HYPOTHALAMUS

● Below the Thalamus, just

● Secretion of hormones starts at here and will stimulate the Pituitary Gland
HORMONES RELEASED BY HYPOTHALAMUS
● Corticotropin-Releasing Hormone (CRH) - Release Each
● Thyrotropin-Releasing Hormone (TRH) - Release of TSH and Prolactin
● Gonadotropin-Releasing Hormone (GnRH) - Responsible FSH and LH
● Growth Hormone-Releasing Hormone (GHRH)
● Growth Hormone-Inhibiting Hormone (SOMATOSTATIN)
● Prolactin-Inhibiting Hormone (PIH)
● Melanocyte-Inhibiting Hormone (MIH)
○ “Cyte” = cell
Hypo Hyper
1. Replacement of Hormone for life 1. Meds to decrease
2. Remove the Gland
DISORDERS OF PITUITARY GLAND
HYPOPITUITARISM
● Deficiency of one or more AP Hormones
PANHYPOPITUITARISM
● Decreased production
HYPERPITUITARISM
● Hypersecretion of Pituitary hormones
● GH, ACTH and Prolactin are commonly oversecreted
● Caused by tumors in the Pituitary Gland
ANTERIOR PITUITARY DISORDERS
GROWTH HORMONE
(DWARFISM and ACROMEGALY)
NOTE!!!! Growth Hormone hates INSULIN!!!!!
DWARFISM
● Hyposecretion of GH characterized by failure to grow in height
MANAGEMENT
● GH replacement
● Thyroid Hormone injections
● Distraction osteogenesis (picture 1)
● Metal rods in bent bones (picture 1)
● GH replacement for life
ACROMEGALY (Gigantism in Children)
● Hypersecretion of GH in Adults
● Excess Growth Hormone (GH) after epiphyseal plate closes
CAUSE : Pituitary Tumor
MANIFESTATIONS Picture 2
● Large extremities
● Organomegaly
● Hyperglycemia
● Joint pains
● Prognathism (picture 2)
● HPN
● Dysphagia
(difficulty in swallowing)
● Deep voice
MANAGEMENT: Post-Operative
● Hob elevated for 2 weeks
● Nasal packing
● No blowing
 ● Monitor nasal drainage
SURGERY: Transsphenoidal Hypophysectomy
MEDS: Parlodel decreases GH, Orthostatic Hypo
SIADH/Schwartz-Bartter Syndrome
● Hypersecretion of ADH
CAUSES: Trauma, Cerebrovascular Disease, Tumor
● Excessive water retention
MANIFESTATIONS/DUE TO
● Edema
● Weight gain
● Hypertension
● Dilutional hyponatremia
MANAGEMENT:
● Hypertonic IV
● Diuretics
● Fluid restriction
● Provide safe environment
DIABETES “INSIPIDUS” (no taste or not sweet)
● Caused by an ADH deficiency
- Decreased in ADH synthesis
- Inability of the kidney to respond to ADH
MANIFESTATIONS MANAGEMENT
● Polyuria Administer ADH: Desmopressin,
● Polyphagia Vasopressin (Sit up when spray)
● Polydypsia Side Effects: Stomatitis, Allergy, Chest
● Dehydration Tightness (SubQ Vasopressin)
● Constipation
● Diluted urine
● Low specific gravity
THYROID GLAND
Thyroid Hormones:
● T3 - Triiodothyronine
● T4 - Thyroxine
● Thyrocalcitonin - Decreases calcium
HYPOTHYROIDISM
Deficiency of Thyroid Hormones
CAUSES: Thyroidectomy, Antithyroid Drugs
MANAGEMENT
● VS
● Diet: Low Calorie, Low Cholesterol, Low Saturated Fat, High Fiber
● Administer Thyroid Replacement Drugs (taken w/o food)
■ Synthroid
■ Levothroid
■ Cytomel
■ Thyrolar
■ Thycar
HYPERTHYROIDISM
● Excessive Thyroid Hormone Section
CAUSES: Emotional Stress, Auto Immune
NOTE!!!! Thyroid Hormones enhance EPI & NOR-EPI!!!!
MANAGEMENT
● Rest
● Non-stimulating Environment
● Diet: High Calorie
 ● Safety
● Artificial tears
● Avoid Stimulants
SURGERY
● Total or Subtotal Thyroidectomy
MEDICATIONS: Radioactive Iodine (8 weeks)
If pregnant give Oral Tapazole
HYPOCALCEMIA SIGNS
1. Chvostek's Sign -is a clinical finding associated with hypocalcemia, or low levels of calcium
in the blood. This clinical sign refers to a twitch of the facial muscles that occurs when gently
tapping an individual's cheek, in front of the ear.
2. Trousseau's Sign - Induction of corporal spasm by inflation of a sphygmomanometer above
SBP for 3 minutes
3. Tetany - a symptom that involves involuntary muscle contractions and overly stimulated
peripheral nerves.
