CARDIO VASCULAR

SYSTEM

Renee Jessee Anthony E.Lopez, RN,

HAAD-RN, LPT, MAN
 CARDIOVASCULAR
SYSTEM
■ Consists: heart, arteries, veins, capillaries

■ Functions:
1. circulation of blood
2. delivery of oxygen and other nutrients to
tissues of the body
3. removal of carbon dioxide and other products
of cellular metabolism
 CARDIOVASCULAR
SYSTEM
■ HEART
■ ANATOMY and PHYSIOLOGY:
A. Heart wall
1. pericardium
a. fibrous pericardium
b. serous pericardium
2. epicardium
3. myocardium
4. endocardium
 CARDIOVASCULAR
SYSTEM
B. Chambers
1. Atria a. right
b. left
2. Ventricles a. right
b. left
C. Valves
1. Atrioventricular valves
a. Mitral valve
b. Tricuspid valve
 CARDIOVASCULAR
SYSTEM
c. Function:
- permit unidirectional flow of blood from
specific atrium to specific ventricle during
ventricular diastole
- prevent reflux during ventricular systole
- valve leaflets open during ventricular diastole
and close during ventricular systole; valve closure
produces the first heart sounds (S1)
 CARDIOVASCULAR
SYSTEM
2. Semilunar valves
a. Pulmonary valve
b. Aortic valve
c. Function:
- permit unidirectional flow of blood from
specific ventricle to arterial vessel during ventricular
systole
- prevent reflux during ventricular diastole
- valves open when ventricles contract and
close during ventricular diastole; valve closure
produces the second heart sound (S2)
 CARDIOVASCULAR
SYSTEM
D. Conduction System
1. Sinoatrial (SA) node
2. Internodal Tracts
3. Atrioventricular (AV) node
4. Bundle of His
- right bundle branch
- left bundle branch
5. Purkinje fibers
 Overview: Heart
Conduction System
■ SA node
■ Located at the junction of
SVC and RA
■ Primary pacemaker →
controlled by Para &
Sympathetic NS
 Overview: Heart
Conduction System
■ AV node
■ Located at interatrial
septum
■ There is a delay of electrical
impulse of 0.08 millisec. to
allow ventricular filling
 Overview: Heart
Conduction System
■ Bundle of His (AV bundle)
■ Divides into R and L main
bundle branches
■ Generates 40-60 bpm
 Overview: Heart
Conduction System
■ Purkinje fibers
■ Located at the walls of
ventricles → ventricular
contraction
 CARDIOVASCULAR
SYSTEM
E. Coronary Circulation
1. Arteries
a. right coronary artery
b. left coronary artery
2. Veins
a. coronary sinus veins
b. thebesian veins
 CARDIOVASCULAR
SYSTEM
■ VASCULAR SYSTEM
Function:
a. supply tissues with blood
b. remove wastes
c. carry unoxygenated blood
back to the heart
 CARDIOVASCULAR
SYSTEM
■ TYPES OF BLOOD VESSELS
A. Arteries
B. Arterioles
C. Capillaries: the following exchanges occur:
- oxygen and carbon dioxide
- solutes between the blood and tissues
- fluid volume transfer between the plasma and
interstitial spaces
D. Venules
E. Veins
 CARDIOVASCULAR
SYSTEM
ASSESSMENT
■ HEALTH HISTORY
A. Presenting problem
1. Nonspecific symptoms may include
- fatigue - shortness of breath
- cough - palpitations
- headache - weight loss/gain
- syncope - difficulty sleeping
- dizziness - anorexia
 CARDIOVASCULAR
SYSTEM
2. Specific signs and symptoms
a. chest pain
b. dyspnea (shortness of breath)
c. orthopnea / paroxysmal nocturnal dyspnea
d. palpitations: precipitating factors
e. edema
f. cyanosis
B. Lifestyle: occupation, hobbies, financial status,
stressors, exercise, smoking, living conditions
 CARDIOVASCULAR
SYSTEM
C. Use of medications: OTC drugs, contraceptives,
cardiac drugs
D. Personality profile: Type A, manic-depressive,
anxieties
E. Nutrition: dietary habits, cholesterol, salt intake,
alcohol consumption
F. Past Medical History
G. Family history: heart disease (congenital, acute,
chronic); risk factors (DM, hypertension, obesity)
 CARDIOVASCULAR
SYSTEM
PHYSICAL EXAMINATION
A. Skin and mucous membranes:
- color/texture, temperature, hair distribution on
extremities, atrophy or edema, petechiae
B. Peripheral pulses:
- palpate and rate all arterial pulses (temporal,
carotid, brachial, radial, femoral, popliteal,
dorsalis pedis and posterior tibial) on scale of:
0=absent, 1=palpable, 2=normal, 3=full, 4=full
and bounding
 CARDIOVASCULAR
SYSTEM
C. Assess for arterial insufficiency and venous
impairment
D. Measure and record blood pressure
E. Inspect and palpate the neck vessels:
a. jugular veins: note location, characteristics,
jugular venous pressure
b. carotid arteries: location and characteristics
F. Auscultate heartsounds
- normal (S1, S2)
- abnormal (S3, S4)
 CARDIOVASCULAR
SYSTEM
LABORATORY / DIAGNOSTIC TESTS
A. Blood Chemistry and electrolyte analysis
1. Cardiac enzymes: in MI
a. Troponin T: detected 3-12 hours after chest
pain
b. Troponin I: detected 3-12 hrs
c. CPK – MB: 6-12Hrs
d. Aspartate aminotransferase (AST) (SGOT): 24
Hrs after chest pain
e. LDH: 36 Hrs
 CARDIOVASCULAR
SYSTEM
2. Electrolytes
a. Sodium (Na) 135-148meq/L
- hyponatremia: fluid excess
- hypernatremia: fluid deficit
b. Potassium (K) 3.5-5 meq/L
- inc. or dec. levels can cause dysrhythmias
c. Magnesium (Mg) 1.3-2.1 meq/L
- dec. levels can cause dysrhythmias
 CARDIOVASCULAR
SYSTEM
d. Calcium (Ca) 4.5-5.3 meq/L:
- nec. For blood clotting and neuromuscular
activity
- dec. levels cause tetany, inc. levels causes
muscle atony
- dec. and inc. levels cause dysrhythmias
3. Serum Lipids
a. Total Cholesterol 150-200mg/dl:
- high levels predispose to atherosclerotic HD
 CARDIOVASCULAR
SYSTEM
b. High density lipids (HDL) 30-85 mg/dl
- low levels predispose to CVD
c. Low density lipids (LDL) 50-140 mg/dl:
- high levels predispose to atherosclerotic
plaque formation
d. Triglycerides 10-150 mg/dl:
- high levels increase risk of atherosclerotic
heart disease
 CARDIOVASCULAR
SYSTEM
B. Hematologic Studies
1. CBC
2. Coagulation time: 5-15mins; inc. levels indicate
bleeding tendency, used to monitor heparin tx.
3. Prothrombin time (PT) 9.5-12sec.; INR 1.0, used
to monitor warfarin tx.
4. Activated partial thromboplastin time (APTT)
20-45sec; used to monitor heparin therapy
5. Erythrocyte sedimentation rate(ESR)
