Lecture 9 & 10 Cardiovascular.pptx

NUR 118 Gaseous Transfer Lecture 9 & 10 Cardiac Circulation & Perfusion Objectives • Function of Autonomic Nervous System in cardiovascular function: • Sympathetic vs Parasympathetic stimulation • Cardiovascular Assessment • Inspection • Palpation • Auscultation • Laboratory studies r/t cardiova...

NUR 118 Gaseous Transfer Lecture 9 & 10 Cardiac Circulation & Perfusion Objectives • Function of Autonomic Nervous System in cardiovascular function: • Sympathetic vs Parasympathetic stimulation • Cardiovascular Assessment • Inspection • Palpation • Auscultation • Laboratory studies r/t cardiovascular assessment • Diagnostic tests r/t cardiovascular assessment • Nursing Interventions, including patient teaching Objectives ●Heart Failure: ●Right-sided Heart Failure ○ Possible etiology ○ Signs & symptoms ●Left sided Heart Failure ○ Possible etiology ○ Signs & symptoms ●Peripheral Vascular Disease: 5 P’s and a T ○ Peripheral Arterial Disease: S&S, Nursing Interventions ○ Peripheral Venous Disease: S&S, Nursing Interventions ● Unit 2 Medications CIRCULATORY SYSTEM CARDIAC BLOOD FLOW Structures of the Cardiovascular System HEART • 4 chambers • Valves • Conduction system • Coronary arteries Four Chambers of the Heart Valves of the Heart Valves of the Heart https://www.youtube.com/watch?v=X0p9GqvaKDw Circulation of the Heart Coronary Arteries BLOOD CLOT OR BLOCKAGE FROM CAD MYOCARDIAL INFARCTION Cardiac Cath & Coronary Angioplasty Blocked/Narrowed Coronary Artery Coronary Artery Conduction System of the Heart • Sinoatrial Node • pacemaker of heart • 60-100 beats/min • signals both atria to contract together • Atrioventricular node • transmits impulses down • Right & Left Bundle of His branches • into Purkinje fibers in ventricles • signals ventricles to contract • can take over if SA fails Structures of the Cardiovascular System Systemic and pulmonary blood vessels • Arteries - Contract (systole) & recoil/relax (diastole) • Arterioles - Control blood flow - help maintain blood pressure • Capillaries - Facilitate gas, nutrient, & waste exchange • Veins - Contract & relax in response to blood volume • Low volume contract • High volume relax • Venules • A venule is a small blood vessel in the microcirculation that allows deoxygenated blood to return from capillary beds to veins Regulating Cardiovascular Function • Autonomic Nervous System • Cardiac Rate • Cardiac Muscle Contractility • Vascular tone (BP) • Sympathetic and Parasympathetic Fiber Stimulation • Sympathetic = Fast rate & Strong Contraction • Parasympathetic = Slow rate & No impact on contraction Regulating Cardiac Function Sympathetic Fibers • Neurotransmitters: • Norepinephrine (noradrenalin) • Epinephrine (epinephrine) • Stimulate heart to beat faster and stronger • “Fight or Flight” • Our concern Receptors: beta* • Remember beta receptors – for drug, atenolol, is a beta blocker Parasympathetic Fibers – • Regulates heart via vagus nerve, slows heart rate • “Feed & Breed” • “Rest & Digest” Factors That Influence Cardiac Function • Developmental stage • Young and middle adults • Poor nutrition - High fat, sugar & processed foods • Lack of exercise - Sedentary • Substance abuse - Tobacco, alcohol, drugs • Family history - Cardiovascular disease • Older adults— • • • • • thicker and more rigid heart valves More rigid peripheral vessels decreased myocardial strength lower exercise tolerance other health problems Factors That Influence Cardiac Function • Environment: • Lifestyle • Stress • Pregnancy • Allergic Reactions • Nutrition • Altitude • Obesity • Heat & Cold • Exercise • Medications • Tobacco use • Substance abuse Factors That Influence Cardiac Function • Cardiovascular abnormalities • Heart failure* • Cardiomyopathy • Cardiac ischemia (Angina) • Coronary artery disease • Dysrhythmias • Heart valve • Peripheral vascular abnormalities* • Oxygen transport abnormalities • Anemia* • Carbon monoxide Cardiovascular Assessment Urgent Non-urgent • ABC • Assess present S/S that are affecting: -Breathing -Circulation -Oxygenation • Ask simple questions pertaining to these things • Involves