygenated blood enters the right atrium through the
superior and inferior vena cava
b.
enters the right ventricle via the tricuspid valve
c.
travels through the pulmonic valve to pulmonary arteries
and lungs
d.
oxygenated blood returns from lungs through the
pulmonary veins into left atrium and enters the left ventricle
via bicuspid (mitral) valve.
e.
from the left ventricle, through the aortic valve through the
aorta to the systemic circulation
The heart itself is supplied with blood by the left and right coronary
arteries
The vascular system is a continuous network of blood vessels.
a.
the arterial system consists of arteries, arterioles and
capillaries and delivers oxygenated blood to tissues
b.
oxygen, nutrients and metabolic waste are exchanged at
the microscopic level
c.
the venous system, veins and venules, returns the blood to
the heart

Blood Flow to the Heart

II.

Heart Infections
A.

Pericarditis
1.
Definition and related terms
a.
in pericarditis, an infection or collagen disease (from a
bacterium, a fungus, Systemic Lupus Erythematosus
(SLE), etc.) inflames the pericardium.
b.
there may or may not be pericardial effusion or constrictive
pericarditis.
c. Dressler's syndrome, also called postmyocardial infarction
syndrome, is a combination of pericarditis, pericardial
effusion and constrictive pericarditis. It occurs several
weeks to months after a myocardial infarction. Etiology
unclear.
2.
Epidemiology
a.
may be acute or chronic and may occur at any age.
b.
pericarditis occurs in up to 15% of persons with a
transmural infarction.
3.
Findings
a.
sharp chest pain often relieved by leaning forward
b.
pericardial friction rub
c. dyspnea
d.
fever, sweating, chills
e.
dysrhythmias
f.
pulsus paradoxus
g.
client cannot lie flat without pain or dyspnea

ASSESSING CLIENTS WITH CARDIOVASCULAR DISORDERS

4.

Management

a.
b.

5.

6.

antibiotics to treat underlying infection

corticosteroids: usually reserved for clients with pericarditis
due to SLE, or clients who do not respond to NSAID
c.
NSAIDS/Asprin for pain and inflammation
d.
oxygen: to prevent tissue hypoxia
e.
surgical
i. emergency pericardiocentesis if cardiac tamponade
develops
ii. for recurrent constrictive pericarditis, partial
pericardiectomy (pericardial window) or total
pericardiectomy
Nursing interventions
a.
manage pain and anxiety
b.
the cardio-care six (refer to box below)
c.
maintain a pericardiocentesis set at the bedside in case of
cardiac tamponade.
d.
assess respiratory, cardiovascular, and renal status often.
e.
observe for findings of infiltration or inflammation at the
venipuncture site, a possible complication of long-term IV
administration. Rotate the IV sites often.
f.
client and family teaching - teach the cardio five (refer to
box below)
Diagnostic studies
a.
EKG changes, arrythmias
b.
echocardiography to determine pericardial efusion or
cardiac tamponade
c.
history and physical exam

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

THE CARDIO-CARE SIX: A,B,C,D,E,F

ADL: Help the client with activities of daily living.
Bed rest
Commode at bedside (it stresses the heart less than using a bedpan does).
Diversions: offer diversions that don't stress the heart.
Elevate head of bed, or sit client up.
Feelings: Let clients express concern; reassure when activity will resume.

1.
2.
3.
4.
5.

TEACH THE CARDIO FIVE: TDDDS

Tests and treatments: explain them in simple, culturally sensitive ways.
Drugs, their side effects, and how long client will take them.
Diet: good nutrition and restrictions (such as low sodium).
Disease, its treatment, and what signs to report promptly: the 'watch-fors'.
Smoker? Teach and encourage 'stop smoking'.

B.

Myocarditis

1.

2.

3.

Definition - an inflammatory condition of the myocardium caused

by
a.
viral infection
b.
bacterial infection
c.
fungal infection
d.
serum sickness
e.
rheumatic fever
f.
chemical agent
g.
as a complication of a collagen disease, i.e. SLE
Epidemiology
a.
may be acute or chronic and may occur at any age
b.
usually an acute virus and self-limited, but it may lead to
acute heart failure
Findings
a.
depends on the type of infection, degree of myocardial
damage, capacity of myocardium to recover, and host
resistance
b.
may be minor or unnoticed: fatigue and dyspnea,
palpitations, occasional precordial discomfort manifested
as a mild chest soreness and persistent fever
c.
recent upper-respiratory infection with fever, viral
pharyngitis, or tonsillitis
d.
cardiac enlargement
e. abnormal heart sounds: murmur, S3 or S4 or friction rub
f.
possibly findings of congestive heart failure such as pulsus
alternans, dyspnea, and crackles
g.
tachycardia disproportionate to the degree of fever

CLASSIFYING HEART MURMURS BY INTENSITY

4.

Diagnostic studies
a.
EKG for changes and arrythmias
b.
labs
i.
increases ESR
ii.
increases myocardial enzymes such as:

AST

CK

LDH
c.
endomyocardial biopsy (EMB)
d.
myocardial imaging

5.

6.

Management
a.
antibiotics to treat underlying infection
b.
corticosteroids to decrease inflammation
c.
analgesics for pain
d.
oxygen to prevent tissue hypoxia
Nursing interventions
a.
the cardio-care six with modified bedrest and less help with
ADLs
b.
assess for edema weigh daily; record intake and output
PITTING EDEMA GRADING SCALE

c.
d.

e.
f.
g.
PULSE GRADING SCALE
(4-Point Scale)
a.

No pulse

=0

b.

Weak pulse

= 1+

c.

Difficult to palpate

= 2+

d.

Normal

= 3+

e.

Bounding

= 4+

assess cardiovascular status frequently

observe for findings of left-sided heart failure (dyspnea,
hypotension and tachycardia)
check often for changes in cardiac rhythm or conduction;
auscultate heart sounds
evaluate arterial blood gas levels as needed to ensure
adequate oxygenation
client and family teaching
i.
ii.
iii.
iv.
v.

vi.
PULSE SITES (LANDMARKS FOR PULSE)

physical activity may be slowly increased to sitting

in chair, walking in room, then outdoors.
avoid pregnancy, alcohol, and competitive sports.
immunize against infections.
teach client about anti-infective drugs. Stress
importance of taking drugs as ordered.
teach clients taking digitalis at home to:

check pulse for one full minute before taking

the dose, and withhold the drug if heart rate
falls below 60 beats/minute.

observe for findings of digitalis toxicity

(anorexia, nausea, vomiting, blurred vision,
cardiac arrhythmias) and for factors that
may increase toxicity, such as electrolyte
imbalance and hypoxia.
teach client to report rapidly beating heart.

1. Temporal: found over temporal bone lateral to eye

2. Apical: found between fourth and fifth intercostal space usually
mid-clavicular line
3. Carotid: found over the carotid artery in neck
4. Brachial: found in the antecubital area of arm
5. Radial: found on thumb side of wrist
6. Ulnar: found medial wrist
7. Femoral: found below the inguinal ligament
8. Popliteal: found behind the knee
9. Posterior tibial: found on inner side of each ankle
10. Dorsalis pedis: found along top of foot

C.

Endocarditis
1.
Definition and related terms
a.
an infection of the endocardium, heart valves, or cardiac
prosthesis resulting from bacterial or fungal invasion.
b.
endocarditis can be classified as
i.
native valve endocarditis
ii.
endocarditis in I.V. drug users
iii.
prosthetic valve endocarditis
2.
Epidemiology
a.
with proper treatment about 70% of clients recover
b.
the prognosis is worse when endocarditis damages valves
severely or involves a prosthetic valve
c.
infective endocarditis occurs in 50 to 60% of clients with
previous valvular disorders
d.
systemic lupus erythematosus (SLE) often leads to
nonbacterial endocarditis
e.
in 12% to 35% of clients with subacute endocarditis,
lesions produce clots that show the findings of splenic,
renal, cerebral or pulmonary infarction, or peripheral
vascular occlusion
3.
Findings of endocarditis
a. cardiac murmurs in 85 to 90% of clients
b.
fever
c.
especially, a murmur that changes suddenly, or a new
murmur that develops in the presence of a fever
d.
pericardial friction rub
e.
anorexia
f.
malaise
g.
clubbing of fingers
h.
neurologic sequelae of embolus
i.
petechiae of the skin (especially on the chest)
j.
splinter hemorrhage under the nails
k.
infarction of spleen: pain in the upper left quadrant,
radiating to the left shoulder, and abdominal rigidity
l.
infarction in kidney: hematuria, pyuria, flank pain, and
decreased urine output
m.
infarction in brain: hemiparesis, aphasia, and other
neurologic deficits
n.
infarction in lung: cough, pleuritic pain, pleural friction rub,
dyspnea and hemoptysis
o.

peripheral vascular occlusion: numbness and tingling in an

arm, leg, finger, or toe, or signs of impending peripheral
SIGNS OF gangrene
VENOUS INSUFFICIENCY IN THE EXTREMITIES

1.
2.
3.
4.
5.