<20mm/hr; inc. level indicate inflamm. process
 CARDIOVASCULAR
SYSTEM
C. Urine Studies (routine U/A)
D. Electrocardiogram (ECG)
1. Noninvasive ECG – a graphic record of the
electrical activity of the heart
2. Portable recorder (Holter monitor) – provides
continuous recording of ECG for up to 24 hrs.
E. Exercise ECG (stress test): the ECG is recorded
during prescribed exercise; may show heart
disease when resting ECG does not
F. Echocardiogram: noninvasive recording of the
cardiac structures using ultrasound
 CARDIOVASCULAR
SYSTEM
G. Cardiac catheterization: invasive, but often
definitive test for diagnosis of cardiac disease.
1. A catheter is inserted into the right or left side
of the heart to obtain information
2. Purpose: to measure intracardiac pressures and
oxygen levels in various parts of the heart; with
injection of a dye, it allows visualization of the
heart chambers, blood vessels and blood flow
(angiography)
 CARDIOVASCULAR
SYSTEM
3. Nursing care: prior to the test
- informed consent
- any allergies esp. to iodine
- keep client on NPO for 8-12 hrs
- record height, weight, V/S
- inform client that a feeling of warmth and
fluttering sensation as catheter is inserted
 CARDIOVASCULAR
SYSTEM
4. Nursing care: post test
- assess circulation to the extremity used for
catheter insertion
- check peripheral pulses, color, sensation of
affected extremity
- if protocol requires, keep affected ext.
straight for approx. 8 hrs.
- observe catheter insertion site for swelling,
bleeding
- assess V/S and report for sig. changes
 CARDIOVASCULAR
SYSTEM
H. Coronary arteriography
1. visualization of coronary arteries by injection
of radiopaque contrast dye and recording on a
movie film.
2. Purpose: evaluation of heart disease and
angina, location of areas of infarction and extent
of lesions, ruling out coronary artery disease in
clients with MI.
3. Nursing care: same as cardiac
catheterization
 ANALYSIS
Nursing diagnosis for the client with CVD include
A. Fluid volume excess
B. Decreased cardiac output
C. Altered peripheral tissue perfusion
D. Impairment of skin integrity
E. Risk for activity intolerance
F. Pain
G. Ineffective coping
H. Fear
I. Anxiety
 PLANNING AND
IMPLEMENTATION
GOALS
A. Fluid imbalance will be resolved, edema minimized
B. Cardiac output will be improved.
C. Cardiopulmonary and peripheral tissue perfusion
will be improved
D. Adequate skin integrity will be maintained
E. Activity intolerance will progressively increase
F. Pain in the chest will be diminished
G. Client’s level of fear and anxiety will be decreased
 PLANNING AND
IMPLEMENTATION
INTERVENTIONS
CARDIAC MONITORING
A. ECG
1. strip: small square: 0.04secs.
large square: 0.2secs.
2. P wave: produced by atrial depolarization;
indicates SA node function
 PLANNING AND
IMPLEMENTATION
3. P-R interval (N˚= 0.12 - 0.20 secs.)
a. indicates AV conduction time or the time it takes
an impulse to travel from the atria down and
through the AV node
b. measured from beginning of P wave to
beginning of QRS complex
4. QRS complex (N˚= 0.06-0.10 secs.)
a. indicates ventricular depolarization
b. measured from onset of Q wave to end of S
wave
 PLANNING AND
IMPLEMENTATION
5. ST segment
a. indicates time interval between complete
depolarization of ventricles and repolarization of
ventricles
b. measured after QRS complex to beginning of T
wave
6. T wave
a. represents ventricular repolarization
b. follows ST segment
 PLANNING AND
IMPLEMENTATION
HEMODYNAMIC MONITORING
(Swan Ganz Catheter)
A. A multilumen catheter with a balloon tip that is
advanced through the superior vena cava into the
RA, RV, and PA. When it is wedged it is in the
distal arterial branch of the pulmonary artery.
B. Purpose:
1. Proximal port: measures RA pressure
2. Distal port:
a. measures PA pressure and PCWP
 PLANNING AND
IMPLEMENTATION
b. normal values: PA systolic and diastolic less
than 20mmHg; PCWP 4-12mmHg
C. Nursing care
1. a sterile dry dressing should be applied to site
and changed every 24 hours; inspect site daily
and report signs of infection
2. if catheter is inserted via an extremity,
immobilize extremity to prevent catheter
dislodgment or trauma.
 PLANNING AND
IMPLEMENTATION
3. Observe catheter site for leakage
4. Ensure that balloon is deflated with a syringe
attached except when PCWP is read
5. Continuously monitor PA systolic and diastolic
pressures and report significant variations
6. Irrigate line before each reading of PCWP
7. Maintain client in same position for each reading
8. Record PA systolic and diastolic readings at least
every hour and PCWP as ordered.
 PLANNING AND
IMPLEMENTATION
CENTRAL VENOUS PRESSURE (CVP)
A. Obtained by inserting a catheter into the external
jugular, antecubital, or femoral vein and
threading it into the vena cava. The catheter is
attached to an IV infusion and H2O manometer
by a three way stopcock
B. Purposes:
1. Reveals RA pressure, reflecting alterations in the
RV pressure
 PLANNING AND
IMPLEMENTATION
2. Provides information concerning blood volume
and adequacy of central venous return
3. Provides an IV route for drawing blood samples,
administering fluids or medication, and possibly
inserting a pacing catheter
C. Normal range is 4-10 cmH20;
elevation indicates hypervolemia,
decreased level indicates hypovolemia
D. Nursing care
1. Ensure client is relaxed
 DISORDERS OF THE
CARDIOVASCULAR SYSTEM
HEART
CORONARY ARTERY DISEASE (CAD)
A. General Information
1. refers to a variety of pathology that cause
narrowing or obstruction of the coronary arteries,
resulting in decreased blood supply to the
myocardium
2. major causative factor: Atherosclerosis
3. bet 30-50 y.o., men>women
4. may manifest as angina pectoris or MI
 CORONARY ARTERY
DISEASE
5. Risk factors:
- family history of CAD - DM
- el. Serum lipoproteins - hypertension
- cigarette smoking - obesity
- el serum uric acid - lifestyle

