CARDIOVASCULAR DISEASES

Overview of function & structure of the heart

HEART
- Muscular, pumping organ of the body
- Left mediastinum
- Weigh 300 – 400 grams
- Resembles a closed fist
- Covered by serous membrane – pericardium
Pericardium

Parietal layer Pericardial Visceral layer

Fluid – prevent
Friction rub

Layer
1. Epicardium – outermost
2. Myocardium – inner – responsible for pumping action/ most dangerous layer - cardiogenic shock
3. Endocardium – innermost layer
Chambers
1. Upper – collecting/ receiving chamber - Atria
2. Lower – pumping/ contracting chamber - Ventricles
Valves
1. Atrioventricular valves - Tricuspid & mitral valve
Closure of AV valves – gives rise to 1st heart sound or S1 or “lub”
2. Semi lunar valve
a.) Pulmonic
b.) Aortic
Closure of semilunar valve – gives rise to 2nd heart sound or S2 or “dub”
Extra heart Sound
S3 – ventricular Gallop – CHF
S4 – atrial gallop – MI, HPN

Heart conduction system

1. Sino atrial node (SA node) (or Keith-Flock node)
Loc – junction of SVC & Rt atrium
Fx- primary pace maker of heart
-Initiates electric impulse of 60 – 100 bpm
2. Atrioventicular node (AV node or Tawara node)
Loc – inter atrial septum
Delay of electric impulse to allow ventricular filling
3. Bundle of His – location interventricular septum
Rt main Bundle Branch
Lt main Bundle Branch
4. Purkenjie Fiber
Loc- walls of ventricles-- Ventricular contractions

SA node

AV
 Purkenjie Fibers
Bundle of His

Complete heart block – insertion of pacemaker at Bundle Branch

Metal – Pace Maker – change q3 – 5 yo

Prolonged PR – atrial fib T wave inversion – MI

ST segment depression – angina widening QRS – arrhythmia
ST – elev – MI

CAD – coronary artery dse or Ischemic Heart Dse (IHD)

Atherosclerosis – Myocrdial injury
Angina Pectoris – Myocardial ischemia
MI- myocardial necrosis

ATHEROSCLEROSIS ARTERIOSCLEROSIS
- Hardening or artery due to fat/ lipid deposits at - Narrowing or artery due to calcium & CHON deposits at
tunica intima. tunica media.

Artery – tunica adventitia – outer

- Tunica intima – innermost
- Tunica media – middle

ATHEROSCLEROSIS
Predisposing Factor
1. Sex – male
2. Black race
3. Hyperlipidemia
4. Smoking
5. HPN
6. DM
7. Oral contraceptive- prolonged use
8. Sedentary lifestyle
9. Obesity
10. Hypothyroidism
Signs & Symptoms
1. Chest pain
2. Dyspnea
3. Tachycardia
4. Palpitations
5. Diaphoresis
Treatment
P – percutaneous
T – tansluminar
C – coronary
A – angioplasty

Obj:
1. To revascularize the myocardium
2. To prevent angina
3. Increase survival rate
PTCA – done to pt with single occluded vessel .
Multiple occluded vessels
C – coronary
A – arterial
B – bypass
A –and
G – graft surgery

Nsg Mgt Before CABAG

1. Deep breathing cough exercises
2. Use of incentive spirometer
3. Leg exercises

ANGINA PECTORIS- A clinical syndrome characterized by paroxysmal chest pain usually relieved by REST
or NGT nitroglycerin, resulting fr temp myocardial ischemia.
Predisposing Factor:
1. sex – male
2. black raise
3. hyperlipidemia
4. smoking
5. HPN
6. DM
7. oral contraceptive prolonged
8. sedentary lifestyle
9. obesity
10.hypothyroidism
Precipitating factors
4 E’s
1. Excessive physical exertion
2. Exposure to cold environment - Vasoconstriction
3. Extreme emotional response
4. Excessive intake of food – saturated fats.
Signs & Symptoms
1. Initial symptoms – Levine’s sign – hand clutching of chest
2. Chest pain – sharp, stabbing excruciating pain. Location – substernal
-radiates back, shoulders, axilla, arms & jaw muscles
-relieve by rest or NGT
3. Dyspnea
4. Tachycardia
5. Palpitation
6.diaphoresis
Diagnosis
1.History taking & PE
2. ECG – ST segment depression
3. Stress test – treadmill = abnormal ECG
4. Serum cholesterol & uric acid - increase.
Nursing Management
1.) Enforce CBR
2.) Administer meds
NTG – small doses – venodilator
Large dose – vasodilator
1st dose NTG – give 3 – 5 min
 2nd dose NTG – 3 – 5 min
3rd & last dose – 3 – 5 min
Still painful after 3rd dose – notify doc. MI!

