NCM202B_A NCM of Clients with Alterations in O2 Transport Mechanism Miss Dyna A.

. Abello, RN MN ***Talks about a disorder in the Respi and Cardio Specific Objectives To discuss the structure and function of the CV system. Perform CV assessment Discuss the pathophysiologic mechanism of every dse process. Discuss the rationale of every clinical manifestation. ID the specific med treatment of every dse process Formulate a plan of care for every patient with alteration in O2 transport mechanism using the Nsg process.

Course Outline Review of basic structure and function of the CV System Assessing clients with CV problems NCM of patients with alterations in Oxygen Transport mechanism o CV Dse o Peripheral Vascular Dse

Grading System Quizzes 50% Attendance and Participation 10% Exam 40%

References: Contemporary Medical Surgical Nursing by Rick Daniels Medical-Surgical Nursing 8th Edition by Black and Hawks

House Rules Allowable absences: 5 (NCM 202) o Unexcused absence: NO Special Test o Excused absence: special test WILL BE GIVEN ON THE DAY OF THE EXAM Sickness med certificate (20% will be deducted, 80% is higher score) School function Death of any family members o Tardiness: 7:01-7:15 is late - .15 deduction from class participation;3 lates, 1 absent o Absent: .25 deduction o During test, o 5 points will be deducted from the total score (quiz) if a student submits a test paper with rough edges o No giving of paper to late comer o No texting/eating inside the classroom o No going in and out of the classroom while the lecture is ongoing. 25

NCM202B_A NCM of Clients with Alterations in O2 Transport Mechanism Miss Dyna A. Abello, RN MN o o o Personal necessities should be done before the class and at break time A 15-30 minute break will be given. Attendance will be rechecked. No special projects/assignments will be given to a failing student.

The Cardiovascular System Functions: Circulation of blood ***which is oxygenated and unoxygenated Delivery of Ox and other nutrients ***to the cells of the body Removal of CO2 (from lungs and capillaries) other products of cellular metabolism

The Heart A muscular pump that propels blood into the arterial system and receives blood from the venous system (300g, fist sized, cone shaped); located in the mediastinum space between the lungs; tilted forward and to the left; the hearts rests for 0.4s in between beats. to prevent cardiac arrhythmias cardiac fibrillation cardiac arrest

Pericardial Layers 1. Pericardium protects the heart from injury, infection and friction a. Visceral closely adheres to the heart b. Parietal outer surface of the pericardium In between, the pericardial space contains pericardial fluid 10-30mL 2. Epicardium next layer after the pericardium 3. Myocardium actual contracting muscle of the heart; works the hardest and the most 4. Endocardium innermost layer of the heart Other Structures Papillary Muscle arise from the endocardial and myocardial surface of the ventricles and attach to the chordae tendinae Chordae tendinae attach to the tricuspid and mitral valves and prevent eversion (of valves falling backwards) during systole; acts as a splint; prevents backflow of blood during ventricular contraction

Chambers Atria main purpose is to receive blood Right atrium receives blood from IVC and SVC Left atrium - receives blood from the lungs via pulmonary veins Diastolic time blood delivered to ventricles Diastolic filling time amt of time that the contents of the atria are delivered to the ventricles Ventricles main function pumps blood Right Ventricle pumps blood to the lungs via pulmonary artery 26

NCM202B_A NCM of Clients with Alterations in O2 Transport Mechanism Miss Dyna A. Abello, RN MN Left Ventricle pumps blood to the system via the aorta; works the strongest; fails first Valves A. Atrioventricular (AV) Valves between the atria and the ventricles a. Tricuspid between right atrium and right ventricle; with 3 leaflets attached to chordae tendinae b. Bicuspid (mitral valve) between left atrium and left ventricle; with 2 leaflets attached to chordae tendinae Functions Permit unidirectional flow of blood from specific atrium to specific ventricle during ventricular diastole (relaxation) Prevents reflux flow during ventricular systole (contraction) Valve leaflets open during ventricular diastole and close during ventricular systole Lub closure of bicuspid and tricuspid sound S1 B. Semilunar Valves a. Pulmonic Semilunar Valve located between right ventricle and pulmonary artery b. Aortic Semilunar Valve located between the left ventricle and the aorta Functions Permit unidirectional flow of blood form specific ventricle to arterial vessel during ventricular systole Prevent reflux blood flow during ventricular diastole Valves open when ventricles contract and close during ventricular diastole

Dub S2; Sound of Semilunar valve closure Conduction System travelling of impulses from one point to another SA Node Initiates the cardiac muscle impulse which spreads across the atria and into the AV Node: natural pace maker of the heart; sets the rate; initiate the transmission of electrical impulse; can generate 60-100 electrical impulse impulses per minute AV Node delays the impulse from the atria while the ventricles fill; 40-50 times per minute: Bundle of His a. Right Bundle Branch transmit impulses down the right side of the interventricular septum toward the right ventricular myocardium b. Left bundle branch - divided into anterior and posterior; transmit impulses to the left side of the heart Purkinje Fibers transmit impulses to the ventricles and provide for depolarization after ventricular contraction

