Anatomy of the Heart

Anatomy of the Heart

• Epicardium is the exterior layer of the heart
• Myocardium consists of muscle fibers that are responsible for pumping action
• Endocardium lines the inside of the heart and valves and contains endothelial tissue
• Pericardium is a thin, fibrous sac that encases the heart
• Visceral pericardium is one layer of the pericardium
• Parietal pericardium is a tough, fibrous tissue that attaches the great vessels, diaphragm, sternum, and vertebral column to support the heart in the mediastinum

Heart Chambers

• Right atrium and ventricle distributes deoxygenated blood to the lungs via the pulmonary artery for oxygenation through pulmonary circulation
• The pulmonary artery is the only artery in the body that carries deoxygenated blood
• The right atrium receives venous blood returning from the superior vena cava, inferior vena cava, and coronary sinus
• Left atrium and ventricle distributes oxygenated blood to the remainder of the body through systemic circulation via the aorta
• The left atrium receives oxygenated blood from the pulmonary circulation via four pulmonary veins

Atrioventricular (AV) Valves

• AV valves are open during diastole
• As ventricular systole begins, the ventricles contract, and blood flows upward into the cusps of the tricuspid and mitral valves, causing them to close
• The tricuspid valve separates the right atrium from the right ventricle
• The bicuspid/mitral valve lies between the left atrium and the left ventricle

Semilunar Valves

• Semilunar valves are closed during diastole
• When pressure diminishes in the pulmonary artery and aorta, blood flows back toward semilunar valves, filling the cusps and closing the valves
• During ventricular systole, the semilunar valves open as blood is ejected from the right and left ventricles into the pulmonary artery and aorta
• The pulmonic valve is between the right ventricle and the pulmonary artery
• The aortic valve is between the left ventricle and the aorta
• Left and right coronary arteries: supply arterial blood to the heart

Blood Flow Circulation

• Vena cava → right atrium → right ventricle → pulmonary valve → pulmonary artery → lungs → pulmonary veins → left atrium → left ventricle → aorta

Functions of the Cardiovascular System

Cardiac Conduction System

• Generates and transmits electrical impulses
• These stimulate contraction of the myocardium starting with the atria and then the ventricles

Three Physiologic Characteristics of Specialized Electrical Cells (nodal cells and Purkinje cells).

• Automaticity: the ability to initiate an electrical impulse
• Excitability: the ability to respond to an electrical impulse
• Conductivity: the ability to transmit an electrical impulse from one cell to another
• Sinoatrial (SA) node: primary pacemaker of the heart
• Atrioventricular (AV) node: the secondary pacemaker of the heart

Cardiac Action Potential

• Depolarization: electrical activation of a cell caused by the influx of sodium into the cell while potassium exits
• Repolarization: return of cell to resting state caused by reentry of potassium into the cell while sodium exits

Refractory Periods

• Effective refractory period: phase in which cells are incapable of depolarizing
• Relative refractory period: phase in which cells require stronger-than-normal stimulus to depolarize

Cardiac Output

• Cardiac output indicates the total amount of blood ejected usually measured in liters per minute by one of the ventricles
• Cardiac output in a resting adult is 4-6L/min but largely based on factors like metabolic demands of the body.
• CO = SV × HR

Influencing Factors impacting CO

• Autonomic nervous system
• Baroreceptors: specialized nerve cells in the aortic arch and both internal carotid arteries

Control of Stroke Volume

• Preload: the degree of stretch of the ventricular cardiac muscle fibers at the end of diastole
• Afterload: the resistance to ejection of blood from the ventricle; affected by systemic vascular resistance, pulmonary vascular resistance
• Contractility: the force generated, pulmonary vascular resistance
• Increased by catecholamines, SNS, and some medications
• Decreased by hypoxemia, acidosis, and some medications

Stroke Volume & Ejection Fraction

• Stroke Volume: indicates the amount of blood ejected from one of the ventricles per heartbeat
• Average resting stroke volume is about 60-130mL
• Ejection fraction: percentage of end-diastolic blood volume that is ejected by the left ventricle with each heartbeat (55-65%)