MANAGEMENT:
● Calcium and Gluconate
● IV
ADDISON’s DISEASE
● Adrenal insufficiency
● Hyposecretion of cortex
HORMONES ( G-S-M )
CAUSES: Autoimmune
MANAGEMENT:
● Monitor VS, weight, I/O
● Monitor Glucose and K level
● Hormone Replacement
○ Glucocorticoid, Mineralocorticoid, Hydrocortisone
MANAGEMENT:
● Diet: High CHON, High CHO, High NA and Low K
CUSHING’S DISEASE (Low K, High GSM)
● Hypercortisolism
CAUSES: Steroid Medications
MANIFESTATIONS:
● Obese trunk
● Moon face
● Buffalo hump
● Reddish - purple striae on trunk
● HPN
● Hyperglycemia
● Hypokalemia
● Hirsutism(abnormal growth of hair on a person's face and body, especially on a woman),
Acne
● Low immunity
MEDICATIONS: Mitotane - Lowers Adrenal Cortex
SURGERY: Adrenalectomy
● If 2 adrenal gland removed replacement for life of 1 removed 2 years of Adrenal
Hormone
PHEOCHROMOCYTOMA
● Catecholamine-producing Tumor PN- Hallmarks of the Disease
CAUSES: UNKNOWN EADACHE
MANIFESTATIONS: YPERHIDROSIS
● 5 H’s YPERMETABOLISM
YPERGLYCEMIA
MANAGEMENT:
● Do not Palpate Abdomen
SURGERY:
Adrenalectomy
*insert DM1 here*
DKA (Diabetic Ketoacidosis)
- is a serious complication of diabetes that can be life-threatening. DKA is most common
among people with type 1 diabetes. People with type 2 diabetes can also develop DKA.
DKA develops when your body doesn't have enough insulin to allow blood sugar into
your cells for use as energy.
CAUSES:
● Underdose or missed dose of insulin
● Illness of infection
● Overeating
● Stress, surgery
MANAGEMENT:
● Administer oxygen
● NaCl or 0.45% NaCl
● Regular insulin IV
DM 2
● Non-insulin dependent
● Maturity - onset - DM - peaks 50 y/o
● Ketosis - Resistant
● Less or Little insulin is produced
MANAGEMENT:
● IV INSULIN
MANIFESTATIONS:
● Same with DM 1
ORAL HYPOGLYCEMIC AGENTS
OHA 1
Sulfonylureas Agents
● Stimulate insulin secretion
○ Chlorpropamide (Diabinese)
○ Glimepiride (Amaryl)
○ Glipizide (Glucotrol)
○ Tolazamide (Tolinase)
OHA 2
Biguanides
● Metformin: Decreases liver glucose release
● 30 mins before meals
● Do not give for 48 hours for contrast dye diagnosis
OHA 3
Alpha-Glucosidase Inhibitors: Slows down intestinal Digestion
● Take with first bite if meals
● Acarbose (Precose)
● Miglitol (Glyset)
Side Effects: Flatulence, Diarrhea, Abdominal Discomfort
OHA 4
Thiazolidinedione Anti-Diuretic Agents
● Increases insulin sensitivity, thus improving glucose absorption
● w/ or w/o food
● Rosiglitazone (Avandia)
● Pioglitazone (Actos)
 GASTROINTESTINAL DISORDERS
GERD
PATHOPHYSIOLOGY
CAUSES:
● Incompetent LES
● Pyloric “Stenosis” (Closing)
● Delayed emptying — Backflow
ASSESSMENT:
● Dyspepsia (difficulty of digestion)
● Pyrosis (Heartburn)
● Regurgitation (the action of bringing swallowed food up again to the mouth)
● Dysphagia (difficulty in swallowing)
● Hypersalivation
DIAGNOSTIC EXAM
● 24- hour ambulatory pH monitoring
● Endoscopy
INTERVENTIONS
Non-Surgical:
● Avoid acids
● No meal before bedtime
● Lifestyle modification
DRUG THERAPY
● Antacids
● H2 receptor blockers
● PPI
Surgical:
● Laparoscopic
● Nissen Fundoplication
PEPTIC ULCER DISEASE

GASTRIC ULCER DUODENAL ULCER

● Poor man’s/Laborer’s ● Executive ulcer

● 50 above ● 25 to 50 y/o
● Malnourished ● Well- nourished
● Pain is felt when eating ● Pain is relieved by eating
● Pain on the left side abdomen ● Pain on the right side abdomen
● Hematemesis (blood on stool) ● Melena
● (+) H-pylori ● (+) H-pylori
DIAGNOSTIC EXAMS:
● Hemoccult Test
● EGD
INTERVENTIONS
Non-Surgical:
● Bland Diet
Drug Therapy
● Same with GERD
Surgical:
● Gastrectomy
● Vagotomy
● Billroth Procedure
● Pyloroplasty
DUMPING SYNDROME
- Rapid Emptying of the stomach contents into small intestines
INTERVENTIONS
● Avoid sugar
● High CHON, High fat & Low Cho
● Small Meals
● Avoid Fluids
● Lie down after meals
HERNIATION
- Weakness in the abdominal muscle wall in which a segment of the bowel protrudes.