B. Medical management, assessment findings and

nursing interventions – Angina pectoris and MI
 ANGINA PECTORIS
A. Gen. info:
1. transient, paroxysmal chest pain produced by
insufficient blood flow to the myocardium
resulting in myocardial ischemia
2. Risk factors:
- CAD - DM
- hypertension - aortic insufficiency
- severe anemia - atherosclerosis
- thromboangiitis obliterans
 ANGINA PECTORIS
3. Precipitating factors:
- physical exertion - sexual activity
- strong emotions - cigarette smoking
- consumption of a heavy meal
- extremely cold weather

B. Medical mgt:
1. Drug therapy: nitrates, beta adrenergic blocking
agents, and/or calcium blocking agents, lipid
reducing drugs if cholesterol is elevated
 ANGINA PECTORIS
2. Lifestyle modification
3. Surgery: coronary bypass surgery

C. Assessment Findings:
1. Pain: substernal with possible radiation to the
neck, jaw, back and arms, relieved by REST
2. Palpitations, tachycardia, dyspnea, diaphoresis
3. el. serum lipid levels
Types of Angina Pectoris
■ 1. Stable Angina
■ 2. Unstable/ Intermittent Coronary
Syndrome
■ 3. Variant Angina/ Prinzmetal’s angina
■ 4. Nocturnal Angina
■ 5. Angina Decubitus
■ 6. Intractable angina
■ 7. Post-infarction angina
 ANGINA PECTORIS
4. Diagnostic tests:
- ECG may reveal ST segment depression and
T-wave inversion during chest pain
- Stress test may reveal an abnormal ECG during
exercise

