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Assessment of

Cardiovascular Function
A look at cardiac anatomy…..
Major Function:

The heart pumps blood to the


tissues supplying them with oxygen
and other nutrients.
Between the layers
Heart Chambers

Right Atrium (RA)


Left Atrium (LA)
Right Ventricle (RV)
Left Ventricle (LV) --- PMI
Inside the heart
Systole
Contraction/Depolarization
1. Isovolumetric contraction phase
2. Ejection phase

Diastole
Relaxation/Repolarization
1. Isovolumetric relaxation phase
2. Filling phase
Heart Valves
Atrioventricular valves
Mitral valve (bicuspid valve)
Tricuspid valve

Semilunar Valve
Aortic Valve
Pulmonic Valve

ONE-WAY VALVE
Coronary Arteries
1. Left Coronary Artery
a. Left Main Coronary Artery
i. Left anterior descending
artery
ii. Left circumflex artery
2. Right Coronary Artery
i. Posterior descending artery

Perfused during DIASTOLE!


Coronary Veins
Venous blood from these
veins returns to the heart
primarily through the
CORONARY SINUS
Located posteriorly in
the right atrium
Transmission of electrical impulses

Generation and transmission of electrical


impulses depend on these cell characteristics:
• Automaticity
• Excitability
• Conductivity
• Contractility
Electrical Conduction System of the Heart
1. Sinoatrial node
2. Atrioventricular
node
3. Common bundle of
his
4. Left and Right
bundle of his
5. Purkinje fibers
Nerve supply to the heart

•The heart is supplied by the two branches of the


autonomic nervous system—the
•sympathetic, or adrenergic, and
•parasympathetic, or cholinergic.
STROKE VOLUME
•Amount of blood ejected from one of the
ventricles per heartbeat
•Average resting SV is about 60 to 130 mL
CARDIAC OUTPUT
•Refers to the total amount of blood ejected by
one of the ventricles in liters per minute.
•Normal resting adult – 4 to 6 liters/minute
Therefore:
Effect of Heart Rate on Cardiac Output
•Heart rate is affected by the central nervous
system and baroreceptors
*baroreceptors are specialized nerve cells located
in the aortic arch and in both right and left
internal carotid artery (at the point of bifurcation
from the common carotid arteries)
•sensitive to changes in BP
Note:
• The percentage of the end-diastolic volume that is
ejected with each stroke is called the ejection
fraction.
• The ejection fraction can be used as an index of
myocardial contractility: the ejection fraction
decreases if contractility is depressed.
Gender considerations

•Structural differences between the hearts of


men and women have significant implications.
• Woman’s heart tends to be smaller than man.
• Coronary arteries are narrower in diameter.
*cardiac catheterization
*angioplasty
Gender considerations

• Women typically develop CAD 10 years later than men.


• Estrogen (cardioprotective effects)
Increase in HDL
Decrease in LDL
Dilation of the blood vessels, which enhance blood flow to
the heart.

*hormone replacement therapy


Risk Factors for Heart Disease

Nonmodifiable risk factors include the following:


•Positive family history for premature coronary
artery disease
•Increasing age
•Gender (men and postmenopausal women)
•Race (higher incidence in African Americans than
in Caucasians)
Risk Factors for Heart Disease

Modifiable risk factors


include the following:
• Hyperlipidemia • Physical inactivity
• Hypertension • Type A personality
• Cigarette smoking characteristics, particularly
• Elevated blood glucose hostility
level • Use of oral contraceptives
• Obesity
Blood Pressure

•Systemic arterial BP is the pressure exerted on


the walls of the arteries during ventricular
systole and diastole.

*invasive arterial monitoring systems


*noninvasively by a sphygmomanometer and
stethoscope
Blood Pressure

PULSE PRESSURE
• difference between the systolic and the diastolic
pressures
• It is a reflection of stroke volume, ejection velocity,
and systemic vascular resistance.
• normally is 30 to 40 mm Hg
• indicates how well the patient maintains cardiac
output
Blood Pressure
POSTURAL BLOOD PRESSURE CHANGES
Gravitational redistribution of approximately 300
to 800 mL into the lower extremities and GI
system immediately upon standing.
Postural (orthostatic) hypotension occurs when
the BP drops significantly after the patient
assumes an upright posture.
It is usually accompanied by dizziness,
lightheadedness, or syncope.
Postural (orthostatic) hypotension

Example:

Lying down, BP 120/70, heart rate 70


Sitting, BP 100/55, heart rate 90
Standing, BP 98/52, heart rate 94
Palpation of arterial pulse
Arterial pulses

*pulse deficit = a difference between the apical rate


and radial rate

NURSING ALERT
• Do not palpate temporal or carotid arteries
simultaneously, because it is possible to decrease the
blood flow to the brain.
Jugular Venous Pulsations

• An estimate of right-sided heart function can be made


by observing the pulsations of the jugular veins of the
neck, which reflects the central venous pressure
(CVP)
• CVP is the pressure in the right atrium and right
ventricle at the end of the diastole.
• Visible just above the clavicle, adjacent to the
sternocleidomastoid muscles.
Heart Inspection and Palpation

•The heart is examined indirectly by inspection,


palpation, percussion, and auscultation of the
chest wall.
•A systematic approach is the cornerstone of a
thorough assessment.
Heart Inspection and Palpation

• Examination of the chest wall is performed in the


following six areas:
Aortic area
Pulmonic area
Erb’s point
Right ventricular or tricuspid area
Left ventricular or apical area/mitral
Epigastric area
Heart Inspection and Palpation

APICAL IMPULSE
•A broad and forceful apical impulse is known as
a left ventricular heave or lift.
Thrill
•Abnormal, turbulent blood flow within the heart
may be palpated with the palm of the hand as a
purring sensation.
•associated with a loud murmur.
Normal heart sounds

• The normal heart sounds:


S1 and S2
are produced primarily by the closing of the heart valves.
S3, S4 gallops—diastole (resistance during ventricular filling)
*gallop sounds are very low frequency sounds and are heard with
the BELL of the stethoscope.
opening snaps, systolic clicks and murmurs.

SUMMATION GALLOP
Murmurs are created by turbulent flow of blood
in the heart.

Friction Rub is a harsh, grating sound that can be


heard in both systole and diastole.
•Caused by the abrasion of the inflamed
pericardial surfaces from pericarditis
•Use diaphragm of the stethoscope
Cardiac biomarker analysis

•Creatine kinase (CK) and its isoenzyme CK-MB


are the most specific enzymes analyzed in acute
MI, and they are the first enzyme levels to rise.
Cardiac biomarker analysis

•Lactic dehydrogenase and its isoenzymes


also are analysed in patients who have delayed
seeking medical attention, because these blood
levels rise and peak in 2 to 3 days, much later
than CK levels
Cardiac biomarker analysis
• Myoglobin
an early marker of MI, is a heme protein with a small
molecular weight.
This allows it to be rapidly released from damaged
myocardial tissue and accounts for its early rise, within
1 to 3 hours after the onset of an acute MI.
Myoglobin peaks in 4 to 12 hours and returns to normal
in 24 hours.
Cardiac biomarker analysis
• Troponin I
a contractile protein found only in cardiac muscle.
elevated serum troponin I concentrations can be
detected within 3 to 4 hours; they peak in 4 to 24 hours
and remain elevated for 1 to 3 weeks.
Blood chemistry, Hematology, and Coagulation Studies

•Lipid profile •C-Reactive Protein


•HDL
•LDL
•Triglycerides
•Brain (B-Type
Natriuretic Peptide)
Diagnostic Exams

•Chest X-ray and •TEE


Fluoroscopy •MPI
•ECG •CT scan
•Hardwire Monitor •Cardiac
•Holter Catheterization
•Cardiac Stress Test
•Echocardiography
Management of
Patients with
Dysrhythmias and
Conduction Problems
Dysrhythmias

•are disorders of the formation or conduction (or


both) of electrical impulse within the heart
•These disorders can cause disturbances of the
heart rate, the heart rhythm, or both.
•diagnosed by analyzing the electrocardiographic
waveform.
Influences on HR and contractility

• Stimulation of the sympathetic system:


increases heart rate (positive chronotropy),
Increases conduction through the AV node (positive
dromotropy),
Increases the force of myocardial contraction
(positive inotropy).

