MED-SURG:

Cardiovascular/
Hematologic Conditions
CARDIOVASCULAR SYSTEM
❒ HEART 🡪 Controls BLOOD 🡪 Carries
OXYGEN 🡪 Promotes TISSUE PERFUSION
4 CHAMBERS

Right Atrium Left Atrium

Right Ventricle Left Ventricle

Unoxygenated Blood Oxygenated Blood

1) SINOATRIAL NODE
AV Valves ✔ The natural pacemaker of the heart
✔ LOCATION: Upper portion of right
Bicuspid Valve/ Tricuspid Valve atrium
2) ATRIOVENTRICULAR NODE
Mitral Valve
❒ The gatekeeper of the heart
− It decides what impulses to let
LBM = Left is Bicuspid/Mitral valve through
❒ LOCATION: border of the right
atrium and the right ventricle
Semilunar Valves 3) BUNDLE OF HIS
4) RIGHT AND LEFT BUNDLE BRANCHES
Pulmonic Valve Aortic Valve 5) PURKINJE FIBERS

NSAIDs or COX Inhibitors

Locations of Valves (Carbonic Oxidase Inhibitors)
“Please Answer My Telephone” COX-1 Inhibitor COX-2 Inhibitor
Receptor of body that Receptor of the body that
Pulmonic valve Left side, 2nd produces protective produces
intercostal space lining prostaglandins.
⮚ GI lining
Aortic Valve Right side, 2nd ⮚ Kidneys
intercostal space NEPHROTOXIC = prone Prostaglandin
to renal failure ⮚ carries stimuli
Bicuspid/Mitral Left side, 4th-5th
Valve intercostal space Prone to ULCERS Brain = interprets stimuli
⮚ Pain
Tricuspid Valve Left side; 3rd-4th ⮚ Fever
intercostal space ⮚ Inflammation

WITH meals ANALGESIC

Conduction System of the Heart (PROCESS) (prevent ulcers)
ANTIPYRETIC
 Increase Oral Fluid ANTI-INFLAMMATORY ❒ Occurs during strenuous activities
Intake 2) Unstable
(prevent renal problems)
Angina/Preinfarction
❒ Unexpected
Atherosclerosis Arteriosclerosis ❒ Duration: >15 minutes
Fat deposits/Plaque Hardening of blood ❒ Not relieved by REST
vessels ❒ This can lead to Myocardial
Infarction
3) Variant Angina/Prinzmetal
❒ PAIN during REST
4) Nocturnal Angina
❒ PAIN occurs at NIGHT
5) Silent Angina
❒ NO PAIN
❒ Observed at the ECG tracing:
Myocardial Injury Elevated ST Segment
Myocardial Ischemia Inverted T Wave
Myocardial Infarction Pathologic Q Wave

⮚ MANAGEMENT: BACONS
a) Beta-Adrenergic Blockers “-olol”
Beta-1 (B1) Beta-2 (B2)

Stimulates Stimulates LUNGS

HEART

Increase HR

Bronchodilation
Increase
Cardiac
Workload

Increase BP
ANGINA PECTORIS ❒ BETA-BLOCKERS are:
✔ GOOD for the HEART
✔ BAD for the LUNGS
❒ Blocks stimuli:
⮚ Levine’s Sign: Cardinal Sign/Hallmark Sign ✔ Decreases BP
⮚ TYPES: (Antihypertensive)
1) Stable Angina ✔ Decreases RR
❒ Predictable/Expected (Bronchoconstriction)
❒ Duration: <15 minutes ✔ Decreases HR
❒ Relieved by REST (Anti-arrhythmia)
b) Aspirin “Acetylsalicylic Acid”
❒ NSAID and Antiplatelet

