Medical Surgical Nursing Lecture 1

III. Care of Patients with Cardiovascular Disorders MEDICATION RECONCILIAION PROCESS

ANATOMY OF THE HEART

2. SBAR Approach - Provides a framework of communication

between the interdisciplinary team about a patient’s condition
• Situation
• Background
✓ WHO: Leading cause of morbidity & mortality • Assessment
worldwide • Recommendation
✓ Leading Cause of heart diseases in the PH is RF then a. General appearance
HPN, followed by Atherosclerosis. b. Skin color and temperature
✓ Associated with stroke c. Cardiac sounds
✓ Globalization, urbanization, aging population, poverty d. Pulses
and stress e. Urine output
✓ Technology increase survival rate f. LOC
✓ Requires continuous clinical care - increasing cost of 3. Complications
care • Heart failure
• Dysrhythmias
• Renal failure
• Cerebrovascular accident
• Retinopathy
• Hypertensive crisis
Laboratory and diagnostics
• Cardiac enzymes
o CK-MB
o Troponin I
Risk factors (non-modifiable)
• Biophysical markers
• Family history, race, sex, and age
o Type B Natriuretic Peptide (BNP)
Risk factors (modifiable)
o NT-pro-BNP
• Diet, inactivity, diabetes, stress, smoking, HPN
o Erythrocyte Sedimentation Rate (ESR)
o C-Reactive Protein (CRP)
1. History o Homocysteine
a. Emergent vs. stable patient – Triage • CBC
b. Common presenting symptoms - Chest pain, o Hemoglobin & hematocrit (H & H)
c. fatigue, dyspnea, cough, weight gain • Basic Metabolic Panel (BMP)
d. Symptom analysis - Typical vs. Atypical symptoms o Sodium, potassium, magnesium
e. Medication history – Medication Reconciliation
• Lipid profile
Process (National Patient Safety Goals, JCAHO, 2008)
o Total cholesterol, LDL, VLDL, HDL, LDL:HDL
f. Chronic medical conditions ratio
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 Medical Surgical Nursing Lecture 1

• Glycosylated hemoglobin (HbA1c) Preventive Cardiology

• Coagulation studies
✓ Maintain IBW
• Cardiac Stress Test
✓ Dietary modification
o Physical
✓ Stress management technique
o Pharmacological
✓ Physical activity
o Mental/Psychological
✓ Prophylactic use of antibiotics
• Echocardiography ✓ Prompt treatment of streptococcal infections
• Cardiac catheterization Nursing Responsibilities
• Scans
1. Patient education of preventive care
o PET
2. Diet and exercise
Nursing Responsibilities
3. Body Weight - Body Mass Index = <25
1. Diagnosis of coronary vascular disease, cardiac a. >30 obese
functional capacity; determines effectiveness of b. >25 overweight
medications 4. Stress Management
2. Explain procedure: physical, pharmacological, mental 5. Prophylaxis with antibiotics
3. Physical stress test
CARDIOVASCULAR MANAGEMENT PROTOCOLS (ORDER SETS)
a. Bruce protocol
• Chest Pain Protocol
b. NPO 4 hours prior, no alcohol , caffeine, beta-
o Nitroglycerin
blockers
• Acute Coronary Syndrome Protocol
4. Monitor VS, chest pain
• Acute Myocardial Infarction Protocol
5. Target heart rate: (220 – age) x 80%-90%
• DVT Protocol
6. May be done with echocardiography
o Heparin
7. Visualizes the heart in motion; diagnoses structural
o Anticoagulation devices
defects
• CABG Protocol
8. ECG recording is done simultaneously
o Pace wire monitoring
9. May be done during stress test and compares resting
o Shoulder precautions
and stress images
• Cardiac catheterization protocol
a. NPO 6 hours prior and until gag reflex returns
• Dysrhythmia protocol
b. IV line for sedation or other meds
Cardioversion
10. Determines patency of coronary blood vessels,
• Synchronized with QRS
pulmonary artery pressure
11. Pre-procedure • Scheduled

a. Ensure signed informed consent • Sedation

b. Review results of coagulation studies, • Anticoagulation

BMP/CMP Defibrillation

c. Assess hypersensitivity to iodine ✓ Emergency management for ventricular tachycardia or

