NCM 112: MEDSURG - CARDIOVASCULAR SYSTEM PDF

NCM 112: MEDSURG CARDIOVASCULAR SYSTEM 2. Right Ventricle = receives blood ANATOMY AND PHYSIOLOGY from the RA and pumps it to the...

NCM 112: MEDSURG CARDIOVASCULAR SYSTEM 2. Right Ventricle = receives blood ANATOMY AND PHYSIOLOGY from the RA and pumps it to the lungs via Pulmonary Artery HEART  Located at the left side of mediastinum 3. Left Atrium = Receives oxygenated blood from the lungs via the 4 pulmonary veins A. LAYERS 4. Left Ventricle = largest and most 1. Epicardium = covers the outer muscular chamber and receives surface of the heart oxygenated blood from the LA and 2. Myocardium = middle layers; pumps blood into the systemic contracting muscle circulation via aorta 3. Endocardium = innermost layer; lines inner chamber and heart D. HEART VALVES valves 1. Atrio-Ventricular Valves = lies between the atria and the B. PERICARDIUM = encases and protects ventricles Closed at the beginning the heart from trauma and infection of ventricular contraction and 1. Parietal Pericardium = Tough prevents blood from flowing back fibrous membrane that attach to to the atria, opens when ventricles the sternum, thoracic vertebrae and relax diaphragm 2. Semilunar Valves = Opens when 2. Visceral Pericardium = Thin ventricles contact and prevent membrane that attach to the heart blood from flowing back into 3. Pericardial Space = In between: ventricles, closed when ventricles holds 5-20 ml 0f fluid which relax lubricates the pericardial surfaces 3. Bicuspid or Mitral Valve = located at the left side of the heart C. HEART CHAMBERS 4. Tricuspid Valve = located at right 1. Right Atrium = receives side of the heart deoxygenated blood from the body via SVC and IVC 1 NCM 112: MEDSURG CARDIOVASCULAR SYSTEM 5. Pulmonic Valve = Between RV and 3. Bundle of HIS (AV Bundle) Pulmonary Artery  Fuses with AV node to form 6. Aortic Semilunar Valve = Between another pacemaker site LV and Aorta  Branches into the left and right Bundle Branch and terminates into Purkinjie Fibers  If SA node fails it can initiate and sustain HR of 40-60bpm 4. Purkinjie Fibers  Spread waves of depolarization through ventricles E. ELECTRICAL CONDUCTIVITY OF THE F. CORONARY ARTERIES = Supply the HEART myocardium with blood 1. Sinoatrial Node (SA node)  Pacemaker of the Heart; G. HEART SOUNDS initiates each heart beat S1 = 1st heart sound = heard when  Located at junction of SVC and AV valve closed RA  Generates electrical impulse at S2 = 2nd heart sound = heard when 60-100 times/ min semilunar valve closed S3 = 3rd heart sound = CHF S4 = 4th heart sound = HTN i. ACUTE CORONARY SYNDROME 2. Atrioventricular Node (AV node)  Located at the lower aspect of the atrial septum  Receives electrical impulse from the SA node 2 NCM 112: MEDSURG CARDIOVASCULAR SYSTEM PATHOPHYSIOLOGY: Thrombus/Emboli Increase Oxygen Demand Atherosclerosis 1. Exercise Artheriosclerosis 2. Sex 3. Eating heavy meal 4. Cold Environment Obstruction Decreased TP to Heart Decreased Oxygen Supply Cell Ischemia (Anaerobic Inverted T Wave Metabolism) Reversible Origin 5-30 minutes Relieves by Rest and NTG Increased Lactic Acid Acidosis Injury Elevated ST NANDA: Alt in Comfort segment CHEST PAIN NECROSIS L Shoulder, L Irreversible Arm, L Jaw (MI) > 30 minutes Unrelieved by N/V rest And NTG Pathologic Q wave Apprehension and Fear Release of Cathecolamine Decreased Heart Rate Diaphoresis 3 NCM 112: MEDSURG CARDIOVASCULAR SYSTEM  HCT decreases due to DIAGNOSTIC TESTS: decreased vascular flow 1. STRESS TEST = non-invasive, studies heart during activity and evaluates 4. NUCLEAR CARDIOLOGY = radionuclide coronary artery disease and scanning A. Treadmill = Most common 1. Technitium Pyrophosphate B. Radionuclide = Injected for