Skin color reddish brown or cyanotic if extremity lowered

Normal temperature
Normal pulse
Often marked edema, usually foot to calf
Brown pigmentation around ankles

1.
2.
3.
4.
5.
6.
7.
8.
9.

SIGNS OF ARTERIAL INSUFFICIENCY IN THE EXTREMITIES

Pale color on elevation, dusky red color when lowered
Cool to touch
Decreased or absent peripheral pulses
Little or no edema
Thin, shiny skin and decreased growth of hair
Thickened nails
Pain unrelieved by rest and/or activity
Chronic pain may be either steady or intermittent
Claudication pain as tight feeling, burning, fatigue, ache or cramping

4.

5.

6.

D.

Management - clients at risk for prosthetic valves

a.
prophylaxis - to prevent endocarditis; i.e. MVP, cardiac
lesions
b.
antibiotics - to treat underlying infection
c.
antipyretics - to control fever
d.
anticoagulants - to prevent embolization
e.
oxygen - to prevent tissue hypoxia
f.
surgical - possible valve replacement
Nursing interventions
a. the cardio-care six
b.
observe for findings of infiltration or inflammation at
venipuncture site; rotate sites often.
c.
client and family teaching
i.
explain all procedures in a simple and culturally
sensitive manner.
ii.
involve the client and family in scheduling the daily
routine activities. Allow client and family to
participate in care.
iii.
teach client relaxation techniques (meditation,
visualization, or guided imagery) to cope with
stress, pain, or insomnia.
iv.
explain endocarditis and the need for long-term
therapy.
v.
explain the need for prophylactic antibiotics before
dental work and other invasive procedures.
vi. teach client to report fever, tachycardia, dyspnea
and shortness of breath.
Diagnostic studies
a.
health history
b.
lab data
i.
CBC
ii.
blood cultures
iii.
ESR
c.
CXR - to detect CHF
d.
EKG - transesophageal echocardiogram to detect
vegetation and abscess on valves

Rheumatic heart disease (rheumatic endocarditis)

1.
Definition and related terms
a. rheumatic heart disease is damage to the heart by one or
more episodes of rheumatic fever. Pathogen is a group A
streptococci.
b.
rheumatic endocarditis is damage to the heart, particularly
the valves, resulting in valve leakage (regurgitation) and/or
stenosis. To compensate, the heart's chambers enlarge
and walls thicken.
2.
Epidemiology
a.
worldwide, 15 to 20 million new cases of rheumatic fever
are reported each year.
b.
rheumatic fever follows a group A streptococcal infection.
We could prevent it by finding and treating streptococcal
pharyngitis.
c.
where malnutrition and crowded living are common,
rheumatic fever is commonest in children between ages 5
and 15.
d.
rheumatic fever strikes most often during cool, damp
weather. In the U.S., it is most common in the northern
states.

e.

3.

4.

5.

6.

it is unknown how and why group A streptococcal

infections cause the lesions called Aschoff bodies.
f.
damage depends on site of infection: most often the mitral
valve in females and the aortic valve in males.
g.
malfunction of these valves leads to severe pericarditis,
and sometimes pericardial effusion and fatal heart failure.
Of those who survive this complication, about 20% die
within ten years.
Findings
a.
streptococcal pharyngitis
I.
sudden sore throat
II.
throat reddened with exudate
III.
swollen, tender lymph nodes at angle of jaw
IV.
headache and fever to 104 degrees Fahrenheit
b.
polyarthritis manifested by warm and swollen joints
c.
carditis
d.
chorea
e.
erythema marginatum (wavy, thin red-line rash on trunk
and extremities)
f.
subcutaneous nodules
g.
fever to 104 degrees Fahrenheit
h.
heart murmurs pericardial friction rub and pericardial rub
i.
no lab test confirms rheumatic fever, but some support the
diagnosis.
Management
a.
give antibiotics steadily to maintain level in blood.
b.
provide analgesics - for pain/inflammation
c.
oxygen to prevent tissue hypoxia.
d.
surgical - commissurotomy, valvuloplasty, prosthetic heart
valve
Nursing interventions
a. the cardio-care six
b.
help the client with chorea to grasp objects; prevent falls.
c.
encourage family and friends to spend time with client and
fight boredom during the long, tedious convalescence.
d.
client and family teaching
I.
explain all tests and treatments
II.
nutrition
III.
hygienic practices
IV.
to resume ADLs slowly and schedule rest periods
V.
to report penicillin reaction: rash, fever, chills
VI.
to report findings of streptococcal infection
i.
sudden sore throat
ii.
diffuse throat redness and
oropharyngeal exudate
iii.
swollen and tender cervical lymph
glands
iv.
pain on swallowing
v.
temperature of 101 to 104 degree
Fahrenheit
vi.
headache
vii.
nausea
VII.
keep client away from people with respiratory
infections
VIII.
explain necessity of long-term antibiotics
IX.
arrange for a visiting nurse if necessary
X.
help the family and client cope with temporary
chorea
Diagnostic studies
a.
antistreptolysin 0 titer - increased
b.
ESR - increased

c.
d.
e.
f.

throat culture - positive for streptococci

WBC count - increased
RBC parameters - normocytic, normochromic anemia
C-reactive protein - positive for streptococci

III. Valve Disorders

A.

Mitral stenosis
1.
Definition - mitral valve thickens and gets narrower, blocking blood
flow from the left atrium to left ventricle.
b.
physiology
i.
function of the heart is the transport of
oxygen, carbon dioxide, nutrients and waste
products
ii.
cardiac cycle consists of:

systole - the phase of contraction

during which the chambers eject
blood

diastole - the phase of relaxation

during which the chambers fill with
blood. When heart pumps,
myocardial layer contracts and
relaxes.
iii.
blood flow:

deoxygenated blood enters the right

atrium through the superior and
inferior vena cava

enters the right ventricle via the

tricuspid valve

travels through the pulmonic valve to

pulmonary arteries and lungs

oxygenated blood returns from lungs

through the pulmonary veins into left
atrium and enters the left ventricle
via bicuspid (mitral) valve.

from the left ventricle, through the

aortic valve through the aorta to the
systemic circulation
iv.
the heart itself is supplied with blood by the
left and right coronary arteries
v.
the vascular system is a continuous network
of blood vessels.

the arterial system consists of

arteries, arterioles and capillaries
and delivers oxygenated blood to
tissues

oxygen, nutrients and metabolic

waste are exchanged at the cellular
level

the venous system, veins and

venules, returns the blood to the
heart
2.
Epidemiology

2.

a. of clients with mitral stenosis, 2/3 are female

b. most cases of mitral stenosis are caused by rheumatic fever
Findings
a. mild - no findings
b. moderate to severe
i. dyspnea on exertion
ii. paroxysmal nocturnal dyspnea
iii. orthopnea

3.

4.

5.

iv. weakness, fatigue, and palpitations

c. peripheral and facial cyanosis in severe cases
d. jugular vein distention
e. with severe pulmonary hypertension or tricuspid stenosis ascites
f. edema
g. hepatomegaly
h. diastolic thrill at the cardiac apex
i. when client lies on left side, loud S1 or opening snap and a
diastolic murmur at the apex
j. crackles in lungs
Management
a. antiarrhythmics if needed
b. if medication fails, atrial fibrillation is treated with
cardioversion.
c. low-sodium diet - to prevent fluid retention
d. oxygen if needed - to prevent hypoxia
e. surgery - mitral commissurotomy or valvotomy
Nursing interventions
a. the cardio-care six
b. observe closely for findings of heart failure, pulmonary edema,
and reactions to drug therapy.
c. if client has had surgery, watch for hypotension, arrhythmias,
and thrombus formation.
d. monitor the cardio seven
e. client and family (teach the cardio-five:TDDS)
i.
explain the need for long-term antibiotic therapy
and the need for additional antibiotics before dental
care.
ii.
report early findings of heart failure such as
dyspnea or a hacking, nonproductive cough.
Diagnostic studies/findings
a. history and physical exam
b. EKG- for changes of left atrial enlargement and right ventricle
enlargement
c. echocardiogram - for restricted movement of the mitral valves
and diastolic turbulance

MONITOR THE CARDIO SEVEN:

Charlie's Ex packed Ruth in Granny's VW.