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NCM202B_A NCM of Clients with Alterations in O2 Transport Mechanism Miss Dyna A. Abello, RN MN Coronary Circulation Coronary Arteries (found at the Epicardium) o Branch off at the base of the aorta and supply the blood to the myocardium and the conduction system o Two main coronary arteries are right and left 1. Right Coronary Artery RA and RV Inferior portion of the LV Posterior Septal Wall SA and AV node 2. Left Coronary Artery LAD (Left Anterior Descending) anterior wall of the LV Anterior ventricular system Apex of the heart

Circumflex CA Lateral and posterior wall of the LV Left atrium Coronary Veins o Return blood from the myocardium back to the RA via the coronary sinus

Factors Affecting Blood Flow Pressure from higher pressure to lower pressure Resistance integrity of the diameter of the artery Autonomic NS contributes to reflex control of total cardiac output and vascular resistance o Sympathetic NS inc BP; constricts blood vessels o Parasympathetic dilates blood vessels; dec HR Baroreceptors sensitive to pressure; stimulates brain to balance BP and blood flow

Laboratory/Dx Tests Electrocardiogram o Non-invasive test that produces a graphic record of the electrical activity of the heart o HOLTER MONITOR portable recorder provides continuous recording of ECG for up to 24 hours; keep a diary of his activities in the next 24 hours Exercise ECG (Stress Test) o Stress test may show heart dse when resting ECG does not ***Dobutamine (Dobutrex) -stimulates hearts activity; pharmacologic stress test; IV infusion 28

NCM202B_A NCM of Clients with Alterations in O2 Transport Mechanism Miss Dyna A. Abello, RN MN Echocardiogram o Noninvasive recording of the structures using UTZ; UTZ of the heart o Transducer is placed in the chest o Types Resting Surface Echocardiogram Transesophageal Echocardiogram patient is sedated and anesthetized; transducer is inserted through gastroscopy tube o Nursing Responsibilities (p. 764) Resting Surface Echocardiogram - No food/drinks restriction - Ask the patient to remain still Transesophageal Echocardiogram - No food/drinks 4-6 hours before the procedure - Prevention of aspiration - Assess for risk of aspiration - Assess for any GI problems (hiatus hernia, ulceration) - Vital signs are monitored during and after the procedure - Eating and drinking may be resumed after gag reflex return ask the patient to swallow CXR o Can check abnormalities as to size, shape, and position of the heart Myocardial Nuclear Perfusion Imaging o Assessed myocardial wall motion, ejection (percentage of blood ejected by the ventricles), fraction, blood flow to the myocardium, size of ventricles, and integrity of valves (Department of Nuclear Medicine performs this test) o Patient needs to receive Thallium Chloride via IV, image is captured at rest; after 24 hours, Exercise ECG with 2nd dose of Thallium Chloride by IV then image is captured o Nursing Responsibilities (pp.764-765) No food and drinks 4-5 hours before the procedure No intake of caffeine or theophylline 24 hours before the procedure Assess for pregnancy, lactation and allergies to contrast medium (drugs is radioactive) Remove jewelry and metal objects Remain still during the procedure (some are given anti anx meds) Monitor for any unusualities during the procedure Wash hands after bowel movements and voiding (Thallium is passed through the feces and urine; inc oral intake) Cardiac Catheterization or Cardiac Angiography o Invasive, but often definitive test for diagnosis of cardiac disease o Visualization of the heart and its structures o Purpose To evaluate blockage of coronary arteries (complete or partial occlusion) To evaluate functions of heart valves and other structures To assess coronary circulation and overall heart function 29

NCM202B_A NCM of Clients with Alterations in O2 Transport Mechanism Miss Dyna A. Abello, RN MN Gold standard of Dx test for cardiac problems Nursing Responsibilities (p. 765-66) Informed consent (make sure patient understood procedure and risks and benefits involved) Assess for allergies skin testing (to radiopaque dye contrast medium, asses for allergies to seafood and iodine), baseline data (height length of catheter, weight amount of dye, v/s) No food/drinks prior to procedure Remove all metal objects/jewelry A hot, flushing sensation is expected Ask patient to hold his/her breath as the dye travels to heart and lungs (for pulsus paradoxus) Monitor cardiac rhythm patient may have cardiac dysrhythmias Assess for bleeding after the procedure pressure dressing must be applied; sandbags 4-6 hours; if venous 2-3 hours; 5 pound sandbags; advice patient to be immobile and avoid exertion Check peripheral pulses; keep affected extremity immobile - 4 Ps Pulselessness, Paresthesia, Pallor, Pain signs of vascular insufficiencies o Right Sided or Right Sided Cardiac Catheterization Right sided Femoral vein or Antecubital vein; integrity of the structures of the heart Left sided Femoral Artery or the Brachial Artery; integrity of the coronary arteries; most common Electrophysiological Study of the Heart o Invasive o Focuses on the electrical activity of specific tissues of the heart o Either venous or arterial access o Various electrodes are placed in various locations of the heart electrode catheter o Nursing Responsibilities No food/drinks prior to procedure 4-6 hours Promote patients comfort Similar to cardiac catheterization; assess for bleeding after the procedure Remain in bed for 2-3 hours; avoid exertion for 24 hours Avoid lifting of items greater than 10 pounds for 2-3 days o o