D. Nursing interventions:
1. administer oxygen
2. give prompt pain relief with nitrates or narcotic
analgesics as ordered.
 ANGINA PECTORIS
3. Monitor V/S, status of cardiopulmonary function,
monitor ECG
4. place patient in semi-high Fowler’s position
5. provide emotional support, health teachings and
discharge instructions.
6. Instruct client to notify physician immediately if
pain occurs and persists, despite rest and
medication administration.
 Medications for A.P.
■ 1. Vasodilators – Amyl Nitrate, NTG,
Isosorbide
■ 2. Beta-adrenergic blockers – Propranolol,
Metoprolol, Nadolol, Timolol, Pindolol
■ 3. Calcium channel blockers – Nifedipine,
Amlodipine, Verapamil, Diltiazem
■ 4. Platelet aggregation Inhibitors – Aspirin,
Ticlopidine
■ 5. Anticoagulants – Heparin, Warfarin
 MYOCARDiAL
INFARCTiON
A. General information:
1. The death of myocardial cells from inadequate
oxygenation, often caused by a sudden complete
blockage of a coronary artery; characterized by
localized formation of necrosis (tissue
destruction) with subsequent healing by scar
formation and fibrosis.
2. Risk factors:
- atherosclerotic CAD - DM
- thrombus formation - hypertension
 MYOCARDiAL
INFARCTiON
B. Assessment findings:
1. Pain same as in angina, crushing, viselike with
sudden onset; UNRELIEVED by rest or nitrates
2. nausea/vomiting, dyspnea
3. skin: cool, clammy, ashen
4. elevated temperature
5. initial increase in BP and pulse, with gradual
drop in BP
6. Restlessness
 MYOCARDiAL
INFARCTiON
7. Occasional findings: rales or crackles; presence of
S4; pericardial friction rub; split S1, S2
8. Diagnostic tests:
a. elevated WBC, cardiac enzymes (troponin,
CPK-MB, LDH, SGOT)
b. ECG changes (specific changes dependent on
location of myocardial damage and phase of the
MI; inverted T wave and ST segment changes
seen with myocardial ischemia
c. inc. ESR, el. serum cholesterol
 MYOCARDiAL
INFARCTiON
C. Nursing interventions:
1. establish a patent IV line
2. provide pain relief; morphine sulfate IV (poor
peripheral perfusion, false + for enzymes)
3. Administer O2 as ordered to relieve dyspnea
and prevent arrhythmias
4. Provide bed rest with semi fowler’s position
5. Monitor ECG and hemodynamic procedures
6. Administer anti-arrhythmias as ordered.
 MYOCARDiAL
INFARCTiON
7. Monitor I & O, report if UO <30 ml/hr
8. Maintain full liquid diet with gradual increase to
soft, low salt
9. Maintain quiet environment
10. Administer stool softeners as ordered
11. Relieve anxiety associated with CCU
environment
12. Administer anticoagulants, thrombolytics (tpa
or streptokinase) as ordered and monitor for S/E
 MYOCARDiAL
INFARCTiON
13. Provide client teaching and discharge instruction
concerning
- effects of MI, healing process and treatment regimen
- Medication regimen: name, purpose, schedule, dosage,
S/E
- Risk factors with necessary lifestyle modification
- Dietary restrictions: low salt, low cholesterol, avoidance
of caffeine
- Resumption of sexual activity as ordered (usually
4-6weeks)
 MYOCARDiAL
INFARCTiON
- Need to report the ff. symptoms:
* increased persistent chest pain
* pain, dyspnea, weakness, fatigue
* persistence palpitations, light headedness
- Enrollment of client in a cardiac rehabilitation
program
 PERCUTANEOUS
TRANSLUMINAL CORONARY
ANGIOPLASTY (PTCA)
A. General information:
1. PTCA can be performed instead of coronary
artery bypass graft surgery in various clients with
single vessel CAD.
2. Aim: revascularize the myocardium
decrease angina – increase survival
3. a balloon tipped catheter is inserted into the
stenotic, diseased coronary artery. The balloon is
inflated with a controlled pressure and thereby
decreases the stenosis of the vessel
PTCA
PTCA
CABG
 CORONARY ARTERY
BYPASS SURGERY
A. General information:
1. A coronary artery bypass graft is the surgery of
choice for clients with severe CAD
2. new supply of blood brought to
diseased/occluded coronary artery by bypassing
the obstruction with a graft that is attached to the
aorta proximally and to the coronary artery
distally
3. Procedure requires use of extracorporeal
circulation (heart-lung machine, cardiopulmonary
bypass)
 CORONARY ARTERY
BYPASS SURGERY
B. Nursing interventions: preoperative
1. Explain anatomy of the heart, function of
coronary arteries, effects of CAD
2. Explain events of the day of surgery
3. Orient to the critical and coronary care units and
introduce to staff
4. Explain equipments to be used (monitors,
hemodynamic procedures, ventilators, ET, etc)
5. Demonstrate activity and exercise
6. Reassure availability of pain medications
 CORONARY ARTERY
BYPASS SURGERY
C. Nursing interventions: post-operative
1. Maintain patent airway
2. Promote lung re-expansion
3. monitor cardiac status
4. maintain fluid and electrolyte balance
5. maintain adequate cerebral circulation
6. provide pain relief
7. prevent abdominal distension
 CORONARY ARTERY
BYPASS SURGERY
8. Monitor for and prevent the ff. complications:
a. Thrombophlebitis / pulmonary embolism
b. Cardiac tamponade
c. arrhythmias
d. CHF
9. Provide client teaching and discharge planning
concerning:
a. limitation with progressive increase in
activities
 CORONARY ARTERY
BYPASS SURGERY
b. sexual intercourse can usually be resumed
by 3rd or 4th week post-op
c. medical regimen
d. meal planning with prescribed modifications
e. wound cleansing daily with mild soap and
H2O and report for any signs of infection
f. Symptoms to be reported:
- fever, dyspnea, chest pain with minimal
exertion
CABG
 CONGESTIVE HEART
FAILURE
A. Gen. Info:
- Inability of the heart to pump an adequate supply
of blood to meet the metabolic needs of the body

B. Types:
1. Left sided heart failure
2. Right sided heart failure
 CONGESTIVE HEART
FAILURE
1. LEFT SIDED HEART FAILURE
a. Left ventricular damage causes blood to back up
through the left atrium and into the pulmonary
veins. Increased pressure causes transudation
into the interstitial tissues of the lungs with
resultant pulmonary congestion

b. Caused by:
- left ventricular damage (MI, CAD)
- hypertension, aortic valve disease (AI, AS)
- mitral stenosis, cardiomyopathy
 CONGESTIVE HEART
FAILURE
c. Assessment findings:
Signs:
- easy fatigability, dyspnea on exertion, PND,
orthopnea, cough, nocturia, confusion

Symptoms:
- S3 gallop, tachycardia, tachypnea, rales,
wheezing, pleural effusion
 CONGESTIVE HEART
FAILURE
d. Diagnostic tests:
- ECG, chest x-ray (cardiomegaly, pleural effusion),
echocardiography, cardiac catheterization, dec.
PO2, inc. PCO2