Risk Factors Impacting Cardiac Output

• Modifiable: hyperlipidemia, cigarette smoking, tobacco use, hypertension, diabetes, metabolic syndrome, obesity, physical inactivity
• Nonmodifiable: family history of CAD (first-degree relative), increasing age, male, African American

Common Laboratory Tests

• Cardiac biomarkers: CK isoenzymes and proteins (myoglobin, troponin T and troponin I) leak into the interstitial spaces of the myocardium and enter the lymphatic system
• Blood chemistry: includes blood urea nitrogen, Calcium, Creatinine, Magnesium, Potassium, Sodium
• Coagulation studies: Activated partial thromboplastin (aPTT), Prothrombin time (PT), INR
• Hematologic studies: Complete blood count (CBC), hematocrit, Platelets, White blood cell count (WBC)
• Lipid profile:
• Triglycerides: stored in adipose tissue and a source of energy
• Triglyceride levels increase after meals and are affected by stress
• Diabetes, alcohol use, and obesity can elevate triglyceride levels, elevating a client's risk for heart disease
• Cholesterol:
• HDL: "good cholesterol" protects coronary arteries from heart disease by transporting cholesterol from the body's cells to the liver
• LDL: "bad cholesterol" transports cholesterol to the body's cell from the liver
• Brain (b-type) natriuretic peptide: hormone that helps regulate BP and fluid volume, is usually high for someone in HF
• C-reactive protein: produced by the liver in response to systemic inflammation
• Homocysteine: an amino acid linked to the development of atherosclerosis

Electrocardiography (ECG)

• ECG: a graphic representation of the electrical current of the heart
• 12-lead ECG: to diagnose arrhythmias, conduction abnormalities, and chamber enlargement, as well as myocardial ischemia, injury, or infarction
• Also suggests cardiac effects of electrolyte disturbances (high or low calcium and potassium levels) and the effects of antiarrhythmic medications
• Continuous ECG: standard of care for patients who are at risk for arrhythmias, detects abnormalities in heart rate and rhythm

Echocardiogram

• Echocardiogram is a noninvasive ultrasound test
• Measures the ejection fraction/pumping mechanism
• Examines the size, shape, and motion of cardiac structures to confirm valves are functioning properly and to identify calcification/vegetation
• Types: transesophageal, transthoracic

Stress Test

• Exercise stress test: a patient walks/runs on a treadmill or pedals a stationary bicycle
• Exercise intensity is guided by a protocol based upon the patient's age and HR goal
• During the test, the following are monitored: two or more ECG leads for heart rate, rhythm, and ischemic change; BP; skin temperature; physical appearance: perceived exertion; and symptoms
• The test is stopped when the target HR is achieved or if the patient experiences signs of myocardial ischemia
• Abnormal findings include: chest pain, ventricular arrhythmia, ST-segment depression, and lack of HR or BP elevation of exercise

Nursing Interventions

• Patient is instructed to fast for several hours before the test and avoid stimulants, such as tobacco and caffeine
• The primary provider is instructed to hold beta-blockers, calcium channel blockers, and digitalis for up to 48 hours before the test
• Encourage wearing clothes and sneakers or rubber-soled shoes suitable for exercising
• Review the exercise method and determine if patients have a solid understanding of how to put their best exercise effort forward
• Monitor the patient for 10-15 minutes post-test until vital signs and assessment findings return to normal.
• Once stable, patients may resume their usual activities
• Pharmacologic stress test: patients who are cognitively impaired and unable to follow directions or physically disabled or deconditioned will be unable to achieve their target HR
  • Vasodilating agents such as dipyridamole, adenosine, or regadenoson are given as an IV infusion to mimic the effects of exercise by exercising on a treadmill or bicycle

Nursing Interventions

• The patient is instructed not to eat or drink anything for at least 3 hours before the test
• The patient must refrain from consuming any chocolate or caffeine for 24 hours
• Patients taking aminophylline, theophylline, or dipyridamole are instructed to stop taking medications for 24-38 hours before the test
• Instruct the patient to report the occurrence of any other symptoms during the test to the cardiologist or nurse
• May take between 1-3hrs to perform