more lengthy questions about: -occupation -smoking habits -lifestyle changes -medical history • Extensive physical examination Assessmen t • Demographic Data • Health history • Family history • Respiratory history • Cardiovascular history • Environmental history • Lifestyle Risk Factors for Coronary Heart Disease* Non Modifiable risks ●Heredity ●Age ●Gender Modifiable risks ●Elevated serum lipid levels ●Hypertension ●Diabetes II ●Obesity ●Dietary factors ●Lifestyle ●Cigarette smoking General Survey/Inspection = LOOK ● Signs of Distress ● Skin and mucous membrane color ● Overall general appearance ● Breathing effort ● Jugular neck vein distention (JVD) Position- 15-45 degrees (semi fowler) ● Edema ● Clubbing of fingertips ● Inspect precordium ○ Size, shape, symmetry ○ Apical impulse/PMI ○ Pulsations, heaves, lifts Inspect Precordium Palpation = FEEL • Skin temperature and moisture • Discomfort in any area • Pulses – rate, rhythm, quality • RATE = Tachycardia/bradycardia • RHYTHM = Regular/irregular • QUALITY = 0 = absent, 1+ weak & thready, 2+ normal, 3+ bounding • Edema – pitting vs dependent Pulses = PALPATION = FEEL Pitting Edema = PALPATION = FEEL Auscultation = LISTEN • Apical • Rate, Rhythm • Identify S1 & S2 • S1 • Closure of atrioventricular valves: mitral & tricuspid • S2 • Closure of semilunar valves: aortic & pulmonary Auscultation of Valves = LISTEN • Mitral – between left atrium and left ventricle • Tricuspid – between right atrium and right ventricle • Aortic – between left ventricle and aorta • Pulmonic – between right ventricle and pulmonary artery • Erb’s Point • Cardiac murmurs caused by aortic insufficiency and mitral stenosis can in particular be heard. Auscultating Valves* = LISTEN • A = aortic • Second right intercostal space, right sternal border • P = pulmonic • Second left intercostal space, left sternal border • E = Erb’s Point = S1 & S2 • Third left intercostal space, left sternal border • T = tricuspid • Fourth left intercostal space, left sternal border • M = mitral • Fifth intercostal space, left midclavicular line Auscultation of Carotids • Have patient turn head a little bit and hold breath… • After palpating the carotid arteries, ONE AT A TIME - listen carefully over both arteries with the diaphragm of your stethoscope. Some examiners use the bell. • Ask the patient to hold breathing for a moment so that breath sounds do not obscure the sound of turbulent flow. • Listen for a bruit, which is a whooshing, murmur-like sound often from artherosclerotic Labs & Diagnostics • Cholesterol • High levels of cholesterol are associated with increased risk of coronary artery disease • Done as part of a lipid panel • Should be under 200 mg/dl • C-reactive protein (CRP) < 10 or hs-CRP < 2.0 for Heart Disease • CRP is an acute-phase reactant protein used to indicate an inflammatory illness. It is believed to be of value in predicting coronary events • Complete Blood Count (CBC) • WBC for infection • Hemoglobin for O2 carrying capacity of blood Labs • Electrolytes • We will discuss electrolytes under chemical regulation • Too much or too little of certain electrolytes affect cardiac function • Potassium (K+) levels have a very strong influence on the function of the heart, both too much or too little (K+ = heart function) • PT/PTT • Both are used to assess the intrinsic system and the common pathway of clot formation • We will discuss in more detail when we discuss the anticoagulant drugs on your unit 2 drug list: warfarin, heparin, enoxaparin Labs • CK-MB (Creatinine Kinase) • A blood test used to diagnose a myocardial infarction and subsequent cardiac muscle damage • If the blood serum levels show an elevated creatinine kinase MB, this indicates cardiac muscle damage • Usually rises 3-6 hours after cardiac event • Troponin • Troponin is a protein that is a biochemical marker for cardiac injury. • They can become elevated as early as 2-3 hours after myocardial injury • This test is faster than CK-MB Labs • BNP Natriuretic Peptides – specifically of the beta type • Used to identify and stratify patients with congestive heart failure (CHF) • Left