MEDICAL-SURGICAL 1 PERIPHERAL ARTERIAL DISEASES PERIPHERAL VASCULAR DISEASES (PVD)

CARDIOVASCULAR SYSTEM (PAD) Varicose veins – prolonged

- Tissue perfusion Arteriosclerosis Obliterans (ASO) = standing/sitting / increase
LE intraabdominal pressure
3 COMPONENTS Raynaud’s disease / Blue – white – Most important: PREVENTION
- Blood red disease = UE Medical mgt: Sclerotherapy
BV: 5-6L Arteriolar vasospasm – cold Surgical mgt: Vein stripping
Decrease BV = hypovolemic shock temperature
- Heart Raynaud’s phenomenon – CT Deep vein thrombosis (DVT) / Venous
Pumping of blood diseases: RA, Scleroderma thromboembolism
Decrease pump = cardiogenic shock RF: Immobilization
- Blood vessels Virchow’s triad
Distribute blood (vascular tone) - endothelial injury
Smooth muscle à loss of vascular tone (vasodilationà decrease BP; circulatory shock) - stasis (hypercoagulable)
- thrombus formation
CARDIOGENIC SHOCK > Thrombophlebitis – pain
1. Coronary causes – CAD & its complications > Phlebothrombosis – asymptomatic
2. Non-coronary causes – RHD, CHD, endocarditis, valvular diseases HOMAN’S sign – not reliable
3. Obstructive shock – compression of the heart * initial intervention à IMMOBILIZE!!

PERIPHERAL VASCULAR DISEASES Most definitive test = angiography

- Lower extremities are more affected PVD – doppler / duplex ultrasound –
1. Venous Insufficiency definitive / noninvasive
2. Arterial Insufficiency

ARTERIAL VENOUS
Leg pain Ischemia; severe & associated with Inc venous pressure à venous HEART – hollow muscular organ; middle mediastinum; to pump
claudication congestion à injury to the
(more pain when the patient walks) endothelium of the vein (phlebitis) Assessment
Less severe; no claudication Aortic valve – auscultate at the 2nd ICS R parasternal area (bell
of the stethoscope)
Skin Pale, cool to touch, thinning of hair Dark, cyanotic, pigmented
Pulmonic valve – auscultate 2nd ICS L parasternal are
Pulses Maybe abnormal Pulses are normal but difficult to Tricuspid valve – 4th ICS L parasternal area
palpate (due to edema) Mitral valve – bet 5th and 6th ICS L mid clavicular line (APEX)
PMI!
Skin lesions Small but deep, with well Lesions are larger with irregular borders
circumscribed edges (+) painful surrounded by dark or pigmented skin
VALVULAR HEART DISEASES
(+) granulation tissues
1. Valvular insufficiency – inability of the valves to close completely – valvular
regurgitation

2. Valvular stenosis – narrowing of the valves – inability of the valves to open completely
Etiology: Congenital / Acquired