2. RIGHT SIDED HEART FAILURE

a. weakened RV is unable to pump blood into the
pulmonary system; systemic venous congestion
occurs as pressure builds up.
 CONGESTIVE HEART
FAILURE
b. caused by:
- left sided heart failure
- RV infarction
- atherosclerotic heart disease
- COPD, pulmonic stenosis, pulmonary embolism

c. Assessment findings:
Symptoms:
- easy fatigability, lower extremity swelling, early
satiety, RUQ discomfort
 CONGESTIVE HEART
FAILURE
Signs:
- elevated jugular venous pressure, hepatomegaly,
ascites, lower extremity edema

d. Diagnostic tests:
- chest x-ray: reveals cardiac hypertrophy
- echocardiography: indicates inc. size of cardiac
chambers
- elevated CVP, dec. PO2, inc. ALT(SGPT)
 CONGESTIVE HEART
FAILURE
C. Medical Management:
1. determination and elimination/control of
underlying cause
2. Drug therapy:
- Diuretics: Furosemide, Spironolactone
- Dilators: ACE inhibitors, nitrates
- Digitalis: digoxin
3. Diet: low salt, low cholesterol
* If medical therapies unsuccessful, mechanical assist devices
(intra-aortic balloon pump), cardiac transplantation or mechanical
hearts may be employed.
 CONGESTIVE HEART
FAILURE
D. Nursing Interventions:
1. Monitor respiratory status and provide adequate
ventilation (when CHF progresses to pulmonary
edema)
2. Provide physical and emotional rest
3. Increase cardiac output
4. Reduce/eliminate edema
5. Provide client teaching and discharge planning
 CARDIAC ARREST
A. General Info:
- sudden, unexpected cessation of breathing and
adequate circulation of blood by the heart

B. Medical management:
1. Cardiopulmonary resuscitation (CPR)
2. Drug therapy:
a. lidocaine, procainamide, verapamil
b. Dopamine, isoproterenol, Norepinephrine
 CARDIAC ARREST
c. Epinephrine to enhance myocardial automaticity,
excitability, conductivity, and contractility
d. Atropine sulfate to reduce vagus nerve’s control over
the heart, thus increasing the heart rate
e. Sodium bicarbonate: administered during first few
moments of a cardiac arrest to correct respiratory and
metabolic acidosis
f. Calcium chloride: calcium ions help the heart beat
more effectively by enhancing the myocardium's contractile
force
3. Defibrillation
 CARDIAC ARREST
C. Assessment findings:
- unresponsiveness, cessation of respiration, pallor,
cyanosis, absence of heart rate/ BP/pulses,
dilation of pupils, ventricular fibrillation

D. Nursing interventions:
1. Begin precordial thump and if successful,
administer lidocaine
2. If unsuccessful, defibrillation - CPR
3. Assist with administration of and monitor effects
of emergency drugs
 INFLAMMATORY
DISEASES OF THE HEART
ENDOCARDITIS
A. General Info:
1. Inflammation of the endocardium; platelets and
fibrin deposit on the mitral and/or aortic valves
causing deformity, insufficiency or stenosis
2. caused by bacterial infection:
- commonly S. aureus. S. viridans, B hemolytic
streptococcus, gonococcus
3. Precipitating factors: RHD, open heart surgery,
GU/OB Gyn surgery, dental extractions
 ENDOCARDITIS
B. Medical management:
1. Drug therapy:
a. antibiotics specific to sensitivity or organism
cultured
b. PenG and streptomycin if org. not known
c. antipyretics
2. Cardiac surgery to replace valve
 ENDOCARDITIS
C. Assessment findings:
1. Fever, malaise, fatigue, dyspnea and cough
acute upper quadrant pain, joint pain
2. petechiae, murmurs, edema, splenomegaly,
hemiplegia and confusion, hematuria
3. elevated WBC & ESR, decreased Hgb & Hct.
4. Diagnostic tests: positive blood culture for
causative organism
 ENDOCARDITIS
D. Nursing interventions:
1. antibiotics as ordered
2. control temperature
3. assess for vascular complications and pulm.
embolism
4. Provide client teaching and discharge planning
- types of procedures, antibiotic therapy
- S/S to report: persistent fever, fatigue, chills,
anorexia, joint pains
- avoidance of individuals with known infections
 MYOCARDITIS
A. General Info: an acute or chronic inflammation of
the myocardium as a result of pericarditis,
systemic infection or allergic response.

B. Assessment:
- fever, pericardial friction rub, gallop rhythm
- murmur, signs of heart failure, fatigue, dyspnea
- tachycardia, chest pain
 MYOCARDITIS
C. Implementation:
1. Assist client to assume a position of comfort
2. Administer analgesics, salicylates, NSAIDS
3. Administer O2, provide adequate rest periods
4. Limit activities, to dec. workload of heart
5. Treat underlying cause
6. Administer meds. as ordered:
- antibiotics, diuretics, ACE inhibitors, digitalis
7. Monitor complications: thrombus, heart failure,
cardiomyopathy
 PERICARDITIS
A. General Info:
1. An inflammation of the visceral and parietal
pericardium
2. caused by bacterial, viral, or fungal infection;
collagen diseases; trauma; acute MI, neoplasms,
uremia, radiation, drugs (procainamide,
hydralazine, Doxorubicin HCL)
 PERICARDITIS
B. Medical management:
1. Determination and elimination/control of
underlying cause
2. Drug therapy
a. Medication for pain relief
b. Corticosteroids, *salicylates (aspirin),
indomethacin, to reduce inflammation
3. Specific antibiotic therapy against the causative
organism may be indicated
 PERICARDITIS
C. Assessment findings:
1. chest pain with deep inspiration (relieved by
sitting up), cough, hemoptysis, malaise
2. tachycardia, fever, pericardial friction rub,
cyanosis or pallor, jugular vein distension
3. Elevated WBC and ESR, normal or inc. SGOT
4. Diagnostic test:
a. chest x-ray may show increased heart size
b. ECG: ST elevation, T wave inversion
 PERICARDITIS
D. Nursing Interventions:
1. Ensure comfort, bed rest with semi- or high
Fowler’s position
2. Monitor hemodynamic parameters
3. Administer medications as ordered and monitor
effects
4. Provide client teaching and discharge planning:
- S/S of pericarditis indicative of recurrence (chest
pain intensified by lying down and relieved when
sitting up; medication regimen
 DYSRHYTHMIAS
■ An arrhythmia is a disruption in the normal events
of the cardiac cycle. It may take a variety of
forms.
■ Treatment varies on the type dysrhythmias

