Cardiovascular System Disorders Management PDF

management of patients with cardiovascular diseases Nisha Sivapalan RN MSN Nisha Sivapalan MSN 1 Objectives By the end of the lecture the students will be able to: 1. Explain the management of patients...

management of patients with cardiovascular diseases Nisha Sivapalan RN MSN Nisha Sivapalan MSN 1 Objectives By the end of the lecture the students will be able to: 1. Explain the management of patients with dysrhythmias & conduction problem 2. Compare the management of Patients With Structural, Infectious, and Inflammatory Cardiac Disorders 3. Describe the management of Patients With Complications From Heart Disease 4. Analyze the Management of Patients With Vascular Disorders and Problems of Peripheral Circulation 5. Describe the assessment and Management of Patients With Hypertension Nisha Sivapalan MSN 2 Circulation through heart Nisha Sivapalan MSN 3  Assessment of the Cardiovascular System Health History -The patient’s ability to recognize cardiac symptoms and to know what to do when they occur is essential for effective self-care management. Common Symptoms Chest pain (angina pectoris, ACS, dysrhythmias, valvular heart disease) Pain or discomfort in other areas of upper body, including one or both arms, back, neck, jaw, or stomach (ACS) Shortness of breath (ACS, cardiogenic shock, HF, valvular heart disease) Peripheral edema, weight gain, abdominal distention due to enlarged spleen and liver or ascites (HF) Palpitations (tachycardia from a variety of causes, including ACS, caffeine or other stimulants, electrolyte imbalances, stress, valvular heart disease, ventricular aneurysms) Vital exhaustion, unusual fatigue (an early warning symptom of ACS, HF, or valvular heart disease, characterized by feeling unusually tired or fatigued) Dizziness, syncope, or changes in level of consciousness (cardiogenic shock, cerebrovascular disorders, dysrhythmias, hypotension, postural hypotension, vasovagal episode) Chest pain It is a common symptom ,caused by a number of cardiac and noncardiac problems. During the assessment the patient is asked to : ✔Identify the quantity of pain using pain scale. ✔Describe the character or quality of the pain and its location. ✔Radiation to other areas ✔Associated signs and symptoms such as diaphoresis or nausea. ✔Events that precipitate the onset of symptoms, the duration of the symptoms, and measures that aggravate or relieve the symptoms. Elimination Nocturia (awakening at night to urinate) is common in patients with HF. Pathophysiology: Fluid collected in gravity-dependent tissues (extremities) during the day (ie, edema) redistributes into the circulatory system once the patient is recumbent at night. The increased circulatory volume is excreted by the kidneys (increased urine production). Imagine you are trying to push something heavy. You might hold your breath and push hard, which is similar to what happens when you strain during a bowel movement. This action is called the Valsalva maneuver. 1. 2. Pressure Increase: When you hold your breath and push, pressure inside your chest increases. This pressure affects certain sensors in your body called baroreceptors. Baroreceptors: These sensors help regulate your blood pressure. When they detect increased pressure, they send signals to slow down your heart rate. 3. Vagal Response: The slowing of the heart rate is part of a “vagal response,” which is controlled by the vagus nerve. 4. Possible Fainting: For some people, this slowing of the heart rate can cause their blood pressure to drop too much, leading to dizziness or even fainting (syncope). Example: Imagine someone sitting on the toilet, straining to have a bowel movement. As they strain, they hold their breath and push hard (like the Valsalva maneuver). This can cause their heart rate to slow down significantly and might make them feel lightheaded or faint because their blood pressure drops temporarily. When straining during defecation, the patient bears down (the Valsalva maneuver), which momentarily increases pressure on the baroreceptors. This triggers a vagal response, causing the heart rate to slow and resulting in syncope in some patients.  Activity and exercise Determine a change in the activity pattern during the past 6 to 12 months. Fatigue, associated with a low left ventricular ejection fraction (less than 40%) and medications (eg, beta-adrenergic blocking agents), can result in activity intolerance Sleep and rest shortness of breath when lying down that's relieved by standing or sitting up. Orthopnea- need to sit upright or stand to avoid feeling short of breath. Sleeping upright in a chair instead of in bed ,Increasing the number of pillows used Paroxysmal Nocturnal Dyspnea (PND): This involves waking up suddenly at night gasping for air, which is relieved by sitting up. Awakening short of breath at night (paroxysmal nocturnal dyspnea [PND]) or Awakening with angina (nocturnal angina) Nocturnal Angina: Some may wake up with chest pain due to reduced oxygen supply at night. All of the above are indicative of worsening Heart Failure Untreated obstructive sleep apnea has been linked to CAD, hypertension, HF and dysrhythmias 7  The Heart as a Pump Reduced Pulse Pressure: Indicates decreased difference between systolic and diastolic blood pressure, suggesting poor heart function. Physical assessment Deviation of PMI: The point of maximal impulse (PMI) may shift due to heart enlargement, often seen in heart failure. Gallop Sounds and Murmurs: Abnormal heart sounds indicating turbulent blood flow or changes in heart structure. Example: A patient with heart failure may have a soft, thready pulse and an enlarged heart that shifts the PMI from its normal location. Atrial and Ventricular Filling Volumes and Pressures Elevated Jugular Venous Distension (JVD): Indicates increased pressure in the The heart as a pump (reduced pulse right atrium. Peripheral Edema and Ascites: Fluid accumulation in tissues and abdomen due to pressure, deviation of PMI from fifth poor circulation. intercostal space midclavicular line, gallop Crackles: Lung sounds from fluid buildup. Postural Changes in BP: Blood pressure drops when standing, indicating volume sounds, murmurs) depletion. Example: A person with heart failure may have swollen ankles, a distended neck vein, Atrial and ventricular filling volumes and and crackling lung sounds upon examination. Cardiac Output pressures (elevated jugular venous Reduced Pulse Pressure and Hypotension: Indicate decreased blood flow from distension [JVD], peripheral edema, ascites, the heart. Tachycardia: Increased heart rate as compensation for low output. crackles, postural changes in BP) Reduced Urine Output: Due to decreased kidney perfusion. Lethargy or Disorientation: From reduced brain blood flow. Cardiac output (reduced pulse pressure, Example: A patient may feel dizzy, have low blood pressure, and produce less urine due to reduced cardiac output. hypotension, tachycardia, reduced urine Compensatory Mechanisms output, lethargy, or disorientation) Peripheral Vasoconstriction: Narrowing of blood vessels to maintain blood pressure. Tachycardia: Increased heart rate to compensate for reduced stroke volume. Compensatory mechanisms (peripheral Example: In response to low cardiac output, a patient’s body may increase heart rate vasoconstriction, tachycardia) and constrict blood vessels to maintain circulation.  