CLASSIFICATIONS
● Irreducible
● Strangulated
ASSESSMENT
● Lump or protrusion in an abdominal area
● Absent bowel sound
INTERVENTIONS
Non-Surgical:
● Truss
Surgical:
● Herniorrhaphy (cannot be fixed with medications)
CHRONIC INFLAMMATORY BOWEL DISEASE
CROHN’s DISEASE
- Idiopathic inflammatory disease of the small/large intestine, or both
ULCERATIVE COLITIS
- Inflammatory disease of the Large intestines that begins in the rectum Upward

CROHN’s DISEASE ULCERATIVE COLITIS

● Regional enteritis ● Large intestine

● Environmental ● Rectum
● Diarrhea ● Emotional
● No bleeding ● Diarrhea
● 5 to 6 stools (soft) ● w/ bleeding
● 20 to 30 watery stools
● Severe form
● Anorexia
● DHN/ Weight loss
● Abdominal Pain
INTERVENTIONS
Non-Surgical:
● NPO, IV fluids
DRUG THERAPY:
● Salicylate compounds (Sulfasalazine)
 ● Prednisone
● Cyclosporine
● Anti-Diarrheals
Surgical:
● Total Proctocolectomy w/ permanent ileostomy
● Ileoanal Anastomosis
DIVERTICULAR DISEASE
DIVERTICULA
- Pouchlike herniations of the small intestines or colon.
DIVERTICULOSIS
- Presence of many pouch like herniations
DIVERTICULITIS
- Inflammation of one or more diverticula
ASSESSMENT:
● Abdominal cramp-like pain
● Distention
● Palpable, tender rectal mass
● Blood in the stools
INTERVENTIONS
Non-Surgical:
● Bedrest
● NPO, or clear liquids
● Fiber rich food
● Avoid gas formers/seeds/nuts
DRUG THERAPY:
● Antibiotics (Metronid, Ciproflox)
● Analgesics
● Laxatives
Surgical:
● Same w/ IBD
● Plus colon resection
APPENDICITIS
- Inflammation of the appendix
ASSESSMENT:
● Pain in Mc Burney’s point
● Fever/ elevated wbc
● Anorexia (eating disorder) , N and V
● Rovsing’s sign
INTERVENTIONS
Non-Surgical:
● NPO
● IV Therapy
● Proper Positioning
Surgical:
● Appendectomy
HEMORRHOIDS
- Unnaturally swollen or distended veins in the anorectal region.
PATHOPHYSIOLOGY
- Activities that increases intra-abdominal pressure leading to prolapse of the
Hemorrhoidal Vessels
INTERVENTIONS
Non-Surgical:
● Cold packs followed by “Sitz bath” (15 mins)
● High fiber diet
 ● Avoid straining
Surgery:
● Hemorrhoidectomy
CIRRHOSIS
- A chronic, progressive, liver disease w/ diffused degeneration and destruction of
hepatocytes.
ASSESSMENT FINDINGS
● Spider Angioma
● Caput Medusae
● Esophageal Varices
● Fetor Hepaticus ( Dead man’s Breath)
● Asterixis (no protein) Ammonia
● Jaundice
● Ascites
● Hepatic Encephalopathy
INTERVENTIONS
Non-Surgical:
● Diet: CHO
DRUG THERAPY:
● Diuretics
● Lactulose
● Neomycin sulfate
● Metronidazole
● Paracentesis
CHOLECYSTITIS(inflammation of the gallbladder) and CHOLELITHIASIS (litho means
Stone)
ASSESSMENT:
● RUQ pain going to the scapula hours post eating fatty foods
● Mass palpated in the RUQ
● Jaundice
● Dark orange and foamy urine
● Steatorrhea (fat malabsorption)
● Clay colored stool
DIAGNOSTICS:
● Elevated WBC, Bilirubin
● Elevated liver function tests, ALT, AST
● X-rays may reveal stones
● UTZ to identify stones, Gallbladder, and ductal
● Dilatation
INTERVENTIONS
● NPO
● Low fat meals
● Eat in small amount
Surgery:
● Cholecystectomy “Removing Gallbladder”
● Choledocolithotomy “Removing of Gallstones”
● Cholecystostomy (Drainage Bile)
PANCREATITIS
- Inflammation of the pancreas with escape of pancreatic enzymes into surrounding tissue.
ASSESSMENT:
● Grey turner sign
● Cullen’s sign
INTERVENTIONS
● NPO
 ● Parenteral (except the mouth) Nutrition
● Gastric decompression
DRUG OF CHOICE:
● Mild - NSAIDs
● Moderate - Codeine (Meperidine, Demerol)
● Severe - Morphine (can cause muscle spasm)

RESPIRATORY DISORDERS
PNEUMONIA
- inflammation of the lung parenchyma leading to pulmonary consolidation because alveoli are
filled with exudates.