d) OXYGEN Supplementation
e) Nitroglycerin (Drug Of Choice)
✔ ROUTES:
a. SL (under the tongue)
⮚ EFFECTIVENESS: burning
sensation under the
tongue (Stingy taste)
⮚ Doses: 3 MAX doses
⮚ Interval: 5 minutes
⮚ MAXIMUM: 15 minutes
⮚ Container: Dark/amber
container (photosensitive)
⮚ Expiration: 6 months
⮚ Change tablets TWICE a
❒ Monitor Signs & Symptoms of
year
BLEEDING:
⮚ S/E:
a. Epistaxis
❖ Hypotension
b. Hematemesis
through Headache
c. Petechiae
❖ Dizziness
d. Ecchymosis
⮚ PRIORITY: Safety
e. Hematuria
b. PO (tablets)
f. Melena
c. IV
g. Hematochezia
d. PATCH
Melena Hematochezia ⮚ Place: PROXIMAL to
HEART (Non-hairy area)
Dark-red Bright-red
⮚ ROTATE the sites
(prevents tolerance and
Old RBC Fresh RBC
skin irritation)
⮚ EFFECTIVENESS:
UPPER GI LOWER GI
absence of chest pain
⮚ S/E:
❖ Hypotension
through Headache
❖ Dizziness
⮚ PRIORITY: Safety
c) Calcium Channel Blockers “-dipine”
f) SETUP resting time
❒ Examples:
❒ Schedule resting periods with the
a. –dipine medications
patient
b. Diltiazem
c. Verapamil
MYOCARDIAL INFARCTION
 d) Lacto dehydrogenase
e) Myoglobin
❒ MANAGEMENT: MONATAS
a) Morphine Sulfate (Drug of Choice)
✔ Class: Opioid Analgesics/Narcotics
✔ Use: Treats SEVERE chest pain
✔ S/E: CNS depressant
✔ Affects: Medulla Oblongata
Depression
a. HR
b. BP
c. RR (Respiratory Depression)
✔ MANAGEMENT:
a. Check RR BEFORE administering
b. Check Reflexes (DTR reflexes)
b) Oxygen Supplementation
c) Nitroglycerin
d) Aspirin

❒ SIGNS & SYMPTOMS: DANCEPAD

a) Dyspnea
b) Anxiety (Feeling of doom)
c) Nausea & Vomiting
d) Crushing Chest pain (radiating to the LEFT
shoulder and LEFT arm)
e) Elevated Temperature
f) Pallor
g) Arrhythmia
h) Diaphoresis
❒ DIAGNOSTICS
a) ECG
Myocardial Injury Elevated ST Segment
Myocardial Ischemia Inverted T Wave
Myocardial Infarction Pathologic Q Wave e) Thrombolytic
b) Cardiac Enzymes (Troponin I) ✔ DISSOLVES Clot
✔ Confirmatory test ✔ E.g. Streptokinase, Urokinase
c) CK-MB
 f) Anti-arrythmias c) COARCTATION OF AORTA
✔ DIGITALIS (Digoxin) d) OBESITY
a. (+) INOTROPIC effect ❒ Primary HPN
❒ Increases force of contraction e) Na+ EXCESS (Na+ Retention)
❒ DIURETIC effect (increases ❒ Secondary HPN
urine output) f) DIABETES
❒ Potassium must be within g) ATHEROSCLEROSIS
NORMAL levels (3.5-5.5 h) RENAL FAILURE
mEq/L) i) INCREASE THYROID & ADRENAL
b. (-) CHRONOTROPIC effect FUNCTIONS
❒ Decreases PR (Bradycardia)
❒ Withhold if PR is < 60 bpm MANAGEMENT of HPN:
c. CUMULATIVE effect a) ANTIHYPERTENSIVES:
❒ Has TOXICITY ❒ Decrease BP
❒ Signs of TOXICITY: VANDAB
1) Vision changes
(flickering flashes of
light/halo visions)
2) Anorexia
3) Nausea & Vomiting
4) Diarrhea
5) Abdominal cramps
(earliest sign)
6) Bradycardia
d. Slows conduction through AV node
e. MAJOR CONCERN: DIGITALIS
TOXICITY
f. ANTIDOTE: Digoxin Immune fab
(DIGIBIND)
g. Most reliable indicator of BETTER
TISSUE PERFUSION:
✔ Urine output
h. Contraindications (potentiates
TOXICITY):
✔ Old age
✔ Acute MI
✔ Severe arrhythmia
g) Stool Softeners
❒ Prevents Valsalva maneuver

HYPERTENSION
❒ Increase of Blood Pressure
❒ TYPES:
a) Primary/Essential HPN
✔ Unknown Cause
b) Secondary/Non-Essential HPN
✔ Known Cause