General appearance Changes in level of consciousness - inadequate perfusion of the brain from a compromised cardiac output or thromboembolic event (stroke). Signs of distress like pain, discomfort, shortness of breath, or anxiety. Patient's size -normal, overweight, underweight, cachectic. Inspection of the skin Signs and symptoms of acute obstruction of arterial blood flow in the extremities, referred to as the 6 P’s, are pain, pallor, pulselessness, paresthesia, poikilothermia (coldness), and paralysis. Edema of the feet, ankles, or legs is called peripheral edema. Pitting edema is the term used to describe an indentation in the skin created by this pressure Scoring: absent (0) , Slight (1+ = up to 2 mm) Very marked (4+ = more than 8 mm) The “Six P’s” are key signs and symptoms of acute arterial occlusion, indicating a sudden blockage of blood flow to an extremity. These symptoms help in identifying the condition quickly to prevent serious complications like tissue death or limb loss. The Six P’s Explained: 1. Pain: Sudden and severe pain in the affected limb, often out of proportion to any apparent injury. 2. Pallor: The limb appears unusually pale due to reduced blood flow. 3. Pulselessness: Absence of a detectable pulse in the affected area, indicating complete or near-complete arterial blockage. 4. Paresthesia: Abnormal sensations such as tingling or numbness due to nerve ischemia. 5. Poikilothermia: The affected limb feels colder compared to other parts of the body because of impaired blood flow and thermoregulation. Nisha Sivapalan MSN 9 6. Paralysis: Loss of movement in the limb, indicating severe ischemic injury. Example: A patient with acute arterial occlusion in their leg may suddenly experience intense pain and notice their leg turning pale and cold. They might also feel tingling or numbness, and find it difficult or impossible to move the leg. Upon examination, no pulse is detectable in the affected area, signaling an urgent need for medical intervention to restore blood flow and prevent permanent damage.  1. Pallor and Cyanosis: Pallor: Pale skin may indicate reduced blood flow or anemia. Central/Peripheral Cyanosis: Bluish discoloration due to low oxygen levels in the Inspection of the skin blood, often seen in heart or lung conditions. 2. Xanthelasma: Yellowish, raised plaques on the skin, usually around the eyes, suggesting high cholesterol levels. 3. Ecchymosis: Bruising or discoloration of the skin, common in patients on anticoagulants or platelet-inhibiting medications due to increased bleeding risk. 4. Cool/Cold and Moist Skin: Pallor, Central/ Peripheral cyanosis Indicative of cardiogenic shock, where reduced cardiac output leads to inadequate circulation and perfusion. Xanthelasma yellowish, slightly raised Example Scenario A patient with heart failure might present with peripheral cyanosis (bluish fingers), plaques in the skin It may indicate xanthelasma indicating high cholesterol, and ecchymosis from anticoagulant therapy. If they experience cardiogenic shock, their skin may feel cold and clammy. These signs help elevated cholesterol levels clinicians assess cardiovascular health and potential complications Ecchymosis -Patients who are receiving platelet-inhibiting medications or anticoagulant therapy Cool/cold and moist skin - cardiogenic shock 10 Blood pressure Affected by factors such as cardiac output; distention of the arteries and the volume, velocity, and viscosity of the blood. Pulse Pressure -The difference between the systolic and the diastolic pressures normally is 30 to 40 mm Hg Increases in conditions that elevate the stroke volume (anxiety, exercise, bradycardia ) or reduce distensibility of the arteries (atherosclerosis, aging, hypertension). Decreased pulse pressure reflects reduced stroke volume (shock, HF, hypovolemia) Postural (orthostatic) hypotension occurs sustained decrease of at least 20 mm Hg in systolic BP or 10 mm Hg in diastolic BP within 3 minutes of moving from a lying or sitting to a standing position. It is usually accompanied by dizziness, lightheadedness, or syncope Nisha Sivapalan MSN 11  Arterial pulses Pulse Rate 0: pulse not palpable or absent Pulse Rhythm 1: weak, thready pulse; difficult Pulse Quality to palpate; obliterated with Do not simultaneously palpate both the pressure temporal and carotid arteries, because it is 2: diminished pulse; cannot be possible to decrease the blood flow to the obliterated brain 3: easy to palpate, full pulse; Jugular venous pulsations cannot be obliterated Right-sided heart function can be estimated by 4: strong, bounding pulse; may observing the pulsations of the jugular veins of be abnormal the neck https://youtu.be/KDpPRyVE4nI?si=957jsPBMvbYautiZ The jugular vein is a major vein in the neck that returns deoxygenated blood from the head to the heart. Jugular venous pulsation (JVP) reflects the pressure in the right atrium and provides insights into cardiac function. The JVP waveform has three peaks: the a wave (atrial contraction), the c wave (ventricular contraction), and the v wave (venous filling). Right vs. Left JVP: 12 Right JVP: Commonly used for assessment as it directly reflects right atrial pressure. Left JVP: Less commonly used but can be assessed if right JVP is not visible.  Heart inspection and palpation 1. Aortic area—second intercostal space to the right of the sternum. To determine the correct intercostal space, the nurse first finds the angle of Louis by locating the bony ridge near the top of the sternum, at the junction of the body and the manubrium. From this angle, the second intercostal space is located by sliding one finger to the left or right of the sternum. 2. Pulmonic area—second intercostal space to the left of the sternum 3. Erb’s point—third intercostal space to the left of the sternum 4. Tricuspid area—lower half of the sternum along the left parasternal area 5. Mitral (apical) area—left fifth intercostal space at the midclavicular line 6. Epigastric area—below the xiphoid process Nisha Sivapalan MSN 13 Heart auscultation Normal heart sounds, referred to as S1 and S2, are produced by closure of the AV valves and the semilunar valves, respectively. 14  Abnormal heart sounds S3—Third Heart Sound. An S3 occurs early in diastole during the period of rapid ventricular filling. It is heard immediately after S2. S4—Fourth Heart Sound. S4 occurs late in diastole, S4 occurs just before S1 and is generated during atrial contraction as blood forcefully enters a noncompliant ventricle. Opening snaps are abnormal diastolic sounds heard during opening of an AV valve. Nisha Sivapalan MSN 15 Diagnostic Evaluation Telemetry -ECG can be continuously observed by telemetry.. The patient has electrodes placed on the chest with a lead cable that connects to the transmitter. The transmitter can be placed in a disposable pouch and worn around the neck Ambulatory Electrocardiography – continuous or intermittent ECG home monitoring. The patient wears the Holter monitor for 24 hours to detect dysrhythmias that may occur during waking hours or sleep. The patient keeps a diary, noting the time of any symptoms or performance of unusual activities. Nisha Sivapalan MSN 16 Cardiac Implantable Electronic Devices Include pacemakers and ICDs for managing serious cardiac illnesses. Allow remote wireless monitoring to determine battery life, pacing parameters, therapies, and serious atrial and ventricular dysrhythmias. It can record ECGs continuously for up to 3 years. Nursing Interventions for Inpatient Cardiac Monitoring Nurses dealing with excessive alarms develop alarm fatigue ECG recordings should be free of artifact (abnormal patterns) caused by muscular activity, patient movement, electrical interference or electrode malfunction. Proper skin preparation before applying electrodes and changing electrodes every 24 hours can eliminate artifact. DIAGNOSTIC EVALUATION Exercise Stress Testing: the patient walks on a treadmill (most common). Exercise intensity progresses according to established protocols. The goal is to increase the heart rate to the “target heart rate,” During the test, the following are monitored: two or more ECG leads for heart rate, rhythm, and ischemic changes; BP; skin temperature; physical appearance; perceived exertion; and symptoms, including chest pain, dyspnea, dizziness, leg cramping, and fatigue. Nursing Interventions 1. NPO for 3 hours before the test 2. Avoid stimulants such as tobacco and caffeine. Medications may be taken with sips of water. 