B. Mitral insufficiency (or regurgitation)

1. Definition and related terms
a. a damaged mitral valve allows blood from the left ventricle
to flow back into the left atrium during systole.
b. to handle the backflow, the atrium enlarges. So does the
left ventricle, in part to make up for its lower output of
blood.
2. Epidemiology
a. follows birth defects such as transposition of the great
arteries.
b. in older clients, the mitral annulus may have become
calcified.
c. cause unknown; may be linked to a degenerative process.
d. occurs in 5 to 10% of adults.
3. Findings
a. client may be asymptomatic
b. orthopnea, dyspnea, fatigue, weakness, weight loss
c. chest pain and palpitations
d. jugular vein distention
e. peripheral edema
4. Management
a. low-sodium diet - to prevent fluid retention
b. oxygen as needed - to prevent tissue hypoxia
c. antibiotics - to treat infection
d. prophylactic antibiotics - to prevent infection
e. surgery - mitral valvuloplasty or valve replacement
5. Nursing interventions
a. the cardio-care six
b. monitor the cardio seven
c. monitor for left-sided heart failure, pulmonary edema,
adverse reactions to drug therapy, and cardiac
dysrhythmias especially atrial and ventricular fibrillation
d. if client has surgery, monitor postoperatively for
hypotension, arrhythmias and thrombus formation
e. client and family teaching
1. diet restrictions and drugs
2. explain tests and treatments
3. prepare client for long-term antibiotic and follow-up
care.
4. stress the need for prophylactic antibiotics during
dental care.
5. teach client and family to report findings of heart
failure:
dyspnea and hacking, nonproductive cough.
6. Diagnostic findings
a. EKG for arrythmias and changes of left atrial enlargement
b. echocardiogram - to visualize regurgitant jets and flail
chordae/leaflets
c. cardiac cath shows regurgitation of blood from left ventricle
to left atrium

C. Tricuspid stenosis
1. Definition: narrowing of the tricuspid valve between right atrium
and right ventricle
2. Epidemiology
a. relatively uncommon
b. usually associated with lesions of other valves
c. caused by rheumatic fever
3. Findings
a. dyspnea, fatigue, weakness, syncope
b. peripheral edema
c. jaundice with severe peripheral edema and ascites can
mean that tricuspid stenosis has led to right ventricular
failure
d. may appear malnourished
e. distended jugular vein
4. Management: surgery - valvulotomy or valve replacement;
valvuloplasty
5. Nursing interventions
a. the cardio-care six
b. monitor the cardio seven
c. monitor for findings of heart failure, pulmonary edema, and
adverse reactions to the drug therapy
d. post valve surgery, monitor client for hypotension,
arrhythmias and thrombus formation
e. when client sits, elevate legs - to prevent dependent
edema
f. client and family teaching
1. teach the cardio five
2. client must comply with long-term antibiotic and
follow up care
3. emphasize the need for prophylactic antibiotics
during dental care
6. Diagnostic findings
a. EKG - for arrythmias
b. echocardiogram - right ventricular dilation and paradoxic
septal motion
D. Tricuspid insufficiency (regurgitation)
1. Definition - tricuspid valve lets blood leak from the right ventricle
back into the right atrium
2. Epidemiology
a. results from dilation of the right ventricle and tricuspid
valve ring
b. most common in late stages of heart failure from rheumatic
or congenital heart disease
3. Findings
a. dyspnea, fatigue, weakness and syncope
b. peripheral edema may cause discomfort
4. Management: surgical - valve replacement
5. Nursing interventions
a. the cardio-care six
b. monitor for cardio seven
c. monitor for findings of heart failure, pulmonary edema, and
adverse reactions to the drug therapy
d. post-op monitor client for hypotension, arrhythmias and
thrombus formation
e. when sitting, client should raise legs - to prevent
dependent edema

f.

client and family teaching

1. the cardio five
2. emphasize the need for prophylactic antibiotics
during dental care
3. instruct client to raise legs when sitting - to prevent
dependent edema

E. Pulmonic stenosis
1. Definition - obstructed right ventricular outflow resulting in right
ventricular hypertrophy
2. Epidemiology
a. usually congenital, often with other birth defects such as
tetralogy of Fallot
b. rare among the elderly
c. may result from rheumatic fever
3. Findings
a. dyspnea, fatigue, chest pain and syncope
b. peripheral edema may cause discomfort
4. Management: surgical - replace the valve via balloon and cardiac
catheter
5. Nursing interventions
a. same as tricuspid stenosis and tricuspid insufficiency
b. monitor for findings of heart failure, pulmonary edema, and
adverse reactions to to the drug therapy
c. post-op: monitor client for hypotension, dysrhythmias and
thrombus formation
d. monitor the cardio seven
e. client and family teaching - same as tricuspid stenosis and
tricuspid insufficiency
F. Pulmonic insufficiency (regurgitation)
1. Definition - pulmonary valve fails to close, so that blood flows back
into the right ventricle
2. Epidemiology
a. a birth defect, or a result of pulmonary hypertension
b. rarely, result of prolonged use of a pressure-monitoring
catheter in the pulmonary artery
3. Findings
a. dyspnea, fatigue, chest pain and syncope
b. peripheral edema may cause discomfort
c. if advanced: jaundice with ascites and peripheral edema
d. possible malnourished appearance
4. Management
a. diuretics - to mobilize edematous fluid to reduce pulmonary
venous pressure
b. sodium-restricted diet - to control underlying heart disease
c. anticoagulants - to prevent blood clots
d. digitalis - to increase the force or strength of cardiac
contractions (inotropic action)
e. surgery for severe cases: valvulotomy or valve
replacement
5. Nursing interventions
a. the cardio-care six
b. monitor the cardio seven
c. monitor for findings of heart failure, pulmonary edema, and
adverse reactions to drug therapy
d. post-op: monitor client for hypotension, arrhythmias and
thrombus formation
e. provide rest periods
f. when client sits, raise legs
g. client and family teaching: (same as tricuspid stenosis,
tricuspid insufficiency, and pulmonic stenosis)

1. the cardio five

2. client's dentist must give client prophylactic
antibiotics to prevent infection
3. instruct client to raise legs when sitting to prevent
dependent edema
G. Aortic stenosis
1. Definition - aortic valve narrows. left ventricle must work harder,
so needs more oxygen, and may suffer ischemia and heart failure.
2. Epidemiology
a. most significant valvular lesion seen among elderly people.
It usually leads to left-sided heart failure
b. incidence increases with age
c. occurs in 1% of the population
d. about 80% of these people are male
e. 20% of them die suddenly, around age 60
3. Findings
a. classic triad: dyspnea, syncope, angina (see Assessing
Clients with Cardiovascular Disorders)
b. fatigue
c. palpitations
d. left-sided heart failure may bring on orthopnea, paroxysmal
nocturnal dyspnea, and peripheral edema
4. Management
a. nitroglycerin to relieve chest pain
b. low-sodium diet - to prevent fluid retention
c. diuretics - to mobilize edematous fluid and to reduce
pulmonary venous pressure
d. digitalis - to increase the force or strength of cardiac
contractions (inotropic action)
e. oxygen - to prevent hypoxia
f. surgery - percutaneous balloon valvuloplasty, then valve
replacement
5. Nursing interventions
a. the cardio-care six
b. monitor the cardio seven
c. monitor for findings of heart failure, pulmonary edema, and
adverse reactions to the drug therapy
d. post-op: monitor client for hypotension, arrhythmias and
clots
e. when client sits, raise legs to prevent dependent edema
f. client and family teaching: (same as tricuspid stenosis,
tricuspid insufficiency, pulmonic stenosis and pulmonic
insufficiency)
1. the cardio five
2. client's dentist must administer prophylactic
antibiotics
3. client should raise legs when sitting
H. Aortic insufficiency (regurgitation)
1. Definition
a. blood flows back into the left ventricle during diastole
overloading the ventricle and causing it to hypertrophy.
b. extra blood also overloads the left atrium and, eventually,
the pulmonary system.
2. Epidemiology
a. by itself, most common among males
b. with mitral valve disease, more common among females
c. may accompany Marfan's syndrome, ankylosing
spondylitis, syphilis, essential hypertension or a defect of
the ventricular septum
3. Findings