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 3. Mitral valve prolapsed (MVP) – ballooning of the mitral valve onto the left atrium Embolization (right – pulmonary embolism) (left – embolic stroke)
Mitral click / systolic click that can be heard on the apex Osler’s nodes – painful nodules on finger pads & toes
Etiology: ? / Congenital Janeway lesion – painless macules on palms and soles
RF: Females, Stress Roth’s spot – hemorrhages with pale center
Signs & Symptoms: chest pain, easy, fatigability, palpitation, tachycardia, dizziness, Splinter hemorrhages – brownish streaks in fingernails and toenails
syncope Petechial rashes
Complications: Ecchymosis
- Mitral regurgitation F – FEVER
- Dysrhythmias R – ROTH’S SPOT
Diagnostic Test: 2D echocardiography O – OSLER’S NODES
Mgt: M – MURMUR / CHANGES IN MURMUR
1. Valvular repair (valvuloplasty) J – JANEWAY LESIONS
2. Valvular replacement – replace the valve with prosthesis A – ANEMIA
3. Support cardiac function N – NAIL CHANGES
Rest E – ECCHYMOSIS / EMBOLIZATION
Drugs that support cardiac function & decrease cardiac workload Nursing Diagnosis:
4. Manage heart failure Ineffective Peripheral Perfusion
Hyperthermia
3 Layers of the Heart Acute Pain
Endocardium – innermost layer of the heart Diagnostic Test:
Myocardium – middle layer of the heart - Culture & Sensitivity – most definitive
Epicardium / visceral pericardium – outer layer of the heart - CBC – anemia, increase WBC
Parietal Pericardium – Outer lining of the heart - Elevated ESR – systemic inflammation
Pericardial Fluid – to decrease friction when ventricles contract - 2D Echo – another definitive
- ECG
INFLAMMATORY HEART DISEASES Nursing Management:
1. ENDOCARDITIS – inflammation of the endocardium - Manage fever – TSB
Infective endocarditis – most common (Bacterial) - Assess changes in murmur (assess every shift)
Etiology: Group A Beta Hemolytic Streptococcus (GAHBS) - Monitor vital signs
Staphylococcus - Provide rest – decrease cardiac workload
Risk Factors: - Provide safety
- Immunocompromised Medical Management:
- Already has an existing cardiac disease - Prevention – prophylaxis = antibiotics prior to any surgical or invasive procedure
- Any invasive procedure of surgery patient with existing cardiac condition (valvular defects, RHD, CHD, atrial fibrillation)
Tooth extraction à GAHBS à bacteremia à stasis in the heart à bacteria enter, MVP – don’t give prophylaxis anymore
multiply & cause damage à inflammation Penicillin / Erythromycin
Systemic inflammation - Antipyretic
Signs & Symptoms: chest pain, FEVER – intermittent or no fever at all especially if the - Antibacterial
patient is immunocompromised, tachycardia, weakness, easy fatigability, syncope, - Support cardiac function
increase WBC – leukocytosis - Prevent & manage complications
* there can be clot inside the heart that covers the bacteria (can cause deeper a. Heart failure
damage in the endocardium) that can develop to thrombus (microthrombi – b. Shock – cardiogenic / septic shock
vegetations) 2. MYOCARDITIS

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3. PERICARDITIS – inflammation of the pericardial sac b. Cardiac tamponade – life threatening condition characterized by too much fluid
Etiology: in the pericardial causing decrease pumping ability of the heart à cardiogenic
1. Idiopathic shock / obstructive shock End of depolarization,
2. Infection early repolarization
3. Trauma CARDIOPHYSIOLOGY – pump Phase1 Ca¯ Plateau formation
Phase2
4. Malignancy Conducting System (+) Phase 0
5. SLE Sinoatrial node (SA node) RMP – 80mv Na® K®
6. MI – induced pericarditis (Dressler’s syndrome) Atrio-ventricular node (AV node) Phase 4 (-) Repolarization
Signs & Symptoms: Bundle of HIS (Right and left branches) Phase 3
Most prominent: (+) chest pain – worsens with deep inspiration, lying down or turning Purkinje fibers
and relieved by sitting or leaning forward (orthopneic)
(+) friction rub – auscultate at the 4th ICS L parasternal area – leathery, creaky, * Action potential – is a rapid change in the membrane potential (electrical activity stimulates
scratching sound heard best at the end of expiration and when patient is sitting & the muscles to contract)
leaning forward P wave – atrial depolarization Heartbeat – cardiac cycle
Diagnostic tests: QRS – ventricular depolarization Cardiac cycle – events taking place in the
- 2D Echocardiography T wave – ventricular repolarization heart in one heartbeat
- Chest x-ray
- CBC EVENTS Abnormal s4 – lub lub dub
- Elevated ESR Atrial systole à S4 (enlargement of the atria) Atrial gallop
- Culture & Sensitivity à S1 (1ST HEART SOUND)
Abnormal s3 – lub dub dub
- Biopsy Isovolumetric ventricular contraction
Ventricular gallop
- Anti-nuclear antibody test (ANA test) Maximum ejection -
- Coronary angiography à S2 (2ND HEART SOUND) Stroke volume – volume of blood ejected by
Management: Isovolumetric ventricular relaxation the heart in one beat
- Position the patient – orthopneic Rapid ventricular filling à S3 50-100ml/beat
- Pain reliever – NSAIDs Diastasis – time after rvf before another atrial systole
- Anti-inflammatory – Steroids
- Manage the cause FACTORS AFFECTING STROKE VOLUME
a. Infection – anti-infective 1. PRELOAD – volume of blood that is already in the heart before it contracts
b. Cancer – treat ca - Venous return
c. SLE – steroids, immunosuppressant drugs - Factors affecting preload
d. MI – treat MI a. Position
- Prevent & manage complications - best position (shock) à modified Trendelenburg – only the legs are elevated
a. Pericardial effusion – accumulation of fluid in the pericardial sac b. Breathing
Constrictive Pericarditis 2. AFTERLOAD – pressure that must be exceeded by the heart before it contracts
Signs & Symptoms: chest pain, dyspnea, easy fatigability, weakness - Factors affecting afterload
BECK’s TRIAD (decrease BP, increase venous pressure - distended neck vein, a. hypertension
muffled heart sounds / distant heart sound) b. atherosclerosis of the aorta
Do pericardiocentesis – doctor! 3. Contractility
Position – semi fowler’s position - ( - ) inotropic effect (+) inotropic effect
Recurrent pericardial effusion Number of beats/min = heart rate = 60-100 bpm
Pericardiotomy Factors affecting HR
Pericardiectomy – removal of pericardial sac 1. SNS