3. Not to take beta adrenergic blocking agents, before the test. 4. Instruct patient to wear Clothes and sneakers for exercising 5. IV catheter inserted , After the test, the patient is monitored for 10 to 15 minutes. Nisha Sivapalan MSN 19  DIAGNOSTIC EVALUATION Echocardiography - Traditional Echocardiography-noninvasive ultrasound test that is used to measure the ejection fraction and examine the size, shape, and motion of cardiac structures Nursing Interventions - Explaining to patient that it is painless Periodically, the patient is asked to turn onto the left side or hold a breath Radionuclide Imaging: Myocardial Perfusion Imaging, Computed Tomography, Magnetic Resonance Angiography Nisha Sivapalan MSN 20 Cardiac Catheterization common invasive procedure used to diagnose structural and functional diseases of the heart and great vessels. involves the percutaneous insertion of radiopaque catheters into a large vein and an artery. Fluoroscopy is used to guide the advancement of the catheters through the right and left heart, referred to as right and left heart catheterization, respectively. Angiography -a contrast agent is injected into the vascular system to outline the heart and blood vessels. Nursing Interventions Fasting, usually for 8 to 12 hours, before the procedure The patient may be asked to cough and to breathe deeply, especially after the injection of the contrast agent Observing the catheter access site for bleeding or hematoma formation and assessing peripheral pulses in the affected extremity (dorsalis pedis and posterior tibial pulses in the lower extremity, radial pulse in the upper extremity) every 15 minutes for 1 hour, every 30 minutes for 1 hour, and hourly for 4 hours or until discharge. Maintaining bed rest for 2 to 6 hours after the procedure Monitoring the patient for contrast-induced nephropathy by observing for elevations in serum creatinine levels.  MANAGEMENT OF PATIENTS WITH DYSRHYTHMIAS Dysrhythmias are disorders of the formation or conduction (or both) of the electrical impulse within the heart. These disorders can cause disturbances of the heart rate, the heart rhythm, or both. Normal sinus Rhythm Nisha Sivapalan MSN 22 Components of the Electrocardiogram  Normal ECG rhythms and Arrythmias Normal sinus rhythm 24  Clinical Manifestations- vary with each type of arrythmia. Common signs/symptoms are: o Chest pain o Dizziness o Shortness of breath o Low blood pressure from decreased cardiac output o Altered level of consciousness Assessment and Diagnostic Findings History and physical examination to identify onset, nature, frequency, duration, and response to medications. 12-lead ECG performed to verify atrial fibrillation rhythm and identify dysrhythmias. Transthoracic echocardiogram (TEE) to identify valvular heart disease, left ventricular and right ventricular size and function Nisha Sivapalan MSN 25  ADJUNCTIVE MODALITIES AND MANAGEMENT 1.Cardioversion and Defibrillation Used to treat tachydysrhythmias by delivering an electrical current that depolarizes a critical mass of myocardial cells. One major difference between cardioversion and defibrillation is the timing of the delivery of electrical current. Cardioversion and defibrillation are both medical procedures used to treat abnormal heart rhythms, but they differ in timing and application: Cardioversion: This procedure is used to treat arrhythmias in patients who have an irregular or unstable pulse but are not in immediate danger of cardiac arrest. It involves delivering a synchronized low-energy shock timed with the heart’s electrical cycle, specifically the R-wave, to restore normal rhythm. Cardioversion can be elective or urgent, depending on the patient’s condition. Defibrillation: Used in life-threatening situations like cardiac arrest, defibrillation delivers an unsynchronized high-energy shock at any point in the cardiac cycle. It is crucial for treating pulseless ventricular tachycardia or ventricular fibrillation, where immediate 26 action is needed to restart the heart 2.PACEMAKER THERAPY An electronic device that provides electrical stimuli to the heart muscle. Pacemakers are usually used when a patient has a permanent or temporary slower-than-normal impulse formation, or a symptomatic AV disturbance pacemaker is a small electronic device implanted in the chest to help regulate the heartbeat. It sends electrical signals to the heart to ensure it beats at a normal rate and rhythm. Why is a Pacemaker Used? Pacemakers are used when the heart’s natural electrical system is not working properly. This can happen in conditions like: Bradycardia: When the heart beats too slowly. AV Block: When there is a delay or block in the electrical signals between the upper and lower chambers of the heart. How Does a Pacemaker Work? Pulse Generator: This is the main part of the pacemaker, which contains the battery and electronic circuits. Leads (Wires): These are thin wires that connect the pulse generator to the heart. They deliver electrical impulses from the 27 pacemaker to the heart muscle. 3. IMPLANTABLE CARDIOVERTER DEFIBRILLATOR An electronic device that detects and terminates life-threatening episodes of tachycardia or fibrillation, especially those that are ventricular in origin. Patients at high risk of VT or ventricular fibrillation are those who have survived sudden cardiac death syndrome 4.Electrophysiology(EP) Studies An EP study is an invasive procedure used to evaluate and treat various chronic dysrhythmias that have caused cardiac arrest or significant symptoms. Nisha Sivapalan MSN 28  NURSING MANAGEMENT OF THE PATIENT WITH AN IMPLANTABLE CARDIAC DEVICE 1. After a permanent electronic device (pacemaker or ICD) is inserted, the patient’s heart rate and rhythm are monitored by ECG 2. The incision site is observed for bleeding, hematoma formation, or infection, which may be evidenced by swelling, unusual tenderness, drainage, and increased warmth 3. The patient may complain of pain. These symptoms are reported to the physician 4. Avoid wearing tight, restrictive clothing that may cause friction over the insertion site. Initially avoid soaking in the tub and lotion, creams, or powders in the area of the device 5. Educate the patient to adhere to activity restrictions. a. Restrict movement of arm until incision heals; do not raise arm above head for 2 weeks. b. Avoid heavy lifting for a few weeks. c. Avoid contact sports, It may take up to 2 to 3 weeks to resume normal activities 6. Avoid large magnetic fields, such as MRI 7. At security gates at airports, or other secured areas, show identification card and request a hand (not handheld device) search 8. Some electrical and small motor devices, as well as products that contain magnets (e.g., cellular phones), may interfere with the functioning of the cardiac device, place cellular phone on opposite side of cardiac device. 