Scanning perfusion and imaging 2. Thallium Imaging  If the patient cannot tolerates 3. Multigated Cardiac Blood Pool stress test – Persantine Imaging (Diphyridamole)  Hot-spots viable tissue of  After the procedure avoid Hot the Heart Shower  Cold-spots-necrotic tissue 2. ECG = Records electrical activity of the heart  1st test to MI patients 5. CARDIAC CATHETERIZATION  Best Test for Cardiac Pathology, determines the patency of the artery (Femoral or Brachial) 3. LABORATORY A. Cardiac Enzymes: 1. CK-MB = most definitive of cardiac damage, it rises within 4-6 hours 2. LDH = Rises within 1-2 days  If LDH 1 is higher that LDH 2 = MI 3. Troponin I = Rises within 3 hours 4. Myoglobin = Rises after 1 hour 5. SGOT/AST B. CBC  RBC rises due to inadequate oxygenation  WBC rises due to necrotic tissue 4 NCM 112: MEDSURG CARDIOVASCULAR SYSTEM NURSING CONSIDERATIONS: - If effective: causes 1. Informed Consent hyperventilation 2. Assess for allergy to seafood, iodine and dyes B. Complete Bed Rest 3. NPO 6-8 and liquids 4 C. Oxygen Inhalation 4. Fluttery Feeling – when the catheter D. Work Quietly and Systematically passes to the heart 5. Flushed Warm Feeling - when the dye is injected 2. HEMODYNAMIC STABILITY 6. Desire to cough and palpitation – due A. Monitor Vital Signs – Pulse Rate: to irritability Monitors skip beats it can lead to 7. Check most distal pulses arrhythmia DOC: Xylocaine 8. Apply sandbag - 4 hours check for (Lidocaine) bleeding H – Hypokalemia 9. Keep extremities extended – Hypocalcemia 10. Check for bleeding – 6 hours apply – Hypometabolic State ice – Hypoxia 11. Encourage Oral Fluid Intake – to A – Acidosis excrete dye T – Toxic Agents (Digoxin) - Cardiac Glycoside E – Exercise INTERVENTIONS: 1. COMFORT THE PATIENT CARDIOGENIC SHOCK A. Drug of Choice 1. Angina Pectoris: If Blood Pressure goes DOWN Nitroglycerine - Vasodilator (Cardiogenic Shock) Complication: O. HTN, Dizziness, Headache 1. Narrowing of Pulse Pressure 2. Oliguria ≤ 400 ml  Aspirin with NTG to prevent Headache 3. Altered Level of Consciousness  Given 3x with an interval CARDIOGENIC SHOCK of 5 minutes  Expires within 6 months Severe Left Ventricular Dysfunction  Apply to non-hairy part except forehead to Poor Pumping of the Heart prevent syncope 2. Myocardial Infarction: Decreased Carbon Dioxide Morphine Sulfate Concentration  Narcotic, Depressant, Analgesic  Antidote: Narcan Hypoxia (Naloxone) 5 NCM 112: MEDSURG CARDIOVASCULAR SYSTEM INTERVENTION: 1. Adrenergic Agonist – Increases Myocardial Contraction A. Dopamine (Intropin) B. Dobutamine (Dobutrex)  Titrate according to patient’s Blood Pressure C. Epinephrine (Adrenaline) 3. Antiplatelet = inhibits aggregation  Emergency drug for asthma of platelet in the clotting process, D. Isoproterenol HCL (Isoptel) decreases viscosity of the blood E. Norepinephrine (Levophed) A – Aspirin (acethylsalysilic acid) P – Plavix (Clopidogrel) 2. Inotropic / Cardiotonic Drugs P – Persantine (Dipherydamol) A. Milrinone (Primacor) T – Ticlid (ticlopidiac HCL) 3. Intra Aortic Balloon Pump – to increase Can’t cause GI Distress Carbon Dioxide by counter causation  Catheter is inserted via Femoral 4. Antilipidemic = lowers cholesterol 4. If the 3 interventions failed: Prepare the in the blood Family for Death and Dying A. Bile Acid Sequestrant = Blocks bile; combines with bile to B. Maintain Patent IV Line excrete in feces C. DRUGS: Ex. Cholestyramine 1. Fibrinoytic Drugs = Dissolve clots - (Questran), Cholestipol 6- 12 hours (Colestid) U – Urokinase Side Effects: Constipation, S – Streptokinase Flatulence A – Activase (Tissue Palsminogen Activase) B. HMG-Co A reductase Side Effects: Bleeding Inhibitor = inhibits the Antidote: Aminocaproic Acid formation of HMG- Primary State