MEDICAL PATHOLOGIES

CARDIOVASCULAR PATHOLOGIES

Introduction

Heart Screening Methods

1) X-rays: chest x-rays provide still pictures, frequently helpful in the examination of the
heart. Helpful in determining enlargement of the heart.
2) Electrocardiogram (ECG or EKG): it is the graphic measurement of electrical currents
generated by the conduction system within the heart. Connections are made between the
patient and the machine by placing electrodes or leads at different sites on the patient’s
body (e.g. ankles, wrists and six positions on the chest).
3) Stress testing: consist of taking an ECG during a prescribed amount of exercise. The test
is specifically designed to tax the physical activity of the patient. If there is myocardial
ischaemia or lack of oxygen to the heart muscles, during the test, there will be a change
in a specific portion called the S-T segment of the electrocardiogram pattern. Test can
take several forms e.g. treadmill testing, bicycle testing and climbing up and down a set
of steps.
4) Echocardiogram: uses ultrasound to determine the size, shape and position of cardiac
structures. Test is painless and non-invasive. Patient may be asked to lie still for about 20
to 40 minutes. More accurate that X-ray. Frequently done before cardiac catheterisation.
Valuable in determining congenital malformation, pericardial perfusion, cardiac tumours
etc.
5) Cardiac catheterisation: here a small catheter is inserted into a vessel in the arm or leg ad
threaded into the heart. Blood samples for analysis are removed from various parts of the
heart and the pressure within the chambers of the heart measured. Before the procedure
patient has to sign a consent form, omit breakfast on the morning of the study. Sedatives
or antihistamines may be administered before procedure.

Other heart diagnostic tests include

- Angiography
- Coronary arteriography
- CT scan
- MRI Scan
- Laboratory test (e.g. WBC, CBC, coagulation time, cholesterol etc)

Common Nursing Observations in Patients with Heart Diseases

1) Skin changes e.g. cyanosis and/or jaundice

 2) Changes in respiration: patient may experience cough, dyspnoea, orthopnoea and
increased respiratory rate.
3) Palpitations: uncomfortable awareness of the heartbeat, especially a rapid or irregular
beat.
4) Pains: chest pain is a common experience of patients with heart diseases. Pain may be
dull aching,, sharp, squeezing pain or crushing etc. may radiate to arms, jaw or neck. Pain
may occur when patient is at rest or associated with activity, breathing or strong
emotions.
5) Gastrointestinal symptoms: nausea, vomiting, indigestion or abdominal distention.
6) Pulse changes: patient may have pulse changes as a result of the illness or/and therapy.
When measuring the pulse observed the rate, rhythm and amplitude. Usually important to
count the apical pulse for a full minute.
7) Blood pressure: Bp may be abnormally high or low. Hypertension (high blood pressure)
is a major risk factor often present in persons with heart diseases. Blood pressure may
drop following myocardial infarction or in certain cardiac arrhythmias.
8) Temperature: patients with heart problems may develop fever if infection or an
inflammatory process is involved.
9) Oedema: patients may develop oedema an abnormal collection of fluid in intracellular
tissue spaces. May be observed in the eyelids, wrists, sacrum, buttock, thighs, ankles and
feet. In addition to observing the patient, two most common methods of estimating
oedema are measuring the daily weight and recording fluid intake and output.
10) Syncope: patient with syncope or fainting has a temporary loss of consciousness caused
by decreased blood flow to the brain.
11) Behavioural changes: fatigue is a common experience of patients with heart diseases. In
some cases even a small amount of activity causes the patient to become overly tired and
need rest. Other behavioural changes associated to lack of oxygen include irritability and
mood swings.

CONGESTIVE HEART FAILURE

Definition

It is a chronic condition in which the heart is unable to pump blood as well as it should (inability
to perform its umping function efficiently enough to meet the demand placed on it). This results
in the collection of fluid in the tissues, which is referred to as oedema. Since most symptoms are
caused by congestion, the condition is called congestive heart failure. It can also be referred to as
cardiac failure or cardiac decompensation.