CAUSES of HYPERTENSION:
a) SMOKING
❒ due to vasoconstricting effects of
nicotine
❒ Secondary HPN
b) ELDERLY
❒ Primary HPN
 ❒ TYPES: ABCD
1) ACE INHIBITORS “-pril”
✔ Blocks ACE
✔ Promotes Vasodilation (Decrease
BP)
2) BETA-ADRENERGIC BLOCKERS
3) CALCIUM-CHANNEL BLOCKERS
4) DIURETICS
✔ Use: Promotes Urine Excretion
✔ S/E: Increase Urine Output
✔ Body fluids: DOWN
✔ Blood Volume: DOWN
✔ Blood Pressure: DOWN
✔ TYPES:
1) POTASSIUM-SPARING
● E.g. Aldactone,
Spironolactone
● Increases Na+ and Water
excretion; Retains K+
2) LOOP DIURETICS
● E.g. Furosemide
● Most potassium wasting
diuretics
3) OSMOTIC DIURETICS
● E.g. Mannitol
● DOC for Increased ICP
4) THIAZIDE DIURETICS
● E.g. Hydrochlorothiazide
● For LONG TERM use of
diuretics
5) CARBONIC ANHYDRASE
INHIBITORS
● DOC for Glaucoma
BLOOD TYPING (Going DOWN ONLY)
O access to the mother’s Rh (-)
(Universal Donor)
A − This time, the Rh (-) mother will
B form ANTIBODIES against the
AB
A B
A B
AB AB
AB
(Universal Recipient)
O
A
B
AB
ABO INCOMPATIBILITY (ISOIMMUNIZATION)
⮚ Rh NEGATIVE mother carries a Rh POSITIVE
fetus
⮚ What is the meaning of the (+) and (-) in blood
typing?
✔ Indication of whether or not the person
has a D antigen
− Protein that is found in the cell walls
of every RBC
− If have D antigen: Blood type is
POSITIVE
− If have absence of D antigen: Blood
type is NEGATIVE
⮚ How does Rh Incompatibility Happens?
✔ When an Rh NEGATIVE person exposed
to a (+) D antigen blood ONLY!
✔ The Rh NEGATIVE person will regard
the (+) D antigen blood as an
INVADING ORGANISM.
✔ DEFENSE MECHANISM of the Rh (-)
person:
− Forms ANTIBODIES to the (+) D
antigen blood
✔ In the 1st pregnancy of the Rh (-)
mother to a Rh (+) fetus:
− NO COMPLICATIONS; NORMAL
✔ The beginning problem comes in the 3rd
Stage of LABOR (PLACENTAL STAGE)
− In the separation and expulsion
of the placenta, the placental
barrier dissipates.
− The fetus Rh (+) blood gains
blood
fetus Rh (+) D antigen blood.
✔ WHY is it SUCCESSFUL for the Rh (-)
mother to have a NORMAL delivery of an
Rh (+) fetus?
− REMEMBER: The baby is out in
the 2nd Stage of LABOR (Delivery
of the Baby)
− Meaning, the baby is out before the
placenta had dissipated in the
uterus.
✔ The ACTUAL PROBLEM comes in the 2nd
pregnancy of the Rh (-) mother with Rh
(+) fetus.
− The maternal blood of the Rh (-)
mother was pre-exposed before
 during her 1st pregnancy;
ANTIBODIES HAVE ALREADY
FORMED!
− The ANTIBODIES can now CROSS
THE PLACENTAL BARRIER!
− The ANTIBOIES can now DESTROY
the fetus’ RBCs, resulting to a
EXCESSIVE LOSS OF RBCs
(Hemolytic Anemia), leading to a
condition called
ERYTHROBLASTOSIS
FETALIS!
✔ Why do people have Rh NEGATIVE blood?
− 85% of people have Rh POSITIVE
Blood
− 15% of people will have Rh
NEGATIVE blood.
− This happens when the MOTHER
is HOMOZYGOUS(Rh NEGATIVE
gene) and the FATHER is
HETEROZYGOUS
o one copy is Rh NEGATIVE
gene
o one copy is Rh POSITIVE
gene
− 50% chance to have a Rh
NEGATIVE baby
MANAGEMENT:
1) Administer RHOGAM within 72 hours
− Prevents formation of antibodies
(anti-D antigen)
− RHOGAM must be administered
every after delivery of the Rh (-)
mother
− RHOGAM lasts only for 2 months
− ALL Rh (-) WOMEN with
UNTYPABLE PREGNANCIES must
take RHOGAM!
2) Anti-D Titer Screening (COOMBS TEST)
− Determines if the mother has
ANTIBODIES (Anti-D antigen)
− Types of Coombs Test:
a) DIRECT COOMBS TEST
o Fetal blood sample is
tested
b) INDIRECT COOMBS TEST
o Maternal blood sample is
tested
ASSESSMENT:
1) ALL Rh (-) WOMEN should undergo COOMBS
TEST
a) If test is NEGATIVE/LOW:
1. Receives RHOGAM at 28 weeks
(7 months)
− For PROPHYLACTIC measure
− To prevent seepage of the
placenta filled with Rh (+)
blood
− Prevent sensitization of the
mother
2. within 72 hours postpartum
b) If test is POSITIVE/HIGH:
1. The mother is sensitized; TOXIC
to the baby
2. Do not give RHOGAM
3. Fetus is monitored via DOPPLER
VELOCITY
c) DOPPLER VELOCITY is ABNORMAL:
✔ Indicates child has ANEMIA
✔ RBCs has been destroyed
d) DOPPLER VELOCITY is NORMAL:
✔ CHILD is likely to be Rh (-)
CONGESTIVE HEART FAILURE (CHF)
❒ Congestion of the heart
❒ CAUSES:
a) Heart Problems
❒ TYPES of CHF:
1) Right-sided Heart Failure (RSHF)
⮚ Unoxygenated blood (SYSTEMIC)
⮚ The unoxygenated blood will forced
to go back to the body (lower
extremities) and to the head.
⮚ S/Sx:
a. Jugular Vein Distention
− The unoxygenated blood that
goes from the heart, forces
back to the HEAD.
b. Bipedal Edema
− The unoxygenated blood that
goes from the heart, forces
back to the FEET.
c. Ascites
− The unoxygenated blood that
goes from the heart, forces
back to the STOMACH.
d. Hepatomegaly
− The unoxygenated blood that
goes from the heart, forces
back to the LIVER.
2) Left-sided Heart Failure (LSHF)
⮚ Oxygenated blood (PULMONARY)
⮚ The oxygenated blood will force to go
back to the lungs.
⮚ S/Sx:
a. Pulmonary Edema
− The oxygenated blood that
goes from the heart, forces
back to the LUNGS.
 ❒ GABHS’s mimics normal tissues
b. Crackles which the immune system destroys
c. Difficulty of Breathing the normal tissues
d. Hemoptysis ❒ Happens after school age
❒ MANAGEMENT: UNLOAD FASTER SIGNS & SYMPTOMS OF RHD
a) Upright Position MAJOR SIGNS & MINOR SIGNS &
b) Nitroglycerin SYMPTOMS (JONES) SYMPTOMS (FEELPA)
c) Lasix (Furosemide) ❒ Joints (Polyarthritis) ❒ Fever
d) Oxygen ✔ Painful joints
e) Aspirin
✔ ABSENT
f) Digoxin
g) Fluid Restriction deformities
h) Aminophylline
i) Sodium Restriction ❒ O – shaped Heart ❒ ECG changes
j) Thrombolytic ✔ Carditis (may ✔ Prolonged PR &
k) Edema (reliable indicator of worsening of cause permanent QT interval
CHF) valvular damage)
⮚ Weigh once a day every morning
l) Rest (decrease cardiac workload) ❒ Nodular ❒ Evidence of GABHS
(Subcutaneous ✔ Increased ASO
HOW TO INTERPRET ABG ANALYSIS: Nodules) titer
1) Label pH
✔ Called Aschoff
❒ 7.35-7.45 = NORMAL
❒ <7.35 = ACIDOSIS Bodies
❒ >7.45 = ALKALOSIS ✔ Painless
2) Find the CAUSE (ROME) ✔ LOCATION:
❒ R = Respiratory a) Back of wrist
b) Outside elbow
❒ O = Opposite c) In front of
❒ M = Metabolic knees
❒ E = Equal
❒ RESPIRATORY = PaCO2 ❒ Erythema ❒ Lab abnormalities
● NORMAL PaCO2 = 35-45 Marginatum ✔ Increased WBCs
● <35 = ALKALOSIS ✔ Pinkish-macular ✔ Increased
● >45 = ACIDOSIS rashes on skin C-reactive protein
❒ METABOLIC = HCO3 ✔ WORSENS by heat (inflammation)
● NORMAL HCO3 = 22-26
✔ NEVER starts in ✔ Increased ESR
● <22 = ACIDOSIS
● >26 = ALKALOSIS the face
3) Determine COMPENSATION ✔ LOCATION:
❒ FULLY COMPENSATED a) Trunk
● NORMAL pH b) Inner thighs
❒ PARTIALLY COMPENSATED
● ALL ARE ABNOMAL (pH, PaCO2 and ❒ Sydenham’s Chorea ❒ Previous
HCO3) ✔ Called St. Vitus rheumatic fever
❒ UNCOMPENSATED dance
● Either PaCO2/HCO3 is NORMAL
✔ Sudden, rapid,
purposeless ❒ Arthralgia
RHEUMATIC HEART DISEASE (RHD)
movements of
❒ Autoimmune disorder
❒ CAUSE: GABHS (Group A Beta extremities
Hemolytic Streptococcus) ✔ Involuntary facial
grimaces
 ✔ Present at LATER
part of disease
✔ Relieved by REST
& SLEEP

