Nursing Care of Clients with Cardiovascular Disease

Midterm
II. DISTURBANCES IN CORONARY CIRCULATION

I. ANATOMY & PHYSIOLOGY

CORONARY ATHEROSCLEROSIS
Cardiovascular system consists of heart, blood, and
blood vessels. Its function is to transport O2 from the
lungs to the body tissues and remove CO2 from body
tissues to lungs.

Heart- a hollow, muscular organ located im the center of

the thorax where it occupies the space between the
lungs (mediastinum).

Heart Layers 4 Chambers 4 Valves

● A most common cause of coronary artery
Pericardium- Right Atrium - are one way disease (CAD).
outer layer, a Right Ventricle structures that help ● It is the thickening/ hardening of the arteries
double walled (carries separate chambers due to build up of plaque.
protective sac. deoxygenated and prevents ● Abnormal accumulation of lipid, or fatty
Epicardium- blood, from the backflow. substances and fibrous tissue in the lining of
also called as heart to the arterial wall vessels.
the visceral lungs) - Tricuspid Valve ● Process of fatty substances, cholesterol,
pericardium. - Pulmonic Valve cellular waste products, calcium, and fibrin
Myocardium- Left Atrium (carries (a clotting material in the blood) building up
thick middle Left Ventricle deoxygenated in the inner lining of an artery leading to a
layer, (carries blood, from the reduced blood flow in the myocardium.
responsible for oxygenated heart to the lungs) ● Injury/changes in endothelium due to the
the beating of blood, from the deposits of lipids/fats/calcium in our body.
heart which is lungs to the - Bicuspid/Mitral ● Loss of antithrombotic properties and
stimulated by body tissues) Valve vasodilating agents. (Mgt: antithrimbotic
SA node. - Aortic Valve agents to reduce formation of blood clots).
Endocardium (carries ● the lipid buildup may cause damage to the
- innermost oxygenated blood, vessel, therefore causing a thrombus to form
layer. from the lungs to ● ATHEROMA: atheromatous plaque, is an
the body tissues) abnormal and reversible accumulation of
material in the inner layer of an arterial wall.
○ A fatty substance that builds up in
the arteries (plaque).
○
Obstruction in the arteries ⇒ ↓ blood flow ⇒↓ O2 =
Ischemia ⇒ Infarction = Cardiac Arrest

Heart and Brain- most sensitive organ when having

decreased oxygen.

Clinical Manifestations:
● Individuals may present w/ or w/o symptoms,
depending on whether they are observant of
these occurrences
LAD or Left Anterior Descneding Artery- most affected ● Angina pectoris (chest pain)
site for angina, atherosclerosis, and heart failure. ● Shortness of breath
● Palpitations
Coronary Artery- supplies the pericardium and ● Tachycardia
myocardium.
 ● Weakness or dizziness
● Nausea
● Sweating
● Hyperlipidemia - increased lipids in the
blood
Modifiable Factors:
● Elevated serum lipids
● HPN
○ Pressure against the blood vessels
= rupture of bv.
● Cigarette smoking: Nicotine
causes/triggers the release of
catecholamines
○ Catecholamines:
- Hormones made by your adrenal
glands, two small glands located
above your kidneys.
- It causes coronary arteries to
constrict. (ex. Epinephrine,
Dopamine)
- Makes hr, bp, and rr increased.
● Impaired glucose tolerance
● Diet high in saturated fat, cholesterol, and
calories.
● Physical activity (sedentary lifestyle)
● Psychological Stress (sympathetic nervous
system increases our heart rate ; it releases
catecholamines).
● When hr is increased, there is
vasoconstriction of BV = lower blood flow +
oxygen to organs
● Personality (Type A Personality: competitive,
perfectionist)
Non-Modifiable Factors:
● Age
● Sex
● Race (African Americans more are risk)
● Family history
Therapeutic Interventions:
Prevention and Management
1. Controlling Cholesterol Abnormalities
The fasting lipid profile should demonstrate the ff.
Values: (pt must be NPO for 10-12 hrs before
checking their lipid profile)
● LDL < 100mg/dl
- Low Density Lipoprotein
- Bad cholesterol
- Should be maintained low.
● Triglycerides < 150mg/dl
● Total Cholesterol < 200mg/dl
● HDL > 40mg/dl (males) > 50mg/dl (females)
- High Density Lipoprotein
- Good cholesterol
- Should be maintained high.
● Check every 6 weeks if levels are not
normalized.
2. Dietary measures, physical activity and medications
(Atorvastatin and Simvastatin) -Antilipidemics (lowers
cholesterol) ; best taken at night because enzymes
that makes cholesterol is more active at night ;
hepatotoxic: damage to liver.
- Billirubin normal breakdown of the RBC;
secreted in urine, the yellow coloring.
Elevated = liver damage
3. Promoting Cessation of Tobacco use (lower nicotine
& catecholamines)
4. Managing Hypertension (lower BP to lower risk of
damage to arteries)
5. Controlling Diabetes
Balloon Angioplasty
- Angiogram is done first before angioplasty.
- Done by Interventional cardiologists
- They perform angioplasty, which opens narrowed
arteries. They use a long, thin tube called a catheter
that has a small balloon on its tip. They inflate the
balloon at the blockage site in the artery to flatten or
compress the plaque against the artery wall.
- Pt must be NPO before doing this procedure.
- The access site is at the groin.
Post-Angioplasty Care:
- Obtain VS
- Access groin site for bleeding.
- Bed rest for 6-8 hrs before sitting up or standing.
- Check for distal pulses of lower extremities (posterior
tibial pulse).
Stent
- Breaks down the plaque build-up in the arteries.
- An open heart surgery, if still occluded.
 Nursing Interventions:
● Teach the client the hazards of smoking
● Encourage the following dietary program:
● Low cholesterol, low fat (↓ cholesterol ↓ fat )
● Eat fish that are high in omega-3 fatty acids
several times per week (salmon, tuna)
● Increase intake of high fiber foods such as
fruits, vegetables, cereal grains, and
legumes; soluble fiber is particularly effective
in reducing blood lipids (oatmeal, legumes).