55 yrs old with chest pain:

1st question to ask pt: what did you do before you had chest pain.
2nd question: does pain radiate? If radiate – heart in nature. If not radiate – pulmonary origin

Venodilator – veins of lower ext – increase venous pooling lead to decrease venous return.

Meds:
A. NTG- Nsg Mgt:
1. Keep in a dry place. Avoid moisture & heat, may inactivate the drug.
2. Monitor S/E:
orthostatic hypotension – dec bp
transient headache
dizziness
3. Rise slowly from sitting position
4. Assist in ambulation.
5. If giving NTG via patch:
i. avoid placing it near hairy areas-will dec drug absorption
ii. avoid rotating transdermal patches- will dec drug absorption
iii. avoid placing near microwave oven or during defibrillation-will burn pt due aluminum
foil in patch

B. Beta blockers – propanolol

C. ACE inhibitors – captopril
D. Ca antagonist - nefedipine
3.) Administer O2 inhalation
4.) Semi-fowler
5.) Diet- Decrease Na and saturated fats
6.) Monitor VS, I&O, ECG
7.) HT: Discharge planning:
a. Avoid precipitating factors – 4 E’s
b. Prevent complications – MI
c. Take meds before physical exertion-to achieve maximum therapeutic effect of drug
d. Importance of follow-up care.

MI – MYOCARDIAL INFARCTION – hear attack – terminal stage of CAD

- Characterized by necrosis & scarring due to permanent mal-occlusion

Types:

1. Trasmural MI – most dangerous MI – Mal-occlusion of both R&L coronary artery

2. Sub-endocardial MI – mal-occlusion of either R & L coronary artery

Most critical period upon dx of MI – 48 to 72h

- Majority of pt suffers from PVC premature ventricular contraction.

Predisposing factors Signs & symptoms Diagnostic Exam

 1. sex – male 1. chest pain – excruciating, vice like, visceral 1. cardiac enzymes
2. black raise pain located substernal or precodial area (rare) a.) CPK – MB – Creatinine
3. hyperlipidemia - radiates back, arm, shoulders, axilla, jaw & Phosphokinase
4. smoking abd muscles. b.) LDH – lactic acid dehydrogenase
5. HPN - not usually relived by rest r NTG c.) SGPT – (ALT) – Serum Glutanic
6. DM 2. dyspnea Pyruvate Transaminase- increased
7. oral contraceptive 3. erthermia d.) SGOT (AST) – Serum Glutamic
prolonged 4. initial increase in BP Oxalo-acetic - increased
8. sedentary lifestyle 5. mild restlessness & apprehensions 2. Troponin test – increase
9. obesity 6. occasional findings 3. ECG tracing – ST segment
10. hypothyroidism a.) split S1 & S2 increase,
b.) pericardial friction rub widening or QRS complexes – means
c.) rales /crackles arrhythmia in MI indicating PVC
d.) S4 (atrial gallop) 4. serum cholesterol & uric acid -
increase
5. CBC – increase WBC

Nursing Management
1. Narcotic analgesics – Morphine SO4 – to induce vasodilation & decrease levels of anxiety.
2. Administer O2 inhalation – low inflow (CHF-increase inflow)
3. Enforce CBR without BP
a.) Bedside commode
4. Avoid valsalva maneuver
5. Semi fowler
6. General liquid to soft diet – decrease Na, saturated fat, caffeine
7. Monitor VS, I&O & ECG tracings
8. Take 20 – 30 ml/week – wine, brandy/whisky to induce vasodilation.
9. Assist in surgical; CABAG
10. Provide pt HT
a.) Avoid modifiable risk factors
b.) Prevent complications:
1. Arrhythmias – PVC
2. Shock – cardiogenic shock. Late signs of cardiogenic shock in MI – oliguria
3. thrombophlebitis - deep vein
4. CHF – left sided
5. Dressler’s syndrome – post MI syndrome
-Resistant to medications
-Administer 150,000 – 450,000 units of streptokinase
c.) Strict compliance to meds
- Vasodilators
1. NTG
2. Isordil
- Antiarrythmic
1. Lydocaine blocks release of norepenephrine
2. Brithylium
- Beta-blockers – “lol”
1. Propanolol (inderal)
- ACE inhibitors - pril
1. Captopril – (enalapril)
- Ca – antagonist
1. Nifedipine
- Thrombolitics or fibrinolytics– to dissolve clots/ thrombus

S/E allergic reactions/ uticaria

1. Streptokinase
2. Urokinase
3. Tissue plasminogen adjusting factor

Monitor for bleeding:

- Anticoagulants
1. Heparin 2. Caumadin – delayed reaction 2 – 3 days

PTT PT

If prolonged bleeding prolonged bleeding

Antidote antidote Vit K

Protamine sulfate
- Anti platelet PASA (aspirin)
d.) Resume ADL – sex/ activity – 4 to 6 weeks
Post-cardiac rehab
1.)Sex as an appetizer rather then dessert –
Before meals not after, due after meals increase metabolism – heart is pumping hard after meals.
2.) Position – non-weight bearing position.