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NCM202B_A NCM of Clients with Alterations in O2 Transport Mechanism Miss Dyna A. Abello, RN MN Assessment Subjective Data Information gathered from patient Biographical data (Gordons) Risk factors (life style sedentary, smoking number of sticks in a day, alcohol use) Past medical history (surgical, childhood diseases, illnesses, immunization, medication from the very past to the very present) Family history Reasons for seeking care chief complaint Chest pain DOB Headache Blurring of vision Fatigue Clubbing of fingers Cyanosis Pallor Paresthesia P Precipitating Event Q Quality(crashing, intermittent, knife like, continuous) R - Radiating/Region (shoulder area, head, back) S Severity (pain scale) T Timing (frequency, time started) Guide Questions (box 23-2; p. 756) Objective Data Pay attention to what the client is telling you Inspection Color Posture (scoliosis, kyphosis, lordosis) Breathing pattern (DOB, sternal retraction, wheezing) Sores/Ulcerations (arterial/venous insufficiency; poor tissue perfusion) Palpation/Inspection (Supine) Nurse should be preferably at the right Apical impulse (through the use of the finger pads) Pulsation (extremities/precordium) Thrills abnormal tremors /chest vibrations Palpation Sites 1. Aortic area 2nd intercostal space at the Right of the sternum 2. Pulmonic area 2nd intercostal space at the Left of the sternum 3. Erbs Point 3rd intercostal space at the Left of the sternum 4. Tricuspid area 4th intercostal at the Left of the sternum 5. Mitral area (Apex/Apical) 5th intercostal at LMCL 31

No Throbbing upon palpation.

NCM202B_A NCM of Clients with Alterations in O2 Transport Mechanism Miss Dyna A. Abello, RN MN Auscultation Precordium

Heart sounds High Pitch: Diaphragm S1 Mitral valve S2 Aortic and Pulmonic Area Low Pitch: Bell S3 Associated with ventricular problem (Auscultate in Tricuspid/Mitral area) S4 associated with atrial contractions (Auscultate in Aortic/Pulmonic area Murmurs auditory vibrations that varies in loudness, pitch, and duration of the sound (harsh, blowing, hissing, musical); turbulence of blood flow when it is pushed through as opening that is narrowed/irregular in shape Risk Factors (Assess after Subjective and Objective cues) Non Modifiable (cannot be altered, changed, improved) Age greater than 40 for CV disorders Congenital chromosomal aberration; CHD, TOF, PDA Gender: Male is more susceptible F = 45-55 y/o risk is equal with males F > 55 y/o > risk than males Race: African Americans Heredity Modifiable Risk Factors Hyperlipidemia o Cholesterol - </= 200mg/dl o LDL - </= 100mg/dl o HDL - > 60mg o Triglycerides - </= 150mg/dl HTN o persistent elevation of BP above 140/90 o Causes a sheering force injury to arterial wall o ***stresses the heart and puts pressure on the blood vessels o Enhances lipid infiltration and calcium accumulation Cigarette smoking - Inc risk of dying from CAD by 200%-400% and is proportional to the number of cigarettes smoke per day Nicotine vasoconstrictor; releases catecholamines, inc HR and inc BP Tar hardens artery CO competes with O2 at receptor sites - The irritant effects of cigarette promotes atherosclerosis changes (caused by nicotine) DM - Promotes atherogenesis (build up of atherosclerosis) 32

NCM202B_A NCM of Clients with Alterations in O2 Transport Mechanism Miss Dyna A. Abello, RN MN Physical Inactivity - Slows down metabolism - Clot formation - *** Physical activity inc HDL - Brisk walking 3-4x a week for 15-30 minutes Obesity Other Risk Factors o Low daily fruit and vegetable intake o Alcohol consumption o Psychological index (Type A personality) Disorders of the CV System - Leading cause of death worldwide Heart Coronary Artery Dse (aka Ischemic Heart Dse, Coronary Heart Syndrome) - Caused by a block in the coronary artery 1. Refers to a variety of pathology that cause narrowing or obstruction of the coronary artery resulting in dec blood supply and O2 to the myocardium 2. Major causative factor: Atherosclerosis 3. Affects persons 30-50 y/o; men has greater chances of having it than women. 4. May be manifested as Angina Pectoris or MI Pathophysiology (p.774) Injury to the endothelial lining (tunica intima, a protective barrier that protects it from 1. Platelet aggregation and 2. Vasoconstriction) - Which becomes an entry point for lipids Allows the flow of lipids LDL particles recruit monocytes and stimulate the release of inflammatory mediators (Prostaglandins, Catecholamines, Bradykinin) Monocytes act as macrophages Ingest LDL in large quantities Engorged lipid laden macrophages (foam cells) Formed to a fatty streak Progress to fibrous plaques Inc in size Artery may be occluded 33

NCM202B_A NCM of Clients with Alterations in O2 Transport Mechanism Miss Dyna A. Abello, RN MN *** the process takes about 2-3 decades A. Angina Pectoris - Transient (temporary) paroxysmal (sudden on/off) chest pain produced by insufficient blood flow to the myocardium resulting in myocardial ischemia - Imbalance in supply and demand of O2 - *** Ischemia lack of O2; Infarction absence of O2 Types: 1. Stable Angina (Exertional Angina) - Stable onset, duration, precipitating event or degree of emotion or exertion - This types is predictable, could be avoided - Can be Relieved by rest and nitroglycerin 2. Unstable Angina - Aka Pre-infarction/Crescendo Angina; can be produced by unpredictable degree of exertion and emotion - Can be Relieved by rest and nitroglycerin 3. Variant Angina - Aka Prinzmetals/Vasospastic angina - Coronary artery spasm - Usually occurs bet 12MN-8AM due to cool temperatures and vasoconstriction; spasm would result 4. Silent Angina - Ischemia angina with no pain at all in patients with altered peripheral pain receptors - Prognosis is same with stable angina; usually with DM px 5. Syndrome X - With classic angina symptoms but without angiographic evidence; assumption is that tiny blood vessels cant be evaluated. Precipitating Factors Physical exertion sexual activity Strong emotions Cigarette smoking Extremely cold weather (esp Prinzmetals or Vasospastic or Variant Angina) Consumption of a heavy meal