ETIOLOGIC AGENTS
● Streptococcus pneumoniae (pneumococcal pneumonia)
● Haemophilus influenzae (bronchopneumonia)
● Klebsiella pneumoniae
● Diplococcus pneumoniae
● Escherichia coli
● Pseudomonas aeruginosa
HIGH RISK GROUPS
● Children less than 5 yo
● Elderly

PREDISPOSING FACTORS
● Smoking
● Air pollution
● Immunocompromised
● Prolonged immobility (hypostatic pneumonia)
● Aspiration of food (aspiration pneumonia)
● Over fatigue
● (+) AIDS
○ Kaposi’s Sarcoma
○ Pneumocystis Carinii Pneumonia
○ DOC: Zidovudine (Retrovir)
■ Bronchogenic Ca
SIGNS AND SYMPTOMS
● Productive cough, greenish to rusty
● Dyspnea with prolonged expiratory grunt
● Fever, chills, anorexia, general body malaise
● Cyanosis
● Pleuritic friction rub
● Rales/crackles on auscultation
DIAGNOSTICS
● Sputum GS/CS à confirmatory; type and sensitivity; (+) to cultured
microorganism
● CXR – (+) pulmonary consolidation
● CBC
● Elevated ESR (rate of erythropoiesis) N = 0.5- 1.5% (compensatory mech to
decreased O2)
● Elevated WBC
● ABG – PO2 decreased (hypoxemia)
NURSING MANAGEMENT
● Enforce CBR (consistent to all respiratory disorders)
● Strict respiratory isolation
● Administer medications as ordered
○ Broad-spectrum antibiotics
 ● Penicillin – pneumococcal infections
● Tetracycline
● Macrolides
○ Azithromycin (OD x 3/days)
○ Antipyretics
○ Mucolytics/expectorants
● Administer O2 inhalation as ordered
● Force fluids to liquefy secretions
● Institute pulmonary toilet – measures to promote expectoration of secretions
○ DBE, Coughing exercises, CPT (clapping/vibration), Turning and
repositioning
● Nebulize and suction PRN
● Place client of semi-fowler's to high fowlers
● Provide a comfortable and humid environment
● Provide a dietary intake high in CHO, CHON, Calories and Vit C
● Assist in postural drainage
○ Patient is placed in various position to drain secretions via force of gravity
○ Usually, it is the upper lung areas which are drained
○ Nursing management:
■ Monitor VS and BS
■ Best performed before meals/breakfast or 2-3 hours p.c. to prevent
gastroesophageal reflux or vomiting
■ Encourage DBE
■ Administer bronchodilators 15-30 minutes before procedure
■ Stop if pt. can’t tolerate the procedure
■ Provide oral care after procedure as it may affect taste sensitivity
○ Assist in postural drainage
■ Contraindications:
■ Unstable VS
■ Hemoptysis
■ Increased ICP
■ Increased IOP (glaucoma)
● Provide pt health teaching and d/c planning
○ Avoidance of precipitating factors
○ Prevention of complications
■ Atelectasis
■ Meningitis
○ Regular compliance to medications
○ Importance of ffup care
COVID-19
Coronavirus 2019 (COVID-19) 
is a disease caused by a new strain of coronavirus called severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2) that can cause symptoms from common cold to more severe
disease such as pneumonia and eventually it may lead to death especially those in vulnerable
groups such as the elderly, the very young, and people with an underlying chronic health
condition.
Coronavirus 2019 (COVID-19) 
● COVID-19 is a betacoronavirus, like MERS and SARS, all of which have their origins in
bats.
● Wuhan Huanan Seafood Wholesale Market is believed to be the original place of the
outbreak of COVID-19.
● An outbreak of pneumonia of unknown etiology in Wuhan City was initially reported to
WHO on December 31, 2019.
● The first suspected case in the Philippines was investigated on January 22, 2020.
MANIFESTATIONS: (appear within 2-14 days after exposure)
● Fever
● Dry cough
● SOB
● Fatigue
● Body aches
● Headache
● Loss of taste
● Loss of smell
● Sore throat
● Congestion or runny nose
● Sore eyes
DIAGNOSTIC FINDINGS:
● Reverse Transcription-Polymerase Chain Reaction (rRT-PCR) test that can diagnose
COVID-19 in respiratory serum samples from clinical specimens.
● Antigen testing (RAT)
● Antibody testing
● Xray and CT scan
● Other blood tests
MEDICAL MGT:
● Strict airborne isolation
● Wearing of PPE
● Medications:
○ Symptomatic treatments
○ Antiviral medication: remdesivir
○ Tocilizumab
○ Corticosteroids
NURSING MGT:
● Monitor V/S: Temp. and RR
● Monitor O2 saturation
● Maintain respiratory isolation
● Handwashing
● Health Education and awareness
● IMPORTANTLY!