SINUS TACHYCARDIA
A. General Information:
1. A heart rate of over 100 beats/min, originating
in the SA node
 DYSRHYTHMIAS
2. May be caused by:
- fever - anemia
- apprehension - hyperthyroidism
- physical activity - myocardial ischemia
- caffeine - drugs (epi., theo)

B. Assessment findings:
1. Rate: 100-160 beats /min
2. Rhythm: regular
 DYSRHYTHMIAS
3. P wave: precedes each QRS complex with
normal contour
4. P-R interval: normal (0.08 sec)
5. QRS complex: normal (0.06 sec)

C. Treatment;
- correction of underlying cause, elimination of
stimulants, sedatives, propranolol (Inderal)
 DYSRHYTHMIAS
SINUS BRADYCARDIA
A. General Information:
1. A slowed heart rate initiated by SA node
2. Caused by:
- excessive vagal or decreased sympathetic tone
- MI - IC tumors
- meningitis - myxedema
- cardiac fibrosis
- normal variation of the heart rate in well trained
athletes
 DYSRHYTHMIAS
B. Assessment findings:
1. Rate: <60 beats/min
2. Rhythm: regular
3. P wave: precedes each QRS with a normal
contour
4. P-R interval: normal
5. QRS complex: normal
C. Treatment: usually not needed
- if cardiac output is inadequate: atropine and
isoproterenol; pacemaker
 DYSRHYTHMIAS
ATRIAL FIBRILLATION
A. General information
1. An arrhythmia in which ectopic foci cause rapid,
irregular contractions of the heart
2. seen in clients with
- rheumatic mitral stenosis - thyrotoxicosis
- cardiomyopathy - pericarditis
- hypertensive heart disease - CHD
 DYSRHYTHMIAS
B. Assessment findings:
1. Rate: atrial: 350-600 beats/min
ventricular: varies bet. 100-160 beats /min
2. Rhythm: atrial and ventricular regularly
irregular
3. P wave: no definite P wave; rapid undulations
called fibrillatory waves
4. P-R interval: not measurable
5. QRS complex: generally normal
 DYSRHYTHMIAS
C. Treatment: digitalis preparations, propanolol,
verapamil in conjunction with digitalis; direct
current cardioversion

PREMATURE VENTRICULAR CONTRACTIONS

A. General Information:
1. Irritable impulses originate in the ventricles
2. Caused by:
- electrolyte imbalance (hypokalemia)
- digitalis drug therapy
 DYSRHYTHMIAS
Cont’d: (causes)
- stimulants( caffeine, epinephrine, isoproterenol)
- hypoxia
- CHF

B. Assessment findings:
1. Rate: varies according to no. of PVC’s
2. Rhythm: irregular because of PVC’s
3. P wave: normal; however, often lost in QRS
complex
 DYSRHYTHMIAS
4. P-R interval: often not measurable
5. QRS complex: greater then 0.12secs, wide

C. Treatment:
1. IV push of Lidocaine (50-100mg) followed by IV
drip of lidocaine at rate of 1-4 mg/min
2. Procainamide, quinidine
3. Treatment of underlying cause
 DYSRHYTHMIAS
VENTRICULAR TACHYCARDIA
A. General information:
1. 3 or more consecutive PVC’s; occurs from
repetitive firing of an ectopic focus in the
ventricles
2. caused by:
- MI - CAD
- digitalis intoxication - hypokalemia
 DYSRHYTHMIAS
B. Assessment findings:
1. Rate: atrial: 60-100 beats/min
ventricular: 110-250 beats/min
2. Rhythm: atrial(regular), ventricular (occly.
irregular)
3. P wave: often lost in QRS complex
4. P-R interval usually not measurable
5. QRS complex: greater than 0.12 secs, wide
 DYSRHYTHMIAS
C. Treatment:
1. IV push of lidocaine (50-100mg), then IV drip of
lidocaine 1-4 mg/min
2. Procainamide via IV infusion of 2-6 mg/min
3. direct current cardioversion
4. bretylium, propanolol
 THE BLOOD VESSELS
A. HYPERTENSION
- persistent elevation of the SBP above 140mmHg and
of DBP above 90mmHg (WHO)

Types:
a. Essential (primary, idiopathic): marked by loss of
elastic tissue and arteriosclerotic changes in the aorta
and larger vessels coupled with decreased caliber of
the arterioles
b. Benign: a moderate rise in BP marked by a
gradual onset and prolonged course
 HYPERTENSION
c. Malignant: characterized by a rapid onset and
short dramatic course with a DBP of >150mmHg
d. Secondary: elevation of the BP as a result of
another disease such as renal parenchymal disease,
Cushing’s disease, pheochromocytoma, primary
aldosteronism, coarctation of the aorta

A. Essential hypertension usually occurs between ages

35-50; more common in men over 35, women over
45; African-American men affected twice as often as
white men/women
 HYPERTENSION
Risk Factors:
- (+) family history, obesity, stress, cigarette smoking,
hypercholesterolemia, inc. sodium intake

