MEDSURG PRELIMS_Cardiovascular (1).pdf

NCM 112 | Medical Surgical Nursing (Prelim) |01 CARDIOVASCULAR DISEASES LEGEND: Stent : a metal mesh that p...

NCM 112 | Medical Surgical Nursing (Prelim) |01 CARDIOVASCULAR DISEASES LEGEND: Stent : a metal mesh that provides structural support BLACK- Reporting SKY BLUE Italic-Book tors coronary vessel, preventing its closure DARK BLUE- Google/Youtube ANATOMY AND PHYSIOLOGY DEFINITION OF TERMS Atheroma : fibrous cap composed of smooth muscle cells that forms over lipid deposits within arterial vessels and protrudes into the lumen of the vessel, narrowing the lumen and obstructing blood flow; also called plaque Atherosclerosis : abnormal accumulation of lipid deposits and fibrous tissue within arterial walls and the lumen (a disease of atheroma) The coronary arteries that wrap around the heart's surface, provide the main blood supply to the Angina : chest pain or discomfort heart. The functional blood supply that oxygenates and nourishes the Coronary Artery Bypass Graft (CABG) : a surgical myocardium is provided by the right and left coronary procedure in which a blood vessel from another part arteries. of the body is grafted onto the occluded coronary artery below the occlusion in such a way that blood MAJOR BRANCHES OF CAD flow bypasses the blockage Ischemia : insufficient tissue oxygenation, a less- ANTERIOR..INTERVENTRICULAR ARTERY than-normal amount of blood flow to part of your body. CIRCUMFLEX ARTERY POSTERIOR..INTERVENTRICULAR ARTERY High-density lipoprotein (HDL) : a protein-bound MARGINAL ARTERY ON THE RIGHT lipid that transports cholesterol to the liver for excretion in the bile: composed of a higher proportion They are compressed when the ventricles are contracting and of protein to lipid than low-density lipoprotein; exerts a fills when the heart is relaxed. The myocardium is drained by beneficial effect on the arterial wall several cardiac veins, which empty into an enlarged vessel on Low-density lipoprotein (LDL) : a protein-bound the posterior of the heart called coronary sinus. The coronary lipid that transports cholesterol to tissues in the body. sinus, in turn, empties into the right atrium. Metabolic syndrome : a cluster of metabolic CORONARY ARTERY DISEASE abnormalities including insulin resistance, obesity, dyslipidemia, and hypertension that increase the risk of cardiovascular disease Coronary artery disease (CAD) is a condition characterized by the narrowing or blockage of the Percutaneous coronary intervention (PCI) : a coronary arteries, which supply oxygen-rich blood to procedure in which a catheter is placed in a coronary the heart muscle. artery, and one of several methods is employed to The most prevalent type of cardiovascular disease in reduce blockage within the artery adults. Percutaneous transluminal coronary angioplasty Coronary arteries delivers a constant supply of blood (PTCA) : a type of percutaneous coronary to heart muscle; starts to develop fatty plaques intervention in which a balloon is inflated within a which leads to restriction of blood flow to the heart. coronary artery to braln atheroma and open the Fatty Plaques caused by a condition vessel lumen, improving coronay artery blood flow “Atherosclerosis” that occurs in the arterial wall. TUMULAK, MA. KARLA DEAR M. 1  unstable, depending on the degree of inflammation and thickness of the fibrous cap. If the fibrous cap PATHOPHYSIOLOGY over the plaque is thick and the lipid pool remains relatively stable, it can resist the stress of blood flow and vessel movement. ATHEROSCLEROSIS (D). As the plaque enlarges, the vessel narrows and blood is an abnormal accumulation of lipid, or fatty flow decreases substances, and fibrous tissue in the lining of If the cap is thin and inflammation is ongoing, the arterial blood vessel walls. These substances block lesion becomes what is called vulnerable plaque. and narrow the coronary vessels in a way that reduces blood flow to the myocardium. (E). The plaque may rupture and a thrombus might form, obstructing blood flow. Plaques can rupture → thrombosis formation → At this point, the lipid core may grow, causing the condition leads to: High blood pressure, Chest pain, fibrous plaque to rupture. MI, Heart Failure A ruptured plaque attracts platelets and causes thrombus formation. A thrombus may then obstruct blood flow, leading to acute coronary syndrome (ACS), which may result in an acute myocardial infarction (MI). When an MI occurs, a portion of the heart muscle no longer receives blood flow and becomes necrotic. CLINICAL MANIFESTATIONS Ischemia - impediment to blood flow is usually progressive, causing an inadequate blood supply that deprives the cardiac muscle cells of oxygen needed for their survival ➔ Angina pectoris - refers to chest pain brought