a. uncomfortable awareness of heartbeat

b. palpitations along with a pounding head
c. dyspnea with exertion
d. paroxysmal nocturnal dyspnea, with diaphoresis,
orthopnea and cough
e. fatigue and syncope with exertion or emotion
f. anginal chest pain unrelieved by sublingual nitroglycerin
g. heartbeat that seems to jar the client's entire body
h. client's nailbeds appear to be pulsating
i. if nail tip is pressed, the root will flush and then pale
(Quincke's sign)
j. if left ventricle fails, client may show ankle edema and
ascites
k. pulsus biferiens
4. Management
a. digitalis - increases the heart's contractility (inotropic
action)
b. diuretics - to mobilize edematous fluids and to reduce
pulmonary venous pressure
c. sodium-restricted diet - to prevent fluid retention
d. anticoagulant agents - to prevent blood clots
e. surgical - valve replacement. however, aortic insufficiency
often damages the ventricle before it is detected.
5. Nursing interventions
a. same as all other valve disorders - the cardio-care six
except don't need to elevate head unless pulmonary
problems have begun.
b. monitor the cardio seven
c. monitor for signs of heart failure, pulmonary edema, and
drug reactions.
d. post-op: monitor client for hypotension, arrhythmias and
clots.
e. client and family teaching
1. same as all other valve disorders - the cardio five
2. emphasize the need for prophylactic antibiotics
during dental care
3. instruct client to raise legs when sitting

IV. Failures of the Heart Muscle

A.

Myocardial infarction (MI)

1.
Definition - insufficient oxygen supply kills (causes necrosis of)
myocardial tissue. MI may be sudden or gradual. total event takes
3 to 6 hours.
2.
Epidemiology
a.
almost equal for men and women
b.
client history of smoking, obesity, high cholesterol/low
density lipoprotein diet, physical/emotional stress
c.
a common killer in North America and Western Europe
d.
mortality about 25%. Of the sudden deaths from MI, more
than half happen within an hour
e.
of those who survive the initial MI and recover, up to 10%
die within the first year
3.
Findings
a.
persistent, crushing substernal chest pain
b.
pain that may radiate to the left arm, jaw, neck and
shoulder blades, with a feeling of impending doom
c.
pain may persist for 12 hours or more
d.
some clients report no pain, or call it mild indigestion
e.
fatigue, nausea, vomiting and shortness of breath
f.
sudden death

g.

4.

5.

6.

within the first hour after an anterior MI, about 25% of

clients experience tachycardia or hypertension.
h.
up to 50% of clients with an inferior MI experience the
opposite: bradycardia or hypotension.
i.
women may experience fatigue, achiness, flu-like
symptoms
Management
a.
cardiac monitoring for arrythmias
b.
oxygen - to prevent tissue hypoxia
c.
bed rest - to decrease the workload of the heart
d.
pharmacologic agents - to stabilize client
e.
stool softeners - to decrease the workload of the heart
caused by straining, which can cause vagal stimulation
producing bradycardia and arrythmias
f.
narcotic analgesics - to reduce pain, anxiety and fear and
decrease the workload of the heart
g.
beta-blocking agents - to slow heart rate
h.
sedatives - to decrease anxiety and fear and to decrease
the workload of the heart
i.
antiarrhythmic - to prevent arrythmias which are the most
common complications after an MI
j.
thrombolytic agents - to dissolve the thrombus in the
coronary artery and reperfuse the myocardium
k.
nitrates - to decrease pain and decrease preload and
afterload while increasing the myocardial oxygen supply
l.
anticoagulants - to prevent blood clots
m.
Swan-Ganz catheter to monitor pressure in pulmonary
artery (measure functioning of left ventricle)
n.
intra-aortic balloon counterpulsation may be used for
cardiogenic shock
o.
cardiac catheterization may be performed for PTCA
p.
surgery - coronary atherectomy or graft of a coronary
artery bypass
Diagnostic studies
a.
history and physical
b.
EKG - monitor for changes, arrythmias
c.
serum cardiac markers (CK - MB) - rises 4-6 degrees after
acute MI; Returns to normal in three to four days. Troponin
- rises quickly but remains elevated for two weeks.
Nursing Interventions
a.
The cardio-care six plus monitor the following to prevent
heart failure, infections and complications
i.
ii.
iii.
iv.
v.
vi.
vii.
viii.
ix.
b.
c.
d.
e.
f.
g.

temperature
daily weight
intake and output
respiratory rate
breath sounds
blood pressure
serum enzyme levels
EKG readings
Heart sounds especially S3 and S4

Assess pain and give analgesics as ordered. Record the

severity, location, type and duration of pain.
Do NOT give IM injections, or CK will be falsely elevated
Watch for crackles, cough, tachypnea and edema which
may predict left ventricle is failing.
Use antiembolism stockings to prevent venostasis and
thrombophlebitis.
Assistance with range of motion exercises
Client and family teaching

i.
ii.
iii.
iv.
v.
vi.
vii.
viii.

the cardio-five
explain the ICU or coronary care unit,
routine and machinery
ask dietician to speak with the client and
family to reinforce teaching
encourage client to join the cardiac rehab
exercise program
counsel gradual resumption of sexual
activity, taking nitroglycerin before sex may
prevent chest pain
advise client to report typical or atypical
chest pain
describe postmyocardial infarction
syndrome ; have client report it to physician
stress that client must modify high-risk
behaviors

EKG MEASURES ELECTRICAL ACTIVITY OF HEART

A. Electrocardiogram = (ECG) = (EKG); do not confuse with echocardiogram
B. An EKG is a graphic recording of the electrical currents of the heart.
C. The EKG records two basic events - depolarization and repolarization as a series of waves:
1. P-wave
2. P-R Interval
3. QRS complex
4. T wave
5. S-T interval
6. U wave
7. PVCs
D. An EKG can show these conditions:

CARDIAC MECHANICS AND HEART SOUNDS

Cardiac cycle

Systole: contraction
Diastole: relaxation
Cardiac cycle: one systole and its diastole. Average time: four-fifths of a second
Normal: 60-100 cycles (heart beats) per minute; faster in infants, slower in elderly

Cardiac output (CO)

Volume of blood ejected by ventricle per minute

CO = Stroke volume times heart rate

Preload: capacity of ventricle at height of diastole

Afterload: force required to overcome arterial resistance and empty the ventricle
Blood pressure

Systolic pressure is maximum force of blood against arteries at systole

Diastolic pressure is force of blood against arteries at diastole.
BP is measured indirectly by Sphygmomanometer or Doppler echocardiography, or directly by arterial
catheter

Body controls cardiac output and blood pressure

Starling's law of heart
Baroreceptors
Chemoreceptors
Cause: Blood moves from regions of greater to lesser pressure
Variations in Pressure: Pressure highest in left ventricle and aorta: fresh from heart.
Pressure lowest in central veins, vena cava, and right atrium: coming back to heart.
Heart sounds

Normal
S1 closure of mitral and tricuspid valves marking the beginning of systole
S2 closure of aortic and pulmonic valves

Exceptional
S3 - sound produced when blood first rushes into a stiff or loaded ventricle. S3 sounds are
early signs of left-sided heart failure
S4 - sound produced during late phase of filling an overloaded ventricle, associated with
hypertension
Pressure too low: not enough blood (and oxygen) to brain and heart.
Pressure too high: vessels damage and rupture.

B.

Congestive heart failure

1.
Definition/etiology
a.
heart fails to pump enough blood to support the body's
functions
b.
types of CHF depend on which part of the heart fails: the
left half that pumps to the body, or the right half that pumps
to the lungs.
c.
etiology
i.
coronary artery disease

ii.

myocarditis
cardiomyopathy
infiltrative disorders: amyloidosis, tumors,
sarcoidosis
v.
collagen-Vascular disease: systemic lupus
erythematosus, scleroderma
vi. dysrhythmias that reduce cardiac filling time
vii.
disorders that increase cardiac workload:
hypertension, valve disease, anemia,
hyperthyroidism
viii.
cardiac tamponade
Findings of Left CHF and Right CHF

iii.
iv.