Sympathetic stimulation also constricts peripheral blood vessels,


therefore increasing blood pressure.
Influences on HR and contractility

• Parasympathetic stimulation:
reduces the heart rate (negative chronotropy),
reduces AV conduction (negative dromotropy),
reduces the force of atrial myocardial contraction
(negative inotropy)
The decreased sympathetic stimulation results in dilation of
arteries, thereby lowering blood pressure.
DETERMINING VENTRICULAR HEART RATE
FROM THE ELECTROCARDIOGRAM
Sequence method
DETERMINING VENTRICULAR HEART RATE
FROM THE ELECTROCARDIOGRAM
1500 method

HR= 1500/small boxes


DETERMINING VENTRICULAR HEART RATE
FROM THE ELECTROCARDIOGRAM
300 method

HR= 300/big boxes


DETERMINING VENTRICULAR HEART RATE
FROM THE ELECTROCARDIOGRAM
• Six-second ECG strip
V1 Fourth intercostal space at the right sternal border
V2 Fourth intercostal space at the left sternal border
V3 Halfway between leads V2 and V4
V4 Fifth intercostal space in the midclavicular line
V5 Left anterior axillary line on the same horizontal plane as V4
Left midaxillary line on the same horizontal plane as V4 and
V6
V5
RA Right arm (inner wrist)
LA Left arm (inner wrist)
RL Right leg (inner ankle)
LL Left leg (inner ankle)
Sinus Arrhythmia
ATRIAL DYSRHYTHMIAS: Premature Atrial Complex (PAC)

• PAC is a single ECG


complex that occurs
when an electrical
impulse starts in the
atrium before the
next normal impulse
of the sinus node.
ATRIAL DYSRHYTHMIAS: Premature Atrial Complex
Atrial Flutter

•P wave: Saw-toothed shape. These waves are


referred to as F waves.
Atrial Flutter
Atrial Fibrillation (a-fib)

• Atrial fibrillation
causes a rapid,
disorganized, and
uncoordinated
twitching of atrial
musculature.
Atrial Fibrillation (a-fib)
Atrioventricular Nodal Reentry Tachycardia
Remember!
Don’t perform carotid sinus massage
on older patients.
Ventricular Tachycardia
Ventricular Fibrillation

• Ventricular fibrillation is a rapid but disorganized


ventricular rhythm that causes ineffective quivering of
the ventricles. There is no atrial activity seen on the ECG.
Ventricular Fibrillation
Ventricular asystole
• flatline
CONDUCTION ABNORMALITIES

•First-Degree Atrioventricular Block


•Second Degree AV block Type I
•Second Degree AV block Type 2
CONDUCTION ABNORMALITIES
Second-Degree Atrioventricular Block, Type I.
(Wenckebach)
Second-Degree Atrioventricular Block, Type II.
Mobitz II
Third-Degree Atrioventricular Block
(Complete Heart Block)
Adjunctive modalities and management

Remember:
Acute dysrhythmias may be treated with
medications or with external therapy.

CARDIOVERSION AND DEFIBRILLATION


CARDIOVERSION

•Defibrillation---- an emergency treatment,


•Cardioversion, usually a planned procedure.

•Electrical current may be delivered through


paddles or conductor pads.
PACEMAKER THERAPY

• A pacemaker is an
electronic device that
provides electrical
stimuli to the heart
muscle.
Management of
Patients with
Coronary Vascular
Disorders
Coronary Artery Disease (CAD)
•Most prevalent type of cardiovascular disease in
adults
•results from the narrowing of the coronary
arteries over time due to atherosclerosis
(coronary atherosclerosis)
•The primary effect of CAD is the loss of oxygen
and nutrients to myocardial tissue because of
diminished coronary blood flow.
•Angina pectoris
•ischemia
•infarction
Diagnostic studies
•Electrocardiography
•Cardiac catheterization
•Blood lipid levels
Surgical procedures
1. PTCA
2. Laser angioplasty
3. Atherectomy
4. Vascular stent
5. Coronary artery bypass grafting
Medications
1. Nitrates to dilate the coronary arteries and
decrease preload and afterload
2. Calcium channel blockers to dilate coronary
arteries and reduce vasospasm
3. Cholesterol-lowering medications to reduce
the development of atherosclerotic plaques
4. b-Blockers to reduce the BP in individuals who
are hypertensive
Types of angina
• Stable angina
• predictable and consistent pain that occurs on
exertion and is relieved by rest
• Unstable angina (also called preinfarction angina or
crescendo angina)
• symptoms occur more frequently and last longer than
stable angina.
• The threshold for pain is lower, and pain may occur at
rest.
Types of angina
• Variant angina (also called Prinzmetal’s angina):
• pain at rest with reversible ST-segment elevation;
thought to be caused by coronary artery vasospasm
Clinical Manifestations
Pharmacologic therapy