B. Medical management:
1. Diet and weight reduction (restricted sodium, kcal,
cholesterol)
2. Lifestyle changes: alcohol moderation, exercise
regimen, cessation of smoking
3. Antihypertensive drug therapy
 HYPERTENSION
C. Assessment findings:
1. Pain similar to anginal pain; pain in calves of legs after
ambulation or exercise (intermittent claudication);
severe occipital headaches, particularly in the
morning; polyuria; nocturia; fatigue; dizziness;
epistaxis; dyspnea on exertion
2. BP consistently above 140/90, retinal hges and
exudates, edema of extremities
3. Rise in SBP from supine to standing position (indicative
of essential hypertension)
4. Diagnostic tests: elevated serum uric acid, sodium,
cholesterol levels
 HYPERTENSION
D. Nursing interventions:
1. Record baseline BP in 3 positions (lying, sitting,
standing) and in both arms
2. Continuously assess BPand report any variables that
relate to changes in BP (positioning, restlessness)
3. Administer antihypertensive agents as ordered; monitor
closely and assess for S/E
4. Monitor intake and hourly output
5. Provide client teaching and discharge planning:
- risk factors, dietary instructions, compliance of
antihypertensive medications, routine follow up w/ MD
 ARTERIOSCLEROSIS
OBLITERANS
- a chronic occlusive arterial disease that may affect
the abdominal aorta or the LE. The obstruction to
blood flow with resultant ischemia usually affects
the femoral, popliteal, aortic and iliac arteries
- occurs most often in men ages 50-60
- caused by atherosclerosis
- Risk Factors: cigarette smoking, hyperlipidemia,
hypertension, DM
 ARTERIOSCLEROSIS
OBLITERANS
B. Medical management:
1. Drug therapy
a. Vasodilators: papaverine, Isoxsuprine Hcl
(Vasodilan), Nylidrin Hcl (Arlidin), nicotinyl alcohol
(Roniacol) cyclandelate (Cyclospasmol), tolazoline Hcl
(priscoline) to improve arterial circulation;
effectiveness questionable
b. Analgesics to relieve ischemic pain
c. Anticoagulants to prevent thrombus formation
d. Lipid reducing drug: cholestyramine, colesti[pol
Hcl, dextrothyroxine sodium, clofibrate, gemfibrozil
(Lopid), niacin, lovastatin (Mevacor), atorvastatin
 ARTERIOSCLEROSIS
OBLITERANS
2. Surgery: bypass grafting, endarterectomy, balloon
catheter dilation, lumbar sympathectomy (to increase
blood flow), amputation may be necessary

C. Assessment findings:
1. Pain both intermittent claudication and rest pain,
numbness or tingling of the toes
2. Pallor after 1-2 mins. Of elevating feet, and dependent
hyperemia/rubor; diminished or absent dorsalis pedis,
posterior tibial and femoral pulses; shiny, taut skin
with hair loss on lower legs
 ARTERIOSCLEROSIS
OBLITERANS
3. Diagnostic tests:
a. Oscillometry may reveal decrease pulse volume
b. Doppler U/S reveals decreased blood flow through
affected vessels
c. Angiography reveals location and extent of
obstructive process
4. Elevated serum triglycerides; sodium

D. Nursing Interventions:
1. Encourage slow, progressive physical activity
 ARTERIOSCLEROSIS
OBLITERANS
2. Administer medications as ordered
3. Assist with Buerger-Allen exercises qid
a. client lies with legs elevated above heart for 2-3 mins
b. client sits on edge of bed with legs and feet
dependent and exercises feet and toes – upward and
downward, inward and outward – for 3 mins
c. client lies flat with legs at heart level for 5 mins
4. Assess for sensory function; protect client from injury
5. Provide client teaching and discharge planning: stop
cigarette smoking, diet, drug compliance, exercise
 THROMBOANGIITIS
OBLITERANS
(BUERGER’S DISEASE)
- Acute inflammatory disorder affecting medium/smaller
arteries and veins of the LE. Occurs as focal,
obstructive process; results in occlusion of a vessel
with subsequent development of collateral circulation
- Most often affects men ages 25-40; disease is idiopathic;
high incidence among smokers

A. Medical management: same as arteriosclerosis obliterans

but only cessation of smoking is effective treatment
 THROMBOANGIITIS
OBLITERANS
(BUERGER’S DISEASE)
B. Assessment findings:
1. Intermittent claudication, sensitivity to cold (skin of
extremity may at first be white, changing to blue then
red)
2. Decreased or absent peripheral pulses (post. tibial and
dorsalis pedis), ulceration and gangrene (advanced)
3. Diagnostic tests: same as arteriosclerosis obliterans
except no elevation in serum triglycerides

C. Nursing Interventions:
1. Prepare client for surgery
 THROMBOANGIITIS
OBLITERANS
(BUERGER’S DISEASE)
2. Provide client teaching and discharge planning
- drug regimen, avoidance of trauma to the affected
extremity, need to maintain warmth esp. during cold
weathers, importance of stopping smoking
 RAYNAUD’S
PHENOMENON
- intermittent episode of arterial spasms, most frequently
involving the fingers; most often affects women
between the teenage years and age 40; cause
unknown
- Predisposing factors: collagen diseases (SLE, RA), trauma
(from typing, playing piano)

A. Medical management: vasodilators,

catecholamine-depleting antihypertensive drugs
(reserpine, guanethidine monosulfate)
 RAYNAUD’S
PHENOMENON
B. Assessment findings:
1. coldness, numbness, tingling in one or more digits; pain
(usually pptd. By exposure to cold, emotional upsets,
tobacco use)
2. intermittent color changes (pallor, cyanosis, rumor);
small ulcerations and gangrene tips of digits

C. Nursing interventions
1. provide client teaching concerning:
- importance of stopping smoking; need to maintain
warmth; need to use gloves in handling cold objects;
drug regimen
 ANEURYSM
- a sac formed by dilation of an artery secondary to
weakness and stretching of an arterial wall. The
dilation may involve one or all layers of the arterial
wall.