2.

3.

4.

5.

C.

Management
a.
objective: to restore balance between myocardial oxygen
supply and demand
b.
treatments include oxygen, digitalis, vasodilators, nitrates
antihypertensives, cardiac glycosides, diuretics, intra-aortic
balloon counterpulsation, ventricular assist pumping, etc.
Nursing interventions
a. the cardio care six
b.
administer medications as ordered
c.
administer oxygen as ordered - to prevent tissue hypoxia
d.
monitor hemodynamic indicators
e. monitor for findings of hyponatremia, hypokalemia
f.
restrict fluids and assess for findings of fluid retention
g.
client and family teaching
i.
medications and side effects
ii.
how to conserve energy and thus oxygen
iii.
teach client to report

weight gain of more than two pounds in 24

hours (equals 1 liter)

dyspnea

decreased exercise tolerance

iv.
importance of sodium-restricted diet
Diagnostic findings - the primary goal is to determine the
underlying cause of the heart failure
a.
history and physical exam
b.
CXR - to determine heart size and pleural effusions
c.
EKG for changes, arrythmias
d.
echocardiogram to measure valvular abnormalities
e.
nuclear imaging - to determine myocardial contractility,
myocardial perfusion, and acute cell injury
f.
hemodynamic monitoring of arterial blood pressure,
pulmonary artery pressure, pulmonary artery wedge
pressure and cardiac output

Cardiac tamponade
1.
Definition/etiology
a. fluid quickly fills pericardial sac and limits cardiac output;
cardiac tamponade is a medical emergency
b.
etiology
i.
acute pericarditis
ii.
post-op after cardiac surgery
iii.
pericardial effusions
iv.
chest trauma
v.
myocardial rupture
vi.
aortic dissection
vii.
anticoagulant therapy
2.
Findings: classic triad of findings
a.
hypotension with
b.
muffled heart sounds with
c. high jugular venous pressure (increased CVP)
3.
Diagnosis (above)
4.
Management
a.
pericardiocentesis: needle aspiration of pericardial sac
5.
Nursing interventions
a.
bed rest with elevated head of bed
b.
prepare client for pericardiocentesis
c.
provide emotional support

PRINCIPLES OF CARDIOPULMONARY RESUSCITATION (CPR) ADVANCED CARDIAC LIFE SUPPORT

Early access
Early CPR
Early defibrillation
Early advanced cardiac life support
Give drugs after defibrillation (in the adult)
For drug delivery, antecubital veins are first choice because central-line placement would
interrupt CPR
Endotracheal tube placement
Intraosseous route for drugs is alternative (in children)
V. Disorders of the Circulatory System:
A.
Hypertension
1.
Definitions
a.
hypertension - systolic blood pressure of 140 mm Hg or
greater, diastolic blood pressure of 90 mm Hg or greater,
or taking antihypertensive medication
b.
chronic hypertension of pregnancy - high blood pressure
already present before week 20 of gestation
c.
accelerated hypertension - a hypertensive crisis: blood
pressure rises very rapidly, threatening the brain
EIGHT FACTORS THAT AFFECT ARTERIAL BLOOD PRESSURES
1. Cardiac output
2. Resistance in peripheral vessels (arterioles)
3. Arterial elasticity: Elastic vessels let blood flow at lower pressures; rigid, sclerotic vessels
require higher pressures.
4. Viscosity
a. Too many red blood cells (RBCs) or plasma proteins increases pressure.
b. Lower viscosity, from anemia or lack of RBCs, decreases pressure
5. Age: newborns have low blood pressure, which increases with age
6. Weight: the higher your weight, the higher your blood pressure
7. Exercise: faster heart rate means higher systolic blood pressure
8. Autonomic Nervous System: The sympathetic nervous system speeds the heart rate; the
parasympathetic (via the vagus nerve ) slows the heart rate.

2.

Etiology and epidemiology

a. essential hypertension: cause unknown.
b.
possible factors include:
i.
family history- immediate family: mother, father,
siser, brother
ii.
race- African American, Hispanic, Native American,
more susceptible
iii.
stress
iv.
obesity- 20% more than ideal weight
v.
a diet high in sodium or saturated fat
vi.
use of tobacco
vii.
use of hormonal contraceptives
viii.
sedentary life-style
ix.
aging
c.
besides hypertension, most individuals have other risk
factors for cardiovascular disease (CVD).
d.
secondary hypertension may result from
i.
renovascular disease
ii.
renal parenchymal disease
iii.
cushing's syndrome
iv.
diabetes mellitus
v.
dysfunction of the thyroid, pituitary, or parathyroid
vi. coarctation of the aorta
vii.
pregnancy
viii.
neurologic disorders

HOW THE BODY CONTROLS BLOOD PRESSURE

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

3.

4.

Findings
a.
may be asymptomatic
b.
findings reflect the effect of hypertension on organ systems
c.
occipital headache, blurred vision, dizziness
d.
dizziness, palpitations, weakness, fatigue, and impotence
e.
nosebleeds
f.
bloody urine
g.
chest pain and dyspnea, if heart is involved
Diagnosis
a.
based on the average of two or more blood pressure
readings, two minutes apart, at each of two or more visits
after an initial screening visit
b.
classification of adult hypertension

c. hypertension is classified according to its cause:

i.
primary or essential hypertension (about 90% of
clients)
ii.
secondary hypertension (results from another
disease; about 5% to 10% of clients)
iii.
accelerated hypertension - a hypertensive crisis
5.

6.

Management
a.
pharmacological
i. initial therapy - for uncomplicated hypertension, it is
recommended to start with a diuretic or Betaadrenergic blocking agent
ii.
oxygen PRN in acute crisis
iii.
angiotensin-converting enzyme (ACE) inhibitors are
used to treat left-sided heart failure and preferred if
client is diabetic
iv.
antilipemics
b.
goals of treatment
i.
BP <130/85 mm Hg
ii.
control dyslipidemia, obesity, inactivity
iii.
control diabetes mellitus, if indicated
Nursing interventions: reinforce client and family teaching
regarding:
a.
client to use self-monitoring blood pressure cuff
b.
client to record readings at least twice weekly in a journal
or calendar for review by care provider during visits
c.
client to set up routine for taking antihypertensive
medications

d.
e.
f.
g.

the need to warn against high-sodium antacids, and cold

or sinus remedies with vasoconstrictors such as
antihistamines
diet low in sodium, cholesterol (see cholesterol level
classification) and saturated fat
when client is to report extremely high blood pressure
readings
lifestyle modifications
i.
optimize body weight
ii.
drink alcohol based on current guidelines
iii.
moderate dietary sodium (two gm sodium diet)
iv.
exercise: regular moderately intense aerobic
activity
v.
avoid tobacco products

vi.
manage stress triggers and responses to triggers
CHOLESTEROL LEVEL CLASSIFICATION

(Source: Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults, Summary of
the Second Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation,
and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III), Journal of the American Medical
Association 285 (2001): 2486-2497)

B.

Coronary artery disease

1.
Definition - fatty deposits in coronary arteries (atheroma or plaque)
narrow the artery (by 75% or more) and cut flow of blood and
oxygen to the heart muscle.
2.
Epidemiology and etiology
a.
CAD is epidemic in the western world.
b.
more than 30% of men age 60 or older show signs of CAD
on autopsy.
c.
most common cause: Atherosclerosis
d.
risk factors:
i.
over 40 white male
ii.
family history of CAD
iii.
high blood pressure
iv.
high cholesterol (see cholesterol level
classification)
v.
smokers are twice as likely to have a myocardial
infarction and four times as likely to die suddenly.

3.

The risk drops sharply within one year after

smoking ceases.
vi. obesity (waist predominance); [added weight
increases the risk of diabetes, hypertension and
high cholesterol]
vii.
sedentary life style
Findings: angina
TYPES OF ANGINA

A. Angina, especially after physical exertion, is the classic symptom of Coronary Artery
Disease.
B. Angina appears commonly with nausea, vomiting, fainting, sweating, and cool
extremities
C. Angina may follow excitement, a large meal, or exposure to extreme cold or heat.
D. Types of angina
1. Nocturnal angina
2. Angina predictable and relieved by nitroglycerine: stable angina.
3. More frequent and lasting angina: unstable angina.
4. Effort-induced pain that occurs more and more often: crescendo angina
5. Severe angina at rest: Prinzmetal's angina - associated with coronary artery
spasm

4.