Nitroglycerin (NTG)
•Nitrates are the standard treatment for angina
pectoris.
•Potent vasodilator
NTG might be given in several routes:
•Sublingual or spray
•Oral capsule
•Topical agent, and
•IV
Guidelines
1. Instruct the patient to make sure the mouth is
moist, the tongue is still, and saliva is not
swallowed until the nitroglycerin tablet dissolves.
If the pain is severe, the patient can crush the
tablet between the teeth to hasten sublingual
absorption.
Guidelines
2. Advise the patient to carry the medication at all
times as a precaution. However, because
nitroglycerin is very unstable, it should be carried
securely in its original container (eg, capped dark
glass bottle); tablets should never be removed and
stored in metal or plastic pillboxes.
Guidelines
3. Explain that nitroglycerin is volatile and is
inactivated by heat, moisture, air, light, and
time. Instruct the patient to renew the
nitroglycerin supply every 6 months.
Guidelines
4. Inform the patient that the medication should
be taken in anticipation of any activity that
may produce pain. Because nitroglycerin
increases tolerance for exercise and stress
when taken prophylactically (ie, before angina-
producing activity, such as exercise, stair-
climbing, or sexual intercourse), it is best taken
before pain develops.
Guidelines
5. Recommend that the patient note how long it
takes for the nitroglycerin to relieve the
discomfort. Advise the patient that if pain
persists after taking three sublingual tablets at
5-minute intervals, emergency medical
services should be called.
Guidelines
6. Discuss possible side effects of nitroglycerin,
including flushing, throbbing headache,
hypotension, and tachycardia.
Guidelines
Most physicians prescribe application of topical
nitroglycerin paste three or four times daily or every 6
hours (excluding the midnight dose), and application of
the nitroglycerin patch every morning and removed at
10 PM.
This dosing regimen allows for a 6- to 8-hour nitrate-
free period to prevent the body’s development of
tolerance.
Other medications
•Beta Adrenergic Blocking Agents
•Calcium Channel Blocking Agents
•Aspirin
•Heparin
•Oxygen Therapy
ACUTE CORONARY SYNDROME (ACS)
an emergent situation characterized by an acute
onset of myocardial ischemia that results in
myocardial death if definitive interventions do not
occur promptly.
ACUTE CORONARY SYNDROME (ACS)
The spectrum of ACS includes:
•Unstable angina
•NSTEMI
•STEMI
Myocardial infarction (MI)

occurs when myocardial tissue is abruptly


and severely deprived of oxygen
Ischemia can lead to necrosis of myocardial tissue
if blood flow is not restored.
Infarction does not occur instantly but evolves
over several hours.
Assessment
1. Pain
Levine Sign
Assessment
1. Pain
2. Nausea and vomiting
3. Diaphoresis
4. Dyspnea
5. Dysrhythmias
6. Feelings of fear and anxiety
7. Pallor, cyanosis, coolness of extremities
Risk factors
1. Atherosclerosis 6. Obesity
2. Coronary artery 7. Physical inactivity
disease 8. Impaired glucose
3. Elevated cholesterol tolerance
levels 9. Stress
4. Smoking
5. Hypertension
Diagnostic studies

•Cardiac biomarkers
•ECG
•Echocardiography
•Cardiac Stress testing
•Cardiac catheterization
Begin routine medical interventions:

MONA
• Supplemental oxygen
• Nitroglycerine • Beta blocker
• Morphine • ACE inhibitor
• Aspirin 162-325 mg • Anticoagulation therapy
Management of Patients with
Structural, Infectious, and
Inflammatory Cardiac Disorders
VALVULAR HEART DISORDERS
Valvular Heart Disease

•Valvular heart disease can affect any of the


valves in the heart.
•Diseased valves may have an altered structure,
which changes the blood flow.
•Disorders of the endocardium, the innermost
lining of the heart and valves, damage heart
valves.
Valvular Heart Disease

Valvular heart diseases include:


• Mitral stenosis.
• Mitral regurgitation.
• Mitral valve prolapse.
• Aortic stenosis.
• Aortic regurgitation.
REVIEW OF VALVES
Cardiomyopathies
There are three types of cardiomyopathy:
• Restrictive: ventricles are stiff and cannot fill properly.
• Hypertrophic: walls of the ventricles thicken and become
stiff.
• Dilated: ventricles enlarge but are not able to pump enough
blood for the body’s needs.
• Ischemic cardiomyopathy is a term frequently used to
describe an enlarged heart caused by coronary artery
disease, which is usually accompanied by heart failure
Infectious Diseases of the Heart
•Among the most common infections of the heart
are infective endocarditis, myocarditis, and
pericarditis.
•The ideal management is prevention.
Prevention

primary prevention in high-risk patients:


• Antibiotic prophylaxis:
• Dental procedures
• Tonsillectomy or adenoidectomy
• Surgical procedures that involve intestinal or
respiratory mucosa
Nursing Management

NURSING ALERT
Patients with myocarditis are sensitive to
digitalis.
• They must be closely monitored for digitalis toxicity,
which is evidenced by dysrhythmia, anorexia, nausea,
vomiting, headache, and malaise and BLURRED OR
DOUBLE VISION and GREENISH-YELLOW HALOS
AROUND IMAGES.
Nursing Management

• Assesses the patient’s temperature


• continuous cardiac monitoring with personnel and
equipment readily available to treat life-threatening
dysrhythmias.
• Elastic compression stockings and passive and active
exercises should be used:
• embolization from venous thrombosis and mural thrombi
can occur.
MONITORING AND MANAGING POTENTIAL
COMPLICATIONS
•Cardiac tamponade.
• Pericardial effusion.
• Infection.
MANAGEMENT OF PATIENTS
WITH COMPLICATIONS FROM
HEART DISEASE
Heart Failure (HF)
•often referred
to as
congestive
heart failure
(CHF)
Heart Failure (HF)
•A clinical syndrome resulting from structural or
functional cardiac disorders that impair the
ability of the ventricles to fill or eject blood.
•is the inability of the heart to pump sufficient
blood to meet the needs of the tissues for
oxygen and nutrients.
CHRONIC HEART FAILURE
Types of HF
1. diastolic heart failure
2. systolic heart failure
Heart Failure (HF)
•Low EF is a hallmark of systolic HF
•New York Heart Association (NYHA) classification
of heart failure:
(NYHA) Classification of Heart Failure
Classific Signs and symptoms
ation
I No limitation of physical activity
Ordinary activity does not cause undue fatigue; palpitation, or dyspnea

II Slight limitation of physical activity


Comfortable at rest, but no ordinary physical activity causes fatigue,
palpitation, or dyspnea
III Marked limitation of physical activity
Comfortable at rest, but less than ordinary activity causes fatigue,
palpitation, or dyspnea.
IV Unable to carry out any physical activity without discomfort
Symptoms of cardiac insufficiency at rest
If any physical activity is undertaken, discomfort is increased
Classification of Heart Failure (HF)
1. Left-sided heart failure
2. Right-sided heart failure
Diagnostic Exam
• Electrocardiography
• Chest x-ray
•BNP level: increased
• Echocardiogram
Treatments for HF
Goal is to decrease workload on the heart.
• Diuretics
• ACE inhibitors: dilate blood vessels decreasing workload
of heart.
• Angiotensin II receptor blockers: can be used in place of
ACE inhibitors.
• Beta-blockers: slow the heart rate; prevent remodeling.
• Vasodilators: cause blood vessels to dilate.
Treatments for HF
• Positive inotropic drugs
• Anticoagulants: prevent clot formation.
• Opioids: relieve anxiety and decrease the workload on
the heart especially in pulmonary hypertension.
• Oxygen therapy: improves oxygenation.
• Lifestyle modification: exercise; weight loss
Cardiogenic shock
• called pump failure
• Condition of diminished cardiac output that severely
impairs tissue perfusion.
• can happen because of a damaged muscle, poor
ventricular filling, or poor outflow from the heart.
• As cardiogenic shock progresses, the vital organs
begin to lose perfusion until the heart is no longer able
to perfuse itself!
THROMBOEMBOLISM

• Causes (cardiac in origin)

Intracardiac thrombus
atrial fibrillation
Mural thrombi
Deep vein thrombosis (DVT)
PERICARDIAL EFFUSION AND
CARDIAC TAMPONADE
• Pericardial effusion refers to the accumulation of fluid
in the pericardial sac.
Management: Pericardiocentesis
Cardiac arrest
The heart is unable to pump and circulate blood
to the body’s organs and tissues

Pulseless Electrical Activity (PEA)