about by myocardial ischemia. Heaviness, tightness, burning, squeezing Sudden cardiac death Dysrhythmias Epigastric distress and pain that radiates to the jaw or (A, B) Atherosclerosis begins as monocytes left arm (macrophages) and lipids enter the intima (innermost coat Shortness of breath - pt who are older or have a hx of of an organ such as a blood vessel )of an injured vessel. DM or HF Smooth muscle cells proliferate within the vessel wall. Diaphoresis - excessive sweating The endothelium undergoes changes and stops producing the normal antithrombotic and vasodilating Women symptoms often include: (women are prone to CAD agents. The presence of inflammation attracts because A woman's heart and blood vessels are smaller, and inflammatory cells, such as macrophages. The the muscular walls of women's hearts are thinner.) macrophages ingest lipids, becoming “foam cells” that Atypical symptoms such as nausea/ vomiting, transport the lipids into the arterial wall. Some of the indigestion, palpitations, and numbness lipid is deposited on the arterial wall, forming fatty Back pain streaks. Jaw pain SOB with no chest pain (C), contributing to the development of fatty Prodromal symptoms may occur (e.g., angina a few accumulations and atheroma hours to days before the acute episode), or a major cardiac event may be the first indication of coronary Following the transport of lipid into the arterial wall, atherosclerosis. smooth muscle cells proliferate and form a fibrous cap ---- over a core filled with lipid and inflammatory infiltrate. Many patients are asymptomatic during the early phases Atheromas, or plaques - deposits that protrude of CAD development. into the lumen of the vessel, narrowing it and obstructing blood flow. Plaque may be stable or TUMULAK, MA. KARLA DEAR M. 2  Chest pain during activity (stable angina…not a medical emergency but patients need to let their doctor NON - MODIFIABLE know about this chest pain so diagnostic testing can be performed). The pain may feel like heaviness on chest….can progress to unstable angina (medical Family history of CAD emergency) where the patient will have pain at rest and it Increasing Age ( Men > 45 yrs; Women > 55 yrs) - is more intense…may not be relieved by Nitroglycerin. As people age, their risk of CAD increases. This is partly due to the natural aging process. Types of Angina Gender (men develop CAD at an earlier age than Stable Angina  most common form of women) - Men are more likely to develop CAD at a angina. younger age compared to women. This difference  It usually happens during activity, also called exertion. may be due to protective effects of estrogen in It goes away with rest or women before menopause, which tends to delay the angina medicine. Pain that starts when you're walking onset of CAD. uphill or in the cold weather Race (higher incidence in African American) may be angina. History of premature menopause (before age 40)  Stable angina is predictable. It is usually similar to and history of pregnancy-associated disorders previous episodes of chest such as preeclampsia pain. The chest pain typically lasts a short time, perhaps Primary hypercholesterolemia (a genetic condition five minutes or less. resulting in elevated LDL) Unstable Angina  unpredictable and occurs at rest.  pain is worsening and MODIFIABLE occurs with less physical effort.  typically severe and lasts Hyperlipidemia high lipid levels – including longer than stable angina, maybe 20 minutes or triglycerides and LDL – in your blood. longer. Tobacco use - Firsthand and secondhand smoke  The pain doesn't go away increases blood vessel constriction. with rest or the usual angina Alcohol use - Alcohol weakens the heart muscle and medicines. If the blood flow doesn't improve, the heart affects blood clot formation causing blood vessel doesn't get enough oxygen. obstruction A heart attack occurs. Unstable angina is HTN (>140/90)- The arteries may become stiff and dangerous and needs rigid if high blood pressure is uncontrolled. emergency treatment Diabetes - Diabetes or insulin resistance causes Variant angina  This type of angina isn't due to coronary artery disease. hardening of the blood vessels and fatty plaque (aka Prinzmetal angina)  It's caused by a spasm in buildup. the heart's arteries. The Metabolic syndrome - a cluster of metabolic spasm temporarily reduces blood flow. Severe chest pain abnormalities A diagnosis of this syndrome is made is the main symptom of when a patient has three of the following five risk variant angina. It most often occurs in cycles, typically at factors: rest and overnight. The pain ➔ Enlarged waist circumference (>35.4 may be relieved by angina medicine. inches in males, >31.4 inches in females) Refractory  Angina episodes are ➔ Elevated triglycerides (greater than or angina frequent despite a equal to 175 mg/dL, or currently on drug combination of medicines and lifestyle changes. treatment for elevated triglycerides) ➔ Reduced HDL (40 mg/dL and LDL3mg/dL  Arthralgia (joint stiffness)  Fever > 38.5 (> 3.8.0 HIGH RISK)  Prolonged PR Interval  Anamnesis suggestive of rheumatism  Leukocytosis (chorea does not need evidence of a prior GAS) TOTALS: ♥ Sydenham Chorea a neurologic disorder that some ➔ Evidence of Group A Strep.; if has 2 moajor criteria children experience after rheumatic fever or strep throat. or 1 major and 2 minor criteria It leads to uncontrollable dance-like movements and other symptoms that can strike at any time. Severe symptoms OTHERS can affect daily life. 1. ECG - 1° AV Block most commonly; 2°/3° blocks possible 2. Chest X-ray- Congestion; Cardiomegaly 3. Echocardiogram - Effusion; Valvular Dysfunction 4. Throat Culture 5. Serology- Anti streptolysin O; AntiDeoxyribonucluease B ASSESSMENT FINDINGS 1. Flu-like Symptoms: Fever, sore throat, and joint pain, often linked to initial streptococcal infection. 2. Dyspnea: Shortness of breath due to impaired heart valve function. 3. Fatigue: Persistent tiredness from reduced cardiac output. 4. Syncope: Fainting episodes from poor blood flow to the brain. 5. Palpitations: Irregular heartbeats, often due to arrhythmias. TUMULAK, MA. KARLA DEAR M. 23  MEDICAL MANAGEMENT 1. ERADICATE INFECTION a. Preventive and prophylactic therapy is indicated after rheumatic fever and acute rheumatic heart disease to prevent further damage to valves. b. Primary prophylaxis (initial course of antibiotics administered to eradicate the streptococcal infection) also serves as the first course of secondary prophylaxis ♥ They may also sustain sudden cardiac death or into (prevention of recurrent rheumatic fever and rheumatic severe congestive heart failure (fulminant myocarditis) heart disease). PREVENTION c. An injection of 0.6-1.2 million units of benzathine penicillin G intramuscularly every 4 weeks is the The major interventions for prevention and control of RHD recommended regimen for secondary prophylaxis include reduction of exposure to GAS; Prevention strategies are the most appealing option for sustainable disease control d. Administer the same dosage every 3 weeks in areas in developing nations. where rheumatic fever is endemic, in patients with residual carditis, and in high-risk patients. ♥ PRIMORDIAL PROPHYLAXIS: essentially focuses on socioeconomic development as it directly impacts e. Continue antibiotic prophylaxis indefinitely for hygiene, access to medical care, and living conditions patients at high risk (eg, health care workers, teachers, (such as avoidance of overcrowding). daycare workers) for recurrent Group A beta-hemolytic streptococcal (GABHS) infection. ♥ PRIMARY PROHYLAXIS: Primary prevention of RHD depends on preventing the initial attacks of ARF by f. Patients with rheumatic fever, with carditis and valve means of short-term oral or IM penicillin treatment of disease should receive antibiotics for at least 10 patients presenting with acute sore throat (pharyngitis) years or until age 40 years. caused by GAS infection. Barriers to primary prevention in developing countries include poor access to primary g. Patients with rheumatic heart disease and valve care, a shortage of skilled personnel, the expense of damage require a single dose of antibiotics 1 hour microbiological diagnosis, poor public awareness about before surgical and dental procedures to help prevent the diagnosis and prompt treatment of suspected GAS bacterial endocarditis. pharyngitis, and a high incidence of ARF without sore throat. h. Patients who had rheumatic fever without valve damage do not need endocarditis prophylaxis. ♥ SECONDARY PROHYLAXIS: The World Health Organization defines secondary prophylaxis as “the i. Do not use penicillin, ampicillin, or amoxicillin for continuous administration of specific antibiotics to endocarditis prophylaxis in patients already receiving patients with a previous attack of rheumatic fever, or well- penicillin for secondary rheumatic fever prophylaxis documented rheumatic heart disease. The purpose is to (relative resistance of PO streptococci to penicillin and prevent colonization or infection of the upper respiratory aminopenicillins. tract with group A beta-hemolytic streptococci and the development of recurrent attacks of rheumatic fever.” The minimum duration of secondary prophylaxis in most 2. MAXIMIZE CARDIAC OUTPUT guidelines is 10 years. In severe cases, lifelong a. Corticosteroids are used to treat carditis, especially if regular benzathine penicillin G administration may be heart failure is evident. recommended. b. If heart failure develops, treatment, including ACE ♥ TERTIARY PROHYLAXIS: Tertiary interventions for RHD inhibitors, beta blockers and diuretics, is effective. include medical management of heart failure, operative management of valve lesions, and treatment for the consequences of RHD, including 3. PROVIDE COMFORT stroke, infective endocarditis, and arrhythmia. a. Client with arthritic manifestations obtain relief with salicylates. b. Bed rest is usually prescribed to reduce cardiac effort until evidence of inflammation has subsided. TUMULAK, MA. KARLA DEAR M. 24  SURGICAL MANAGEMENT 1. BALLOON VALVULOPLASTY ➔ Balloon valvuloplasty is a cardiac intervention to open up a stenotic or stiffed heart valves (e.g., aortic or mitral) using a catheter with a balloon on the tip. It is also known as balloon valvotomy. ➔ It is a less invasive procedure because it is done by inserting a catheter into the blood vessel from groin percutaneously rather than valve replacement with cardiothoracic surgical or other open methods. Balloon valvulotomy has several types, depending upon which 4. CHORDOPLASTY heart valve is involved for example: ➔ Chordoplasty is a surgical procedure aimed at ♥ Percutaneous balloon tricuspid valvuloplasty repairing the chordae tendineae, the string-like ♥ Percutaneous balloon pulmonary structures in the heart that help control the function of valvuloplasty the heart valves, particularly the mitral valve. ♥ Percutaneous balloon mitral valvuloplasty ➔ In patients with rheumatic heart disease, chordoplasty ♥ Percutaneous balloon aortic valvuloplasty can be performed to: 1. Restore Valve Function: Repairing or reconstructing damaged chordae to improve the mobility and alignment of the mitral valve leaflets. 2. Prevent Valve Replacement: In some cases, chordoplasty allows for valve repair instead of valve replacement, which is beneficial in preserving native valve function. 3. Reduce Regurgitation: By correcting chordae abnormalities, chordoplasty helps reduce or eliminate mitral regurgitation, where blood leaks 2. MITRAL COMMISSUROTOMY backward through the valve. ➔ A commissurotomy is a surgery (usually openheart) that treats mitral valve stenosis due to rheumatic heart disease. It helps blood flow better through your 5. ROSS PROCEDURE heart, reducing strain on your heart and lungs. ➔ The Ross procedure is a type of heart surgery ➔ The commissurotomy can be performed through many commonly used to treat aortic valve disease, approaches, including an open, closed, and even including cases caused by rheumatic heart disease. The percutaneous ballooning technique. The closed Ross procedure involves replacing the diseased aortic technique for repair was used for several years, but this valve with the patient’s own pulmonary valve. Then, has slowly changed to open repair and, more recently, a donor valve (homograft) or a tissue valve is used to to percutaneous technique. replace the pulmonary valve 3. LEAFLET RESECTION ➔ Leaflet resection involves removing a portion of the damaged or redundant valve tissue (leaflet) that is contributing to regurgitation. ➔ The goal is to restore the valve’s normal shape and function by correcting prolapse (when one of the leaflets does not close properly, allowing blood to flow backward). Typically, the procedure targets the posterior leaflet of the mitral valve. TUMULAK, MA. KARLA DEAR M. 25  6 BENTALL PROCEDURE NURSING MANAGEMENT 1. Replacement of the Aortic Valve: If the valve is severely damaged, it is replaced with a mechanical or bioprosthetic valve. 2. Replacement of the Ascending Aorta: The affected portion of the aorta (often the root) is replaced with a synthetic graft. 3. Re-implantation of Coronary Arteries:The coronary arteries are reattached to the graft, ensuring proper blood supply to the heart. Outcome and Risks The Bentall procedure is a highly effective surgery, but it is also complex and carries risks such as bleeding, infection, and complications related to the re implantation of the coronary arteries. However, with proper care, many patients have good long-term outcomes\ 7 VALVE REPLACEMENT Process: 1. Performed when valvuplasty is not suitable 2. Approached through a median sternotomy or mitral valve (at times) - right thoracotomy incision POST-SURGICAL MANAGEMENT After surgery, patients typically require:  Anticoagulation Therapy: Depending on the type of valve used and the presence of other conditions.  Regular Monitoring: Echocardiography and clinical assessments to monitor valve function and detect complications early.  Infective Endocarditis Prophylaxis: Especially after valve replacement, patients need antibiotics before certain dental or surgical procedures.  Lifelong Follow-up: Rheumatic heart disease is progressive, and continued care is essential to manage symptoms and prevent further complications TUMULAK, MA. KARLA DEAR M. 26