of building Cholesterol 2. Anticoagulant = prevent Ex. thrombus formation; formation of R – Rosovostatin (Crestort) new clots; extension or A – Atorvastatin (Lipitor) enlargement of clot S – Simvastatin (Zocor) Side Effects: Rhabdomyomyelysis (muscle weakness) 6 NCM 112: MEDSURG CARDIOVASCULAR SYSTEM  Discontinue if blood lipids did not NOTES ON COMPLICATIONS decrease within 3 months A. CARDIAC TAMPONADE = accumulation of fluid/blood in the pericardial cavity (20-50ml) N = 5-20 ml 3. EMOTIONAL SUPPORT - Restrict ventricular filling 4. SEDATION - limit visitors, maintain quiet environment Hallmark Sign: 5. TAKE TIME TO MAINTAIN ADEQUATE 1. Pulsus Paradoxus (Decreased BP NUTRITION during INSPIRATION)  NPO to decrease workload of the 2. Jugular Vein Distention heart for 24 hours 3. Distant muffled heart sound  Clear Liquids  Soft Diet after 48 hours Intervention: PERICARDIOCENTESIS - The needle will be inserted in the PRUDENT DIET: Low Salt, Low Fat, pericardium; Semi-fowlers thru the Low Cholesterol xiphoid process 6. PREVENT CONSTIPATION E-CART in place during cardiac arrest  Increase fiber and fluids if not contraindicated  Assist Exercise (Passive ROM) 7. ASSESS UNDERSTANDING OF SEXUALITY  4-6 weeks can resume for uncomplicated MI  Medications before sexual activity  Doctor’s clearance  Early morning foreplay  If 3 chest pain STOP then turn to side lying position B. DRESSLER’S SYNDROME = acute 8. INSTRUCTION OF REHABILITATION pericarditis that occur 2-3 weeks after  Maximum of 10 days MI attack  1 to 5 days ICU; CBR in 1-3 days on day 4-5 may sit (dangle the Hallmark Sign: legs) 1. Chest pain- aggravated by coughing  After 2 weeks follow-up care and breathing 2. Fever - pericarditis 3. Pericardial Friction Rub – scratchy/ high-pitched sound due to rubbing inflamed pericardial layers 7 NCM 112: MEDSURG CARDIOVASCULAR SYSTEM Hallmark Sign: 1. Low grade fever 2. Joint pain 3. Roth’s spot = retinal hemorrhage 4. Osler’s node = painful nodules on the pads of fingers and toes 5. Splinter’s hemorrhage = nail beds 6. Janeway’s Lesion = non-painful/non-tender hemorrhagic lesion at the sole of the foot Intervention: - Sitting on High-fowlers/Leaning forward - NSAID’s – Indomethacin - Anti-inflammatory - Steroids: Dexamethasone C. ENDOCARDITIS = inflammation of the inner lining of the heart and heart valves Etiology:  Dental abscess = most common cause  Drug users: fibrin  Vegetation (collection of bacteria, fibrin, RBC) Interventions:  Bedrest = to prevent dislodgement of vegetation  Anti-embolic stocking  Monitor for signs of emboli  Blood Culture = determination of causative agent (Streptococcus/Staphylococcus)  NSAID’s  ATB: Penicillin G (cloxacillin/oxacillin)  Advise good oral hygiene 10-14 days to sterilize vegetations 8 NCM 112: MEDSURG CARDIOVASCULAR SYSTEM  Prophylaxis of ATB before any invasive procedures ii. CONGESTIVE HEART FAILURE  inability of the ventricles to pump normally PATHOPHYSIOLOGY: MANAGEMENT: U – Upright position N – Nitrates L – Lasix O – Oxygen A – Aminophylline D – Digoxin 9 NCM 112: MEDSURG CARDIOVASCULAR SYSTEM Digoxin Toxicity: GIT A. BRADYARRYTHMIAS = heart blocks; V – Vomitus delayed transmission of impulse A – Anorexia PATHOPHYSIOLOGY: N – Nausea D – Diarrhea 1st AV-Block: Prolonged PR Interval SA -> AV A – Abdominal Pain XXX -> XXX Asympotomatic Therapeutic Level: 0.5-2 mg/dl Do nothing because it is asymptomatic Antidote: Digibind or Ca EDTA - Withdraw blood before giving the drug or 8 hours after drug administration F – Fluid Decrease A – Afterload Decrease ACE Inhibitor (Captopril) Beta Blockers (olol) S – Sodium Restriction T – Test for Electrolytes (K level) Avoid 2nd AV-Block: Hypokalemia MOBITS I – WEN KEBACHS - Evident of U wave Progressive