Assessment Findings 1. Pain: substernal heavy, crashing, squeezing, constricting, suffocating radiates to shoulder, epigastric, neck, jaw, back and arms *** Pain is felt because from aerobic metabolism of the heart it turns to anaerobic, increase in lactic acid result to pain 34

NCM202B_A NCM of Clients with Alterations in O2 Transport Mechanism Miss Dyna A. Abello, RN MN

2. Palpitations, tachycardia, dyspnea, diaphoresis 3. Universal sign of angina pectoris Levines sign clutching of chest in response to pain. Dx Test a. b. c. d. e. f. Differential Dx from GIT problems, muscle spasm 12 Lead ECG ST segment depression/T wave inversion during chest pain Holter Monitor Stress ECG/Echocardiogram Pharmacologic Stress Test dobutamine (Dobutrex) Nuclear Scans injection of radioactive agent following an exercise/stress test; repeated after 24h; Thallium Chloride g. Coronary angiography Management Goals Problem: Imbalance of O2 supply and demand Goal: to correct Imbalance of O2 supply and demand To improve the quality of life by decreasing episodes of angina and ischemia Relieve acute pain and restore coronary circulation Prevent further attack To inc the quantity of life by preventing progression to MI and death

Pharmacologic Management Drugs that dec the workload of the heart and inc myocardial perfusion o Nitrates inc blood flow and o2 to the myocardium; gold standard of tx for angina pectoris; transdermal patch or sublingual Nurse Teachings Do not chew or swallow sublingual meds Dont take anything PO during administration of the drug; take drug before any angina producing activity 5-3-15 rule, take drug every 5 minutes; not exceeding 3 tablets in 15 minutes Tingling and Burning sensation is normal to prevent spitting of drug Replace supply every 3-4 months Do not exposed drug to sunlight Avoid placing the drug on the chest pocket skin might absorb the drug Side Effects: Headache, bradycardia, Hypotension

Apply patch on non hairy areas Beta Blockers decreases the force of myocardial contraction and slows the heart rate (olol) 35

NCM202B_A NCM of Clients with Alterations in O2 Transport Mechanism Miss Dyna A. Abello, RN MN Ca Channel Blockers blocks the influx of Ca and causes vasodilation; dec force of myocardial contraction and slow HR (Verapamil, Nifedipine, Diltiazem) Drugs that prevent myocardial infarction and death o Aspirin inhibits platelet aggregation (assess for bleeding, take it on a full stomach because it is a gastric irritant o ACE inhibitors promote endothelial vasodilation; reduce myocardial o2 demand; inhibits angiotensin 1 to angiotensin 2 formation thus vasodilation occurs; prevents release of rennin aldosterone dec fluid volume (pril drugs) o Statins lower lipid levels, lower inflammatory markers. Stabilize atherosclerotic plaques. (atorvastatin) o

Patient and Family Teaching Medication Risk factors modification (table 24-5 pp. 789-90) Compliance to treatment: medication and regular check up

B. Myocardial Infarction (Necrosis) Acute Coronary Syndrome or Heart Attack General Information 1. Death of myocardial cells 2. Formation of necrosis (tissue destruction) (20-45 minutes irreversibly damage and death) Assessment Findings 1. 2. 3. 4. 5. 6. Pain same as in angina, crushing, viselike with sudden onset Nausea and Vomiting, dyspnea Skin: cool, clammy, ashen Elevated temperature pain, release of prostaglandin Inc BP and Pulse, with gradual drop in BP (compensatory mechanism to inc blood supply) Restlessness feeling of doom

Dx Test ECG ST elevation, T wave inversion, pathologic Q wave Serum Cardiac Markers released into blood from necrotic heart muscles after an ischemic event o Creatine Kinase (CK ) MB CPK (Creatine Phosphokinase) o Creatine Kinase is not a specific cardiac marker because it has 3 isoenzymes Isoenzyme of Creatine Kinase 1. CKBB inc if there is a brain injury 2. CKMM musculoskeletal injury 3. CKMB myocardial injury o Troponin highly specific indicators of cardiac damage 36

NCM202B_A NCM of Clients with Alterations in O2 Transport Mechanism Miss Dyna A. Abello, RN MN CKMB Onset Peak Duration 3-12 h 24 h 2-3 days Troponin 3-12 h 24-48 h 5-14 days