12. Post-procedure ventricular fibrillation

a. Assess access site for bleeding

b. Vascular assessment
c. Keep leg straight. No flexion.
d. Pressure dressing
Hemodynamic Monitoring
i. Central Venous Pressure Monitoring
ii. Pulmonary Artery Pressure Monitoring

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 Medical Surgical Nursing Lecture 1

Percutaneous Coronary Interventions INTRA-AORTIC BALLOON PUMP (IABP)

₋ Percutaneous Transluminal Coronary Angioplasty
(PTCA)

Heart transplantation
Nursing Responsibilities

1. Coagulation studies
2. Assessment of access site for bleeding/clotting
a. Vascular closure devices (Angio-Seal,
VasoSeal)
3. Positioning of affected extremity
4. Sheath removal • Atropine sulfate
5. Analgesia and sedation
CORONARY ARTERY BYPASS GRAFTING (CABG)

Cardiovascular Pharmacology

1. Anti-hypertensives
✓ Diuretics
✓ Vasodilators
✓ Beta-adrenergic blockers
✓ Calcium channel blockers
PACEMAKER ✓ ACE inhibitors
✓ Angiotensin receptor blockers
2. Anti-dysrhythmics
✓ Sodium-channel blockers
✓ Calcium-channel blockers
✓ Beta-adrenergic blockers
3. Cardiac glycosides
✓ Digoxin
✓ Lanoxin
4. Prophylactic anticoagulants
✓ Heparin
✓ Lovenox
5. Vasopressors

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 Medical Surgical Nursing Lecture 1

Cardiac Rehabilitation LIPOPROTEINS AND TRANSPORT

Phase i
₋ Low level activities and initial pt. and family education
₋ S/Sx, meds, rest-activity balance, follow-up
appointments
Phase Ii
₋ Supervised out-patient activities
₋ ECG-monitored exercises, lifestyle modification,
adherence to treatment plan
Phase Iii
₋ Self-directed phase
₋ Maintenance of CV stability and long-term conditioning
National Pt. Safety Goals R/t Cardiovascular Care, JCaho (2008)
Goals:
➢ Improve the safety of using medications.
Requirement: Reduce the likelihood of pt. harm
associated with the use of anticoagulation therapy DEVELOPMENT OF ATHEROMA
➢ Accurately and completely reconcile medications
across the continuum of care
➢ Improve recognition and response to changes in a
patient’s condition
Requirement: The organization selects a suitable
method that enables health care staff members to
directly request additional assistance from a specially
trained individual(s) when the patient’s condition
appears to be worsening.
Coronary Artery Disease (CAD)

▪ Leading cause of death in the older person

o Arteriosclerosis – thickening and hardening of
the walls of the arteries, usually occurring with
old age
o Atherosclerosis – abnormal accumulation of
lipid or fatty substances, and fibrous tissue in
the lining of the arterial vessel wall
a. CAD – Arteriosclerosis
CONSEQUENCES OF ATHEROSCLEROSIS
₋ General term for all types of arterial changes
₋ Best for degeneration in small arteries and
arterioles
₋ Loss of elasticity, walls thick and hard, lumen
narrows
b. CAD – Atherosclerosis
₋ Presence of atheroma
o Plaques (Consist of lipids, cells, fibrin, cell
debris)
o Lipids usually transported with lipoproteins

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 Medical Surgical Nursing Lecture 1

PATHOPHYSIOLOGY OF ATHEROSCLEROSIS c) Variant angina (Prinzmetal’s angina) – May occur in the