● Maintain RESPIRATORY SUPPORT AND OXYGEN THERAPY
○ POSITIONING:
○ HFNC
○ MECHANICAL VENTILATORS
CHRONIC OBSTRUCTIVE PULMONARY DISEASES
CHRONIC BRONCHITIS
● (Blue Bloaters) – Inflammation of the bronchi due to hypertrophy or hyperplasia of goblet
mucous producing cells leading to narrowing of smaller airways
○ PREDISPOSING FACTORS
■ Smoking
■ Air pollution
○ SIGNS AND SYMPTOMS
■ Consistent productive cough
■ Dyspnea on exertion with prolonged expiratory grunt
■ Anorexia and generalized body malaise
SIGNS AND SYMPTOMS
● Cyanosis
● Scattered rales/rhonchi
● Pulmonary hypertension
○ Peripheral edema
○ Cor pulmonale
DIAGNOSTICS
● ABG analysis: decreased PO2, increased PCO2, respiratory acidosis; hypoxemia à
cyanosis
NURSING MANAGEMENT
● Enforce CBR
● Administer medications as ordered
○ Bronchodilators
○ Antimicrobials
○ Corticosteroids
○ Mucolytics/expectorants
● Low inflow O2 admin; high inflow will cause respiratory arrest
● Force fluids
● Nebulize and suction client as needed
● Provide comfortable and humid environment
● Health teaching and d/c planning
○ avoidance of smoking
○ prevent complications
■ Cor pulmonale
■ Pleural effusion
■ Pneumothorax
○ Regular adherence to meds
○ Importance of ffup care
PULMONARY EMPHYSEMA
● terminal and irreversible stage of COPD characterized by :
● Inelasticity of alveoli
● Air trapping
● Maldistribution of gasses (d/t increased air trapping)
● Overdistention of thoracic cavity (Barrel chest) 🡪 compensatory mechanism 🡪
increased AP diameter
PREDISPOSING FACTORS
● Smoking
● Air pollution
● Hereditary: involves alpha-1 antitrypsin 🡪 for elastase production 🡪 for recoil of the
alveoli
● Allergy
● High risk group 🡪 elderly 🡪 degenerative 🡪 decreased vital lung capacity and thinning of
alveolar lobes
SIGNS AND SYMPTOMS
● Productive cough
● Dyspnea at rest
● Prolonged expiratory grunt
● Resonance to hyperresonance
● Decreased tactile fremitus
● Decreased breath sounds ( if (-) BS 🡪 lung collapse)
● Barrel chest
● Anorexia and generalized body malaise
● Rales or crackles
● Alar flaring
● Pursed-lip breathing (to eliminate excess CO2)
BRONCHIAL ASTHMA
● reversible inflammatory lung condition caused by hypersensitivity to allergens leading to
narrowing of smaller airways
PREDISPOSING FACTORS
● COMMON (Atopic/Allergic Asthma)
● Pollens, dust, fumes, smoke, fur, dander, lints
TRIGGERS (Non-Atopic/Non-Allergenic)
● Drugs (aspirin, penicillin, B-blockers)
● Foods (seafoods, eggs, chicken, chocolate)
● Food additives (nitrates, nitrites)
● Sudden change in temperature, humidity and air pressure
● Genetics
● Physical and emotional stress
SIGNS AND SYMPTOMS
● Cough that is productive
● Dyspnea
● Wheezing on expiration
● Tachycardia, palpitations and diaphoresis
● Mild apprehension, restlessness
● Cyanosis
NURSING MANAGEMENT
● Enforce CBR
● Administer medications as ordered
○ Bronchodilators à administer first to facilitate absorption of corticosteroids
■ Inhalation
■ MDI
● Corticosteroids
● Mucolytics/expectorants
● Mucomyst
● Antihistamine
● Administer oxygen inhalation as ordered
● Forced fluids
● Nebulize and suction patient as necessary
● Encourage DBE and coughing
● Provide a comfortable and humid environment
● Health teaching and d/c planning
○ Avoidance of precipitating factors
○ Prevention of complications
● Status asthmaticus
■ DOC: Epinephrine
■ Aminophylline drip
○ Emphysema
● Regular adherence to medications
● Importance of ffup care
CARDIOVASCULAR | HEMATOLOGY
 PERIPHERAL | RESPIRATORY
CARDIOVASCULAR SYSTEM ANATOMY
● BLOOD FLOW – RIGHT (UNOXYGENATED BLOOD)
● LEFT ( OXYGENATED BLOOD)
● HEART CHAMBERS – R / L ATRIA, R / L VENTRICLES
● HEART VALVES – PREVENT BACKFLOW
● ATRIOVENTRICULAR VALVE
● TRICUSPID - RIGHT
● BICUSPID/ MITRAL – LEFT (LBM)
HEART CONDUCTION SYSTEM
● SA Node (Natural / Primary Pacemaker) – 60-100 bpm
● AV Node (Secondary Pacemaker) – 60 bpm
● BUNDLE OF HIS – 40-60 bpm
● L/R BUNDLE BRANCHES - 20-30 bpm
● PURKINJE FIBERs – 10 – 30 bpm
● CONTRACTION
● HEARTBEAT
CORONARY ARTERY DISEASE
● Most common type of cardiovascular disease (world’s no.1 killer)
AKA:
● Coronary heart disease or Ischemic Heart disease
● ISCHEMIA – insufficient supply of blood (thus including oxygen) to the tissues
due to narrowing.