CRITERIA (+) RHD:

a) 2 Major S/Sx + History of streptococcal
infection
b) 1 Major S/Sx + 2 Minor S/Sx + History of
streptococcal infection

COMPLICATION OF RHD:
1) PERMANENT Cardiac damage
2) Cardiac Arrest
MANAGEMENT OF RHD: HEART
1) Heart Valve Surgery:
a) If possible repair: Valvuloplasty
b) If NOT: Valve Replacement Surgery
2) Erythromycin/Penicillin
3) Anti-Inflammatory (Corticosteroids)
4) Rest
5) Throat Care

PATHOPHYSIOLOGY:

BUERGER’S DISEASE RAYNAUD’S DISEASE

Thromboangiitis Arteriosclerotic
Obliterans (TAO) Obliterans (ASO)
Clot and Inflammation Intermittent vasospasms
❒ Opens and Closes
all of a sudden

Common in MALES Common in FEMALES

Smoking Smoking
Involves arteries and Involves small arteries
veins (arterioles) ONLY
LOWER extremities UPPER extremities
(Legs) (Fingers)
 Manifests: Manifests: e. Dizziness
1) Pain (Anytime) 1) Pain in the
✔ CONFIRMATORY TEST:
2) Intermittent fingers (expose to
Schilling’s Test
claudication COLD)
3) Leg cramps
a. Give radioactive
vitamin B12 via
DOC: Vasodilators DOC: Vasodilators Oral and IM
AVOID: 4 C’s AVOID: 4 C’s b. Collect urine
Cold Cold within 24 hours
Caffeine Caffeine c. RESULT:
Cigarettes Cigarettes Greater than 10% NEGATIVE
Constrictive Clothing Constrictive Clothing
Vitamin B12
SURGERY: SURGERY:
excretion
Debridement Debridement Less than 10% POSITIVE
Amputation Amputation Vitamin B12
excretion
PERNICIOUS ANEMIA ✔ DOC: Vitamin B12 via
❒ Vitamin B12 Deficiency IM once a month for life
❒ CAUSES:
a) Unknown
b) Autoimmune
c) GI problem (Stomach)
⮚ Surgery in the stomach
⮚ Parietal cells dysfunction
(production of intrinsic factor)
⮚ NO Intrinsic Factor (absence
of absorption Vitamin B12)
⮚ Vitamin B12 Deficiency
✔ Absence of production of
RBCs
✔ Unhealthy of the nerves
(Paresthesias)

✔ S/Sx of Anemia:
a. Pallor
b. Red, Beefy
Tongue (Cardinal
Sign)
c. Coldness upon
touch
d. Fatigue