Analysis of serum lipids absence of CAD; d/t a major coronary spasm

₋ Total cholesterol, triglycerides, LDL, HDL d) Silent Ischemia – Associated with DM

LDL has high cholesterol content. Factors

₋ Transports cholesterol liver cells ✓ Upon physical exertion

₋ Dangerous component ✓ Extremes of temperature

HDL ✓ Consumption of a heavy meal

- Good and has low cholesterol content ✓ Stress

- Transports cholesterol cells – liver ✓ Sexual activity

Etiology ✓ Stimulants

▪ Age Signs and Symptoms of Angina Pectoris

▪ Gender ✓ Retrosternal pain

▪ Genetic factors ✓ SOB

▪ Obesity, diet high in cholesterol, animal fats ✓ Pallor

▪ Cigarette smoking ✓ Dizziness

▪ Sedentary life style ✓ Nausea and vomiting

▪ Diabetes mellitus ✓ ST segment depression

▪ Poorly controlled hypertension Cardiac Catheterization

▪ Combo of BC pills and smoking ➢ To confirm suspected heart disease

Diagnostic Tests ➢ Determines patency of coronary blood vessels,

▪ Serum lipid levels pulmonary artery pressure

▪ Exercise stress test Indications

▪ Radioisotope - For unstable angina

Treatment - Uncontrolled heart failure

▪ Decrease cholesterol and LDL - To assess if cardiac surgery is necessary

▪ Decrease sodium ion intake Nursing Responsibilities

▪ Control primary disorders a. Pre-procedure

▪ Quit smoking • Ensure signed informed consent
▪ Physical activity • Review results of coagulation studies
▪ Oral anticoagulant • NPO
▪ Surgical intervention
• Skin preparation
o Percutaneous transluminal coronary
• Assess hypersensitivity to iodine
angioplasty (PTCA)
• Ensure an IV access
o Cardiac catheterization
b. Post-procedure
o Laser beam technology
• Assess access site for bleeding
o Coronary artery bypass grafting
• Keep extremity site straight. No flexion.
Angina pectoris
• Bed rest for 4-6 hours
₋ Temporary imbalance between the coronary arteries
• Patient is usually attached to a cardiac monitor
ability to supply oxygen and cardiac muscles demand
• Monitor urine output
for oxygen
Managements
Types of Angina Pectoris
✓ O2 administration
a) Stable angina – Usually associated with a stable
✓ Drug therapy
plaque
✓ Nitrates
b) Unstable angina – Usually associated with a ruptured
✓ Beta blockers
plaque
✓ Calcium channel blockers

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 Medical Surgical Nursing Lecture 1

✓ Anti-platelet and anti-coagulant medications  Workload demands of the myocardium

o Aspirin, Clopidogrel, Heparin Assessment - Laboratory
Myocardial infarction a. Cardiac Enzymes
- Myocardial tissue is severely deprived of O2 Creatinine Kinase MB- peak action occurs 12-24 hours
- Caused by atherosclerosis after chest pain onset and returns to normal at 48-72
- Risk factors: modifiable/non-modifiable hours
How is infarction developed? Myoglobin- heme CHON that helps transport oxygen
❖ Thrombus may build up. Troponin I, T- CHON found in the myocardium
❖ Part of the thrombus may break away. Managements
❖ Vasospasm may occur 1. Pain
Warning signs a) Nitroglycerin
Feeling of pressure, heaviness or burning in the chest b) Morphine sulfate- analgesic of choice
SOB c) Other interventions:
Sweating a. O2 therapy
Weakness and fatigue b. Assume position of comfort
Nausea and indigestion c. Promote a quiet environment
Substernal chest pain 2. Altered tissue perfusion
Pallor a) Thrombolytic therapy- most effective when
Diaphoresis administered within the first 6 hours of a coronary event
Hypotension a. Streptokinase, t-PA
Low grade fever Nursing Considerations