Cardiac Catheterization

• Cardiac Catheterization is a common invasive procedure used to diagnose the structural functional diseases of the cardiac system
• Guides treatment decisions, including revascularization needs (PCI or CABG) and other interventions to manage structural defects of valves or septum
• Procedure percutaneously inserts radiopaque catheters into a large vein and artery
• Should only be performed if a patient comes in with chest pain or exhibits signs of an acute MI and should be done immediately
• Right heart catheterization: pulmonary artery pressure and oxygen saturations may be obtained, and a biopsy of myocardial tissue may be obtained
• Left heart catheterization: contrast agent assists with ID of blockage of plaque or thrombus in blood vessels
• Nursing interventions:
  • Observe cath site for bleeding and hematoma, usually assessed at femoral artery or radial artery
  • Assess peripheral pulses: insertion of catheter can cause damage to vessels which means distal pulses must be assesed
  • Evaluate temperature, color, and capillary refill of the affected extremity
  • Screen for arrhythmias - common after Cath insertion because it's very irritating to the heart
  • Maintain bed rest for 2-6 hrs, based on site of insertion
  • Instruct patient to report chest pain, bleeding
  • Monitor for contrast-induced nephropathy
  • Ensure patient safety: the patient should remain supine to prevent irritation

Coronary Vascular Disorders

• Angina pectoris: term used to describe chest pain and often occurs when the heart sustains decreased perfusion because of narrowing of blood vessels
• Results in ischemia when blood flow is compromised

Types of Angina

• Stable (exertional) angina: occurs with exercise or emotional stress and is relieved by rest or nitroglycerine
• Unstable (preinfarction) angina: occurs with exercise or at rest, but increases in occurrence, severity, or duration over time
• Variant (prinzmetal/vasospastic) angina: due to a coronary spasm, often occurring during periods of rest

Acute Coronary Syndrome (ACS).

• ACS is an acute onset of ischemia to the myocardium that can result in myocardial death
• An emergent situation that encompasses unstable angina and non-ST-elevation and ST-elevation myocardial infarction (NSTEMI, STEMI) which are results of an imbalance between myocardial oxygen supply and demand
• Early recognition and treatment of an acute MI is essential

Myocardial Infarction

• Myocardial Ischemia due to the heart being abruptly cutoff form oxygen supply
• Can lead to tissue necrosis (infarction) if blood supply and oxygen are not restored, but ischemia is reversible
• An infarction results in permanent damage
• Cardiac enzymes are released into bloodstream providing specific markers of MI as cardiac muscle suffers ischemic injury
• MIs are classified:
• Area of heart affected: anterior, lateral, inferior, or posterior
• ECG changes produced: ST-elevation myocardial infarction vs. non-ST elevation myocardial infarction

Expected MI findings

• Anxiety and a feeling of impending doom
• Chest pain: substernal or precordial
• Can radiate to neck, shoulder, or arm, or present as jaw pain (MI)
• Weakness or numbness
• Indigestion and nausea
• Dizziness
• Women might experience atypical angina- characterized by pain between shoulders, ache in the jaw, or sensation of choking with exertion.
• Pallor, and cool, clammy skin during physical assessment
• Assess for Tachycardia and heart palpitations
• Tachypnea and SOB
• Check for Diaphoresis
• Check for Vomiting
• Reduced LOC during assessment
• Myoglobin: earliest marker of injury to cardiac injury
• Creatinine kinase-MB: peaks around 24 hours after the onset of chest pain
• Troponin I or T: any positive value indicates damage to cardiac tissue

Treatment Guidelines For Acute MI

• Transit rapidly to the hospital (call 911)
• Obtain 12-lead electrocardiogram (ECG, EKG) to be read within 10 minutes
• Obtain laboratory blood specimens of cardiac biomarkers – troponin
• Obtain diagnostics to clarify diagnosis
• Administer supplemental oxygen
• Prescribe Nitroglycerine
• Prescribe Morphine
• Aspirin 162-325 mg: prevents platelets formation and helps slow down formation of clot
• Beta-blocker
• Angiotensin-converting enzyme inhibitor within 24 hours
• Anticoagulation and platelet inhibitors – heparin
• Evaluate for indications of reperfusion therapy, such as a percutaneous coronary intervention or thrombolytic (fibrinolytic) therapy