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 2. PNS SV x HR = CO i. Provide safety
3. Thyroid hormones Vol/beat x beats/min = vol/min j. Relaxation techniques
4. Exercise 70 x 70 = 4900/min
Dependent Interventions
5. Temperature
MAP = CO X TPR Inc BP à decrease BP back to normal à primary adv effect (overdose) à hypotension
MAP = (SP + 2DP) / 3 Ex: Pheochromocytoma – tumor of adrenal medulla à increase release of Epi/Ne
HYPERTENSION = increase BP at least twice at least 2
à inc SNS à increase BP
weeks apart
BP = CO X TPR (SVR)
Goal – to control BP
a. Viscosity Decrease BP
Normal BP <130/<85 b. Diameter
AHA normal BP <120/<80 AHA
Vasoconstrict – increase Antihypertensive drugs
Prehypertension = 131-139/81-89 Stage 1 Vasodilate - decrease
Stage2 1. Alpha 1 adrenergic antagonist (BV – vasodilators)
Stage 1 140-159/90-99
Prazosin, Terazosin, Doxazosin
Stage 2 160&up/100&up
2. Alpha 2 agonist à CNS à stimulate à decrease NE flow from the CNS à decrease SNS
CLASSIFICATIONS
effect
1. Primary Hypertension – idiopathic / unknown /
Centrally acting antihypertensive drugs
essential hypertension
Clonidine (Catapres), Methyldopa (aldomet)
RF: family history (familial HPN), age, obesity, sedentary lifestyle, smoking, cholesterol,
3. Beta Blockers à decrease HR à decrease BP
alcohol, stress adrenal gland à catecholamines, cortisol, caffeine
Propanolol, Metoprolol
2. Secondary hypertension – known causes – sign of a disease
Ex: DM, Renal disorder
Inc RAAS – Renin – Angiotensin – Aldosterone – System
*hypertension is also a risk factor! – modifiable
Increase pressure in the systemic circulation
4. ACE Inhibitors à no production
In pressure in the microcirculation of angiotensin II (vasodilators)
Inc pressure in Inc pressure in Inc pressure in Renal vessels – nephropathy Captopril, Enalapril, Quinapril
the cerebral the coronary the peripheral Retinal vessels - retinopathy 5. AIIR blockers à vasodilators
circulation à circulation à circulation à Losartan, Valsartan, Telmisartan
CVA/Stroke CAD/MI PVD 6. Diuretics
Thiazide D.
S/Sx of hypertension: Asymptomatic
Ex: Hydrochlorothiazide
Headache – occipital pain
7. Vasodilators
Dizziness
a. Direct acting v-dilator – directly relaxes the smooth muscles of the BV
Blurring of vision
Hydralazine
Epistaxis
Nitrates – nitroglycerine
MANAGEMENT:
Isosorbide di/mono nitrate
Independent interventions
b. Indirect acting v-dilator – decrease the release of calcium in the smooth muscles
a. Diet – low salt, low fat, low cholesterol, low sugar
of BV CCBs
b. Weight reduction
Nifedipine Amlodipine Diltiazem
c. Exercise
Felodipine Verapamil
d. Avoid stress
e. Avoid smoking
Coronary Arteries – blood supply of the heart
f. Avoid alcohol
1. Left coronary artery – anterior and lateral portion
g. Restrict caffeine
a. Left anterior descending branch (LAD)
h. Promote rest