✓ Check for bleeding

✓ May give aspirin and heparin IV (other drugs: beta-
blocker and ACE inhibitor)
3. Activity intolerance
3.1 Cardiac rehabilitation - A process of actively assisting the
client to achieve and maintain a vital and productive life.
a) Phase 1 - begins with the acute illness up to discharge
o Decrease in SBP > 20mmhg
o Changes in PR of 20bpm
o Dyspnea
Zones of injury b) Phase 2 - upon discharge up to home setting
c) Phase 3 - long term conditioning
4. Complications
 Dysrhythmias
 Heart failure
 Recurrent chest discomfort and extension of injury
Percutaneous coronary interventions
a. Percutaneous Transluminal Coronary Angioplasty
- Insertion of a balloon tipped catheter to open blocked
coronary vessels
Check for:
✓ Bleeding
Factors to Consider ✓ Dysrhythmia
 Collateral circulation
✓ Hypokalemia
 Anaerobic metabolism
✓ Hypotension
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 Medical Surgical Nursing Lecture 1

✓ Acute closure of vessel Factors affecting blood pressure

b. Coronary Artery Stent
- Insertion of a metal mesh that provides structural
support to a vessel at risk of acute closure

Activities of the renal system

Nursing Responsibilities

➢ Monitor for signs of bleeding

➢ Sheath removal
o Vascular closure devices (Angio-Seal,
VasoSeal)
➢ Check for blood studies
➢ 3Positioning of affected extremity
➢ Analgesia and sedation
➢ IV bolus of Atropine maybe given
➢ Application of pressure dressings
c. Coronary Artery Bypass Graft
- Blood vessel is grafted to the occluded coronary artery
so that blood can flow beyond the occlusion Blood Pressure Classification
BP Classification SBP mmHg DBP mmHg
Indications
Normal <120 and < 80
• Angina with more than 50% occlusion of the left Pre-HTN 120-139 or 80-89
coronary artery Stage 1: HTN 140-159 or 90-99
Stage 2: HTN ≥ 160 or ≥ 100
• Unstable angina with 2 or 3 vessel disease * Newly recognized,
requiring lifestyle
• Ischemia with HF
modifications
• Acute MI Hypertension
Cardio Pulmonary Bypass  For persons over age 50, SBP is more important than
✓ Cannulation of the inferior and superior vena cava DBP as a CVD risk factor
✓ To provide oxygenation, circulation and hypothermia  Starting at 115/75 mmHg, CVD risk doubles with each
during induced cardiac arrest increment of 20/10 mmHg throughout the BP range
Post Operative
 Transported to a post open heart surgery unit a. Primary (Essential) Hypertension
 On mechanical ventilation for 6- 24 hours ✓ Elevated BP with unknown cause
Complications ✓ 90% to 95% of all cases
▪ Fluid and electrolyte imbalance Contributing Factors
▪ Hypotension •  SNS activity
▪ Hypothermia • Diabetes mellitus
▪ Impaired cerebral tissue perfusion
•  Sodium intake
• Excessive alcohol intake

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 Medical Surgical Nursing Lecture 1

b. Secondary Hypertension ✓ Hypertensive Heart Disease

✓ Elevated BP with a specific cause • Coronary artery disease
✓ 5% to 10% in adults • Left ventricular hypertrophy
Contributing Factors • Heart failure
• Coarctation of aorta ✓ Cerebrovascular Disease (Stroke)
• Renal disease ✓ Peripheral Vascular Disease
• Endocrine disorders ✓ Nephrosclerosis
• Neurologic disorder ✓ Retinal Damage
Rx: Treat the underlying cause

- Diagnosis requires several elevated readings over

• Age (> 55 for men; > 65 for women) several weeks (unless > 180/110)
• Alcohol - BP measurement in both arms