Classification
1. Fusiform: uniform spindle shape involving the entire
circumference of the artery
2. Saccular: outpouching on one side only, affecting part of
the arterial circumference
 ANEURYSM
3. Dissecting: separation of the arterial wall layers to form
a cavity that fills with blood
4. False: the vessel wall is disrupted, blood escapes into
surrounding area but is held in place by surrounding
tissue

A. General info:
1. an aneurysm, usually fusiform or dissecting, in the
descending, ascending, or transverse section of the
thoracic aorta
2. usually occurs in men ages 50-70; caused by
arteriosclerosis, infection, syphilis, hypertension
 ANEURYSM
B. Medical management:
1. control of underlying hypertension
2. Surgery: resection of the aneurysm and replacement
with a Teflon/Dacron graft; client will need
extracorporeal circulation

C. Assessment findings:
1. Often asymptomatic; deep, diffuse chest pain;
hoarseness; dysphagia; dyspnea
2. Pallor, diaphoresis, distended neck veins
 ANEURYSM
3. Diagnostic tests:
a. Aortography shows exact location of the aneurysm
b. X-rays: chest film reveals abnormal widening of
aorta; abdominal film may show calcification within
walls of aneurysm

4. Nursing interventions: same as in Cardiac surgery

 THROMBOPHLEBITIS
A. General info:
1. Inflammation of the vessel wall with formation of a clot
(thrombus); may affect superficial or deep veins
2. Most frequent veins affected are the saphenous,
femoral, and popliteal.
3. Can result in damage to the surrounding tissues,
ischemia and necrosis
4. Risk Factors: obesity, CHF, prolonged immobility, MI,
pregnancy, oral contraceptives, trauma, sepsis,
cigarette smoking, dehydration, severe anemias,
venous cannulation, complication of surgery
 THROMBOPHLEBITIS
B. Medical management:
1. Anticoagulation therapy:
a. Heparin: blocks conversion of prothrombin to
thrombin and reduces formation of thrombus
- S/E: spontaneous bleeding, injection site
reactions, ecchymoses, tissue irritation and sloughing,
reversible transient alopecia, cyanosis, pain in arms or
legs, thrombocytopenia
b. Warfarin (coumadin): blocks prothrombin synthesis
by interfering with vit. K synthesis
- S/E: GI: anorexia, nausea/vomiting, diarrhea,
stomatitis
 THROMBOPHLEBITIS
- hypersensitivity: dermatitis, urticaria, pruritus, fever
- other: transient hair loss, burning sensation of feet,
bleeding complications.

2. Surgery
a. Vein ligation and stripping
b. venous thrombectomy: removal of a clot in the
iliofemoral region
c. plication of the inf. vena cava: insertion of an
umbrella-like prosthesis into the lumen of the vena
cava to filter incoming clots
 THROMBOPHLEBITIS
C. Assessment findings:
1. Pain in the affected extremity
2. Superficial vein: tenderness, redness, induration along
course of the vein
3. Deep vein: swelling, venous distension of limb,
tenderness over involoved vein, (+) Homan’s sign
4. Elevated WBC and ESR
5. Diagnostic tests:
a. venography (phlebography): inc. uptake of
radioactive material
 THROMBOPHLEBITIS
b. Doppler ultrasonography: impairment of blood flow
ahead of thrombus
c. Venous pressure measurements: high in affected
limb until collateral circulation is developed

D. Nursing interventions
1. Provide bed rest, elevating involved extremity
2. Apply continuous warm, moist soaks to dec. lymphatic
congestion
3. Administer anticoagulants as ordered
 THROMBOPHLEBITIS
a. Heparin
1. monitor PTT, use infusion pump to administer IV heparin
2. assess for bleeding tendencies (hematuria;
hematemesis; bleeding gums; epistaxis, melena)
3. have antidote ( protamine sulfate) available

b. Warfarin (Coumadin)
1. assess PT daily, advise client to withhold dose and notify
physician immediately if bleeding or signs of bleeding
occurs
2. instruct client to use a soft toothbrush and to floss
gently, prepare antidote: Vit. K
 THROMBOPHLEBITIS
4. monitor for chest pain or SOB (possible pulmonary
embolism)
5. Provide client teaching and discharge planning:
a. need to avoid standing, sitting for long periods;
constrictive clothing; crossing legs at the knees;
smoking; oral contraceptives
b. importance of adequate hydration
c. use of elastic stockings when ambulatory
d. importance of planned rest with elevation of feet
e. importance of weight reduction and exercise
 VARICOSE VEINS
A. General info:
1. Dilated veins that occur most often in the lower
extremities and trunk. As the vessel dilates, the valves
become stretched and incompetent with resultant
venous pooling/edema
2. most common between ages 30-50
3. predisposing factor: congenital weakness of the veins,
thrombophlebitis, pregnancy, obesity, heart disease

B. Medical management: vein ligation (involves ligating the

saphenous vein where it joins the femoral vein and
stripping the saphenous vein system from groin to ankle)
 VARICOSE VEINS
C. Assessment findings:
1. Pain after prolonged standing (relieved by elevation)
2. Swollen, dilated, tortuous skin veins
3. Diagnostic tests:
a. Trendelenburg test: varicose veins distend very
quickly (less than 35 secs)
b. Doppler U/S: decreased or no blood flow heard after
calf or thigh compression

D. Nursing interventions:
1. Elevate legs above heart level
 VARICOSE VEINS
2. Apply knee length elastic stockings
3. Provide adequate rest
4. Prepare client for vein ligation, if necessary
a. Provide routine pre-op care
b. keep affected extremity elevated above the level
of the heart to prevent edema
c. apply elastic bandages and stockings, which
should be removed every 8hrs for short periods.
d. assist out of bed within 24hrs, ensuring that
elastic stockings are applied.
e. assess for increased bleeding