•Occurs when electrical activity is present on the
ECG but cardiac contractions are ineffective
ASSESSMENT AND
MANAGEMENT OF PATIENTS
WITH VASCULAR DISORDERS
AND PROBLEMS OF PERIPHERAL
CIRCULATION
Vascular System
The vascular system consists of TWO
interdependent systems.
1. right side of the heart pumps blood through
the lungs to the pulmonary circulation
2. left side of the heart pumps blood to all other
body tissues through the systemic circulation.
100,000 km of blood vessels
WALLS OF ARTERIES
composed of
three layers:
1. intima
2. media
3. adventitia
(externa)
ANATOMY OF THE VASCULAR SYSTEM:
Lymphatic Vessels
• Peripheral lymphatic vessels join larger lymph
vessels and pass through regional lymph nodes
before entering the venous circulation.

lymph nodes filter foreign particles.


permeable to large molecules and provide the
only means by which interstitial proteins can return
to the venous system
ARTERIAL DISORDERS
• Arterial disorders
cause ischemia
and tissue
necrosis
Arteriosclerosis vs Atherosclerosis

Arteriosclerosis
• most common disease of the arteries
•hardening of the arteries
Atherosclerosis
•Changes consist of the accumulation of lipids,
calcium, blood components, carbohydrates, and
fibrous tissue on the intimal layer of the artery
Arteriosclerosis vs Atherosclerosis
Treatments

• Antiplatelets: thin the blood, prevent clot formation.


• Lipid-lowering agents: lower cholesterol.
• Antihypertensives: lower blood pressure.
• Thrombolytics: dissolve blood clots.
• Anticoagulants: thin the blood; prevent clot
formation.
• Exercise: to improve circulation and help with weight
control
AORTIC ANEURYSM
Aneurysm: a localized sac or dilation formed at a
weak point in the wall of the aorta
•The most common forms of aneurysms are
saccular or fusiform.
•A saccular aneurysm projects from one side of
the vessel only.
Thoracic aortic aneurysm
• occurs in the part of the
aorta that passes through the
chest (thorax).
• It is an abnormal widening of
the ascending, transverse, or
descending part of the aorta
Causes
• High blood pressure
• Syphilis
• Blunt injury to the chest
• Atherosclerosis
• Bacterial infections, usually at an atherosclerotic
plaque
• Rheumatic vasculitis
• Coarctation of the aorta
Abdominal aortic aneurysm
•bulge in the wall of
the aorta is
located in the part
of the aorta that
passes through the
abdomen.
Causes
•Atherosclerosis
•Hypertension
•Hereditary connective-tissue disorders (Marfan’s
syndrome)
•Blunt trauma
•Infections (syphilis)
•Thrombus formation
Signs and symptoms

•Change in LOC
•Pulsatile mass in periumbilical area
•Systolic bruit over aorta
•Lumbar pain that radiates to the flank and groin;
severe, persistent abdominal and back pain
•Weakness, sweating, tachycardia, hypotension
Test and treatments

•Pain- usually a late clue.


• Palpitation: pulsating mass in midline of
abdomen; tenderness.
• Auscultation: bruit.
• Abdominal x-ray
• Ultrasonography: shows size of aneurysm.
•CT SCAN and MRI
Buerger’s disease (Thromboangiitis Obliterans)

Buerger’s disease is an
occlusive disease of
the median and small
arteries and veins.
The distal upper and
lower limbs are
affected most
commonly.
Clinical Manifestations

• Intermittent claudication
• Ischemic pain occurring in the digits while at rest
• Aching pain that is more severe at night
• Cool, numb, or tingling sensation
• Diminished pulses in the distal extremities
• Extremities that are cool and red in the dependent
position
• Development of ulcerations in the extremities
Interventions

• Instruct the client to stop smoking.


• Monitor pulses.
• Instruct the client to avoid injury to the upper and
lower extremities.
• Administer vasodilators as prescribed.
• Instruct the client regarding medication therapy.
Raynaud’s disease
Raynaud’s disease is vasospasm of the arterioles
and arteries of the upper and lower extremities.
Vasospasm causes constriction of the cutaneous
vessels.
Attacks are intermittent and occur with exposure to
cold or stress.
Affects primarily fingers, toes, ears, and cheeks
Clinical Manifestation
•Blanching of the extremity, followed by cyanosis
during vasoconstriction; Reddened tissue when
the vasospasm is relieved
•Numbness, tingling, swelling, and a cold
temperature at the affected body part
Venous Disorders
Venous Thromboembolism