Management
a.
pharmacology
i.
nitrates such as nitroglycerin, isosorbide dinitrate
(Isordil), or beta-adrenergic neuron-blocking agents
ii.
oxygen - to prevent hypoxia
iii.
diuretics and beta-adrenergic blocking agents
iv.
aspirin - decreases platelet aggregation
v.
antilipemics - to decrease circulating lipids
b.
diet: reduce calories, salts, fats, cholesterol
c. cardiac catheterization
i. after cardiac catheterization and percutaneous
transluminal coronary angioplasty (PTCA), maintain
heparinization; observe for bleeding systemically at
the site, and keep the affected leg straight and
immobile for six to 12 hours.
ii.
check for distal pulses.
iii.
to counter the diuretic effect of the dye, increase IV
fluids and make sure client drinks plenty of fluids.
iv.
assess potassium level- observe for dysrhythmias
v.
observe findings of hypotension, bradycardia,
diaphoresis, dizziness; give atropine and lay the
client flat.
d.
rotational ablation
i.
after rotational ablation, monitor the client for chest
pain, hypotension, coronary artery spasm and
bleeding from the catheter site.
ii.
provide heparin and antibiotic therapy for 24 to 48
hours or as ordered.
e.
laser coronary angioplasty
f.
surgical treatment - coronary artery bypass graft (CABG)

CARE OF THE CLIENT UNDERGOING CARDIAC SURGERY WITH

CARDIOPULMONARY BYPASS
1. Monitor hemodynamics for lower cardiac output or excess fluid
2. Measure fluid intake and output
3. Monitor specific gravity of urine
4. Monitor ECG (EKG) rate and rhythm
5. Monitor peripheral perfusion
6. Monitor neurological status
7. Administer IV fluids as ordered
8. Administer oxygen as ordered
9. Care of the client on a ventilator
10. Administer medications as ordered
11. Provide comfort measures
12. Limit fluid intake as ordered
13. Weigh client daily
14. Monitor for signs of cardiac tamponade
15. Administer blood and blood products as ordered
16. Provide emotional support
17. Observe incision sites for signs of infection
18. Care of the client with chest tubes
19. Monitor arterial blood gases as ordered

5.

Nursing interventions
a.
help client with ADL (activities of daily living)
b.
partial bed rest
c.
reassure client
d.
assist with turning, deep breathing and coughing exercises
e.
relieve chest pain by oxygen and medication as ordered
f.
during angina attacks, monitor bp, heart rate, pain, meds,
symptoms; get electrocardiogram
g.
keep nitroglycerin available for immediate use
h.
client and family teaching
i.
risks

teach the risk factors for CAD (coronary

artery disease)

encourage client to lose excess weight;

review low-fat, low-cholesterol diet

teach smoking cessation

teach side effects of drugs for CAD

stress - teach stress reduction techniques

ii.
avoid

activities known to cause angina

physical activities for two hours after meals

very cold and very hot weather

alcohol and caffeine drinks

diet pills, nasal decongestants, or any

remedy that can raise heart rate or blood
pressure
iii.
use

nitroglycerin tablets; carry at all times

if necessary nitroglycerin patch

iv.
report

angina

angina >15 minutes, go to clinic or hospital

C.

Shock
1.
Definition - body cells need more oxygen than blood is supplying.
cells and then organs fail. shock has many different causes. It is a
medical emergency.
2.
Five types of shock:
a.
cardiogenic
b.
septic
c.
neurogenic
d.
anaphylactic
e.
hypovolemic
Types of shock are classified according to etiology: CHANS

Cardiogenic - ventricle loses pumping power and cardiac

output becomes inadequate
Hypovolemic - excessive blood loss
Anaphylactic - severe allergic reaction inappropriately dilates
the veins to pool blood
Neurogenic - sympathetic NS inappropriately dilates the
veins to pool blood
Septic shock - systemic infection causes excessive capillary
permeability with excess intravascular volume
loss
3.

Findings: progression of shock

a.
initial stage:
i.
decreased cardiac output and perfusion
ii.
cellular function interrupted
iii.
anaerobic metabolism increases
iv.
no clinical symptoms at this stage
b.
compensatory stage: neural, chemical, and hormonal
mechanisms act to restore perfusion.
i. neural compensation: pressoreceptors in aorta
activate sympathetic nervous system (NS), which
contracts blood vessels so that skin cools;
sympathetic NS stimulates heart, so tachycardia
sets in; it cuts blood flow to kidneys and
gastrointestinal system, and dilates pupils.
ii. Hormonal compensation: decreased blood flow to
kidneys releases angiotensin, which constricts
vessels and increases BP; Angiotensin stimulates
the secretion of aldosterone. Aldosterone makes
kidneys retain sodium, which increases serum
osmolality, which in turn stimulates antidiuretic
hormone; ADH causes water retention.

increased sodium and water retention

results in increased BP, decreased urine
volume and increased urine specific gravity.

anterior pituitary is stimulated to secrete

Adrenocorticotropic hormone , and ACTH
acts on adrenal cortex to increase secretion
of glucocorticoids, which increase serum
glucose.
iii.
chemical compensation: decreased pulmonary
blood flow causes hypoxemia; hypoxemia is
sensed by chemoreceptors that increase rate and

c.

d.

depth of respirations, which results in respiratory

alkalosis
iv.
findings of compensatory stage of shock

altered L.O.C.

tachypnea

anxiety, restlessness

skin cool and clammy

diaphoresis

thirst

pupils dilated

tachycardia

weak peripheral pulses

decreased bowel sounds

decreased urine output

concentrated urine
progressive stage of shock - compensatory mechanisms
can no longer maintain perfusion.
i.
severe hypoperfusion
ii.
massive cell death
iii.
organs begin to fail
iv.
findings of progressive stage of shock

consciousness - L.O.C. severely

depressed

lungs -hypoventilation, moist crackles

cardiovascular - decreased BP: systolic

below 90 mm mg, narrowing pulse
pressure, tachycardia, irregular pulse,
peripheral pulses weak, thready

elimination - urine volume below 20

cc/hour, urine osmolality dilute, absent
bowel sounds
refractory stage: shock irreversible: death from multisystem organ failure is evident
i.
findings of refractory stage of shock

cardiac failure

respiratory failure

renal shutdown

liver dysfunction

loss of consciousness
ii.

1.
2.
3.
4.
5.

diagnostics

FLUID FACTORS IN DIAGNOSIS OF SHOCK

Hematocrit: decreased except in hypovolemic where it is increased
Serum osmolality: decreased in hypervolemia, increased in hypovolemia
Urine osmolality: decreased in hypervolemia, increased in hypovolemia
Urine Specific gravity: decreased in hypervolemia, increased in hypovolemia
Sodium level: decreased in hypervolemia; increased in hypovolemia

iii.

management - objective: to correct underlying

cause and prevent progression
cardiogenic shock
o pharmacologic treatments (see
emergency cardiac drugs)

positive inotropic agents:

increase myocardial

EMERGENCY CARDIAC DRUGS

Oxygen
Morphine sulfate
Diuretics
Aminophylline
Dopamine hydrochloride
Digoxin
Lidocaine
Epinephrine
Sodium bicarbonate
Atropine
Procainamide
Bretylium
Verapamil
Isoproterenol
Sodium nitroprusside
Magnesium
Adenosine
Diltiazem
Propranolol
Esmolol
Amiodarone
Calcium chloride

contractility and improve

systolic ejection: dobutamine
(Dobutrex), amrinone lactate
(Inocor)

vasodilators: improve heart's

pumping action by reducing its
workload: nitroglycerin
(Corobid), nitroprusside
sodium (Nipride), (Usually
limited to clients with failing
ventricular function)

vasopressors: increase
peripheral vascular resistance
and elevate blood pressure:
norepinephrine (Levophed),
dopamine hydrochloride
(Intropin)
oxygen therapy
surgical treatments
intra-aortic balloon
counterpulsation
left and right ventricular assist
pumping
heart transplant

hypovolemic shock: rapid fluid replacement

therapy to replace lost volume
anaphylactic shock:
o epinephrine (adrenalin)
o antihistamines
o aminophylline (truphylline)
neurogenic: depends on causative agent
septic: antibiotic therapy