● No.1 / common cause of narrowing :
ATHEROSCLEROSIS
CORONARY ATHEROSCLEROSIS - common cause
● Fat-herosclerosis
● Plaque – atheroma
● Arteriosclerosis – hardening of your vessels – large/middle arteries
● Arteriosclerosis – hardening of your vessels – arterioles / smaller arteries
ATHEROMA (plaque) obstruction partial obstruction/ incomplete occlusion
ANGINA PECTORIS (Ischemia)
full/ complete occlusion or obstruction
(rupture of atheroma - clotting)
Myocardial Infarction (necrosis)
RISK FACTORS
NON – MODIFIABLE
1. AGE > 45 - MEN; >55 WOMEN
2. GENDER – Male develops CAD earlier than female
3. RACE – African Americans than Caucasians
4. HEREDITARY – 1st degree relatives
MODIFIABLE
1. HYPERLIPIDEMIA
Diagnostic test = lipid profile fasting (10-12 hrs)
CHOLESTEROL - <200 mg/dL ; hormone synthesis & cell membrane formation
Sources: diet / liver
LIPOPROTEINS
LDL – low is bad - <160 mg/dL; func: carry cholesterol in the vessel & deposit <70 mg/dL
HDL – high is good – 35- 70 mg/dL; func: transports cholesterol to liver for excretion>40 mg/dL
TRIGLYCERIDES – 100-200 mg/dL

MODIFIABLE
2. Cigarette smoking – nicotine / nicotinic acid – activates catecholamines (epi) vasoconstriction;
dec. vascular flexibility (fragile); CO binds with hemoglobin – dec. o2 hypoxia
3. Hypertension - vessel to stiffen – injury – inflammation response – thickening of vessel walls
& hyperresponsiveness – narrowing – constriction inc. BP
4. Diabetes Mellitus
● DKA – dehydration (nss) ; dry and high sugar (250 - >500 mg/dL)- ketones; kussmaul’s
breathing; acidosis; abdominal pain
● HHNS – high dehydration; higher sugar (600-1000); no ketones no abdominal pain no
kussmaul’s; slower onset
● 18 mmol/l
ANGINA PECTORIS
Characterized by episodes or paroxysms of chest pain during increase o2 demand
PATHOGNOMONIC SIGN: LEVINE’S SIGN
● Atherosclerosis
● FAT deposit
● narrowing
● dec. blood supply
● dec. o2 supply (poor tissue perfusion)
● ISCHEMIA
● anaerobic respiration
● lactic acid
● CHEST PAIN
TRIGGERING FACTORS:
E – XPOSURE TO COLD
P – HYSICAL EXERTION
E – XCESSIVE EATING / EATING A HEAVY MEAL
S – TRESS OR ANY EMOTION-PROVOKING SITUATION
TYPES:
1. Stable angina – relieved with rest, predictable, nitroglycerin
2. Unstable angina – unrelieved with rest, unpredictable
3. Variant angina / Prinzmetal /Resting Angina – vasospasm
4. Refractory angina – unmanaged with medication
ASSESSMENT
● Chest pain relieved with rest with 3-15min,max 20 mins
DOC: NITROGLYCERIN
PQRST
Precipitating factors - causes/ triggers pain
Quality
Radiation – where does the pain radiate?
Severity – pain scale
Timing
ASSESSMENT - Quality
● Mild indigestion (burning pain/heartburn)
● Choking/strangling sensation
● Feeling of tightness, dull or heavy – although some people (especially women) may have sharp,
stabbing pain
● Heavy sensation to upper chest
● Discomfort to agonizing pain
● Radiates to the neck, jaw, shoulder, inner aspect of the arm (L)
Diagnostic findings:
ECG 12 Leads – myocardial ischemia – T – wave inversion
Lab studies:
● cardiac biomarkers (cardiac enzymes)
● TROPONIN I – (confirmatory test for MI) – more sensitive
● CK-MM – skeletal muscles
 ● CK-BB – brain
● CK-MB – heart
● Myoglobin
● LDH
● BNP – Brain natriuretic peptide – produced by ventricles when there is increased preload
and increased ventricular pressure.
● indicative of HF
● CRP –C-Reactive protein – inflammation
● Cardiac catheterization
GOAL:
● Dec. cardiac O2 demand
● Increase o2 supply
PHARMACOLOGY
● Nitrates : Nitroglycerin – DOC
○ Vasodilation
○ Max: 3 tabs interval: 5 mins
○ Sublingual – under the tongue
○ Offer sips of water prior giving SL med
○ Burning sensation
○ 6 months ; amber/dark container
● Nitroglycerin Patch
○ rotated / not in the same area skin irritation
NC: Patient’s safety
● dizziness
● hypotension
● Discuss possible side effects like headache, flushing, and hypotension.