• Deep vein thrombosis • Pulmonary embolism


Pathophysiology
•Virchow’s
triad
Causes
•Estrogen therapy, oral contraceptives
•Hypercoagulability states
•Pregnancy and childbirth
•Orthopedic surgery
Causes
•Obesity
•Dehydration
•Smoking
•Prolonged immobility: postoperative clients,
bed-ridden clients, persons who experience
prolonged travel, and spinal cord injury clients
Clinical manifestations

•Heat; erythema
•Swelling
•Pain
Diagnostic Tests
• Doppler ultrasonography: confirms diagnosis by
checking leg for clots.
Treatments
• Prevention of pulmonary embolism.
• Elevate the affected leg: prevents thrombus
enlargement.
• Anticoagulants: thin the blood.
• Thrombolytics: dissolve the thrombus.
• Filter (umbrella) placement: traps emboli before they
can reach the lungs.
Varicose Veins
• Varicose veins are
abnormally enlarged
superficial veins of
the lower extremities.
• They occur most often
in the saphenous
veins located on the
insides of the lower
extremities.
Causes
•Familial predisposition
•Congenital weakness of the vein
•Obesity, pregnancy, abdominal tumors
prolonged standing, major surgeries, prolonged
bed rest.
•Trauma
Clinical Manifestations
• Edema
• Cramping or pain in affected extremity
• Heaviness in affected extremity
• Itching, redness, rash
• Phlebitis
Diagnostic Tests
• Palpation: May feel the veins when they are not
visible.
• X-ray: assesses functioning of deep veins.
• Ultrasonography: assesses functioning of deep
veins.
Treatments
• Elevating the legs
• Elastic stockings (support hose): compress the veins
and prevent them from stretching and hurting.
• Surgical stripping: removes varicose veins.
• Sclerotherapy (injection therapy)
• Laser therapy: cuts or destroys tissue.
Assessment and
Management of Patients
With Hypertension
Hypertension
• Hypertension is an abnormally
high pressure in the arteries.
• peripheral vasoconstriction.
• Vasoconstriction decreases
blood flow to end organs
Causes
• Primary hypertension • Lifestyle: obesity,
• Secondary hypertension sedentary lifestyle, stress,
smoking, excessive
• Pheochromocytoma
alcohol consumption,
• Hyperthyroidism increased salt intake
• Hyperaldosteronism • Arteriosclerosis
• Cushing’s syndrome
• Renal disease
CLASSIFICATION OF BLOOD PRESSURE FOR ADULTS
Clinical Manifestations

Primary HPN- no symptoms


silent killer
Secondary HPN
Associated with the underlying cause
HPN Emergency:
Confusion, drowsiness, chest pain, breathlessness
Diagnostic Exam

• Test for suspected underlying cause.


• Blood pressure monitoring.
• 24-hour blood pressure monitor: confirms consistent
hypertension.
• Serum BUN: elevated.
• Serum creatinine: elevated.
• Urinalysis: positive for blood cells and albumin.
Diagnostic Exam

• Auscultation: check for abdominal bruit, irregular


heart sounds.
• Eye examination with ophthalmoscope: views
arterioles of retina is an indication that other blood
vessels in the body are damaged.
• Electrocardiography:detects enlargement of the
heart.
Treatments
• Lifestyle modification
• Diuretics: dilate blood vessels; help kidneys eliminate
sodium and water.
• Beta-blockers: decrease blood pressure; decrease
chest pain.
• ACE inhibitors: dilate arterioles and lower blood
pressure.
Treatments
• Angiotension II blockers: lower blood pressure.
• Calcium-channel blockers: dilate arterioles and lower
blood pressure.
• Direct vasodilators: dilate blood vessels and lower
blood pressure.
Hypertensive Crises
• There are two hypertensive crises that require nursing
intervention:
1. hypertensive emergency
2. hypertensive urgency

180/120 mmHg
HYPERTENSIVE EMERGENCY

Hypertensive emergency
• situation in which blood pressure must be lowered
immediately (not necessarily to less than 140/90 mm
Hg) to halt or prevent damage to the target organs.
HYPERTENSIVE URGENCY

Hypertensive urgency
• a situation in which blood pressure must be lowered
within a few hours.
• Blood pressure is elevated but there is no evidence of
impending or progressive target organ damage.
• Elevated BP associated with severe headache,
nosebleeds or anxiety are classified as urgencies.
end