When to resume sex/ act: When pt can already use staircase, then he can resume sex.
e.) Diet – decrease Na, Saturated fats, and caffeine
f.) Follow up care.

CHF – CONGESTIVE HEART FAILURE - Inability of heart to pump blood towards systemic
circulation.
- Backflow
1.) Left sided heart failure:

Predisposing factors:
1.) 90% mitral valve stenosis – due RHD, aging
RHD affects mitral valve – streptococcal infection
Dx: - Aso titer – anti streptolysine O > 300 total units
- Steroids
- Penicillin
- Aspirin
Complication: RS-CHF
Aging – degeneration / calcification of mitral valve
Ischemic heart disease
HPN, MI, Aortic stenosis

S/Sx
Pulmonary congestion/ Edema
1. Dyspnea
2. Orthopnea (Diff of breathing sitting pos – platypnea)
3. Paroxysmal nocturnal dysnea – PNO- nalulunod
4. Productive cough with blood tinged sputum
5. Frothy salivation (from lungs)
6. Cyanosis
7. Rales/ crackles – due to fluid
8. Bronchial wheezing
9. PMI – displaced lateral – due cardiomegaly
 10. Pulsus alternons – weak-strong pulse
11. Anorexia & general body malaise
12. S3 – ventricular gallop

Dx
1. CXR – cardiomegaly
2. PAP – Pulmonary Arterial Pressure
PCWP – Pulmonary CapillaryWedge Pressure

PAP – measures pressure of R ventricle. Indicates cardiac status.

PCWP – measures end systolic/ diastolic pressure
PAP & PCWP:
Swan – ganz catheterization – cardiac catheterization is done at bedside at ICU
(Trachesostomy – bedside) - Done 5 – 20 mins – scalpel & trachesostomy set

CVP – indicates fluid or hydration status

Increase CVP – decrease flow rate of IV
Decrease CVP – increase flow rate of IV
3. Echocardiography – reveals enlarged heart chamber or cardiomayopathy

4. ABG – PCO2 increase, PO2 decrease = = hypoxemia = resp acidosis

2.) Right sided HF

Predisposing factor
1. 90% - tricuspid stenosis
2. COPD
3. Pulmonary embolism
4. Pulmonic stenosis
5. Left sided heart failure

S/Sx
Venous congestion
- Neck or jugular vein distension
- Pitting edema
- Ascites
- Wt gain
- Hepatomegalo/ splenomegaly
- Jaundice
- Pruritus
- Esophageal varies
- Anorexia, gen body malaise

Diagnosis:
1. CXR – cardiomegaly
2. CVP – measures the pressure at R atrium
Normal: 4 to 10 cm of water
Increase CVP > 10 – hypervolemia
Decrease CVP < 4 – hypovolemia
Flat on bed – post of pt when giving CVP
Position during CVP insertion – Trendelenburg to prevent pulmonary embolism &
promote ventricular filling.
 3. Echocardiography – enlarged heart chamber / cardiomyopathy
4.Liver enzyme
SGPT ( ALT)
SGOT AST

Nsg mgt: Increase force of myocardial contraction = increase CO

3 – 6L of CO

1. Administer meds:
Tx for LSHF: M – morphine SO4 to induce vasodilatation
A – aminophylline & decrease anxiety
D – digitalis (digoxin)
D - diuretics
O - oxygen
G - gases

a.) Cardiac glycosides

Increase myocardial = increase CO
Digoxin (Lanoxin). Antidote: digivine
Digitoxin: metabolizes in liver not in kidneys not given if with kidney failure.
b.) Loop diuretics: Lasix – effect with in 10-15 min. Max = 6 hrs
c.) Bronchodilators: Aminophillin (Theophyllin). Avoid giving caffeine
d.) Narcotic analgesic: Morphine SO4 - induce vasodilaton & decrease anxiety
e.) Vasodilators – NTG
f.) Anti-arrythmics – Lidocaine

2. Administer O2 inhalation – high! @ 3 -4L/min via nasal cannula

3. High fowlers
4. Restrict Na!
5. Provide meticulous skin care
6. Weigh pt daily. Assess for pitting edema.
Measure abdominal girth daily & notify MD
7. Monitor V/S, I&O, breath sounds
8. Institute bloodless phlebotomy. Rotating tourniquet or BP cuff rotated clockwise q 15 mins = to promote
decrease venous return
9. Diet – decrease salt, fats & caffeine
10. HT:
a) Complications :shock
Arrhythmia
Thrombophlebitis
MI
Cor Pulmonale – RT ventricular hypertrophy
b.) Dietary modifications
c.) Adherence to meds