prolonged Interval Hypoactive Bowel Sounds MOBITS II – Fixed prolonged interval Weakness SA -> AV D – Dry Phlebotomy - 3 extremities XXX XX occluded, rotate every 15 minutes  Alteration in the patient’s level of iii. ARRYTHMIAS conscious  Atropine Sulfate 10 NCM 112: MEDSURG CARDIOVASCULAR SYSTEM -HICCUPS - 1st sign of PM malfunction a. Failure to pace = fail to initiate impulse Mx: Check the battery and placement of electrode b. Failure to capture = regenerates impulse with no depolarization (tip of the catheter does not touch the heart) Mx: Put the patient in Left Side-lying position c. Failure to sense = does not sense 3rd AV-Block = Complete Block cardiac rhythm and initiates an electrical impulse SA -> AV Mx: Check the battery XXX (No Impulse) 6. Advise to keep pacemaker ID card in the Treatment: Pacemaker wallet and wear Types of Pacemakers: - Medic-Alert Bracelet 1. Fixed/ Asynchronous = 4 beats/min= Notify - Present Cardiac Rate 2. Demand/Synchronous = Physiologic Demand B. TACHYARRYTHMIAS NURSING CONSIDERATIONS: 1. Take the patient’s pulse daily 2. No Contact sports/ wear loose fitting clothes 3. Daily dressing to prevent infection 4. Avoid electromagnetic devices 5. Common Pacemaker problems: 11 NCM 112: MEDSURG CARDIOVASCULAR SYSTEM ATRIAL FIBRILLATION: - Cardiac Arrhythmias - Cardiac Output Decreased - Cold Leg - Clot Formation TREATMENT: - Calan (Verapamil) - Calci Bloc - Cardizem Management: 1. Vagal Maneuver = induced vagal stimulation a. Carotid Massage = 6-8 seconds b. Valsalva Maneuver = Induces straining (Bear Down) c. Induced Gag Reflex 2. Chemical Cardioversion a. Quinidine (Quinine) Nursing Consideration: b. Procainamide - adverse reaction = SLE 1. Stop Oxygen during the procedure to c. Amniodarone (Cornderone) avoid fire 3. Electrical Cardioversion 2. Make sure to apply lubricant on paddles to avoid burns 3. Stay away from the bed when doctor say CLEAR iv. VALVULAR HEART DISEASE 12 NCM 112: MEDSURG CARDIOVASCULAR SYSTEM Diagnostic Test: Echocardiogram - Trigerred by: Smoking - BV = small and medium sized Treatment: Only Surgical arteries of hands and feet a. Valvuloplasty - surgical repair of valve b. Valvulotomy v. PERIPHERAL VASCULAR DISEASE Hallmark Signs (6 P’s) 1. Paresthesia (Earliest) 2. Pain 3. Pallor 4. Paralysis 5. Poikilothermia 6. Pulselessness Diagnostic Test: 1. Ankle Brachial Index: Formula: Ankle Pressure/Arm Pressure 110/70 / 120/80 40/40 = 1 Positioning: Interpretation: If >.90 = Normal ARTERIAL: Flat on Bed 0.71 – 0.90 = Mild 0.41 – 0.70 = Moderate VENOUS: Elevated 0.00 – 0.40 = Severe PATENCY OF THE VESSEL: 1. Atherosclerosis Obliterans (ASO) - Chronic inflammation of vessels due to atheroma 2. Thromboanginitis Obliterans (TAO) Buerger’s Disease - Common: Men 13 NCM 112: MEDSURG CARDIOVASCULAR SYSTEM Pre-Op: - Psychological Preparation - Teach to prevent deformity - Phantom limb sensation Post-Op: - Monitor for bleeding (always have a tourniquet) - No pillow under the knee 2. Doppler UTZ = monitor BV based on (can cause flexion turbulence deformity) 3. Arteriography – Most reliable - Passive ROM - Prepare for crutchwalking Management: P – Promote adequate tissue perfussion 3 RAYNAUD’s PHENOMENON – unknown etiology U – Understand Medications - Common: Female 1. Pentoxifylline - Triggered by: Smoking, Stress, Cold 2. Papavarine environment 3. Plasma Expanders (Dextran) Hallmark Sign: Flat color changes sign 4. Anticoagulant 5. Platelet Inhibitor Pallor = Whole Vasoconstriction 6. Antithrombotic (Cilostazol) Cyanotic = Blue Vasodilation Erythema = Red L – Limit/Stop Smoking and Caffeine S – Safety of the leg = heat sensitive - No warm compress on the leg - Place it on the abdomen - Insulated leather shoes E – Exercise: Buerger-Allen’s