Mitral Valve Prolapse

• Mitral Valve Prolapse is when a portion of one or both mitral valve leaflets balloon back into the atrium during systole, causing regurgitation of blood from the left ventricle back into the left atrium
• Can lead to heart enlargement, atrial fibrillation, pulmonary hypertension, and heart failure
• Causes: may be an inherited connective tissue disorder resulting in enlargement of one or both of the mitral valve leaflets
• S/S: usually asymptomatic, more common in women, but if symptomatic, expect fatigue, SOB, dizziness, palpitations
• Diagnosis: extra heart sound (mitral click), echocardiogram
• Management: control symptoms, eliminate caffeine, alcohol, and tobacco use; give antiarrhythmics, nitrates, calcium channel blockers, and beta-blocker referrals

Mitral Regurgitation

• Mitral Regurgitation is when blood flows back from the left ventricle into the left atrium during systole
• Causes: problems with one or more leaflets, chordae tendineae, annulus or papillary muscle, generative changes, ischemia of left ventricle
• With each beat of left ventricle, some blood is forced back into the left atrium, adding to blood flowing in from the lungs, so the lungs become congested, eventually adding extra strain to the right ventricle and systolic heart failure develops
• S&S: chronic-often asymptomatic, but acute-usually manifests as severe congestive heart
• Expect dyspnea, fatigue, and weakness, along with palpitations, SOB on exertion, and a cough from pulmonary congestion
• Diagnosis is based on heart sounds and echocardiography
• Management: medications to reduce afterload and surgical repair

Mitral Stenosis

• Mitral Stenosis is an obstruction to blood flowing from the left atrium into the left ventricle
• Causes: most often caused by rheumatic endocarditis, which progressively thickens mitral valve leaflets and chordae tendineae
• Poor left ventricular filling can cause decreased cardiac output and increased blood volume in the left atrium causing it to dilate and hypertrophy; the pulmonary circulation becomes congested
• S&S: dyspnea on exertion due to pulmonary venous hypertension, progression of fatigue, decreased exercise tolerance (r/t low CO), dry cough, and/or wheezing (enlarged left atrium creating pressure on the left bronchial tree); hemoptysis, palpitation, orthopnea, paroxysmal nocturnal dyspnea (PND), and repeated respiratory infections
• Diagnostics: auscultation, echocardiography, electrocardiogram (EKG), cardiac catheter testing
• Management: anticoagulants to decrease the risk of developing atrial thrombus, cardioversion, beta-blockers, digoxin, or calcium channel blockers and avoidance of strenuous activities, competitive sports, and pregnancy, surgery-valvuloplasty, Percutaneous transluminal valvuloplasty, or valve replacement

Aortic Regurgitation

• Aortic Regurgitation is when blood flows back into the left ventricle from the aorta during diastole
• Causes: inflammatory lesions that deform aortic valve leaflets, dilation of the aorta, infective or rheumatic endocarditis, congenital abnormalities, disease (syphilis), dissecting aneurysm that causes dilation or tearing of ascending aorta, blunt chest trauma, deterioration of a Surgically replaced aortic valve
• S&S: no symptoms in most patients, forceful heartbeat, especially head or neck, marked arterial pulsation, exertional dyspnea and fatigue, and breathing difficulties related to progressive left ventricular failure
• Diagnose via auscultation, widened pulse pressure, echocardiography, cardiac MRI, radionuclide imaging, and cardiac catheterization
• Management: treatment of choice is aortic valve replacement or valvuloplasty. Avoid physical exertion, competitive sports, and isometric exercise. Vasodilators (calcium channel blocker, ACE inhibitors, and hydralazine) can also be utilized.