EMERGENCY CARDIAC DRUGS

Positive inotropic agents: increase myocardial contractility and improve systolic
ejection:

dobutamine
dopamine hydrochloride
amrinone
epinephrineMp
norepinephrine

Vasodilators: improve heart's pumping action by reducing its workload:

nitroglycerin
nitroprusside
morphine
furosemide (Usually limited to clients with failing ventricular function)

Vasopressors: increase peripheral vascular resistance and elevate blood pressure:

norepinephrine
phenylephrine
epinephrine
dopamine hydrochloride

Oxygen therapy

iv.

nursing interventions for shock: the cardio-care six

except

do not elevate or lower head: maintain

complete bed rest in flat position or with
legs slightly raised to increase venous
return

do not move client; no commode

keep client warm

administer parenteral therapy, drugs, and

O2 as ordered

monitor mean hemodynamic indicators as

ordered

blood plasma expanders or packed cells

VI. Dysrhythmias and Lesser Vascular Disorders

A. Dysrhythmias
1. Definition: disturbance in heart rate or rhythm
2. Types of dysrhythmia
a. supraventricular: sinus, atrial, and junctional
i.
sinus tachycardia
ii.
sinus bradycardia
iii.
sinus arrhythmia
iv.
premature atrial complexes
v.
atrial tachycardia
vi.
atrial flutter
vii. atrial fibrillation
viii.
premature junctional complex
ix.
junctional tachycardia
b. ventricular
i.
premature ventricular contraction
ii.
ventricular tachycardia
iii.
ventricular fibrillation
iv.
asystole
v.
atrioventricular block
vi.
first degree A-V block (no treatment)
vii.
second degree A-V block (no treatment)
viii.
third degree A-V block
3.

Nursing interventions
a. supraventricular dysrhythmias
i.
asymptomatic - no nursing interventions indicated
ii.
symptomatic

administer medications as ordered (see

pharmacologic interventions for
dysrhythmias)

provide emotional support

teach client
o
medications and side effects
o
to wear dysrhythmia identification
jewelry
b.
ventricular dysrhythmias
i.
administer medications as ordered
ii. monitor EKG
iii.
monitor hemodynamic indicators as ordered

iv.
v.

vi.
vii.
viii.
ix.

administer oxygen as ordered

provide a restful environment
prepare the client for cardioversion
initiate cardiopulmonary resuscitation as indicated
provide emotional support
teach client

medications and side effects

importance of dysrhythmia identification

jewelry

c.

1.

2.

3.

4.

5.

atrio-ventricular (AV) conduction disturbances

i.
asymptomatic: no nursing interventions indicated
ii.
symptomatic

administer medications as ordered

prepare client for pacemaker insertion

care of the client undergoing surgery

provide emotional support

provide a restful environment

PACEMAKERS
A battery-powered device that provides electric stimulation for:
a. atrial pacing
b. pacing
c. atrioventricular sequential and physiologic pacing
Pacemakers can be set to
a. sense the person's intrinsic rhythm and pace only if intrinsic rate declines below
rate set on pacemaker
b. pace at a preset rate, regardless of person's rhythm (asynchronous)
c. overdrive and suppress the underlying rhythm in tachyarrhythmia
d. provide increased rate in bradycardias
Indications for pacing
a. symptomatic bradyarrhythmia
b. symptomatic tachyarrhythmia
c. asystole
d. prophylaxis in persons with high-risk bradycardia
e. diagnosis of dysrhythmias during electrophysiologic testing
Types of pacemakers
a. temporary pacemaker
b. endocardial ( transvenous ) pacemakers
c. transcutaneous (external) pacemakers
d. epicardial (applied during cardiac surgery)
e. permanent pacemakers
Complications of pacemakers
a. infection
b. perforation
c. pneumothorax
d. hemothorax
e. dysrhythmias
f. thrombosis

B.

Aneurysms
1.
Definition, four types, two locations
a.
dilation of an artery due to a weakness in the arterial wall
b.
four types of aneurysms
i.
saccular: outpouching of one wall in a
circumscribed area
ii.
fusiform: involves complete circumference of artery
iii.
dissecting: accumulation of blood separating the
layers of the arterial wall
iv.
pseudoaneurysm: tear of the full thickness of the
arterial wall, leading to a collection of blood
contained in the connective tissue
c.
two locations: abdominal aorta and thoracic aorta
i.
location one: abdominal aortic aneurysm

findings of abdominal aortic aneurysm

o
usually asymptomatic
o
vague abdominal or back pain
o
tenderness on palpation
o
hypotension
o
diminished pulses in lower
extremities
o
commonest site: just below renal
arteries and above iliac arteries
ii.
treatment - surgical repair
iii.
nursing interventions

care of the client undergoing surgery

after surgery, watch for back pain, a sign of

retroperitoneal hemorrhage

monitor perfusion

provide comfort measures

provide emotional support

teach client - to avoid prolonged sitting and

lifting of heavy objects
d.
location two: thoracic aortic aneurysm
i.
findings of thoracic aortic aneurysm

may be asymptomatic

vague chest pain

dyspnea

distended neck veins

ii.
management - surgical repair
iii.
nursing interventions

care
of the client
undergoing
surgery
CARE OF THE CLIENT UNDERGOING CARDIAC
SURGERY
WITH
CARDIOPULMONARY
BYPASS

care
of
the
client
undergoing
cardiac
1. Monitor hemodynamics for lower cardiac output or excess fluid
surgery
2. Measure fluid intake and output
3. Monitor specific gravity of urine
- atherosclerosis
4. Monitor ECG 2.
(EKG)Etiology
rate and
rhythm
5. Monitor peripheral perfusion
6. Monitor neurological status
7. Administer IV fluids as ordered
8. Administer oxygen as ordered
9. Care of the client on a ventilator
10. Administer medications as ordered
11. Provide comfort measures
12. Limit fluid intake as ordered
13. Weigh client daily
14. Monitor for signs of cardiac tamponade
15. Administer blood and blood products as ordered
16. Provide emotional support
17. Observe incision sites for signs of infection
18. Care of the client with chest tubes
19. Monitor arterial blood gases as ordered

C.

Arterial occlusive disease

1.
Definition: insufficient blood supply in the arteries; usually in legs.
may be acute or chronic.
2.
Acute arterial occlusive disease
a.
etiology
i.
embolism, thrombosis, and trauma
ii. femoral artery most often affected
b.
findings
i.
pain in affected limb
ii.
cyanosis in affected limb
iii.
paresthesia in affected limb
iv.
if untreated, gangrene
c.
management
i.
pharmacology : anticoagulants

CARE OF CLIENTS TAKING ORAL ANTICOAGULANTS

Medicate same time every day
Wear medical identification jewelry: wearer takes anticoagulants
Use a soft toothbrush
Do not use a straight razor; use an electric razor
Avoid alcohol
Report any signs of bleeding, red or black bowel movements, headaches, rashes, red or
pink-tinged urine, sputum
7. Avoid trauma
8. Monitor levels of the anticoagulant in the blood
1.
2.
3.
4.
5.
6.

ii.

surgical treatment

embolectomy

bypass of affected artery

amputation of limb

percutaneous transluminal coronary

angioplasty

3. Chronic arterial occlusive disease

a. etiology
i. arteriosclerosis obliterans, aneurysms,
hypercoagulability states, tobacco use
ii.
slow, progressive arteriosclerotic changes give
collateral circulation a chance to form
iii.
collateral circulation cannot give tissues enough
oxygen; result is hypoperfusion
iv.
hypoperfusion leads to ischemia
v.
usually affects legs
b. findings
i. intermittent claudication indicates mild to moderate
obstruction
ii.
pain at rest indicates severe obstruction
iii.
affected limb will show
edema
paresthesia
weak or absent pulses
skin: waxy, hairless, cool, pale, cyanotic
iv.
in men, impotence
c. management
i.
pharmacologic
anticoagulants - to prevent blood clots
vasodilators
antiplatelet drugs - to prevent platelet
aggregation
pentoxifylline (Trental): increases blood flow
by thinning blood
ii.
surgical treatment
endarterectomy
femoral-popliteal bypass
sympathectomy
amputation of affected limb for gangrene
laser coronary angioplasty (LTA)
peripheral angioplasty
4. Both acute and chronic arterial occlusive disease
a.
nursing interventions
i.
administer medications as ordered
ii.
monitor peripheral pulses and blanch test
iii.
provide comfort measures
iv.
help client develop an exercise program
v.
care of the client undergoing surgery
vi.
provide foot care
vii.
teach client
to change positions frequently
to avoid crossing legs
to avoid any constrictive clothing on legs
to avoid trauma to lower extremities
foot care
to place legs in dependent position to
increase blood flow
D. Raynaud's phenomenon (arteriopastic disease)