ventricle releases BNP in response to stretching, which occurs as the ventricle becomes stretched secondary to fluid build up, as seen in left sided heart failure • The more elevated BNP – the more severe the CHF Diagnostics • Electrocardiogram* ecg ekg • Records the electrical impulses that stimulate the heart to contract • Used to evaluate arrhythmias, conduction defects, myocardial injury and damage, left and right hypertrophy, and pericardial disease • Echocardiogram* • A noninvasive ultrasound procedure used to evaluate the structure and function of the heart & how they move blood through the heart • Used to detect heart wall function, specifically left ventricle function • Used to detect disease of heart valves • Determines cardiac output & ejection fraction Electrocardiogram Cardiac Monitoring P wave – atrial depolarization, results in atrial contraction QRS complex – ventricular depolarization, results in ventricular contraction T wave – Ventricular repolarization U wave – may see this Depolarization = Contraction Repolarization = Resting Relaxed state Cardiovascular Nursing Diagnosis • Decreased Cardiac Output • Risk for Decreased Cardiac Output • Ineffective Tissue Perfusion • Activity Intolerance • Anxiety • Acute pain • Deficient Knowledge Nursing Interventions Used for any cardiovascular disease • Patient Teaching: * • • • • • • • Diet Weight Loss Exercise Modifiable & Non-modifiable Risk Factors Quitting Smoking Substance Abuse Reduce Stress Nursing Interventions • Manage Anxiety • Promote Venous Return • Promote Peripheral Arterial Circulation • Prevent Clot Prevention • Administer Medications Heart Failure • Heart becomes inefficient pump • Unable to circulate blood to organs & tissues • Leads to systemic and pulmonary edema • Results in fatigue and organ dysfunction • Right-sided heart failure • Right ventricle does not pump sufficient amounts of blood to lungs for oxygenation, blood backs up into the peripheral veins • Left-sided heart failure • Left ventricle does not pump sufficient amounts of blood to organs & tissues, blood backs up into lungs LEFT HEART FAILURE MOST COMMON THINK LEFT = LUNGS S/S • Cough, SOB • Wheezing, Crackles • Pink frothy sputum • Orthopnea, Dyspnea PLUS THESE S/S • Tachycardia • Mental confusion, change in LOC • Fatigue* (any chronic heart disease) • weakness • Exercise intolerance • Lack of appetite RIGHT HEART FAILURE PERIPHERAL VENOUS CONGESTION PERIPHERAL S/S • Peripheral Edema of lower extremities, feet • Ascites – edema of abdomen • Jugular vein distention (JVD) • Weight gain from build up of fluid • Fatigue* (any chronic heart disease) • weakness • Exercise intolerance • Lack of appetite Peripheral Assessment • Always check extremities for any signs of vascular disease • Take covers down and assess lower extremities NO EXCEPTION • Inspection • Palpation • Can see peripheral vascular disease • Peripheral arterial disease • Peripheral venous disease Peripheral Vascular Assessment • 5 P’s and a T • Pain • Pallor • Pulse • Paresthesia • Paralysis • Temperature Peripheral Arterial Disease = PAD ARTERIAL • Pale or bluish (cyanotic) • Weak or absent peripheral pulse • Cool • Loss of hair in lower extremities • Thick toenails • Paresthesias • Un-healing wounds on toes, feet • Intermittent Claudication* - pain in legs with exercise, especially walking, relieved with rest – tissue is ischemic, ischemic tissue is painful Peripheral Arterial Disease • Interventions: *keep legs down in dependent position, if legs are hanging down gravity helps blood flow to lower extremities • If patient has intermittent claudication, have them sit and rest • Patient Teaching: pt has CAD • Regular exercise • Diet • Weight Loss • Exercise • Modifiable & Non-modifiable Risk Factors • Quitting Smoking • Substance Abuse • Reduce Stress • Foot care Peripheral Arterial Disease Peripheral Venous Disease (Venous Insufficiency) Peripheral venous disease (PVD) involves damaged or blocked veins that carry blood from the hands and feet back to the heart. While peripheral venous disease can occur anywhere in the body, it is most often seen in the arms