9. Household appliances (e.g., microwave ovens) should not cause any concern 10. Encourage family members to attend a cardiopulmonary resuscitation class 11. Avoid frightening family or friends with unexpected shocks from an ICD, which will not harm them 29 Nursing diagnoses Decreased cardiac output related to inadequate ventricular filling or altered heart rate Anxiety related to fear of the unknown outcome of altered health state Deficient knowledge about the dysrhythmia and its treatment Nursing Interventions Assess patients' blood pressure, pulse rate, respiration rate, and breath sounds to determine the dysrhythmia's hemodynamic effect. Monitor for symptoms of dysrhythmia, such as lightheadedness, dizziness, or fainting Encourages verbalization of feelings and fears, providing supportive or empathetic statements. Encourage family members to obtain CPR training. Coronary Artery Disease Nisha Sivapalan MSN 31  Coronary Atherosclerosis Atherosclerosis is the abnormal accumulation of lipid deposits and fibrous tissue within arterial walls and lumen. In coronary atherosclerosis, blockages and narrowing of the coronary vessels reduce blood flow to the myocardium. Watch video : Atherosclerosis (2009) - YouTube Nisha Sivapalan MSN 32  RISK FACTORS FOR CORONARY ARTERY DISEASE Nonmodifiable Risk Factors Modifiable Risk Factors Family history of CAD (first-degree Hyperlipidemia relative with cardiovascular Disease) Cigarette smoking, tobacco use Increasing age (more than 45 years Hypertension for men; more than 55 years for women) Diabetes mellitus Gender (men develop CAD at an Metabolic syndrome (Insulin resistance, central obesity, dyslipidemia, BP >130/85, elevated earlier age than women) CRP, elevated Fibrinogen) Race (higher incidence of heart Obesity disease in African Americans than in Caucasians) Physical inactivity The Framingham Risk Calculator is a tool commonly used to estimate the risk for having a cardiac event within the next 10 years Nisha Sivapalan MSN 33  CLINICAL MANIFESTATIONS The most common symptom of myocardial ischemia is chest pain; however, some individuals may be asymptomatic or have atypical symptoms such as weakness, dyspnea, and nausea. Atypical symptoms are more common in women and in persons who are older, or who have a history of heart failure or diabetes Nisha Sivapalan MSN 34 PREVENTION Controlling Cholesterol Abnormalities -A fasting lipid profile should demonstrate the following values LDL cholesterol less than 100 mg/dL (less than 70 mg/dL for very high-risk patients) Total cholesterol less than 200 mg/dL HDL cholesterol greater than 40 mg/dL for males and greater than 50 mg/dL for females Triglyceride less than 150 mg/dL HDL is the “good cholesterol,” and higher levels are better; LDL is the “bad cholesterol,” and lower levels are better Diet low in saturated fat and high in soluble fiber Physical Activity -Regular -30 minutes/day -moderate physical activity increases HDL levels and reduces triglyceride levels Lipid-lowering medications –Statins-Atorvastatin (Lipitor) Promoting Cessation of Tobacco Use Managing Hypertension and diabetes Nisha Sivapalan MSN 35  ANGINA PECTORIS A syndrome characterized by episodes or paroxysms of pain or pressure in the anterior chest caused by insufficient coronary blood flow. Physical exertion, Exposure to cold, Eating a heavy meal or emotional stress increases myocardial oxygen demand and the coronary vessels are unable to supply sufficient blood flow to meet the oxygen demand. Nisha Sivapalan MSN 36 Types of angina Stable angina: predictable and consistent pain that occurs on exertion and is relieved by rest and/or nitroglycerin Unstable angina (also called preinfarction angina or crescendo angina): symptoms increase in frequency and severity; may not be relieved with rest or nitroglycerin Intractable or refractory angina: severe incapacitating chest pain Variant angina (also called Prinzmetal’s angina): pain at rest with reversible ST-segment elevation; thought to be caused by coronary artery vasospasm Silent ischemia: objective evidence of ischemia (such as electrocardiographic changes with a stress test), 37 but patient reports no pain Clinical Manifestations Ischemia of the heart muscle can cause mild to severe pain, ranging from discomfort to agonizing pain. Accompanied by severe apprehension and a sense of impending death. Pain is often felt deep in the chest behind the sternum, radiating to the neck, jaw, shoulders, and inner aspects of the upper arms. Patients with diabetes may not experience severe pain with angina due to diabetic neuropathy. Symptoms may include weakness or numbness in arms, wrists, and hands, shortness of breath, pallor, diaphoresis, dizziness, lightheadedness, and nausea and vomiting. Unstable angina attacks increase in frequency and severity and are not relieved by rest or nitroglycerin and require medical intervention. 38 ASSESSMENT AND DIAGNOSTIC FINDINGS Patient’s history related to the clinical manifestations of ischemia. A 12-lead electrocardiogram (ECG) may show changes indicative of ischemia such as t-wave inversion, ST segment elevation, or the development of an abnormal Q wave Laboratory studies -CRP and cardiac biomarker values to rule out an Acute Coronary Syndrome. Exercise or pharmacologic stress test, cardiac catheterization, coronary angiography Nisha Sivapalan MSN 40  MEDICAL MANAGEMENT Goal:to decrease myocardial oxygen demand and increase oxygen supply Pharmacologic Therapy Nitrates Eg: Nitroglycerin Beta-blockers eg: metoprolol Calcium channel blockers Eg:Amlodipine Antiplatelet Medications Eg: Aspirin Anticoagulants Eg: Heparin Bleeding precautions: Applying pressure to the site of any needle puncture for a longer time than usual Avoiding intramuscular (IM) injections, Avoiding tissue injury and bruising from trauma or use of constrictive devices (e.g., continuous use of an automatic blood pressure cuff) Oxygen -to increase the amount of oxygen delivered to the myocardium and to decrease pain Reduce and control risk factors Nisha Sivapalan MSN 41 Nitroglycerin Standard treatment for angina pectoris. Potent vasodilator that improves blood flow to the heart muscle and relieves pain Sublingual tablet or spray, oral capsule, topical agent, and intravenous (IV) administration Nitroglycerin is not given if the systolic blood pressure is less than 90 mm Hg because it can cause or worsen hypotension, leading to dangerously low blood pressure. Nitroglycerin works by dilating blood vessels, which reduces blood pressure. If a patient already has low blood pressure, administering nitroglycerin can further decrease it, potentially leading to inadequate blood flow to vital organs and causing symptoms like dizziness, fainting, or even shock Not given if the systolic blood pressure is less than 90 mm hg Common adverse effect of nitroglycerin is headache Self-administration of nitroglycerin Ensure mouth is moist, tongue is still, and saliva is not swallowed until the tablet dissolves. Medication should be carried at all times, securely in its original container, and renewed every 6 months The patient should note the time it takes for the medication to relieve discomfort. The patient should sit down for a few minutes when taking nitroglycerin to avoid hypotension and syncope. 