Framingham Risk Calculator

● Used to estimate the risk of having cardiac
event within the next 10 years.
 ANGINA PECTORIS (CHEST PAIN)
● Clinical syndrome usually characterized by
episodes or paroxysms of pain or pressure
in the anterior chest (on/off pain).
● Due to insufficient coronary blood flow
resulting in decreased oxygen supply when
there is an increased myocardial demand for
oxygen.
● ↑ demand for O2.
● Latin term for squeezing of chest (Levine’s
Sign)
● Blood flows to Mesenteric area and
decreases blood flow to heart, therefore
causing pain.
Causes:
● Increased metabolic demands due to
strenuous exercise, exposure to cold, eating
heavy meal, emotional stress (increases
catecholamine) , hyperthyroidism or severe
anemia.
○ Exopthalmus- a fast moving
hyperthyroidism ; have heat
intolerance.
● Oxygen supplied by the blood cannot meet
the metabolic demands of the muscle
(myocardial muscle).
● Anaerobic metabolic demands: Activities that
require an increased amount of
energy/effort. [Eg. Exercising] (Glycolysis -
breakdown of glycogen).
Types of Angina:
● Stable angina: predictable and consistent,
mild pain that occurs on exertion and is
relieved by rest
● Unstable angina (also called pre- infarction
angina or crescendo angina or intermittent
coronary syndrome): symptoms occur more
frequently and last longer than stable
angina. The threshold for pain is lower, and
pain may occur at rest. Rest and
nitroglycerine do not relieve attacks. (Pain
intensity is higher ; emergency case)
● Intractable or refractory angina: severe
incapacitating chest pain (emergency case)
● Variant angina (also called Prinzmetal's
angina): pain at rest with reversible
ST-segment elevation; thought to be caused
by coronary artery vasospasm not of
atherosclerosis usually occurs in the cold
mornings (12am-8am).
○ ST segment elevation can lead to
infarction.
● Silent ischemia: objective evidence of
ischemia (such as electrocardiographic
changes with a stress test), but patient
reports no symptoms - no complaints;
needed ECG to diagnose. (inverted ST
segment , Stress Test can be used to
diagnose where pt will walk on treadmill
while connected to an ECG.)
● Nocturnal angina - possibly occurring
during Rapid Eye Movement (REM) sleep
during dreaming.
● Angina decubitus - paroxysmal and occurs
when client reclines, lessens when the client
sits or stand up.
○ Decubitus- “bed” angina occurs
while lying in bed.
● Post infarction angina - occurs after MI;
residual ischemia may cause episodes of
angina.
Additional:
Clinical Manifestations:
● Chest pain associated with activity generally
subsides after a few minutes of rest.
● Pain is usually substernal and can be
described as crushing or pressure.
(squeezing substernal chest pasin)
● Pain may radiate to the left shoulder and
arm, jaw, epigastric area or right shoulder.
(may be considered as heartburn)
● SOB Pallor
● Palpitations
● Faintness- usually occurs when angina takes
more than 20 mins. It could also lead to
dying of the heart muscles or heart attack.
● Dyspnea- shortness of breath
 ● Levine's sign - client clenches fist over
sternum when describing discomfort.
● Diaphoresis- excessive sweating or cold
clammy diaphoresis.
● Nausea
● Vomiting
● Elevated BP
○ Due to ↑ hr = vasoconstriction of
arteries = ↑ BP
● T wave inversion and ST segment Elevation
or the development of abnormal Q wave.
(STMI- ST Myocardial Infarction)
Medical Management:
● Objective: To decrease oxygen demand of
the heart and to increase the oxygen supply.
● Restricted activity: Complete bedrest w/o
bathroom privileges.
Pharmacologic Management:
● Nitroglycerin (standard tx for angina
pectoris)
● Beta blocking agents:
○ reduces myocardial blocks beta
andrenergic decreases myocardial
contractility and blood pressures.
○ CONTRAINDICATED FOR PT
WITH ASTHMA
○ Metoprolol; lopresosl
○ also affect the bronchus, can
cause excessive
bronchoconstriction.
● Ca channel blocking agents (amlodipine)
○ reduces SA node which starts the
conduction/electrical conduction of
the heart; decreases hr and bp
● Antilipidemics (Simvastatin)
○ reduces/pinapalusaw the lipid
levels