and legs. • Edema - Pitting or nonpitting • Incompetent valves in veins • Varicose veins • Brownish red discoloration of lower extremities • Ulcers on lower extremities Peripheral Venous Disease = PVD • Promote Venous Return • Encourage patient to ambulate – contracting leg muscles help to push venous blood back to heart • When patient not ambulating, have patient elevate legs or sit in a recliner – keeping legs elevated or up uses gravity to help return blood to heart Encourage leg/ankle exercises. • Instruct not to cross legs • Can use compression stockings, or possible venodynes (alternate compression devices) PVD • Arterial* PAD • Keep legs DOWN to get more blood to lower extremities • Regular exercise is good for overall general health, but remember: • “Intermittent Claudication” – this is pain in lower extremities due to ischemia, patient must rest with legs down to get more O2 to legs • Venous* PVD • Keep legs ELEVATED (up) to facilitate venous return back to heart • Regular exercise is beneficial – the exercise causes contraction of the leg muscles which helps to push venous blood back to heart • If unable to walk or exercise encourage leg exercises Cardiovascular Abnormalities • Heart failure – right and left • PVD – venous and arterial • Cardiomyopathy – heart muscle disorder that results in heart enlargement and impaired cardiac contractility • Coronary artery disease – a condition in which plaque builds up inside the coronary arteries, narrowing these arteries • Cardiac ischemia – Angina – coronary arteries are not delivering enough O2 to cardiac muscle; muscle becomes ischemic and that hurts • Myocardial infarction (MI) heart attack – coronary arteries completely blocked, no O2 being transported to cardiac muscle, muscle dies Nursing Interventions • Manage Anxiety • Anxiety activates the sympathetic nervous system – exacerbates any cardiac to vascular condition • Anxiety reduction is a priority intervention • Speak calmly and quietly to patient • Provide clear and factual information and keep patient and family informed about treatments given • See next slide on iCare pp 972 in text – I refer to this slide often iCare • Experiencing cardiac and oxygenation issues is very frightening. Anxiety, fear, and panic can set in very quickly • Use a calm & confident approach when performing interventions • Provide emotional support and comfort to help alleviate fear • Sit down, make eye contact, speak calmly and keep the patient informed of what you are doing • Hold the person’s hand, practice therapeutic touch, and sit with him while providing interventions Promote Venous Circulation Decrease Peripheral Edema • Adequate circulation ensures that oxygenated blood reaches tissues and organs and that venous blood returns to heart • Promote Venous Return Elevate legs above level of heart Encourage and support early and frequent ambulation Anti-embolism stockings, sequential compression devices Encourage or provide range of motion, ankle circles, “calf pumps” • Teach patient not to cross legs • Anticoagulant • • • • Promote Arterial Circulation • Teach smoking cessation • Teach foot care • Inspect feet daily for any signs of breakdown or potential breakdown • Keep feet clean and dry • Teach patient to wear well-fitting shoes with smooth dry socks • Regular exercise improves circulation • Prevent long periods of exposure to cold (causes vasoconstriction) atenolol • atenolol (Tenormin) the “-olols” (metoprolol, naldolol, propanolol) • Classification – beta blocker • Block norepinephrine & epinephrine (sympathetic stimulation) by blocking the beta receptors from receiving the epinephrine, preventing increase in heart rate • Reduces workload of heart and O2 consumption • Management of hypertension, angina pectoris • Prevention of myocardial infarction (MI) heart attack • Implications • Monitor BP, EKG, pulse • May cause dizziness, orthostatic hypotension, advice to rise slowly enalapril • enalapril Vasotec the “prils”(captopril, benazepril, lisinopril, quinapril) • Classification – • antihypertensive = Lowers Blood Pressure • ace inhibitor = angiotensin converting enzyme