When the heart fails over a period of time, the following changes can occur to compensate for it
e.g.
 - Enlargement of cardiac muscle fibres and their increase in number
- Enlargement of heart chambers (myocardial hypertrophy)
- Decreased renal blood activates renin-angiotensin aldosterone system which leads to salt
and water retention.

Causes

Any of the heart diseases may cause the patient to develop congestive heart failure. They include

- Coronary artery disease

- Hypertension
- Valvular heart diseases
- Arrhythmias
- Infections
- Congenital heart defects
- Damaged to heart muscles (cardiomyopathy)
- Heart attack

Signs and symptoms

Failure of the left side: when the left side of the heart is not functioning properly, the blood
being returned to the left atrium through the pulmonary vein becomes congested in the lungs.
Patient is likely to develop pulmonary oedema which is collection of fluid in the air-sacs and
lung tissues. The symptoms include

- Dyspnoea - Paroxysmal nocturnal dyspnoea

- Breathlessness - Cough and wheezing
- Confusion - Tachycardia
- Weakness - Decreased cerebral perfusion due to low
- Fatigue cardiac output.
- Pulmonary congestion
- Hypotension
- Orthopnoea
- Palpitation

Failure of the right side: when the right side of the heart is functioning improperly, the blood
being returned to the right atrium backs up into the inferior vena cava. Oedema which is a
collection of fluid in the tissues resulting swelling, develops in the parts of the body drained of
its venous flow by this large vein. As the blood backs up in the venous system, pressure builds
up in the capillaries. Fluid begins to leak into surrounding cells. Oedema starts from the ankles,
feet (legs) and thigh then abdomen. Collection of fluid in the peritoneal cavity is known as
ascites. Oedema may lead to the following
 - Loss of appetite
- Indigestion and flatus
- Weight gain
- Diuress at rest
- Jugular vein distention
- Hepatomegaly
- Ascites
- Splenomegaly
- Rapid irregular pulse

Prevention

Because heart failure results mainly from heart diseases, preventing heart diseases is the first step
in preventing heart failure. Delay onset may include low salt and fat diet, weight loss diet,
smoking cessation, exercise, prompt treatment of infection.

Laboratory findings

- Electrolyte imbalances
- Hypokalaemia
- Hyponatremia
- Elevated blood urea nitrogen
- Urinalysis reveals proteinuria
- Echocardiography
- Pulmonary artery catheterization

Management

- Digitalis
- Diuretics
- Angiotensin converting enzymes (ACE) inhibitors
- Beta blockers
- Angiotensin II receptor blockers
- Aldosterone antagonist
- Oxygen therapy
- Low salt diet
- Vasodilators

Nursing care

- Rest
- Personal hygiene
- Diet
 - Fluids
- Dehydration

PULMONARY OEDEMA

It is the accumulation of fluid in the air sacs (alveoli) of the lungs making it difficult to breath. It
interferes with gaseous exchange and can cause respiratory failure. This occurs when the left side
of the heart fails to empty completely (congestive heart failure). This reduced cardiac output
(CO) on the left side with a continuous amount of blood getting to the lungs from the right side
of the heart, resulting in an escape of capillary fluid from the blood stream into the alveoli.

Fluid in the alveoli prevents the exchange of O 2 and CO2. This fluid in the alveoli prevents blood
in the pulmonary capillaries from becoming completely oxygenated. The patient develops
cyanosis and dyspnoea.

Causes

1) Cardiogenic causes e.g. congestive heart failure (CHF), heart attack, abnormal heart
valves.
2) Non-cardiogenic causes e.g. acute respiratory distress syndrome (ARDS), kidney failure,
brain trauma, pneumonia, sepsis (blood infection)

Signs and symptoms

- Shortness of breath
- Cyanosis
- Cough
- Frothy blood-tinged sputum
- Low blood oxygen levels (hypoxia)
- Chest pain
- Moist breath sounds (rales)

Diagnosis

- Physical examination
- Chest X-ray
- Kidney function
- Complete blood count
- Ultrasound

Treatment and Nursing Care

The aim of treatment is to improve the cardiac function, reduce the amount of fluids in the lungs
and improve oxygen supply of the blood.

- Place patient in the sitting position (fowler’s) to allow lung expansion

- Oxygen therapy
- Diuretics e.g. furosemide, spironolactone.