Aortic Stenosis

• Aortic Stenosis is the the narrowing of orifice between the left ventricle and aorta
• Causes: degenerative calcification caused by proliferative and inflammatory changes which occur in response to years of normal mechanical stress and risk factors that increase degenerative changes of valve - diabetes, hypercholesterolemia, hypertension, and low levels of high-density lipoprotein cholesterol
• S&S: exertional dyspnea, caused by increased pulmonary venous pressure due to left ventricular failure, Orthopnea, PND, and pulmonary edema as well as dizziness and syncope.
• Diagnosis: auscultation, echocardiography, electrocardiography, cardiac catheter testing
• Management: medications to treat dysrhythmia or left ventricular failure
• Definitive treatment is surgical replacement of aortic valve or balloon percutaneous valvuloplasty procedures with or without transcatheter aortic valve implantation (TAVI, TAVR)
• Continue IV heparin, bivalirudin, or fondaparinux, clopidogrel (plavix), glycoprotein IIB/IIa inhibitor. Bed rest for a minimum of 12-24 hours - recovery before early ambulation

Invasive Cardiovascular Procedures

• Percutaneous transluminal coronary angioplasty: balloon catheter inserted via femoral artery is used to expand the diameter of a coronary artery that has an accumulation of plaque or blockage to reestablish blood flow
• Assess distal peripheral pulses from the affected extremity

Other Heart Procedures

• Coronary artery stent
• Coronary artery bypass graft (CABG)

Potential Complications of Invasive Cardiovascular Procedures

• Myocardial ischemia: chest pain, ischemic changes on ECG, and dysrhythmias
• Bleeding and hematoma formation: continuation of bleeding from vascular access site, swelling at site, formation of hard lump, pain with leg movement, hypotension, and tachycardia
• Retroperitoneal hematoma: back, flank or abdominal pain, hypotension, tachycardia, restlessness, and agitation
• Arterial occlusion: lost/weakened pulse distal to sheath insertion site, extremity cool, cyanotic, and painful
• Pseudoaneurysm formation: swelling at vascular access site, pulsatile mass, a bruit detected, may feel pulsation - Arteriovenous fistula formation: swelling at vascular access site, pulsatile mass, a bruit detected, may feel pulsation - Acute kidney injury: decreased urine output, elevated BUN, serum creatinine

Mechanical Valves

Classified as:

• Bileaflet, tilting-disk, or ball-and-cage design Used for:
• More durable than tissue prosthetic valves; therefore, they often are used for younger patients Used for:
• Require anticoagulation post-operatively
• Used for patients with renal failure, hypercalcemia, endocarditis, or sepsis (mechanical valves do not deteriorate or become infected as easily as tissue valves) Complications involve:
• Thromboemboli and effects of long-term need for required anticoagulants

Tissue Valves

Defined as:

• Bioprosthesis (pig-porcine, cows-bovine horses-equine) - last 7-15 years
• Homografts a.k.a allografts (ie, human valves) obtained from cadaver tissue donations and are used for aortic and pulmonic valve replacement and last for about 10-15 years
• Autografts: obtained by excising the patient's own pulmonic valve and a portion of pulmonary artery for use as the aortic valve and is an alternative for children, women of childbearing age, young adults, patients with a history of peptic ulcer disease, and people who cannot tolerate anticoagulation
• Aortic valve autografts have remained viable for more than >20 years

Nursing Management for Valvuloplasty or Valve Replacement

• Management: Monitor for heart failure and emboli and assess heart sounds Q4 hours

Same care as after cardiac catheterization

• Assess hemodynamic stability and recovery from anesthesia Frequent assessments with attention to neurologic, respiratory and cardiovascular systems

Cardiomyopathy

• Cardiomyopathy defined as a series of progressive events that culminates in impaired cardiac output and inadequate loss of cardiac muscle function

Assessment

• History: predisposing factors, family history
• Document and asses Chest pain
• Perform a Review of systems and note presence of orthopnea and syncope
• perform a Review of diet, specifically sodium reduction and vitamin supplements
• Examine Psychosocial history: impact on family, stressors, and reports of depression
• Physical assessment: VS, pulse pressure, pulsus paradoxus, weight gain or loss, PMI, murmurs, assess presence of S3 or S4, pulmonary auscultation for crackles, JVD, and edema as well