1. Definition: disorder of small cutaneous arteries causing

vasospasm. usually affects the fingers bilaterally.
2. Etiology
a. unknown
b. frequently occurs in women
c. may be triggered by stress, cold
3. Findings signs of arterial insufficiency in the etremities
4. Management
a. pharmacologic agents
b. antihypertensive agents: reserpine (Serpasil)
c. alpha-adrenergic blocking agents: phenoxybenzamine
(Dibenzyline), tolazoline (Piscoline)
d. vasodilators
e. surgery
i. sympathectomy in advanced stages
ii. amputation of fingers showing gangrene
5. Nursing interventions
a. administer medications as ordered
b. care of the client undergoing surgery
c. teach client
i.
to manage stress
ii.
to stop smoking, avoid caffeine
iii.
to avoid temperature extremes
iv.
protection from cold
v.
medications and their side effects
E. Thromboangiitis obliterans (Buerger's disease)
1. Definition: blocking of the medium and small arteries, usually in
the legs and feet.
2. Etiology
a. affects men more than women
b. 25 to 40 age group who smoke
c. the disease only occurs in smokers
3. Findings signs of arterial insufficiency in the etremities
a. intermittent claudication
b. numbness and tingling of toes
c. weak or absent peripheral pulses
d. ischemic ulcerations may occur
e. can lead to gangrene
4. Management
a. smoking cessation
b. other treatment, see arterial occlusive disease
c. analgesics
d. surgery in late stages, amputation
5. Nursing interventions
a. assist client with smoking cessation
b. see nursing interventions for arterial occlusive disease:
i.
administer medications as ordered
ii. monitor peripheral pulses and blanch test
iii.
provide comfort measures
iv.
help client to develop an exercise program
v.
care of the client undergoing surgery
vi.
provide foot care
vii.
teach client how stopping smoking can relieve
symptoms
F. Varicose veins
1. Definition: dilation of superficial veins of the legs and feet.
2. Etiology
a. usually found in greater saphenous vein (leg)

b. incompetent valves (incompetence, vavular) in the

superficial veins
c. increased pressure in veins causing them to distend
d. risk factors: standing for long periods, pregnancy
3. Findings signs of venous insufficiency in the extremities
a. pain after period of standing
b. foot and ankle swelling at end of day
c. distended leg veins
4. Management
a. objective: to reduce pain and halt underlying condition
b. medical: sclerotherapy (injection of sclerosing agent that
causes vein thrombosis)
c. surgical: vein ligation (Vein stripping)
5. Nursing interventions
a. care of the client undergoing surgery
b. post-operative care includes
i.
application of elastic stocking or bandages
ii.
elevation of leg
c. teach client
i.
not to cross legs
ii.
to elevate legs as much as possible
iii.
to avoid prolonged sitting or standing
iv.
avoid anything that impedes venous return
v.
overweight clients should lose weight
G. Thrombophlebitis
1. Definition: A clot inflames the wall of a superficial blood vessel.
2. Etiology
a. trauma
b. intravenous catheters
c. prolonged immobility
d. IV drug use
3. Findings
a. redness
b. swelling
c. tenderness
d. warmth
4. Management
a. bed rest, with elastic stockings
b. elevation of affected extremity
c. anticoagulants - to prevent clot formation
d. analgesics - to control discomfort
5. Nursing interventions
a. keep leg elevated
b. monitor
i.
for findings of pulmonary embolism (sudden pain,
cyanosis, hemoptysis, shock)
ii.
vital signs, including peripheral pulses
iii.
for findings of vascular impairment (pallor,
cyanosis, coolness)
c. administer analgesics as ordered
d. client teaching
i.
avoid tight or constricting clothing
ii.
stop cigarette smoking
iii.
avoid maintaining one position for long periods
H. Deep venous thrombosis
1. Definition: clotting in a deep vein
2. Etiology and risk
a. immobilization
b. sepsis
c. hematological disorders and clotting disorders

d. malignancies
e. congestive heart failure
f. myocardial infarction
g. obesity
h. pregnancy
i. fractures
j. venipuncture
k. surgeries: orthopedic, neurologic, urologic and gynecologic
l. risk of pulmonary embolus
3. Findings - unilateral edema of extremity, signs of venoue
insufficiency in the extremities
4. Management
a. objective: to eliminate the clot and prevent complications
b. bed rest
c. anticoagulant therapy - to prevent new clots
d. thrombolytic therapy - to dissolve thrombus
e. compression stockings
f. surgery - thrombectomy
5. Nursing interventions
a. monitor for findings of pulmonary embolus
b. maintain bed rest
c. administer medications as ordered
d. teach client
i.
medications and side effects
ii.
to avoid prolonged immobility
iii.
to maintain adequate fluid intake
I.

Venous stasis ulcers

1. Definition: chronic skin and subcutaneous ulcers usually found on
legs, ankles or feet.
2. Etiology
a. chronic venous insufficiency
b. incompetent valves (vavular, incompetence) in perforating
veins or deep veins cause venous stasis
c. pressure of blood pooling causes capillaries to leak
d. ulcer begins as small, inflamed, tender area
e. any trauma causes tissue to break or it may break
spontaneously
f. site: pretibial and medial supramalleolar areas of ankle
3. Findings signs of venous insufficiency in the extremities
a. open skin lesion with irregular border
b. skin around ulcer usually brown and leathery
c. pain in affected area
4. Management
a. objective: to correct venous hypertension and both prevent
and correct ulceration
b. local wound care
c. antibiotics and analgesics as indicated
d. surgery
i. debridement
ii.
skin grafting
iii.
removal of veins with incompetent valves
5. Nursing interventions
a. keep legs elevated, with feet above level of heart at all
times
b. apply elastic bandages as ordered
c. cleanse and dress ulcer as ordered
d. administer drugs as ordered
e. teach client
i.
to report any signs of inflammation immediately
ii.
to avoid trauma to affected limb

iii.
iv.

to provide skin care

to apply elastic bandages

Points to Remember

Cardiovascular disease is the leading cause of death among Americans.

Take blood pressures correctly
give client 5 minutes rest.
take blood pressure while client is lying, sitting, and standing.
ask client if he/she has recently smoked, drank a beverage containing
caffeine or was emotionally upset. If so, repeat blood pressure in 30
minutes.
Rarely, the heart may lie on the right side instead of the left, this is called
Dextrocardia.
Valves control the direction of the blood flow through the heart. Flow is
unidirectional.
When the atria contract, the atrioventricular valves swing open, allowing the
blood to flow down into the ventricles.
When the ventricles contract the valves snap shut preventing blood from flowing
back up into the atria. Semilunar valves open allowing blood to eject during
ventricular contraction.
If the SA node fails to generate an impulse, the AV node takes over, generating a
slower rate. If the AV node fails to generate an impulse, the Bundle of His takes
over, generating an even slower rate. If the Bundle of His fails to generate an
impulse, the Purkinje fibers take over and generate an even slower rate.
Damaged areas of the heart may also stimulate contractions and produce
arrhythmias.
Rapid, short-term control of blood pressure is achieved by cardiac and vascular
reflexes that are initiated by stretch receptors (baroreceptors) in the walls of the
carotid sinus and the aortic arch.
Many clients with angina or MIs benefit from involvement in a structured cardiac
rehabilitation program to assist clients to increase their activity level in a
monitored environment.
Current research suggests that life style and personal habits are closely related
to cardiac changes once attributed to aging.
The elderly are less able to physically adapt to stressful physical and emotional
conditions, because their hearts do three things less quickly: the myocardium
contracts less easily, the left ventricle ejects blood less quickly, and the heart is
slower to conduct the impulse for a heartbeat.
Because different enzymes are released into the blood at varying periods after a
myocardial infarction, it is important to evaluate enzyme levels in relation to the
onset of the physical symptoms such as chest pain.
Clients who are in postoperative recovery, on bed rest, obese, taking hormonal
contraceptives or had knee or hip surgery should be monitored closely for
thrombophlebitis.