42 NURSING PROCESS Ineffective Cardiac Tissue Perfusion Definition: This diagnosis refers to a decrease in the oxygenated blood reaching the heart tissue, which can lead to ischemia or damage to the heart muscle. Assessment – Symptoms and activities, risk factors for CAD, the Uses: It is used when there is evidence of reduced blood flow to the heart, such as during a myocardial infarction (heart attack). Example: A patient with coronary artery disease experiencing chest pain and ECG changes indicating reduced blood flow to the heart. patient’s response to angina, the patient’s and family’s Decreased Cardiac Output Definition: This diagnosis indicates that the heart is not pumping enough blood to meet the body’s needs, affecting overall circulation. understanding of the diagnosis Uses: It is applied in conditions like heart failure, where the heart’s pumping ability is compromised. Example: A patient with heart failure showing symptoms like fatigue, shortness of breath, and low blood pressure due to insufficient cardiac output. Nursing Diagnoses Ineffective cardiac tissue perfusion secondary to CAD as evidenced by chest pain Anxiety related to cardiac symptoms and possible death Deficient knowledge about the underlying disease and methods for avoiding complications Noncompliance, ineffective management of therapeutic regimen related to failure to accept necessary lifestyle changes Nisha Sivapalan MSN 43 NURSING INTERVENTIONS Treating Angina ✔Patient is directed to stop all activities and sit or rest in bed in a semi-Fowler’s position to reduce the oxygen requirements of the ischemic myocardium ✔measure vital signs and observing for signs of respiratory distress ✔Start oxygen by nasal cannula at 2 L/min even without evidence of respiratory distress ✔12-lead ECG is usually obtained and scrutinized for ST segment and T-wave changes. ✔Nitroglycerin is administered sublingually Reducing Anxiety - Provide information about the illness, its treatment, and methods of preventing its progression, Address the spiritual needs of the patient and family Preventing Pain - Identify the level of activity that causes the patient’s pain, alternate the patient’s activities with rest periods Promoting Home Care - Avoid using over-the-counter medications, Stop smoking, Carry nitroglycerin at all times; state when and how to use it; identify its side effects. 44 ACUTE CORONARY SYNDROME(ACS) AND MYOCARDIAL INFARCTION(MI) ACS is an emergent situation characterized by an acute onset of myocardial ischemia that results in myocardial death ( MI) if definitive interventions do not occur promptly The spectrum of ACS includes unstable angina, non–ST segment elevation MI (NSTEMI), and ST-segment elevation MI (STEMI). Nisha Sivapalan MSN 45 46  CLINICAL MANIFESTATIONS Chest pain that occurs suddenly and continues despite rest and medication is the presenting symptom in most patients with ACS Patients may present with a combination of symptoms, including chest pain, shortness of breath, indigestion, nausea, and anxiety. Cool, pale, and moist skin. Tachycardia, tachypnea, anxiety, restlessness, and lightheadedness (caused by stimulation of the sympathetic nervous system) Fear with feeling of impending doom, or denial that anything is 47  ASSESSMENT AND DIAGNOSTIC FINDINGS Patient History Electrocardiogram -The classic ECG changes are T-wave inversion, ST-segment elevation, and development of an abnormal Q wave Using the information presented, patients are diagnosed with one of the following forms of ACS: ✔Unstable angina: The patient has clinical manifestations of coronary ischemia, but ECG and cardiac biomarkers show no evidence of acute MI. ✔STEMI: The patient has ECG evidence of acute MI with characteristic changes in two contiguous leads on a 12-lead ECG. In this type of MI, there is a significant damage to the myocardium. ✔NSTEMI: The patient has elevated cardiac biomarkers (e.g., troponin) but no definite ECG evidence of acute MI. In this type of MI, there may be less damage to the myocardium. Echocardiogram -detect hypokinetic and akinetic wall motion and can determine the ejection fraction Laboratory Tests -Cardiac enzymes and biomarkers -troponin, creatine kinase (CK), and myoglobin are used to diagnose an acute MI 48 49 Treatment Guidelines for Acute Myocardial Infarction Use rapid transit to the hospital. Obtain 12-lead electrocardiogram to be read within 10 minutes. Obtain laboratory blood specimens of cardiac biomarkers, including troponin. Obtain other diagnostics to clarify the diagnosis. Begin routine medical interventions: Supplemental oxygen, Nitroglycerin, Morphine, Aspirin, Beta-blocker, Angiotensin-converting enzyme inhibitor within 36 hours, Anticoagulation with heparin and platelet inhibitors, Statin Evaluate for indications for reperfusion therapy: Percutaneous coronary intervention, Thrombolytic (fibrinolytic) therapy Continue therapy as indicated: IV heparin, low–molecular-weight heparin, bivalirudin, or fondaparinux Clopidogrel (Plavix) Glycoprotein IIb/IIIa inhibitor Bed rest for a minimum of 12–24 hours Statin prescribed at discharge. 50  PERCUTANEOUS CORONARY INTERVENTION (PCI) The patient with STEMI may be taken directly to the cardiac catheterization laboratory for an immediate PCI. The procedure is used to open the occluded coronary artery and promote reperfusion to the area that has been deprived of oxygen. Door-to-balloon time - time from the patient’s arrival in the ED to the time PCI is performed should be less than 60 minutes. During the PCI, patients receive IV heparin and are monitored closely for signs of bleeding The patient must remain flat in bed and keep the affected leg straight until the sheaths are removed and then for a few hours afterward to maintain hemostasis. Watch Video: https://youtu.be/MKRGgX5rYbY 51 ADMINISTRATION OF THROMBOLYTIC THERAPY Thrombolytics dissolve all clots, not just the one in the coronary artery. Thus, they should not be used if the patient has formed a protective clot elsewhere, such as after major surgery or hemorrhagic stroke. Because thrombolytics reduce the patient’s ability to form a clot, the patient is at risk for bleeding Thrombolytics should not be used if the patient is bleeding or has a bleeding disorder, should be given within 30 minutes of presentation to the hospital Drugs used are : tPA,Urokinase,Alteplase Nursing Considerations Minimize the number of times the patient’s skin is punctured Start IV lines before thrombolytic therapy Avoid intramuscular injections, continual use of noninvasive blood pressure cuff. Check for signs and symptoms of bleeding Eg: decrease in hematocrit and hemoglobin values, decrease in blood pressure Treat major bleeding by discontinuing thrombolytic therapy and any anticoagulants Nisha Sivapalan MSN 52  Cardiac Rehabilitation Objectives -limit the effects and progression of atherosclerosis, return the patient to work and a pre-illness lifestyle, enhance the patient’s psychosocial and vocational status, and prevent another cardiac event. Phase I: Clinical Phase- begins in the inpatient setting soon after a cardiovascular event ✓ Focus on activities of daily living and educate the patient on avoiding excessive stress. Phase II: Outpatient Cardiac Rehab- occurs after the patient has been discharged. ✓ Supervised exercise training, educational sessions, and long- term conditioning. ✓ Lasts 3-6 weeks may last up to up to 12 weeks. Phase III: Post-cardiac Rehab long-term outpatient program ✓ Centers on increasing flexibility, strengthening, and aerobic conditioning. 