General Cardiomyopathy Treatments

Non-surgical : treat HF and dysrhythmias

Pericarditis

• The inflammation of the pericardium
• Commonly follows a respiratory infection
• Can be due to a myocardial infarction
• Can be due to acute exacerbation of a systemic connective tissue disease

Includes

• Chest pressure/pain aggravated by breathing, cough and swallowing the, pericardial friction rub auscultation at left lower sternal border with, SOB, and relief of pain when sitting and leaning forward

Myocarditis

• The inflammation of the myocardium
• Has a few different causes Like a. Viral, fungal, or bacterial infection, or an autoimmune disorder
• Tachycardia being one of the most prominent, but also murmur, friction rub auscultation in lungs, cardiomegaly, chest pain, and dysrhythmias

Rheumatic Endocarditis

• The infection of endocardium due to complication of rheumatic fever due the the strep
• Findings include: fever, chest pain, joint pain, tachycardia, SOB, rash on trunk and extremities, friction rub, murmur, and muscle spasms

Heart Failure

Can be caused by the structural or functional differences in the heart, where it is no longer able to fill or eject blood. This is a progressive chronic disease that can benefit from lifestyle changes.

• Medical management of patient in HF
• Varies according to severity of patient's condition, comorbidities and cause
• Medical interventions may include:
• Oral and IV medications
• Lifestyle modifications and or Surgical interventions
• Comprehensive education and counseling to patient and family is needed
• Medications Used For HF
  • Diuretics: decreased fluid volume, monitor serum, electrolytes
  • Angiotensin-converting enzyme (ACE) inhibitors: vasodilation; diuresis; decreases afterload; monitor for hypotension, hyperkalemia and altered renal function; cough
  • Angiotensin II receptor blockers: prescribed as alternative to ACE inhibitors; work similarly
  • Beta-blockers: prescribed in addition to ACE inhibitors; may be several weeks before effects seen; use with caution in patients with asthma
  • Ivabradine: decreases rate of conduction through the SA node; observe for decrease HR and BP
  • Hydralazine and isosorbide dinitrate is an alternative to ACE inhibitors and look for decreased BP

Treatments in HF

Digitalis: improves contractility; monitor for digitalis toxicity especially if patient is hypokalemic

• IV medications: indicated for hospitalized patients admitted for acute decompensated HF
• Dopamine: vasopressor to increase BP and myocardial contractility; adjunct with loop diuretics
• Dobutamine: used for patients with left ventricular dysfunction; increases cardiac contractility and renal perfusion
• Milrione: decreases preload and afterload; causes hypotension and increased risk of dysrhythmias
• Vasodilators: IV nitro, nitroprusside, nesiritide; enhance symptoms relief

Nursing Interventions for HF

Focus on the following goals and points in care:

• Promote activity tolerance by using
  • Bed rest for acute exacerbations, which can lead to a gradual increase for regular activity
• Manage fluid volume via assessing:
• Daily weights, and intake and output assessments. Consider diuretic and fluid restrictions.
• Assess Pulmonary edema:
  • Monitor for Clinical manifestations which can include: restlessness, anxiety, tachypnea, dyspnea, cool and clammy skin, cyanosis, weak + rapid pulse, cough, lung congestion and increased sputum production, decreased LOC
• Prevention and action for Thromboembolism due to to decreased mobility and circulation increase risk, especially in HF patients.

