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Cardiac Disorders

Mr. Daryl P. Separo, RN


Coronary Artery Disease
Characteristic Manifestation
Chest pain or discomfort C: substernal chest pain (squeezing,
Chronic aching, burning, choking, strangling,
that is provoked by
Stable exertion pr emotional
and/or cramping
L: behind middle or upper 3rd sternum
Angina stress and relieved by rest R: neck, jaw, shoulders, arms, hands,
and NTG and posterior intrascapular area
D: 2-15 minutes
T: NTG 1 minute
P: hot/cold weather, heavy meal, sex

Chest pain occurring D: longer than 10 minutes


Unstable T: unrelieved by rest or sublingual ntg
at rest; no increase in
Angina oxygen demand is
placed on the heart
Absence of chest pain O: upon awakening
Silent with documented
Ischemia evidence of an
imbalance between
myocardial oxygen and
demand
Diagnostic Examination
• NTG test
• Hemoglobin r/o anemia
• FBS
• Fasting lipid panel
• Resting ECG – LVH, ST-T wave changes,
arrhytmias
• ECG stress testing – ST-T wave changes
• Radionuclide Imaging
• Cardiac catheterization
Management
• Drug Therapy
– Nitrates
•Generalized vasodilation
•Orally, sublingually, transdermally, or IV
– Beta-Adrenergic Blockers
•Inhibits sympathetic stimulation of
receptors
•Vasoconstriction of the large airways in the
lungs
•C/I with COPD and asthma
•Cardioselective affects only the heart
– Low dose aspirin everyday
Management
• Calcium Channel Blockers
– Inhibit movement of calcium within the
heart muscle and coronary vessels
– Promotes vasodilation
• ACE inhibitor
– Therapeutic on the vascular endothelium
• Antilipids
– Reduce cholesterol and triglyceride level
• Antiplatelet agents
– Decrease platelet aggregation
Management
• Surgical Management:
– Percutaneous transluminal angioplasty
– Intracoronary atherectomy
– Intracoronary stent
– CABG
– Transmyocardial revascularization
Management
• Nursing Management:
– Health teaching:
•Cessation of smoking
•Control of BP
•Low saturated fat diet < 10% calories,
cholesterol <300mg/day, Na <6g/day, alcohol
at msot 2 drinks/day in men or 1 in women
•Physical exercise
•Weight control (BMI 18.5 to 24.9 kg/m2)
•Control DM (FBS <110mg/dl)
Complications
• Sudden death due to lethal
dysrhythmias
• Heart Failure
• MI
Myocardial Infarction
Degree of
Damage
Zone of necrosis •Death to the heart
muscle
•Irreversible damage

Zone of injury •Region of the heart


muscle surrounding
the area of necrosis

Zone of ischemia •Region of the heart


surrounding the area
of injury
Manifestation
• Chest Pain
– Severe, diffuse steady substernal pain of
a crushing and squeezing nature
– Requires opioid
– Radiate to the left arm, shoulders, neck,
back and/or jaw
– 15 minutes duration
• Diaphoresis, cool clammy skin, facial
pallor
• Hypertension or hypotension
• Bradycardia or Tachycardia
Manifestation
• Premature Ventricular and/or atrial
beats
• Palpitations, severe anxiety, dyspnea
• Disorientation, confusion, restlessness
• Fainting, marked weakness
• Nausea, vomiting, hiccups
• Atypical symptoms: epigastric or
abdominal distress, dull aching or
tingling sensations, shortness of breath,
extreme fatigue
Diagnostic Evaluation
• ECG changes
– 2 to 12 hours, but may take 72 to 96
hours
– ST segment depression and T wave
inversion
• Cardiac Markers
– Nonspecific markers
•LDH, AST, myoglobin
– Specific cardiac markers
•CTnT & CTnI
– CK-MB
Management
• O2 Therapy
– Usually given by nasal cannula
• Pain control
– Morphine
– Vasodilator
– Benzodiazepines
• Thrombolytics agents
– Activase (tissue plasma activator)
– Streptokinase
– Reteplase
• Antiarrhythmics
– lidocaine
Management
•Medication
– Aspirin (antiplatelet)
– Heparin (antithrombotics)
– Fibrinolytics
– Beta-Adrenergic Blockers
– ACE inhibitors
– NTG
– Morphine
Management