53 NURSING PROCESS Nursing Diagnoses ❖Acute pain related to increased myocardial oxygen demand and decreased myocardial oxygen supply ❖Risk for decreased cardiac tissue perfusion related to reduced coronary blood flow ❖Risk for imbalanced fluid volume ❖Risk for ineffective peripheral tissue perfusion related to decreased cardiac output from left ventricular dysfunction ❖Anxiety related to cardiac event and possible death ❖Deficient knowledge about post-ACS self-care NURSING INTERVENTIONS Administration of oxygen to reduce pain associated with low levels of myocardial oxygen. Physical rest in bed with the backrest elevated for better lung expansion Monitor fluid volume status to prevent overloading the heart and lungs Check skin temperature and peripheral pulses frequently to monitor tissue perfusion. Reducing Anxiety to reduce the sympathetic stress response 54 CORONARY ARTERY BYPASS GRAFTS (CABG) Surgical procedure in which a blood vessel is grafted to an occluded coronary artery so that blood can flow beyond the occlusion The major indications for CABG are: Alleviation of angina that cannot be controlled with medication or PCI Treatment of left main coronary artery stenosis or multivessel Coronary Artery Disease (CAD) Prevention and treatment of MI, dysrhythmias, or heart failure Treatment for complications from an unsuccessful PCI The greater and lesser saphenous veins are commonly used in bypass graft procedures The vein is removed from the leg (or arm) and grafted to the ascending aorta and to the coronary artery distal to the lesion. Watch video: https://www.youtube.com/watch?v=kxc22Fjd1NQ https://youtu.be/3Nf6Q2skGOM Nisha Sivapalan MSN 55  Cardiopulmonary Bypass System Nisha Sivapalan MSN 56 POSTOPERATIVE NURSING MANAGEMENT Assessing the Patient -Neurologic status, Cardiac status, Respiratory, Peripheral vascular, Renal, Fluid and electrolyte status and pain, check all equipment and tubes, monitor for Complications NURSING DIAGNOSIS: Decreased cardiac output related to blood loss and compromised myocardial function Assess arterial blood pressure every 15 minutes until stable Auscultate for heart sounds and rhythm Assess peripheral pulses (pedal, tibial, radial). Monitor ECG pattern for cardiac dysrhythmias NURSING DIAGNOSIS: Impaired gas exchange related to chest surgery Maintain mechanical ventilation until the patient is able to breathe independently Monitor arterial blood gases, tidal volume Auscultate chest for breath sounds Suction tracheobronchial secretions as needed Nisha Sivapalan MSN 57 STRUCTURAL, INFECTIOUS, AND INFLAMMATORY CARDIAC DISORDERS The valves of the heart control the flow of blood through the heart into the pulmonary artery and aorta by opening and closing in response to the blood pressure changes as the heart contracts and relaxes through the cardiac cycle. When any heart valve does not close or open properly, blood flow is affected. When valves do not close completely, blood flows backward through the valve, a condition called regurgitation. When valves do not open completely, a condition called stenosis, blood flow through the valve is reduced. Nisha Sivapalan MSN 58 Mitral Valve Prolapse A portion of one or both mitral valve leaflets balloons back into the atrium during systole. Blood then regurgitates from the left ventricle back into the left atrium. Most people with mitral valve prolapse never have symptoms. A few have fatigue, shortness of breath, lightheadedness, dizziness, syncope, palpitations, chest pain, or anxiety. Often the first and only sign of mitral valve prolapse is an extra heart sound, referred to as a mitral click. A systolic click is an early sign that a valve leaflet is ballooning into the left atrium. Medical management is directed at controlling symptoms Nursing management -inform patients to look for symptoms such as chest pain, palpitations etc., First-degree relatives (e.g., parents, siblings) may be advised to have echocardiograms. 59 A 60 Mitral Regurgitation Mitral regurgitation involves blood flowing back from the left ventricle into the left atrium during systole. Often, edges of mitral valve leaflets do not close completely during systole because leaflets and chordae tendineae have thickened and fibrosed, resulting in their contraction The most common causes are degenerative changes of the mitral valve , ischemia of the left ventricle etc Dyspnea, fatigue, weakness, palpitations, shortness of breath on exertion, and cough are the most common symptoms. Treatment with angiotensin converting enzyme (ACE) inhibitors such as captopril and surgical intervention by mitral valvuloplasty Restrict the activity level to minimize symptoms 61 Mitral Stenosis Obstruction to blood flowing from the left atrium into the left ventricle. It most often is caused by rheumatic endocarditis, which progressively thickens mitral valve leaflets and chordae tendineae. Leaflets often fuse together. Symptom are dyspnea on exertion (DOE), progressive fatigue and decreased exercise tolerance as a result of low cardiac output Treatment by anticoagulants to decrease the risk of developing atrial thrombus , betablockers, digoxin, or calcium channel blockers Surgical intervention consists of valvuloplasty, usually a commissurotomy to open or rupture the fused commissures of the valve. Avoid strenuous activities, competitive sports, and pregnancy, all of which increase heart rate. 62  Aortic Regurgitation Flow of blood back into the left ventricle from the aorta during diastole. It may be caused by inflammatory lesions that deform aortic valve leaflets or dilation of the aorta, preventing complete closure of the aortic valve. Causes - Infective or rheumatic endocarditis, congenital abnormalities Marked arterial pulsations visible or palpable at carotid or temporal arteries may be present as a result of increased force and volume of blood ejected from a hypertrophied left ventricle. A high-pitched, blowing diastolic murmur is heard at the third or fourth intercostal space at the left sternal border Exertional dyspnea and fatigue occurs Treated by calcium channel blockers , ACE inhibitors, avoid physical exertion, competitive sports etc The calcium channel blockers diltiazem (Cardizem) and verapamil (Calan, Isoptin) are contraindicated for patients with aortic regurgitation because they decrease ventricular contractility and may cause bradycardia 63 Aortic Stenosis Narrowing of the orifice between the left ventricle and aorta. In adults, stenosis often is a result of degenerative calcifications. Age, diabetes, hypercholesterolemia, hypertension, smoking, and elevated levels of lowdensity lipoprotein cholesterol may be risk factors for degenerative calcific changes of the valve Symptoms: Exertional dyspnea, Orthopnea, PND, and pulmonary edema , dizziness and syncope & angina pectoris A loud, harsh systolic murmur may be heard over the aortic area Treated by surgical replacement of the aortic valve 64 Nursing Management: Valvular Heart Disorders Educate the patient about the diagnosis, progressive nature of the disease, and treatment plan. Instruct to report new symptoms or changes in symptoms. Monitor the patient’s heart rate, blood pressure, and respiratory rate, compare these results with previous data, and note any changes. Assess the following: Signs and symptoms of heart failure, Dysrhythmias, dizziness, syncope, increased weakness, or angina pectoris. Take a daily weight and report sudden weight gain Assist the patient with planning activity and rest periods Patients with dyspnea/ pulmonary congestion are advised to rest and sleep sitting in a chair or bed with the head elevated. 