inhibitor • Side effects • DRY cough • Hypotension, dizziness • Nursing implications • Monitor blood pressure • Monitor bun, creatinine, electrolytes nitroglycerin • Potent vasodilator • Increases coronary blood flow by dilating coronary arteries and improving collateral circulation to ischemic regions • Used for angina contributing to ^ cardiac output; reduces BP • Nursing implications • Monitor BP and pulse before and after administration • Caution pt to change positions slowly to minimize orthostatic hypotension • Have patient sit down to receive medication • Inform pt that headache is a common side effect, should decrease with continuing therapy digoxin • digoxin - Lanoxin • Classification: cardiac glycoside, positive inotropic • An inotrope is an agent that alters the force or energy of muscular contractions. Positively inotropic agents increase the strength of muscular contraction • Increases the force of cardiac contractions, slows and strengthens the heart rate, used in heart failure • Implications • Monitor apical pulse for one full minute before administering, • Hold drug if apical pulse is less than 60 • Monitor ekg strip digoxin implications, contd • Serum levels of digoxin must be monitored periodically to keep in therapeutic range: 0.5mg/mL – 2mg/mL • Serum potassium must be kept in therapeutic range (3.5-5) to prevent digoxin toxicity • Digoxin toxicity: • Abdominal pain, anorexia, nausea, vomiting • Visual disturbances – pt sees yellow halos around objects • Bradycardia atorvastatin • atorvastatin Lipitor • Classification – lipid lowering agent • Used to prevent cardiovascular disease by lowering serum cholesterol levels; serum cholesterol contributes to build up of plaques in blood vessels, thereby narrowing vessels • Implications • Monitor liver enzymes – can cause hepatitis • Monitor serum cholesterol levels and triglycerides • If patient complains of muscle pain, check CK (creatinine Kinase) levels – could be a sign of rhabdomyolysis (breakdown of muscle fibers and build up of CK in blood. heparin • Given subcutaneously and Given IV (intravenously) SHORT TERM • Anticoagulant, antithrombotic • Use – prophylaxis and treatment of various thromboembolic disorders: venous thromboembolism (DVT), pulmonary embolism (PE), atrial fibrillation (AF) with embolization • Test to monitor serum levels daily is PTT or APTT • Antidote is protamine sulfate • Implications • Asses for bleeding • Bleeding precautions warfarin • warfarin Coumadin – given po LONG TERM • Classification: anticoagulant • Use: prophylaxis and treatment of venous thrombosis, pulmonary embolism, prophylactically to prevent clots in pt with atrial fibrillation • test to monitor serum level is PT, INR (must keep an eye on levels) • Antidote: vitamin K • Implications • Watch for bleeding • Bleeding precautions • Teach pt to avoid green leafy vegetables. • They contain vitamin K which would counteract the medication enoxaparin • Enoxaparin - Lovenox usually in abdomen given subcutaneously • Classification – anticoagulant • Use - indicated to help reduce the risk of deep vein thrombosis (DVT), which may lead to pulmonary embolism (PE). • Is a low molecular weight heparin that can be give more long term than heparin. Used in nursing homes, self-administration at home. Bleeding Precautions • These are things we teach any patient who is on anticoagulants. • We want pt to be aware of and avoid things which could cause him to bleed. Avoid sharp razors, may use electric razor Use soft toothbrush Do not take aspirin Do not strain at BM – take stool softener if necessary • Blow nose gently • Do not go barefoot, wear shoes or slippers to • • • • Bleeding Precautions, contd • Teach pt to contact health care provider if: • Bleeding from any body part that will not stop with 5 minutes of pressure • Headache - New onset • Abdominal pain - New onset • Dark bowel movements • Blood in urine or stool = Hematuria & Hematochezia and melena • We check urinalysis & Stool Occult • Petechiae – small pinpoint red dots on skin • Bruising/Ecchymosis - Without injury • Nurse: no rectal temps, no intramuscular injections