• Surgical:
– PTCA
– Coronary stenting
– Athrectomy
– Emergency CABG
Management
• Nursing
– Reducing Pain
– Alleviating Anxiety
– Increasing Activity Tolerance
– Preventing Bleeding
– Maintaining Tissue Perfusion
Diagnosis Action Rationale
Acute Pain (substernal) Independent:
related to oxygen supply 1. Maintain O2 sat > 92% -To increase O2 supply
and demand imbalance 2. Encourage to take deep - decrease incidence of
breaths dysrhythmias
-Reduce infarct size &
resolve anxiety
3. Offer support and reassurance -To reduce anxiety of
to patient that relief of pain is a patient
priority
4. Use alternative pain relieving -To enhance effect of
methods pain relievers
Dependent;
1. Administer opioids (morphine) -Decreases sympathetic
activity and reduces
heart rate, respirations &
BP)
2. NTG via IV -Acts as a vasodilator
Diagnosis Action Rationale
Decreased Cardiac Independent:
Output related to 1. Monitor BP every 2 hours or -To check for HPN or
decreased cardiac as directed HPoN
contractility 2. Monitor urine output hourly -Indicates adequacy of
renal blood flow
3. Monitor mental status -Indicates a decrease in
cardiac output
4. Employ hemodynamic - assess cardiac
monitoring (CVP, PAP, or CI) performance

Dependent:
1. Administer vasopressors -To improve blood
pressure without
worsening chest pain
Diagnosis Action Rationale
Activity Intolerance Independent:
related to decrease 1. Promote rest with early -To decrease cardiac
oxygen supply gradual increase in demand and increase
mobilization oxygen supply
2. Assist patient with prescribed -To minimize orthostatic
activities hypotension and prevent
injuries
3. Encourage passive and active -To improve circulation
range-of-motion exercises while promoting rest

4. Elevate patient’s feet when out -Promote venous return


of bed
Diagnosis Action Rationale
Risk for Bleeding related Independent:
to inhibition of platelet 1. Observe for hematomas, or - signs of bleeding
aggregation secondary skin breakdown
to thrombolytic therapy 2. Observe for blood in stools,
emesis, urine & sputum
3. Minimize venipunctures and - Prevent chances of
arterial punctures bleeding
4. Avoid IM injections
5. Caution patient about vigorous
tooth brushing, hair combing
or shaving
Diagnosis Action Rationale
Altered Tissue Perfusion Independent:
related to decrease in 1. Promote mobilization gradually - To improve perfusion
cardiac contractility as tolerated