Echocardiography Management Preserve remaining viable tissues 1. Treat the acute attack immediately. Monitor the px for the first 24h because it is the time that sudden cardiac death might occur. 2. Reduce pain (Morphine SO4); O2 administration 3. Monitor Heart Rhythm arrhythmias (irregular heart rate and rhythm 4. Improve perfusion (thrombolytics Streptokinase, Activase, Urokinase, TPA Tissue Plasminogen Activator); given 30 minutes to 1 hour 5. Monitor for complication CHF, arrhythmias 6. Discharge instructions (table 24-7 p. 798) 7. Rehabilitation and education-lifestyle is focus (cardiac rehab program); exercise of the px Function is to: i. improve functional capacity; ii. reduce disability, iii. lessen activity related symptoms MONA Morphine SO4, O2, Nitrates, Aspirin Percutaneous Coronary Interventions (PCI) - surgical intervention that will address CAD; specifically for angina pectoris Advantages - reduce mortality and morbidity - Minimal discomfort - Short hospital stay - Short recovery time - Early return to work A. PTCA (Percutaneous Transluminal Coronary Angioplasty) a. General Information 1. PTCA can be performed in various clients with single vessel CAD 2. Aim: revascularize the myocardium Dec angina inc survival 3. A balloon tipped catheter to the stenotic, diseased coronary artery B. Directional Coronary Atherectomy (removal of plaque or atheroma) for plaques that have hardened in the walls of the coronary artery o Reduces coronary stenosis by excising and removing atheromatous plaque\ o Might cause embolus 37

NCM202B_A NCM of Clients with Alterations in O2 Transport Mechanism Miss Dyna A. Abello, RN MN C. Intracoronary Stents o To reduce restenosis and abrupt closure of coronary vessels resulting from complications of coronary angioplasty Pre Op - Antiplatelet medication - Ca blockers to reduce coronary artery spasm - Blood typing and cross matching - Informed consent - Reinforce teaching regarding the procedure Post OP - Monitoring for changes of V/S and/or ECG - Monitor the puncture site - Sand bags for Bleeding - 4 Ps - Distal circulation evaluation - Pain assessment Discharge teaching - Compliance to anti-platelet therapy

CABG Coronary Artery Bypass (pass through) Graph (anastomosed or attached) invasive procedure that will address the problem of px with CAD A. General Information 1. Surgery of choice for clients with severe CAD (multi-vessel involvement) 2. Procedure requires use of extracorporeal circulation (Cardio-Pulmonary Bypass CPB Machine) anti-coagulate and oxygenate the patient *** Heart stops during the procedure; mid thoracotomy-major surgery; ***Major (thoracotomy) and minor wound -MD will harvest the vessel (before the operation): saphenous vein, internal mammary artery or the femoral artery straightest vessels and wide lumen, vessel harvested will serve as a conduit *** administer high dose of potassium Cardioplegia solution high in K B. Nursing interventions: preoperative 1. Informed consent 2. NPO 8-12h prior to the procedure 3. Reassure availability of pain medications (Morphine SO4 IV) C. Nursing interventions: Post operative 1. Maintain patent airway ***px is in the ICU with all the tubes; O2 suction 2. Promote lung reexpansion *** pre op teaching to cough and deep breathing exercise 3. Monitor cardiac status 4. Maintain fluid and electrolyte balance *** risk for hemorrhage 38

NCM202B_A NCM of Clients with Alterations in O2 Transport Mechanism Miss Dyna A. Abello, RN MN 5. Maintain adequate cerebral circulation ***O2, position 6. Provide pain relief 7. Provide client teaching and discharge planning concerning: a. Limitation with progressive inc in activities (p. 787 patient playbook) b. Modify lifestyle (diet, exercise, enrolled to Cardiac Rehab Program, stop smoking) Congestive Heart Failure aka Cardiac Decompensation; Ventricular Insufficiency; Ventricular Failure A. General Information - Inability of the heart to pump and adequate supply of blood to meet the metabolic needs of the body - After load the amount of pressure, required by the left ventricle to open the aortic valve and to eject blood; strength of contraction to pump blood out of the ventricles ***Frank Starlings Law - the greater the resting myocardial fiber length the greater the force of contraction - Preload the myocardial fiber length at the end of diastole; pag accommodate sang LV of blood before contracting - Cardiac Output HR x Stroke Volume amount of blood pumped by the ventricles for every minute - Stoke Volume amount of blood pumped by the ventricles with each contraction - Ejection fraction percentage of blood that is pumped or ejected by the ventricles B. Types: 1. Left Sided Heart Failure a. Left ventricular damage causes blood to back-up through the left atrium and into the pulmonary veins b. Caused by: o Left ventricular damage (MI and CAD) o HTN, Aortic valve disease c. Assessment Findings o Look for lung manifestations o Shortness of breath, DOB, orthopnea diff of breathing while lying down o Palpitations compensatory mechanism; heart will pump more in an attempt to eject blood of the lungs o Cough attempt of body to remove fluid from the lungs o Fatigue, weakness, syncope feeling of faintness due to lack O2 o Heart murmurs failure to open and close properly, extra heart sounds S3 or S4 o Lung crackles gurgling sound d. Dx Tests: o ECG (chamber enlargement, cardiomegaly), echocardiography, CXR (cardiomegaly, pleural effusion fluid in the pleural cavity/space; high pressure in lungs, fluid will seep out from lung tissue; chest tube to drain fluid and blood) o Stress test (DOB, problems with performing the stress test) o Blood test (CBC, RBC) 2. Right Sided Heart Failure a. Weakened right ventricle is unable to pump blood into the pulmonary system 39