65  CARDIOMYOPATHY Cardiomyopathy is a series of progressive events that culminates in impaired cardiac output and can lead to heart failure, sudden death, or dysrhythmias. Clinical Manifestations -dyspnea on exertion, fatigue, orthopnea, peripheral edema, and nausea Assessment –tachycardia and extra heart sounds ( S3, S4), echocardiogram Medical Management –correcting the heart failure with medications, a low-sodium diet, and an exercise/rest regimen, Surgical Management -Heart transplantation Sodium is the major electrolyte involved with cardiomyopathy. Cardiomyopathy often leads to heart failure, which develops, in part, from fluid overload. Fluid overload is often associated with elevated sodium levels. Nisha Sivapalan MSN 66  PERICARDITIS Inflammation of the pericardium Etiology Idiopathic , Infection ,Disorders of connective tissue: systemic lupus erythematosus, rheumatic fever, rheumatoid arthritis Occurs after pericardiectomy, after acute myocardial infarction Pain or discomfort usually remains fairly constant, but it may worsen with deep inspiration and when lying down or turning. The most characteristic clinical manifestation of pericarditis is a creaky or scratchy friction rub heard most clearly at the left lower sternal border Symptoms: chest pain, although pain also may be located beneath the clavicle, in the neck, or in the left trapezius (scapula) region. Pain may be relieved with a forward-leaning or sitting position. Treatment: determine the cause & treat and symptom relief 67 NURSING PROCESS Assessment -primary symptom of the patient with pericarditis is pain A pericardial friction rub occurs when the pericardial surfaces lose their lubricating fluid because of inflammation. A pericardial friction rub is diagnostic of pericarditis. It has a creaky or scratchy sound and is louder at the end of exhalation. Nurses should monitor for the pericardial friction rub by placing the diaphragm of the stethoscope tightly against the thorax and auscultating the left sternal edge in the fourth intercostal space, the site where the pericardium comes into contact with the left chest wall. The rub may be heard best when a patient is sitting and leaning forward Nursing Interventions Instruct the patient to restrict activity until the pain subsides Patients taking NSAIDs are assessed for gastrointestinal adverse effects. If chest pain and friction rub recur, bed rest or chair rest is resumed Nisha Sivapalan MSN 68  HEART FAILURE (HF) Heart failure (HF) is a clinical syndrome resulting from structural or functional cardiac disorders that impair the ability of the ventricles to fill or eject blood A syndrome characterized by fluid overload or inadequate tissue perfusion. The term heart failure indicates myocardial disease in which impaired contraction of the heart (systolic dysfunction) or filling of the heart (diastolic dysfunction) may cause pulmonary or systemic congestion. Some cases of HF are reversible, depending on the cause. Most heart failure is a chronic progressive, lifelong disorder managed with lifestyle changes and medications Nisha Sivapalan MSN 69  CLINICAL MANIFESTATIONS Right-sided failure RV cannot eject sufficient amounts of blood and blood backs up in the venous system. This results in perpheral edema, hepatomegaly, ascites, anorexia, nausea, weakness, and weight gain. Left-sided failure LV cannot pump blood effectively to the systemic circulation. Pulmonary venous pressures increase and result in pulmonary congestion with dyspnea, cough, crackles, orthopnea, paroxysmal nocturnal dyspnea (PND) and impaired oxygen exchange. Chronic heart failure is frequently biventricular. 70 Assessment and Diagnostic Findings ❖ Echocardiogram -to determine the ejection fraction, valve malfunction etc. ❖ Chest X-ray ❖ 12-lead electrocardiogram (ECG) ❖ Serum electrolytes, blood urea nitrogen (BUN), creatinine, liver function tests, thyroid-stimulating hormone, complete blood count (CBC), BNP, and routine urinalysis. ❖ The Brain natriuretic peptide (BNP) level is a key diagnostic indicator of HF; high levels are a sign of high cardiac filling pressure ❖ Cardiac stress testing or cardiac catheterization - to determine whether coronary artery disease and cardiac ischemia are causing the HF 71  MEDICAL MANAGEMENT OF HEART FAILURE Goals- relieve symptoms, to improve functional status and quality of life, and to extend survival. Major lifestyle changes Restriction of dietary sodium Avoidance of smoking, including passive smoke; Avoidance of excessive fluid and alcohol intake Weight reduction when indicated; and regular exercise. Supplemental oxygen Surgical interventions - Implantation of cardiac devices and cardiac transplantation. Medications ACE inhibitors -Discontinue if the potassium level remains greater than 5.5 mEq/L ,monitor for dry, persistent cough Beta-blockers –monitor for dizziness, hypotension, bradycardia Diuretics –monitor for hypokalemia, orthostatic hypotension Digitalis - effect is enhanced in the presence of hypokalemia toxicity may occur. 72 Nursing Diagnoses Activity intolerance and fatigue related to decreased CO Excess fluid volume related to the HF syndrome Anxiety related to breathlessness from inadequate oxygenation Decreased cardiac output related to inability of the myocardium to pump enough blood Powerlessness related to chronic illness and hospitalizations Ineffective therapeutic regimen management related to lack of knowledge  Nursing Interventions Bed rest for acute exacerbations Encourage regular physical activity; 30–45 minutes daily , Wait 2 hours after eating for physical activity Pacing an activity (eg, chop or peel vegetables while sitting at the kitchen table rather than standing at the kitchen counter). Small, frequent meals, low-sodium diet, fluid restriction by planning the fluid distribution throughout the day Administer diuretics early in the morning so that diuresis does not disturb nighttime rest. Monitor fluid status closely: Auscultate lungs, compare daily body weights, and monitor intake and output. Position patient comfortably- increase number of pillows, elevate the head of bed, sit in a comfortable armchair to sleep. Listen actively to patient often; encourage patient to express concerns and questions Monitor for hypokalemia, Hyponatremia, hyperuricemia (excessive uric acid in the blood) that leads to gout.  HOME CARE Take or administer medications daily, exactly as prescribed. Monitor effects of medication such as changes in breathing and edema. Weigh self-daily at the same time with same clothes. Restrict sodium intake to no more than 2 g/day: Avoid canned or processed foods, eating fresh or frozen foods. Participate in a daily exercise program. Increase walking and other activities gradually Conserve energy by balancing activity with rest periods. Avoid activity in extremes of heat and cold, which increase the work of the heart. Avoid tobacco, alcohol. Engage in social and diversional activities Report immediately : Gain in weight of 2–3 lb (0.9–1.4 kg) in 1 day, or 5 lb (2.3 kg) in 1 week Unusual shortness of breath with activity or at rest Increased swelling of ankles, feet, or abdomen Persistent cough Loss of appetite Development of restless sleep;increase in number of pillows needed to sleep Profound fatigue MANAGEMENT OF PATIENTS WITH VASCULAR DISORDERS AND PROBLEMS OF PERIPHERAL CIRCULATION Nisha Sivapalan MSN 76 PERIPHERAL ARTERIAL OCCLUSIVE DISEASE(PAOD) Arterial insufficiency of the extremities occurs most often in men and is a common cause of disability. The legs are most frequently affected Distal occlusive disease is frequently seen in patients with diabetes mellitus and in elderly patients Clinical Manifestations -The hallmark symptom is intermittent claudication. This pain may be described as aching, cramping, or inducing fatigue or weakness that occurs with the same degree of exercise or activity and is relieved with rest Ischemic rest pain is usually worse at night and often wakes the patient. Elevating the extremity or placing it in a horizontal position increases the pain, whereas placing the extremity in a dependent position reduces the pain. Rest pain is persistent, aching, or boring and is usually present in distal extremities with severe disease Nisha Sivapalan MSN 77  ASSESSMENT AND DIAGNOSTIC FINDINGS A sensation of coldness or numbness in the extremities may accompany intermittent claudication and is a result of reduced arterial flow The extremity is cool and pale when elevated or ruddy and cyanotic when placed in a dependent position. Skin and nail changes, ulcerations, gangrene, and muscle