Dependent:
1. Administer O2 as ordered -To increase perfusion
2. Prepare patient for possible -For venous access
emergency procedures:
cardiac catheterization,
bypass surgery, thrombolytic
therapy
Management
• Health Education:
– Condition
– Design an individualized activity
progression program
– Specific Activity guidelines
•7 hours sleep a day with 20-30 minutes rest
2x a day
•Shorten visitation and communication
– Sexual activity after 2 flights of stairs
Management
• Health Education:
– 3-4 small meals per day
– Limit caffeine and alcohol intake
– No driving
Cardiogenic Shock
• Failure of the heart to pump blood
adequately to meet the oxygenation needs
of the body.
Diagnostic Evaluation
• PCWP >18 mmHg
• CI <2.2
• CXR = pulmonary vascular congestion
• Elevated BUN & creatinine
• Elevated liver enzymes
• Elevated serum lactate
Management
• Pharmacologic Management:
– Cardiac glycosides (digoxin) & Positive
inotropic drugs (dopamine, dobutamine)
• Stimulate cardiac contractility
– Vasodilator therapy
• Decreases the workload of the heart by reducing
venous return and lessening the resistance against
which the heart pumps
• CO improves, left ventricular pressures and
pulmonary congestion decrease
• Reduce myocardial oxygen consumption
Management
• Pharmacologic Management:
– Diuretic therapy:
• Decreases total body fluid volume
• Improves CO and reservation of viable heart tissue
• Surgical Management:
– Bypass Graft
– Heart transplantation
Complications
• Neurologic Impairment
• Acute Respiratory Distress Syndrome
• Renal Failure
• Multi-Organ Dysfunction Syndrome
• Death
Diagnosis Action Rationale
Decreased Cardiac 1. Monitor hemodynamic -To evaluate condition
Output related to parameters and effectiveness of
impaired contractility therapy
due to extensive heart 2. Be alert to adverse responses to
damage treatment
a. Dopamine -Can cause ↑HR
b. Vasodilators NTG & -May worsen
nitroprusside hypotension
c. Digoxin -May result in
dysrhythmias
d. Diuretics -May casue
hyponatremia,
hypokalemia, and
hypovolemia
3. Measure and record urine urine - to note for oliguria
output and fluid intake hourly
4. Obtain daily weight -To note for fulid loss or
gain
5. Evaluate serum electrolytes -To monitor for
hyponatremia &
hypokalemia
Diagnosis Action Rationale
Impaired Gas Exchange 1. Monitor rate and rhythm of -to note for possible
related to pulmonary respiration every hour changes or alterations
congestion secondary to 2. Evaluate arterial blood gas -To note for gas
elevated left ventricular levels exchange alterations
pressures 3. Administer oxygen therapy -To increase oxygen
tension and improve
hypoxia
4. Elevate head of bed 20 to 30 -To facilitate lung
degrees as tolerated expansion
5. Reposition patient frequently -to promote ventilation
and maintain skin
integrity
6. Observe for frothy pink -Indicating pulmonary
sputum and cough edema
Diagnosis Action Rationale
Ineffective Tissue 1. Perform neurologic check -To monitor for the
Perfusion (renal, every hour using the GCS cerebral perfusion
cerebral, 2. Obtain BUN and creatinine -To evaluate renal
cardiopulmonary, GI & blood levels function
peripheral) related to 3. Auscultate for bowel sounds -To evaluate foe paralytic
decrease blood flow every 2 hours ileus
4. Evaluate character, rate, -To check for blood
rhythm, and quality of arterial delivery to peripheries
pulses every 2 hours
5. Monitor temperature every 2 -To not for cool clammy
to 4 hours skin
6. Use sheepskin foot and elbow -To prevent skin
protector breakdown
Management
• Health Education:
– Teach the patients taking digoxin the
importance of taking their medication on time
as prescribed, taking pulse before daily dose
– Teach signs of impending heart failure:
increasing edema, shortness of breath,
decrease urine output, decreasing BP, &
increasing pulse
Infective Endocarditis
• Infection of the inner lining of the heart
caused by direct invasion of bacteria or
other organisms leading to deformity of the
valve leaflets
Manifestations
• Fever, chills, sweat
• Anorexia, weight loss, weakness
• Cough, back & joint pain
• Splenomegaly
• Petechiae
• Splinter hemorrhages in nail beds
Manifestations
• Osler’s nodes – painful red nodes on pads
of fingers and toes
• Janeway’s lesions – light pink macules on
palms or soles,nontender, may change to
light tan within several days, fade 1 to 2
weeks
Diagnostic Evaluation
• Major Criteria:
– Blood cultures – at least two positive serial
blood cultures
– 2D Echo – identification of vegetations and
assessment of location and size of lesions
Complication
• Severe heart failure due to valvular
insufficiency
• Uncontrolled/refractory infection
• Embloic episodes