NCM202B_A NCM of Clients with Alterations in O2 Transport Mechanism Miss Dyna A. Abello, RN MN b. Caused by: o left sided heart failure may progress to right sided heart failure o RV infarction o Atherosclerotic Heart Dse o COPD, Pulmonic stenosis, pulmonary embolism c. Assessment Findings o Ankle edema due to backflow from the right side of the heart to the system o Enlarged liver hepatomegaly fluid in the portals system o Weight gain accumulation of fluid o Distended neck veins inc jugular pressure o Palpable/auscultated dysrhythmias o Ascites fluid in the peritoneum d. Dx Tests o Same as LSHF Management Inc cardiac output 5-8 liters/min priority goal Maintain oxygenation and perfusion 1. Improve ventricular pump performance o Supplemental Oxygen, digoxin (improves myocardial contractility, positive inotropic (improves force of ventricular contraction), negative chronotropic-dec HR) o Px instructions regarding digitalis do take not when the HR is below 60 for adult, child 100; monitor for S/E, BANDA Bradycardia, Anorexia, N and V, Diarrhea, abdominal pain; monitor therapeutic range 0.5-2.0 ng/mL; toxicity premature ventricular contraction, muscle weakness, xanthopsia seeing green halo lights yellow vision o Diet should be high in K; HypoK induces toxicity 1 banana per meal 2. Reduce Cardiac Workload o Vasodilators, positioning high fowlers, [reduced fluid retention Na restriction diuretic potassium sparing (aldactone, spironolactone), ACE inhibitors] 3. Reduce stress and risk of injury turn frequently to prevent bed sores, never elevate foot of bed, might inc cardiac workload 4. Collaborative management Nutritionist, Dietitian, PT, Respi Therapist

Heart Muscles Diseases Cardiomyopathy a problem with the physical shape of the muscle of the heart Origin is unknown Heart muscle us unable to function correctly resulting to an impaired CO and inc workload of the heart 40

NCM202B_A NCM of Clients with Alterations in O2 Transport Mechanism Miss Dyna A. Abello, RN MN 4 types of Cardiomyopathy A. Dilated Cardiomyopathy o Dilated heart chambers resulting a dec ability of the heart to pump strongly and forcefully (inc in preload) o Associated with: CHD, HTN and heart valve dse o Assessment: SOB, dependent edema blood will backflow to the system and/or pulmonary circulation B. Hypertrophic Cardiomyopathy o Inc in size and thickness of the heart muscle resulting to a dec blood volume in the hearts chambers o Idiopathic may be associated with long term alcoholism o Assessment: asymptomatic, SOB, chest pain, palpitation, light headedness and black-out C. Arrhythmogenic Right Ventricular Cardiomyopathy o The heart muscles is replaced by fibrous scar and fatty tissue leading to alteration in the hearts ability to effectively pump o Cause: is unknown, has genetic predisposition o Assessment: palpitation, lightheadedness, fatigue (s/s of HF) D. Restrictive Cardiomyopathy o Caused by long term alcoholism o The ventricular muscle walls become stiff, but not necessarily thickened resulting to ineffective myocardial contraction o Cause: unknown o Assessments: s/s of HF Planning and Implementation Minimizing symptoms Emotional and psych support most cannot perform ADL, cant exert much effort because of dec CO Lifestyle modification: exercise and rest schedule Pharmacologic management: ACE, Diuretics, Anticoagulants, Beta blockers, Antiarrhythmics lidocaine, Procainamide, Quinidine SO4

Inflammation Dysfunction of the Heart (Carditis) Endocarditis Endocardium A. General Information 1. Inflammation of the hearts inner lining (Endocardium) 2. Caused by bacterial infection (Group A Beta Hemolytic Streptococcus) 3. Precipitating factors: medical intubation or dental procedures tooth extraction; breaks in the mucus membrane, invade circulation, bacteria stays in the heart and make a colony Heart has a lot of Beta cells (Beta 1) found in the heart muscles: eat up the valves of the heart B. Assessment Findings 1. Vague signs and symptoms of infection fever, fatigue, weakness, weight loss, body malaise 41

NCM202B_A NCM of Clients with Alterations in O2 Transport Mechanism Miss Dyna A. Abello, RN MN 2. Murmurs 3. Janeway lesions flat, painless, red, to bluish red spots in soles or palms 4. Roths spots (retinal hemorrhages) and petechiae *** bacteria releases emboli that damage the capillary 5. Fingertips may become enlarged , clubbing of nails C. Dx Tests: Blood culture to know the type of bacteria; echocardiogram valve problems Management o Prevent infection endocarditis o Eradication of microorganism Penicillin G Na is DOC o Assess complication (HF, embolism, inc infection) o Pharmacology (4-6 weeks) o Surgery if necessary if the valves are severely damaged bovine valves Myocarditis A. General Information: an acute or chronic inflammation of the myocardium as a result of systemic infection, radiation or toxic agents o Caused dilation of the heart and degeneration of the muscle fibers o Caused by bacterial infection (Group A Beta Hemolytic Streptococcus) B. Assessment o Fever, dyspnea, palpitations, chest discomfort (continuous pressure) o Heart murmurs C. Management o Immunization (HiB) o Reduce cardiac workload, treat causative agent infections Pericarditis A. General Information 1. An inflammation of the visceral and parietal pericardium 2. Caused by bacterial, viral, or fungal infection; trauma B. Assessment o Chest pain with deep inspiration characterized by crushing or stabbing pain Relieved when the patients sit up; upright as it creates distance from the sternum to the pericardium o Fever, dyspnea and abdominal pain o Beck Triad: Hypotension, muffled heart sound, elevated jugular pressure o Pericardial friction rub that can be heard when auscultated leathery, grating sound heard as pericardial layers rub against each other; characteristic sign of pericarditis C. Dx Tests o Blood studies C/S o Imaging studies Echocardiogram CXR D. Management o Antibiotics, High Fowlers, Provide Comfort Reduce work load