atrophy may be evident. Bruits may be auscultated with a stethoscope. Peripheral pulses may be diminished or absent Medical Management Exercise therapy that centers around walking to a point that causes pain three times weekly Weight reduction and cessation of tobacco use Pharmacologic Therapy -Pentoxifylline (Trental) and cilostazol (Pletal) Antiplatelet agents such as aspirin or clopidogrel (Plavix) prevent thromboemboli formation Surgical Management –Endarterectomy Nursing Management -Instruct patient to avoid leg crossing and prolonged extremity dependence Check pulses, doppler assessment, color and temperature, capillary refill, and sensory and motor function of the affected extremity and compare with those of the other extremity Nisha Sivapalan MSN 78  VENOUS THROMBOEMBOLISM Deep vein thrombosis (DVT) and pulmonary embolism (PE) collectively make up the condition known as venous thromboembolism (VTE). Although the exact cause of VTE remains unclear, three factors, known as Virchow’s triad, are believed to play a significant role in its development: stasis of blood (venous stasis), vessel wall injury, and altered blood coagulation Clinical Manifestations -nonspecific Deep veins -edema and swelling of the extremity, tenderness, affected extremity may feel warmer Superficial veins -pain or tenderness, redness, and warmth in the involved area. Assessment and Diagnostic Findings -differences in leg circumference bilaterally from thigh to ankle; increase in the surface temperature of the leg, particularly the calf or ankle Prevention-graduated compression stockings, the use of intermittent pneumatic compression devices, early mobilization and leg exercises Treatment- Anticoagulant therapy-Unfractionated /Low–Molecular-Weight Heparin Nursing Interventions -Encourage to walk once anticoagulation therapy has been initiated. walking is better than standing or sitting for long periods. Bed exercises, repetitive dorsiflexion of the foot, are also recommended 79  Hypertension Defined by the American Society of Hypertension (ASH) and the International Society of Hypertension (ISH) as a systolic blood pressure (SBP) of 140 mm Hg or higher or a diastolic blood pressure (DBP) of 90 mm Hg or higher, based on the average of two or more accurate blood pressure measurements taken 1 to 4 weeks apart by a health care provider Primary hypertension (95%)also called essential hypertension is defined as high blood pressure from an unidentified cause Secondary hypertension(5%) occurs when a cause for the high blood pressure can be identified.Eg: Chronic kidney disease Also called as Silent killer because people who have it are often symptom free.  Risk factors ✓ Advancing adult age ✓ African American ✓ Drinking too much alcohol (i.e., more than two drinks per day for men and more than one drink per day for women) ✓ Family history ✓ Gender-related: Men have greater risks until 45 years of age Gender risks are approximately equal between 45 and 64 years of age Women have greater risks at 65 years of age and later ✓ Overweight/obesity ✓ Poor diet habits, particularly if it includes too much salt ✓ Sedentary lifestyle ✓ Possible Contributing Factors -Use of tobacco products (e.g., cigarettes, e-cigarettes), and secondhand smoke, stress, sleep apnea  Clinical Manifestations People with hypertension may be asymptomatic and remain so for many years Symptoms seen related to organ damage are seen late and are serious Retinal and other eye changes Assessment and Diagnostic Renal damage Findings History and Physical Myocardial infarction Laboratory tests Cardiac hypertrophy Urinalysis Stroke Blood chemistry- sodium, potassium, creatinine Cholesterol levels ECG  Pharmacologic Therapy Recommended initial medications for African American and all patients 60 years and older with stage I hypertension include a calcium channel blocker or a thiazide diuretic. Patients less than 60 years old are typically prescribed an angiotensin- converting enzyme inhibitor (ACE-I) or an angiotensin receptor blocker (ARB). Initial low doses of medication are given, gradually increased if blood pressure doesn't fall to less than 140/90 mm Hg. Gradual reduction of medication types and doses is indicated when blood pressure is less than 140/90 mm Hg for at least 1 year. Clinicians prescribe the simplest treatment schedule, ideally one pill per day. Pharmacologic Therapy Diuretic and related drugs Thiazide diuretics Loop diuretics Potassium sparing diuretics Aldosterone receptors blockers Vasodilators Angiotensin-converting enzyme (ACE) inhibitors Angiotenisin II antagonists Calcium channel blockers NURSING DIAGNOSES Deficient knowledge regarding the relation between the treatment regimen and control of the disease process Noncompliance with therapeutic regimen related to side effects of prescribed therapy Nursing Interventions Sodium and fat restriction Increased fruit and vegetable intake Regular physical activity. Patient should limit alcohol intake and avoid tobacco due to increased risk of heart disease. Support groups for weight control, smoking cessation, and stress reduction Patient Teaching Teach that some medications, like beta-blockers, may cause sexual dysfunction. erectile dysfunction, as a side effect. This occurs because beta-blockers reduce sympathetic nervous system The patient and caregivers should be cautioned that antihypertensive medications might cause hypotension. Low blood pressure or postural hypotension should be reported immediately. Educate patients to change positions slowly when moving from a lying or sitting position to a standing position. The nurse also counsels older adult patients to use supportive devices such as handrails and walkers as necessary to prevent falls that could result from dizziness  HYPERTENSIVE CRISES Hypertensive emergency Blood pressure > 180/120 and must be lowered immediately to prevent damage to target organs Acute, life-threatening blood pressure elevations that require prompt treatment in an intensive care setting because of the serious target organ damage Hypertensive urgency Blood pressure is very high but no evidence of immediate or progressive target organ damage Associated with severe headaches, nosebleeds, or anxiety are classified as urgencies. In these situations, oral agents can be given with the goal of normalizing blood pressure within 24 to 48 hours Taking vital signs every 5 minutes is appropriate if the blood pressure is changing rapidly; taking vital signs at 15- or 30- minute intervals in a more stable situation may be sufficient. 88  REFERENCES ▪ Smeltzer, S.C., & Bare B.G. (2018). Brunner & Suddarth’s textbook of medical surgical nursing. 15th ed. Philadelphia: Lippincott. ▪ Clinical Handbook for Brunner & Suddarth's Textbook of Medical-Surgical Nursing,14th Ed. 2018 Author(s): Lippincott Williams & Wilkins ISBN/ISSN978149635514 ▪ Medical-Surgical Nursing Assessment and Management of Clinical Problems, 12th Edition, 2020. Author(s): Sharon Lewis, Linda Bucher, Margaret Heitkemper, Mariann Harding, Jeffrey Kwong, and Dottie Roberts. eBook ISBN: 9780323371438 Imprint: Mosby Published Date: September 2016 Page Count: 1776 ▪ Doenges, M., Moorhouse, M., Murr, A. (2019). Nursing Care Plans: Guidelines for individualizing client care across the life span 10th edition. Philadelphia: F.A. Davis company. ▪ Vallerand, A. and Sanoski, C. (2019) Davis’s Drug Guide for nurses, 17th ed. D.A. Davis ▪ Adams, M, Holland, L, & Urban, C. (2017). Pharmacology for Nurses: A Pathophysiological Approach, Second Canadian Edition, 5 th edition, Pearson ▪ Berman A. , Snyder, S. , & Frandsen, G. (2021). Kozier & Erb's Fundamentals of Nursing: concepts, process and practice. 11th ed. 89 90