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 b. Circumflex branch ANGINA PECTORIS
2. Right coronary artery – inferior and posterior portion Priority Nursing Diagnosis:
a. Posterior interventricular branch > Ineffective Myocardial Tissue Perfusion
b. Marginal branch – Acute Pain
Venous Drainage – Anxiety related to fear of unknown
1. Great cardiac vein Anxiety à more restless à increase demand for more O2
2. Middle cardiac vein à coronary sinus into the Right atrium – Knowledge deficit
*it is during diastole that the heart is receiving blood supply – Noncompliance
– Ineffective health maintenance
CORONARY ARTERY DISEASE Priority Nursing intervention – depends on the type
- Ischemic heart disease – atherosclerosis cardiovascular disease a. Stable angina à independent
- Acute attack – acute coronary syndrome Rest à semi fowler’s
Etiology: ? / Idiopathic b. Unstable/Prinzmetal à dependent
RF: atherosclerosis NTG
Atheromatous plaque O2 administration
Diagnostic Tests
Types of Angina 1. Angiography – invasive – cardiac catheterization – local anesthesia – done by a
1. Stable – increase cardiac workload cardiologist – inject a die *study NR before, during and after the proc.
2. Unstable – decrease O2 supply due to severe atherosclerosis (pre-infarction angina) 2. ECG – during the pain
- irreversible T wave inversion – myocardial ischemia (definitive)
3. Prinzmetal – decrease O2 supply (reversible) 3. Blood tests
4. Intractable/refractory – severe pain – ischemia & necrosis (Levine sign) a. Elevated homocysteine levels
5. Silent Ischemia – asymptomatic b. Elevated C reactive proteins – Risk for CAD
ANGINA PECTORIS MYOCARDIAL INFARCTION Management:
Imbalance bet O2 supply & cardiac Ischemia & necrosis of cardiac cells 1. Rest
workload 2. O2 administration
Reversible Irreversible 3. Manage risk factors (avoid stress, smoking, alcohol)
Relieving factors Relieving factor 4. Drug therapy
a. Rest NONE a. Nitroglycerine
b. NTG Coronary vasodilator à decrease BP à decrease cardiac workload
Timing - <15mins Timing - >30mins Acute attack – SL (fast onset) 3x every 5mins
Chronic Angina – patch
PQRST – pain assessment Primary adverse effect: hypotension
P – position = location *can cause headache
Chest pain / substernal pain
P – precipitating factor / provocation b. Isosorbide Di Nitrate/ Mono Nitrate – slow onset of action coronary vasodilator,
Q – quality = constant description / subjective peripheral vasodilator
R – radiation – to the left shoulder, left arm, left neck & left jaw c. Beta Blockers – decrease HR à decrease cardiac workload
S – severity / pain scale d. CCBs – peripheral vasodilators
S – symptoms associated with pain: restlessness, pallor, diaphoresis, bowel/bladder Dilitiazem, Verapamil
dysfunction 5. PTCA – Percutaneous Transluminal Coronary Angioplasty
T – timing