Pericardial and Cardiac Tamponade

• Pericardial effusion: accumulation of fluid in pericardial sac leading to Cardiac tamponade which consists of restriction of heart function the to fluid, resulting in decreased venous return and decreased CO
• Cardinal signs of cardiac tamponade: failing systolic BP, narrowing pulse pressure, rising venous pressure, distant heart sounds

For medical management, consider the following:

• Pericardiocentesis: puncture of pericardial sac to aspirate pericardial fluid
• Pericardiotomy: under general anesthesia so a portion of pericardium is excised to permit the exudative pericardial fluid to drain into the lymphatic system

Sudden Cardiac Death, Cardiac Arrest, and Athersclerosis treatment

• Emergency is to manage sudden Cardiac Death or Cardiac Arrest which is: A: airway, B: breathing, and C: circulation, with preparation for Defibrillation. The main goal is for CPR, emergency access via ambu bag and prep for emergency medications. Key Nursing priorities include: Atherosclerosis: affecting the intima of large and medium sized arteries; accumulation of lipids, calcium, blood components, carbohydrates, and fibrous tissue on the intimal layer of artery
• Risk factors for atherosclerosis and PAD
• Modifiable modifactions include nicotine use, diabetes, hypertension, hyperlipidemia, diet, stress, sedentary lifestyle, c-reactive protein, hyperhomocysteinemia
• Nonmodifiable increasing age, familial predisposition and genetics

Peripheral Artery Disease (PAD)

• PAD is a result caused by atherosclerosis that usually occurs in arteries of lower extremities and is characterized by inadequate bloody supply due to a stiffer vessel. Exmaples of PAD include Buerger's disease, and popliteal.

Pharamcology

• Pharmacologic therapy can include:
  • Phosphodiesterase III inhibitor: and Antiplatelet agents
  • Vasodilators
  • Statins
  • Antiplatelet agents

Peripheral Venous Disorder

• Includes venous and vascular issues such as:
• Venous thromboembolism: blood clot formed as a result of venous stasis, endothelial injury or hypercoagulability and may cause pulmonary embolism and include
• Endothelial damage that may occur from truma and venous diseases
• Venous insufficiency: secondary to incompetent valves in deeper veins of lower extremities, which allows pooling of blood and dilation of veins; precipitates development of swelling, venous stasis ulcers, cellulitis
• Varicose veins: enlarged, twisted, and superficial veins Aneurysms: localized sac or dilation formed at a weak point in the wall of an artery The most common forms are saccular and fusiform
• Medical Treatment for Aneurisms: Treatment: based on an iatrogenic injury as well as symptoms
• Medical or Non surgical care typically includes controlling blood pressure and correcting risk factors
• Management: After endovascular repair
• Supine position for a total of 6 hours! HOB can be elevated UP TO, and should always be below - 45 degrees for 2 hours
• Management: Leg Ulcers
• History of condition and treatment depends on the ulcer. Assess the pain/pulses and the nutrition.
• The medical treatment may include:
  • Anti-Infective therapy
  • Compression therapy
  • Debridement

Hypertension

• High blood pressure is a multifactorial and complex diagnosis.
• Classify in order to treat correctly with life style changes.
• Normal blood pressure: <120mmHg and <80mmHg
• Elevated blood pressure: 120-129mmHg/<80mmHg
• Stage 1 hypertension: 130-139mmHg/80-89mmHg
• Stage 2 hypertension: >140mmHg/>90mmHg
• Major risk factors: smoking, obesity, sleep apnea, physical inactivity, dyslipidemia, diabetes mellitus, microalbuminuria or GFR <60 ml/min, older age, family history
• Medical management
  • Maintain blood pressure: <130/80mmHg
  • Weight reduction
  • Diet is always imperative. DASH Diet + restricted salt intake.
  • Regular physical activity as tolerated
  • Reduced alcohol consumption
  • Possible to administer the phamacologic therapy.

What treatment to give?

• Diuretics
• Beta-blockers
• Client who...:
• Reports no changes in vision - exhibits no retinal damage on vision testing
• Client can
• Maintain pulse rate and rhythm and RR within normal ranges; reports no dyspnea or edema
• Client Is able to
• Maintain urine output consistent with intake and has renal function labs within normal range
• Client also
• Demonstrates no motor, speech, or sensory deficits
• Is free of
  • Reports no headaches, dizziness, weakness, changes in gait or falls

Hypertensive crises

• Hypertensive emergency: BP > 180/120mmHg and must be lowered immediately to prevent further damage to target organs
• Hypertensive urgency: BP > 180/120 mmHg but no evidence of immediate or progressive target organ damage