BETA-BLOCKERS – beta adrenergic blocker - antihypertensive
1. Adrenergic – (epi/norepi)
2. Beta1 – heart – inc. HR, inc. BP
BB – dec. hr, dec. BP
1. Beta2 - lungs – bronchodilation
BB – Bronchoconstriction –no no to asthmatic (propranolol)
● OLOL – BB atenolol, propranolol, carvedilol
NURSING CONSIDERATION:
● Assess PR before administration , if patient has bradycardia
● Administer with food.
● Never to asthma patients
● Never to DM patients – mask hypoglycemia
● Antidote: GLUCAGON
CALCIUM CHANNEL BLOCKER - antihypertensive
1. Calcium vessels and heart ( squeeze) constriction
2. NEGATIVE INOTROPIC EFFECT – decrease HR, dec. Cardiac contractility)
3. Block calcium channel/site prevents inc. HR and BP
● PINE – Amlodipine, nicardipine, nifedipine
Nursing considerations:
● Assess BP and PR for signs of hypotension and bradycardia.
● Instruct to take on an empty stomach
● Change position gradually before getting up (orthostatic hypotension)
● Give prescribed laxatives like lactulose if there is any.
ANTIPLATELET MEDICATION – prevent platelet from clot formation
Ex.: ASPIRIN, CLOPIDOGREL
● Blood thinners

Nursing Considerations:
 1. Assess for signs of bleeding.
2. Avoid straining to not induce rectal bleeding
3. NSAID – Take with food.
Anticoagulant – prevent coagulation / decreases the time for your blood to coagulate
Ex: Heparin, Warfarin
Thrombolytics – dissolve clots
Ex: streptokinase
Anticoagulants
1. Heparin – prevent the formation of clot (tx for your unstable angina and NSTEMI)
Nursing consideration:
1. Assess for signs of bleeding
2. antidote: HP – Protamine sulfate
3. If injected SQ, do not give it cold or don’t aspirate to prevent hematoma formation
4. PTT test
Enoxaparin – LMWH, SQ, not inject cold to prevent hematoma
Anticoagulants
2. Warfarin – prevent clot formation
Nursing considerations:
1. Assess for signs of bleeding
2. Antidote: WK – vit. K
3. Monitor - PT or INR
4. Don't take other antiplatelet medication.
5. Diet: avoid green leafy vegetables
● Coumadin
ACUTE CORONARY SYNDROME
EMERGENT SITUATION
● Collective term for 3 critical conditions of CAD:
1. unstable angina
2. NSTEMI – non ST elevation MI
3. STEMI ---- death of myocardial tissue
● MI heart attack ABSENCE OF O2 SUPPLY
● UNSTABLE ANGINA decrease blood flow to coronary artery ruptured atherosclerotic
plaque
● Not fully blocking your artery (diff with MI)
● Untreated MI
● NSTEMI & STEMI dec blood flow to coronary due ruptured atherosclerosis full
blockage n0 O2 supply NECROSIS – tissue death (IRREVERSIBLE / PERMANENT)
Clinical Manifestation:
● Chest pain unrelieved with rest / nitroglycerin; >20 min (presenting symptom for MI)
Diagnostic findings:
1. ECG (EKG) – assist in diagnosing MI; myocardial infarction - 3 zones: 1. zone of
ischemia inverted T wave; 2. zone of injury ST elevation; 3. zone of infarction
pathologic Q wave
2. Echocardiogram (2d echo) – ventricular function ; assist in diagnosis of MI esp when ecg
is non diagnostic.
Laboratories:
● Cardiac biomarkers: trop I, CKMB, myoglobin
● PT PTT lab test results
Cardiac Enzyme (serum test) – confirmatory test for MI (+) but will rule out Angina (-)
(1) Myoglobin – 30 min – 1h (THE FASTEST); Peak: 4-6 hours; Normal: 0-85 mcg/ml
(2) Troponin – 3 hours; peak: 5-7 days; Normal: <0.6 mg/ml
(3) CK-MB – 4 hours; peak: 5-14 days; Normal: 0-5%; second best confirmatory & sensitive for
MI; the most specific enzyme to the cardiac tissue.
(4) LDH (lactic dehydrogenase)– 24 hours; peak: 48-72 hours; Normal: 140-280 IU/L;
The most sensitive, accurate, confirmatory test is the TROPONIN LEVELS.