Management
• Pharmacologic Management
– IV antimicrobial therapy x 4-6 weeks
• Based on sensitivity
• Obtain audiogram before antibiotic regimen start
• Urine culture after 48 hours to assess efficacy of
drug therapy
• Repeat blood cultures after 48 hourss
Diagnosis Action Rationale
Decreased Cardiac 1. Auscultate heart to detect new
Output realte to murmur or change in existing
structural factors murmur; presence of gallop
(incompetent valves) 2. Monitor BP & pulse for pulse -Indicates left-sided heart
pressure difference & pulsus failure
alternans
3. Evaluate for jugular vein
distention
4. Record inrtake & output
5. Record daily weight
6. Auscultate lung fields for
evidence of crackles
Diagnosis Action Rationale
Ineffective Tissue 1. Perform neurologic check -To monitor for the
Perfusion (renal, every hour using the GCS cerebral perfusion
cerebral, 2. Obtain BUN and creatinine -To evaluate renal
cardiopulmonary, GI & blood levels function
peripheral) related to 3. Auscultate for bowel sounds -To evaluate foe paralytic
interruption of blood flow every 2 hours ileus
4. Evaluate character, rate, -To check for blood
rhythm, and quality of arterial delivery to peripheries
pulses every 2 hours
5. Monitor temperature every 2 -To not for cool clammy
to 4 hours skin
6. Use sheepskin foot and elbow -To prevent skin
protector breakdown
7. Observe for splinter
hemmorhages, Oslers nodes
and Janeway’slesion
8. Reposition patient frequently -To prevent skin
breakdown and pulmonar
complications of bed rest
Diagnosis Action Rationale
Hyperthermia related to 1. Observe basic principles of -To prevent introduction
introduction of pyrogens asepsis, good handwashing of further pyrogens
& potential dehydration techniques, and continuity of
patient care by primary nurse
2. Employ meticulous IV care for -To prevent site infection
long-term antibiotic therapy
3. Roate peripheral IV site every
72 hours or PRN
4. Change gauze or transparent -Prevent infection
ressing OD
5. Monitor Moniotr temperature
q2
6. Provide blankets and -To prevent chills
temperature-controlled
comfortable environement
7. Promote adequate hydration -To correct dehydration-
related hyperthermia
Diagnosis Action Rationale
Imbalanced Nutrition: 1. Assess patient’s daily caloric
Less Than Body intake
Requirements related to 2. Discuss food preferences with -To gain cooperation of
anorexia the patient the patient
3. Consult with a dietitian about
nutritional needs of patient
and food preferences
4. Encourage small meals and -To improve calorie
snacks throughout the day intake
5. Record daily caloric intake and
weight
6. Educate family about patient’s
caloric needs
7. Encourage family to assist the
patient with meals and bring in
patient’s favorite food
Management
• Health Education:
– Steps necessary to prevent infection
• Good oralhygiene, regular tooth brushing, and
flossing
– Encourage at-risk individuals to receive
pneumococcal and influenza vaccines
Rheumatic Heart Disease
• Acute, recurrent inflammatory disease that
causes damage to the heart as a sequalae
to group A beta-hemolytic streptococcal
infection
Clinical Manifestation
• Streptococcal pharyngitis
– Sudden onset of sore throat
– Swollen, tender lymph nodes
– Headache & fever (38.9-40C)
– Abdominal pain (children)
• Polyarthritis
• Chorea
• Erythema marginatum
Clinical Manifestation
• Subcutaneous nodules
• Fever
• Prolonged PR interval
• Heart murmurs
Diagnostic Evaluation
• Throat Culture – to determine presence of
streptococcal organisms
• ESR, WBC Count & differential –
increased during acute phase of infection
• ECG – prolonged PR interval
Specific Management
• Anitimicrobial therapy
– Penicillin (drug of choice) x 5 years after inital
attacks and periodic x lifetime
• Rest
– to maintain optimal cardiac function
• Salicylates or NSAIDs
– To control fever and pain
Complications
• Valvular heart disease
• Cardiomyopathy
• Heart Failure
Diagnosis Action Rationale
Hyperthermia related to 1. Adminsiter penicillin therapy -To eradicate hemolytic
presence of pyrogens as prescribed streptococcus
2. Give salicylates or NSAIDs as -To suppress rheumatic
prescribed activity
3. Perform tepid sponge bath
4. Increase fluid intake
5. Provide a more comfortable
environment
Diagnosis Action Rationale
Decreased Cardiac Independent:
Output related to 1. Monitor BP every 2 hours or -To check for HPN or
decreased cardiac as directed HPoN
contractility 2. Monitor urine output hourly -Indicates adequacy of
renal blood flow
3. Monitor mental status -Indicates a decrease in
cardiac output
4. Be alert to development of - PR interval prolongation
second-degree heart block
(Wenckebach’s disease)