PERIPHERAL MUSCULAR DISEASE

Arterial ulcers venous ulcer

1. Thromboangiitis Obliterans – male/ feet 1. Varicose veins
2. Reynauds – female/ hands 2. Thrombophlebitis
1.) Thromboangiitis obliterates/ BUERGER DISEASE- Acute inflammatory disorder affecting small
to medium sized arteries & veins of lower extremities. Male/ feet

Predisposing factors:
- Male
- Smokers

S/Sx
1. Intermittent claudication – leg pain upon walking - Relieved by rest
2. Cold sensitivity & skin color changes

White bluish red

Pallor cyanosis rubor

3. Decrease or diminished peripheral pulses - Post tibial, Dorsalis pedis

4. Tropic changes
5. Ulcerations
6. Gangrene formation

Dx:
1. Oscillometry – decrease peripheral pulse volume.
2. Doppler UTZ – decrease blood flow to affected extremities.
3. Angiography – reveals site & extent of mal-occulsion.
5.

Nsg Mgt:
1. Encourage a slow progression of physical activity
a.) Walk 3 -4 x / day
b.) Out of bed 2 – 3 x a / day
2. Meds
a.) Analgesic
b.) Vasodilator
c.) Anticoagulant
3. Foot care mgt like DM –
a.) Avoid walking barefoot
b.) Cut toe nails straight
c.) Apply lanolin lotion – prevent skin breakdown
d.) Avoid wearing constrictive garments
4. Avoid smoking & exposure to cold environment
5. Surgery: BKA (Below the knee amputation)

2.)REYNAUD’S PHENOMENON – acute episodes of arterial spasm affecting digits of hands & fingers
Predisposing factors:

1. Female, 40 yrs
2. Smoking
3. Collagen dse
a.) SLE – pathognomonic sign – butterfly rash on face
 Chipmunk face – bulimia nervosa
Cherry red skin – carbon monoxide poisoning
Spider angioma – liver cirrhosis
Caput medusae – leg & trunk umbilicus- Liver cirrhosis
Lion face – leprosy

b.) Rheumatoid arthritis –

4. Direct hand trauma – piano playing, excessive typing, operating chainsaw
S/Sx:
1. Intermittent claudication - leg pain upon walking - Relieved by rest
2. Cold sensitivity

Nsg Mgt:
a. Analgesics
b. Vasodilators
c. Encourage to wear gloves especially when opening a refrigerator.
d. Avoid smoking & exposure to cold environment

VENOUS ULCERS
1. VARICOSITIES / Varicose veins - Abnormal dilation of veins – lower ext & trunk
- Due to:
a.) Incompetent valves leading to
b.) Increase venous pooling & stasis leading to
c.) Decrease venous return

Predisposing factors:
a. Hereditary
b. Congenital weakness of veins
c. Thrombophlebitis
d. Heart dse
e. Pregnancy
f. Obesity
g. Prolonged immobility - Prolonged standing
S/Sx:
1. Pain especially after prolonged standing
2. Dilated tortuous skin veins
3. Warm to touch
4. Heaviness in legs

Dx:
1. Venography
2. Trendelenberg’s test – vein distend quickly < 35 secs

Nsg Mgt:
1. Elevate legs above heart level – to promote venous return – 1 to 2 pillows
2. Measure circumference of leg muscles to determine if swollen.
3. Wear anti embolic or knee high stockings. Women – panty hose
4. Meds: Analgesics
5. Surgery: vein sweeping & ligation
Sclerotherapy – spider web varicosities
S/E thrombosis
THROMBOPHLEBITIS (deep vein thrombosis) - Inflammation of veins with thrombus formation
Predisposing factors:
1. Smoking
2. Obesity
2. Hyperlipedemia
4. Prolonged use of oral contraceptives
5. Chronic anemia
6. DM
7. MI
8. CHF
9. Postop complications
10. Post cannulation – insertion of various cardiac catheters

S/Sx:
1. Pain at affected extremities
2. Cyanosis
3. (+) Homan’s sign - Pain at leg muscles upon dorsiflexion of foot.
Dx:
1. Angiography
2. Doppler UTZ
Nsg Mgt:
1. Elevate legs above heart level.
2. Apply warm, moist packs to decrease lymphatic congestion.
3. Measure circumference of leg muscles to detect if swollen.
4. Use anti embolic stockings.
5. Meds: Analgesics.
Anticoagulant: Heparin
6. Complication:
Pulmonary Embolism:
- Sudden sharp chest pain
- Dyspnea
- Tachycardia
- Palpitation
- Diaphoresis
- Mild restlessness