• Cigarette smoking o Use arm with higher reading for subsequent

• Diabetes mellitus measurements

• Elevated serum lipids

• Excess dietary sodium ✓ Goal is to reduce overall cardiovascular risk factors and
• Gender control BP by the least intrusive means possible

• Family history o BP < 140/90

• Obesity (BMI > 30) o In patients with diabetes or renal disease,

• Ethnicity (African Americans) goal is < 130/80

• Sedentary lifestyle
• Socioeconomic status Average % Reduction
• Stress a) Stroke incidence: 35-40%
b) Myocardial infarction: 20-25%
c) Heart failure: 50%
✓ Frequently asymptomatic until severe and target organ
disease has occurred
✓ Fatigue, reduced activity tolerance
✓ Dizziness
✓ Palpitations, angina
✓ Dyspnea

✓ Complications
are primarily
related to
development of
atherosclerosis
(“hardening of
arteries”), or
fatty deposits A. Lifestyle Modifications
that harden with - Weight reduction and stress management
age. - Dietary changes (DASH diet)
✓ Target organ - Limitation of alcohol intake (< 2 drinks/day for men; <
diseases 1/day for women)
occurring in the heart, brain, kidney, and eyes - Regular physical activity
- Avoidance of tobacco use

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 Medical Surgical Nursing Lecture 1

B. Nutritional Therapy: DASH Diet (Dietary Approaches to Stop V. Calcium Channel Blockers
HTN) ✓ Block movement of calcium into cells, causing
- Sodium restriction vasodilation
- Rich in vegetables, fruit, and nonfat dairy products Side Effects
- Calorie restriction if overweight - Bradycardia, heart block
C. Drug Therapy
- Reduce SVR • Drug Therapy and Patient Teaching
- Decrease volume of circulating blood - Identify, report, and minimize side effects
- Diuretics o Orthostatic hypotension
- Adrenergic inhibitors o Sexual dysfunction
- β - Adrenergic blockers o Dry mouth
- ACE (Angiotensin-converting enzyme) Inhibitors o Frequent urination
- Calcium channel blockers - Ineffective health maintenance
- Anxiety
I. Thiazide-type Diuretics - Sexual dysfunction
✓ Inhibit NaCl re-absorption - Ineffective therapeutic regimen management r/t
Side Effects - lack of S/S of HTN, side effects of Rx, cost of Rx, etc.
- Electrolyte imbalances: ↓ Na, ↓ Cl, ↓ K** (advise K-rich • Health Promotion
foods) - Individual pt. evaluation
- Fluid volume depletion (monitor for orthostatic - Screening programs
hypotension) - Cardiovascular risk factor modification
- Impotence, decreased libido
II. Adrenergic Inhibitors ✓ Severe, abrupt elevation in BP
✓ Reduce sympathetic effects that cause HTN by: ✓ The rate of  in BP is more important than the absolute
o Reducing sympathetic outflow value
o Blocking effects of sympathetic activity on ✓ Most common in patients with a history of HTN who
vessels have failed to comply with medications or who have
Side Effects been under-medicated
- Hypotension Clinical Manifestations
- Varied, depending on specific drug - Hypertensive encephalopathy (H/A, N & V, seizures,
III. β – adrenergic blockers (suffix “olol”) confusion, coma)
✓ Metoprolol, propranolol - Renal insufficiency
✓ Block β – adrenergic receptors - Heart failure
o ↓ HR, ↓ inotropy, reduces sympathetic - Pulmonary edema
vasoconstriction)
Side Effects
Hospitalization
- Bradycardia, hypotension, heart failure, impotence
- IV drug therapy
IV. ACE Inhibitors (suffix “pril”)
- Monitor cardiac and renal function
✓ Enalapril, captopril
- Neurologic checks
✓ Prevents conversion of angiotensin I to angiotensin II,
- Determine cause
thereby preventing the vasoconstriction associate with
- Education to avoid future crises
A II.
Side effects
- Hypotension, cough

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