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NCM202B_A NCM of Clients with Alterations in O2 Transport Mechanism Miss Dyna A. Abello, RN MN Cardiac Tamponade Complication of Pericarditis Life threatening complication caused by accumulation of fluid in the pericardium (might be blood or pus) Compress the heart and restrict the blood flow in and out of the ventricles Assessment dec CO o Hypotension, tachycardia, jugular vein distention, cyanosis of lips and nails, dyspnea, muffled heart sound, diaphoresis Management o Pericardiocentesis fluid or air is aspirated from the pericardial space; large bore needle used to puncture the sternum; emergency intervention

Rheumatic Fever Pedia disorder Inflammatory disorder of the heart may involve other structure such as the joints, the connective tissue and CNS May lead to rheumatic heart dse (complication) Thought to be an autoimmune disorder body fighting against itself, antigen antibody rxn Group A Beta Hemolytic Streptococcus Might have tonsillitis or upper respi tract infection strep throat school age, poor immune system, freq exposed to children with RTI Medical Management o Drug therapy Penicillin, steroids, aspirin o Dec cardiac workload bed rest during attack of rheumatic fever Assessment Findings (Jones Criteria) tool used to Dx rheumatic fever (+) 2 major symptoms; 1 minor symptom (+) 2 minor symptoms; 1 major symptom Major symptoms o Carditis Aschoff nodules areas of inflammation and degeneration around the hearts valves, myocardium and pericardium Valvular insufficiency murmurs during auscultation Cardiomegaly X-ray enlargement of the heart o Polyarthritis tender (painful upon palpation) joints commonly seen over the elbows, risks, fingers, knees and ankles o Chorea (Sydenhams chorea, St. Vitus Dance) involves CNS, involuntary movement of extremities neck and face. o Subcutaneous nodules already involve the connective tissues, small non tender swelling over the joints, commonly found over the joints o Erythema Marginatum non pruritic rash starting from the trunk and spreading peripherally

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NCM202B_A NCM of Clients with Alterations in O2 Transport Mechanism Miss Dyna A. Abello, RN MN Minor symptoms o Fever o History of strep infection o Dx Tests Inc ESR test for inflammation, anti inflammatory test Leukocytosis inc in the WBC d/t infection (+) ASO titer (anti-streptolysin O titer) Antigen antibody test (+) CRP (C reactive protein) Antigen antibody test Nursing Interventions o Carditis Penicillin as ordered Prophylactic tx Bed rest o Arthritis Aspirin anti-inflammatory, analgesic, antipyretic o Chorea Never restrain Control stimulation Dark room, cool temperature, avoid stressors Never use fork and knives

The Blood Vessels Persistent elevation of the SBP above 140mmHg and of DBP above 90mmHg (WHO) Silent killer; 50% chance of death through Heart Attack; may predispose client to CVA; kidney failure; retinopathy, blood vessel damage (arteriosclerosis) A. Risk Factors o Family hx 50% if one 60% o Obesity lipids, artery will narrow pressure to pump blood abdominal fat o Stress o Cigarette smoking nicotine hardens blood vessels o Hypercholesterolemia o Inc Na intake inc blood volume o Narrowing of the arteries lifestyle high fat diet; heart will pump more to distribute blood and oxygen Types a. Essential (primary, idiopathic): marked by loss of elastic tissue and arteriosclerotic changes in the aorta and larger vessels; acquired as persons age; incidence is at 30-50 y/o b. Secondary: elevation of the BP as a result of another disease PIH, DM, Medications, Endocrine problems, Kidney problems c. White Coat HTN: HTN in persons who are usually normotensive except when their BP is measured by a medical professional; controversial types of HTN because it is difficult to manage. 44

NCM202B_A NCM of Clients with Alterations in O2 Transport Mechanism Miss Dyna A. Abello, RN MN d. Isolated systolic HTN (ISH): the SBP is 140mmHg, but the DBP remains less than 90mmHg persons above 70 y/o e. Persistent Severe or Resistant Hypertension (Malignant): DBP about 110 to 120mmHg; a result if HTN is left untreated to the px does not comply with the anti HTN (maintenance) meds; emergency situation, Cardipen by IV Classification of HTN in Adults (JNC VII) Dx Evaluate and Treat HTN; updated every 4years Normal: <120/<80mmHg Pre-Hypertension: SBP 120-139 or DBP 80-89 Stage 1 HPN: 140-159 or DBP 90-99 Stage 2 HPN: SBP >= 160 or DBP >=100 B. Assessment findings 1. Severe occipital headaches, polyuria; nocturia; fatigue; dizziness; epistaxis; dyspnea on exertion; dec CO 2. BP consistently above 140/90 C. Management Goal: Reduce CV and renal morbidity and mortality 1. Through life style modification o Weight reduction o Na restriction less than 1 teaspoon for the entire day o Dietary fat modification (DASH diet; table 28-4 p.917); Dietary Approaches to Stop HPN Grains, Fruits o Exercise 3-4 time a week 15-30 minutes o Alcohol restriction (1-2 glass of red wine) o Caffeine restriction o Relaxation techniques o Smoking cessation 2. Pharmacologic Intervention Pre-HPN: Life style modification Stage 1: Thiazide-type diuretic HClthiazide, Diuril (first line treatment for HPN is diuretic) or ACEI ( prevent conversion of Angiotensin1 to angiotensin2 causing vasodilators; inhibits rennin production dec blood volume prils) or ARB (Angiotensin Receptor Blockers sartans losartan)or BB (olols sympatholytics; blocks SNS; catecholamines) or CCB (Ca channels Blockers inhibits influx of Ca) Either of the Groups Stage 2: Two Drug Combination Thiazide Type Diuretic + ACEI or ARB or BB or CCB D. Discharge Instructions 1. Life style modification 45