● I – more sensitive
● T – sensitive
Troponin – can detect micro/macro infarction; can even detect non-ST elevated MI
Myocardial infarction
Goal:
1. decrease myocardial damage
2. preserve myocardial function
3. prevent further complication
ACUTE CORONARY SYNDROME:MYOCARDIAL INFARCTION
MEDICAL MGT : MONATAS
1. MORPHINE – DOC –Narcotic drug/ Opioid CNS depressant
NURSING CONSIDERATION:
● Medulla Oblongata respiratory depression RR
● HYPOTENSION BP
2. Oxygenation
3. Nitroglycerin
4. Antiplatelets : ex.: Aspirin, clopidogrel
5. Thrombolytics ex.: Streptokinase
6. Anticoagulants ex.: heparin, warfarin
7. Stool Softeners ex.: lactulose
PAIN MANAGEMENT – WHO
3 Levels:
1. mild pain – NSAIDs – ex: aspirin, ibuprofen ; ACETAMINOPHEN w/ or w/o adjuvants
● NSAID Complication gastric irritant – take with food; omeprazole
BLEEDING? Nephrotoxic Increase fluid intake
2. moderate pain opioids ex.: tramadol
3. Severe pain strong opioids ex: FENTANYL ; MORPHINE
CONGESTIVE HEART FAILURE
● Failure of the heart to pump the sufficient needed blood for circulation
● Failure of the heart to meet peripheral vascular demand
6 C’s of CHF
1. CAD – AP/ MI CHF
2. Cardiomyopathy
3. Cardiac Valvular Disorder - Regurgitation (backflow); stenosis mitral valve, aortic
valve.
Commissural fusion
4. Cardiac dysrhythmias
5. Chronic HPN
6. Cardiorenal syndrome
TYPES OF HPN
PRIMARY SECONDARY
UNKNOWN Underlying Conditions
ESSENTIAL
Cardiomyopathy – a disease of your heart muscles associated with cardiac dysfunctions.
(problem in your myocardium). Classified according to structural or functional
abnormalities/problems.
Types of Cardiomyopathy:
1. DCM – Dilated cardiomyopathy – dilation of ventricles – eventually progresses to
systolic dysfunction dec. ejection fraction
Common: Pregnancy, Viral Infection, Abusive alc intake, Chemo drugs
2. RCM – Restrictive cardiomyopathy – RIGID diastolic dysfunction, SYSTOLIC = N
idiopathic cause.
3. HCM – Hypertrophic Cardiomyopathy; genetics
Cardiomyopathy dec. SV baroreceptors (help in the regulation of BP)
● activates SNS inc. HR / inc BP / inc AFTERLOAD (inc. systemic vascular resistance)
● RAAS inc. Na & water retention fluid volume fluid overload
● increase cardiac workload CHF
PATHOPHYSIOLOGY: CHF
● 6 C’s dec. blood flow/ dec. CO baroreceptors Sympathetic NS
● epi/norepi release inc. HR, inc contraction, vasoconstrictors tissue perfusion to kidney
activates RAAS mechanism vasoconstriction, Na retention and water retention inc fluid
fluid overload inc cardiac workload
● HF
TYPES HF:
1. Systolic HF – problem in the contraction of ventricles
2. Diastolic HF - problem in the filling up of ventricles
ECHOCARDIOGRAM – Ejection fraction (normal = 50%)
● Dec. EF = Systolic dysfunction
● Normal EF = Diastolic dysfunction
LEFT SIDED HEART FAILURE
● left ventricular failure
● CoLa
● Congestion
● Coughing / Dyspnea
● Hemoptysis
● Orthopnea
● Pulmonary edema / PND
RIGHT SIDED HEART FAILURE
● Right ventricular failure
● RH
● Hepatomegaly
● Edema = bipedal/ dependent edema
● Ascites
● Distended NV/ JV
MANAGEMENT GOAL:
● Increase cardiac contractility
● Reduce preload
● Reduce afterload
DIGOXIN – PINC
● PI – Positive inotropic effect (inc. cardiac contractility)
● NC – Negative chronotropic effect (dec. HR BRADYCARDIA)
● NC: monitor for HR, withhold digoxin
HR <60
Diuretic effect
URINE OUTPUT: most reliable indicator of your CO/tissue perfusion
Accumulative effect
digoxin toxicity: GI upset (abdominal cramps, n/v)
● bradycardia, flashes of light/visual disturbances
● hypokalemia
ANTIDOTE: DIGIBIND / digoxin immune fab
● ACE INHIBITOR = Angiotensin converting enzyme inhibitor
-pril (captopril, enalapril) - ANTIHYPERTENSIVE
NOTE: 1st drug for mild HF
● ACE A1 A2 vasoconstriction
aldosterone prod Na & water retention
● Ace inhibitor vasodilation, diuresis
excretion of Na & water, but retains K+
Nursing Consideration:
● Check for BP
● Check for patients output (diuresis effect)
● Don’t give with spironolactone.
● D/C if hyperkalemia
ARBs – Angiotensin 2 receptor blockers
-sartans (losartan, valsartan, telmisartan)
● VASODILATION
Hydralazine and ISDN (isosorbide dinitrate)
- dec vascular resistance ; vasodilation
DIURETICS inc. urine output dec. blood volume decrease in BP
4 TYPES:
1. Loop diuretics Furosemide (Lasix); potassium wasting
Nursing consideration:
● Before giving Lasix, check first the BP. Withhold if BP <90/60mmHg
● Check the K+ level.
2. Potassium sparing diuretics spironolactone (Aldactone) diuresis but it retains K+
3. Thiazide hydrochlorothiazide Potassium wasting
Nursing Consideration:
● Check for K+ level
4. Osmotic Diuretics Mannitol given to patients with inc. ICP