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MYOCARDIAL INFARCTION b. Anticoagulant – low molecular weight heparin, warfarin
PRIORITY NURSING DIAGNOSIS: 6. Drugs that decrease cardiac workload
• Acute Pain a. Vasodilators c. AIIR blockers e. CCBs
PAIN CONTROL IS PRIORITY! b. ACE inhibitors d. Beta blockers
Pain à restless à increase cardiac workload à increase need for O2 7. PTCA – Percutaneous transluminal coronary angioplasty
• Ineffective myocardial tissue perfusion 8. CABG – Coronary artery bypass graft
• Anxiety related to fear of death Open heart surgery – general anesthesia
• Risk for Dysrhythmias Graft – saphenous vein, internal mammary artery/ internal thoracic artery
• Risk for cardiogenic shock (coronary)
• Risk for decrease cardiac output HEART FAILURE – is caused by inability of the heart to pump effectively
PRIORITY NURSING INTERVENTION: dependent!! Cardiac compensation – the heart has failed to compensate
* no independent intervention can alleviate the pain of the patient CAUSES:
DIAGNOSTIC TEST: 1. Cardiac causes
1. Coronary Angiography – cardiac catheterization – local anesthesia 2. Non cardiac causes – COPD, Renal disorders
2. ECG TYPES:
2 TYPES OF MI a. Left sided heart failure – LV fails
a. STEMI – ST Elevation MI b. Right sided heart failure – RV fails
b. NSTEMI – non-ST Elevation MI DIAGNOSTIC TESTS:
- Atypical symptom 1. 2D Echocardiography
3. Cardiac enzyme elevation 2. Chest X-ray
Cardiac markers 3. (+) BNP – Brain natriuretic peptide –
a. CK-MB isoenzyme – most protein released by the ventricles in
specific and most indicative response to congestion
enzyme NYHA Classifications of Heart Failure
Ave 4 hours from onset of pain Class I – no limitations of ordinary activities
b. Troponin – most reliable, most sensitive test Class II – slight limitation of ADLs
Ave 4 hours from onset of pain Class III – marked limitations of ADLs
(earlier than CKMB) – elevated for 3 weeks Class IV – symptoms manifested even at rest
c. Myoglobin – earliest to be elevated (within 2 hours) MANAGEMENT:
d. CPK e. LDH f. AST (suggestive) Priority: Airway, Breathing, Impaired gas exchange Fluid volume excess
Within 6-12 hours 1. Position – High Fowler’s position 1. Restrict fluid
MANAGEMENT: 2. O2 administration 2. Restrict sodium
1. Pain control is priority 3. IV line 3. Monitor VS
– Morphine as ordered 4. Furosemide 40 mg IV stat 4. Monitor I&O
2. Oxygen administration 5. Monitor urine output (IFC) 5. Weigh patient daily
3. Manage risk factors 6. Monitor intake & output 6. Diuretics
4. Thrombolytic drugs (within 3 hours) – to dissolve the thrombus 7. Monitor VS Loop D. Furosemide (dec K)
Tissue plasminogen activator (tpa) Decrease cardiac output related to inability of the Spironalactone (inc K)
U – Urokinase heart to pump effectively 7. Monitor serum potassium
S – Streptokinase Goal: To increase cardiac output
A – Alteplase How?
5. Anti-thrombotic drugs – prevent further thrombus formation 1. To decrease cardiac workload
a. Antiplatelet drug – Aspirin, Clopidogrel - Provide rest

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 - To administer drugs that decrease cardiac workload
Ex: ACE inhibitors, AIIR blockers, Beta blockers, vasodilators, CCBs
2. To increase cardiac contractility
= CARDIOTONIC DRUGS – (+) INOTROPIC EFFECT – increase cardiac contractility
a. Sympathomimetic drugs – stimulate the beta 1 receptors
(+) inotropic effect
(+) chronotropic effect – increase heart rate
Dobutamine, Dopamine
b. Phosphodiesterase inhibitors – Milrinone
c. Cardiac glycosides
(+) inotropic effect – inc contractility by increasing the release of calcium in the
cardiac cells
(-) chronotropic effect – slow down cardiac repolarization
Digitalis, Digoxin

NURSING CONSIDERATIONS during DIGOXIN administration:

1. Monitor HR prior to administration – do not give the drug if the HR falls below 60
2. Monitor ECG
3. Monitor K level – Hypokalemia increase digoxin toxicity
4. Maintain therapeutic level – 0.5 – 2.0 ng/mL
5. Do not combine with CCBs
6. Do not administer with drug with the same mechanism of action like Amiodarone
7. Monitor for signs of Digoxin toxicity
a. Bradycardia
b. Hallmark – visual disturbances, seeing halos around lights, blurred vision, yellow
vision
c. Lack of appetite
d. Nausea & vomiting
e. ECG changes / dysrhythmias
f. Withhold medication dose & refer to the physician
g. Anticipate antidote administration - Digibind

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