NCM202B_A NCM of Clients with Alterations in O2 Transport Mechanism Miss Dyna A. Abello, RN MN 2. Compliance Medication orthostatic Hypotension major side effect of anti HTN Change position slowly 3. Emotional Support 4. Compliance to tx Aneurysm A permanent bulging and stretching of an artery, in which the dilation is 2 time or greater the size of the artery; weakness of the arterial wall

Classification 1. Fusiform: uniform spindle shape involving the entire circumference of the artery 2. Saccular: outpouching on one side only, affecting part of the arterial circumference; most likely to rupture; pressure is only on one side of the artery 3. Dissecting: separation of the arterial wall layers to form a cavity that fills with blood; most dangerous type of all aneurysm; px is prone to hypovolemic shock 4. False: pseudoaneurysm; no weakening of the blood vessels; the vessel wall is disrupted, blood escapes into surrounding area but is held in place by surrounding tissue; caused by blunt or penetrating, dull injury to the artery A. General Info: 1. Usually occur in men ages 50-70; caused by arteriosclerosis, HPN B. Medical Management 1. Control of underlying HPN lifestyle modification, medical management 2. Surgery: resection of the aneurysm and replacement with w Teflon/Dacron graft; client will need extra corporeal circulation (CPB machine); elective surgery upon Dx C. Assessment o Often asymptomatic o AAA: n/v, back pain, pulsation in the upper abdominal midline (never palpate because it may burst); color changes in the affected area in involvement of tissue perfusion; lower leg paralysis in others o Thoracic Aortic Aneurysm: severe back pain, bronchial obstruction, dyspnea, dysphasia, hoarseness and aphonia D. Dx Tests a. X ray b. CT scan, transesophageal echocardiography E. Discharge Teaching o Avoid straining during defecation o Activity restriction o Freq monitoring of V/S, fluid intake and output o Lifestyle modification o Nutrition and diet o Manage and control of HPN

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NCM202B_A NCM of Clients with Alterations in O2 Transport Mechanism Miss Dyna A. Abello, RN MN Thromboangiitis Obliterans (Buergers Disease) A. Occlusive dse mostly located in small to medium sized arteries and less freq in veins Most often affects men ages 25-40; dse is idiopathic; high incidence among smokers Ascending disorder Assessment Findings o Extreme sensitivity to heat and cold o Pain, digital ulceration o Color changes (cyanosis or redness in the affected extremities) o Nail beds thicken as the extremities has deficient nutrients o Peripheral pulses become weak and thready o Intermittent claudication (cramps during leg exercises) o Differentiates from DM through Hx taking Blood sugar, Cigarette smoking B. Dx: Arteriography, Doppler UTZ reveal deficient blood flow C. Management Goals: Arresting the progress of the dse Produce vasodilation (Ca channel blockers: Nifedipine) Relieve Pain (analgesics) Emotional Support D. Nursing Care: 1. Would care (debridement, can be done by nurse) 2. Client teaching (wound care, inspect foot daily, avoid exposure to extreme temperature, use glove in handling cold objects p. 897 patient playbook) 3. Leg exercises (Buerger-Allen test) series of exercises administered to patient with vascular insufficiencies/problems repeated 6-7 times at each sitting and done several times a day; px is asked to lie down supine, legs elevated 60-90 degrees; 30-180 seconds until blanching occurs; after, px is asked sit on the edge of the bed and hang feet for 2-5 minutes or until redness occurs. Px will be in a horizontal position for 3 minutes and repeat. Raynauds Phenomenon origin is unknown (Raynauds Dse can determine the cause) A. Intermittent episode of arterial spasms, most freq involving the fingers d/t arterial occlusions Raynauds Dse seen in ages 17-50 (female) Raynauds Phenomenon ages over 30 (both M and F) Predisposing factors: atherosclerosis, rheumatoid arthritis Assessment Findings 1. Coldness, numbness, tingling in one or more digits; pain 2. Intermittent color changes (pallor, cyanosis); small ulcerations and gangrene tips of digits B. Medical Management 1. CCB; analgesics C. Nursing Interventions Provide client teaching concerning: o Importance of stopping smoking o Need to maintain warmth 47

NCM202B_A NCM of Clients with Alterations in O2 Transport Mechanism Miss Dyna A. Abello, RN MN o o o o Need to use gloves in handling cold objects Drug regimen (analgesics, CCB) Limit intake of caffeine or chocolate (minimize vasoconstriction) Stress management

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