Dependent:
1. Administer vasopressors -To improve blood
pressure without
worsening chest pain
Diagnosis Action Rationale
Activity Intolerance 1. Maintainaing bed rest for -to decrease BMR
related to joint pain and duration of fever
easy fatigability 2. Provide ROM exercise -to prevent contractures
program due to bed rest
3. Provide diversional activities -to prevent increase of
that prevent exertion BMR
4. Discuss need for tutorial
services with parents to help
child keep up with school
work
Management
• Health Education:
– Maintain good nutrition
– Hygienic practices
– Importance of receiving adequate rest
– Seek treatment immediately should sore
throat occur
Cardiomyopathy
• Disease of the heart muscle
• 3 categories
– Dilated
– Hypertrophic
– restrictive
Clinical Manifestations
• Exertional dyspnea
• Chest pain
• Signs of heart failure
• Pulmonary edema
• Dysrhythmias
• Pericardial effusions
• Cardiac murmur
• Syncope
Diagnostic Evaluation
• Chest X-ray – cardiomegaly
• ECG – dysrhythmias
• Echocardiogram – abnormalities of heart
wall movement
• 24-hour Holter monitoring – dysrhythmias
• Radionuclide Imaging – assess ventricular
function
• Cardiac catheterization – ischemic or non
ischemic
Management
• Maximize ventricular function and prevent
complications
Management
• Dilated cardiomyopathy
– Oral anticoagulants
– Heart transplantation
• Hypertophic Cardiomyopathy
– Beta-Adrenergic blockers (Metorpolol)
• Reduce the force of the heart muscle’s contraction
– Calcium Channel Blockers (Diltiazem)
• Decrease heart rate and contracility, and
vasodilate
Management
• Hypertrophic Cardiomyopathy
– Antidysrhythmic therapy (amiodarone)
• Prophylaxis for lethal dysrhythmia
– Myotomy and myectomy
• Surgical resection of a portion of the septum to reduce
muscle thickness
– Device Implantation
• Pacemakers and autmatic internal defibrillators to treat
severe bradycardias and lethal tachycardias
– Percutaneous transluminal septal myocardial
ablation
• Reduce left ventricular outflow tract
Management
• Restrictive Cardiomyopathy
– Palliative
– Fluid restriction and diuretic therapy
• Heart Failure
– Digoxin
• Atrial fibrillation
– Oral anticoagulant
• Prevent emboli
Complications
• Mural thrombus
• Severe heart failure
• Sudden cardaic death
• Pulmonaryembolism
Diagnosis Action Rationale
Decreased Cardiac Independent:
Output related to 1. Monitor BP every 2 hours or -To check for HPN or
decreased ventricular as directed HPoN
function 2. Monitor urine output hourly -Indicates adequacy of
renal blood flow
3. Monitor mental status -Indicates a decrease in
cardiac output
4. Employ hemodynamic - assess cardiac
monitoring (CVP, PAP, or CI) performance

Dependent:
1. Administer anticogulants -To prevent thrombosis
Management
• Heatlh Education
– Medications
• Digoxin
– Take pulse before taking
– Report if pulse is below 60bpm
– Signs of toxicity: anorexia, nausea, vomiting & yellow
vision
• Low sodium diet
• Report signs of heartfailure
– Weight gain, edema, sob, increase fatigue
• CPR for the family