Exercise - Elevate extremities 5 degrees - Dangle the legs - Flat on bed S – Surgery 1. Femoral-popliteal bypass graft 2. Rotational Atherectomy 3. Amputation 14  NCM 112: MEDSURG CARDIOVASCULAR SYSTEM Diagnostic Test: Allen’s Test Ethiology: Management: 1. Congenital, genetically weak BV 1. Reduce stress 2. Prolonges sitting and standing 2. Avoid cold environment 3. Use gloves and mittens 4. Use brandy/whisky (black label, red label) 5. Monitor pulse 6. Administer vasodilator 4. VENOUS DISORDERS (DVT) PATENCY OFTHE VESSELS: A. Inflammatory - Thrombophlebitis Etiology: 1. Hypercoagability of the blood 2. Endothelial Injury – blood vessel wall damage 3. Venous/Blood stasis- decrease venous return Signs and Symptoms: 1. Homan’s Sign 2. Increase in leg girth 3. Erythema of the leg 4. Edema Signs and Symptoms: Management: 1. Dilated Tortorous vein 2. Dull achy sensation of the leg at 1. Bedrest the end of the day 2. Don’t massage(leg) 3. Elevate Management: 4. Apply warm compress 1. Elevate the leg 5. Use elastic support 2. Foot massage 6. Improve hydration 3. Note color changes 7. Anti-coagulants 4. Hose applications 5. Ulcer treatment: - Stasis Dermatitis = non- B. Functional – Varicose Vein healing ulcer of the leg - abnormal dilation of vessel wall of - UNNA PASTE BOOT = vein dressing with zinc oxide to facilitate wound healing 15 NCM 112: MEDSURG CARDIOVASCULAR SYSTEM - Vein Stripping = veins larger for 4 months - Sclerotherapy = injection of solution to hardened vessels (2 -3 weeks) - Incision and Drainage - Pressure dressing for 12-18 hours DEGENERATIVE: ANEURYSM = outpatching of the artery due to damage in tunica media (congenitally weak) Consideration: Etiology: 1. Do not palpate the abdomen = it can rupture S – Syphilis 2. Asymptomatic A – Artherosclerosis (70%) enhanced by HTN 3. Abdominal mass pulsation 4. Flank pain/ Abdominal Pain M – Marfan Syndrome (sign of aneurysm) 5. Sudden sharp knifelike pain (ruptured aneurysm) CONSTRICTIVE: HYPERTENSION (HTN) TYPES: 1. Primary = BP reading of 140/90 mmHg in 2 consecutive readings with 4-6 hours apart, unknown cause 2. Secondary = Secondary to disease S – Sacular (one-sided dilated) Ex. Chronic Renal Failure F – Fusiform ( 2 sided dilated) 3. Isolated = Calcification of Aorta R/T aging process D – Dissecting (more sided dilated) - Seen in elderly - Asymptomatic - Most dangerous because it is related A – Abdominal to high incidence of stroke 4. Malignant = Occipital headache due to A – Aortic anatomical placement of brain stem A – Aneurysm - Epistaxis - Paresthesia 16 NCM 112: MEDSURG CARDIOVASCULAR SYSTEM - Occipital Headache C – CALCIUM – CHANNEL BLOCKERS (-) Management: INOTROPIC EFFECT = blocks the entrance of Calcium in the myocardial cell 1. Lifestyle Modification Diet: Prudent diet - Decreases Cardiac Contraction Low alcohol C – Calan (Verapamil) Stop smoking 2. Pharmacologic approach: C – Cardizem C – Calcibloc A – ACE INHIBITORS “PRIL” A – Amlodipine (Norvasc) = Vasoconstrictor N – Nifedipine (Procardia) Side Effects: Bradycardia, HOPN, Contraindications: CHF Pruritus, Cough, Angioedema Nursing Considerations: Monitor the action of the drug Contraindications: Patients with Renal Insufficiency B – BETA BLOCKERS “OLOL” B1 = Heart - Increase in Cardiac Rate, Increase BP B2 = Lungs D – DIURETICS - Bronchodilation A – Aldactone (Spinorolactone) K P – Propranolol (Inderal) Sparring A – Atenolol Side Effects: Hyperkalemia = Irregular Heartbeats T – Timolol B – Bumex = Ototoxicity = Contraindications: CHF/COPD C - Chlorthiazide (Diuril)= K wasting; can cause Pancreatitis-monitor M – Metoprolol (Lopressor) Amylase N – Nadolol (Corgard) F – Furosemide (Lasix) = Loop Diuretic = Blocks B1 can be given to asthmatic patients 17