● Antiplatelet (ASA)
○ Aspirin; best taken after meal
because it is a gastric irritant.
Prevents further clotting.
● Anticoagulants (Heparin)- prevents further
clotting.
● Weight loss: lessen effort for tissue that
needs perfusion
● Oxygen therapy during attack
● Coronary artery bypass graft (CABG)
○ Uses saphenous vein and internal
mammary artery in replacement for
occluded veins or arteries.
○ It is an open heart surgery.
● Percutaneous transluminal Coronary
Angioplasty
Anginal Management
● A - spirin, anticoagulant and oxygen therapy,
Nitroglycerine
● G - ive appropriate diet and weight
management
● I - increase patient knowledge (education)
● N - normalize BP (Beta blockers and
Calcium Channel blockers)
● A - void cigarette and control cholesterol and
DM
● L - ifestyle change (stress reduction and
exercise)
Nursing Interventions:
● Provide physical and mental rest.
● Reducing anxiety.
● Relieve pain by administration of
vasodilators.
● Discourage smoking.
● Health teaching regarding diet, medications
and activity.
MYOCARDIAL INFARCTION
(ACUTE CORONARY SYNDROME)
● Emergent situation characterized by an
acute onset of myocardial ischemia that
results in myocardial death
● Is acute necrosis of the heart muscle caused
by interruption of oxygen supply to the area,
resulting altered function and reduced
cardiac output.
● Life threatening ; cannot be relieved by rest.
● Also known as Heart Attack.
● Synonymous with:
○ Coronary occlusion
○ Heart attack
○ Myocardial Infarction (Acute
 Coronary Syndrome) arms, neck and back
● 4-6 hrs after the onset of MI, results to ● SOB
cyanosis and swelling. ● Indigestion
● After 48 hours the muscle tissue becomes ○ Seen as heartburn, it is better to
color gray, indicating that it has lead to determine whether it is associated
infarction. with chest pain or gastric reflux.
● Pallor, increased jugular vein distention
Nausea, Severe anxiety and dyspnea
● Diaphoresis
● Decrease urinary output
● Tachycardia and tachypnea
● Abnormal Q waves, ST segment elevation,
inverted T waves, decrease R wave
● Changes in blood serum enzymes and
isoenzyme levels
● Elevated CK or CPK-MB
○ CPK-MB stands for Creatinine
Phosphokinase- Myocardial
Causes: Band.
● Atherosclerosis- common cause. ○ It is the first cardiac biomarker.
● Thrombus formation ○ It elevates due to injury in the
● Decreased blood flow skeletal muscle (MM) or brain (BB)
● History of smoking within 4-6 hrs of onset. It starts to
● Obesity decrease after 2-3 days.
● High cholesterol diet ○ Normal value: <5%
● Physical and emotional stress ● Elevated LDH and AST
○ LDH stands for Lactate
Pathophysiology: Dehydrogenase.
○ It elevates after 24 hrs and lasts for
7 days.
○ Normal value: 140-280 IU/mL
○ AST stands for Aspartate
Aminotransferase.
○ Also known as SGOT or the Serum
Glutamic Oxaloacetic
Transaminase.
○ It elevates kidney, liver, and muscle
failure as well as inflammation.
● Elevated WBC and ESR (signs of
inflammation)
○ ESR stands for Erythrocyte
Sedimentation Rate
○ It elevates due to infection.
● Signs of shock: ↓ bp ↑ hr
○ cold, clammy skin;
○ profuse diaphoresis,
○ decreased BP
○ Rapid and thready pulse.
● VITALS Q 15 MINS

● Additional:
○ Troponins: CTnT (<0.2mg/ml) and
CTnI (<0.6mg/ml) are accurate and
Clinical Manifestations: sensitive than CTnC.
● Sudden, severe, crushing or viselike pain in ○ They elevate within 2-3 hrs of
the substernal region, may radiate to the onset and lasts up to 7 days.
 Therapeutic Interventions:
Killip Classification: Pharmacologic management:
A system used in individuals with an acute myocardial ● Nitrates (Nitroglycerins)
infarction (heart attack), in order to risk stratify them. ● Narcotic analgesics
(percentage in 30 days) ○ Relief of mod-severe pain.
○ WOF: Respiratory Depression
● Killip class I includes individuals with no ● Beta blocking agents - Calcium antagonist
clinical signs of heart failure. ● Sedative
● Killip class II includes individuals with rales ○ Relaxant, anxiolytic, ↑ drowsiness,
or crackles in the lungs, an S3 (low-pitched ; ↓ LOC (level of consciousness)
third heart sound when pt have ventricular ● Hypnotics
gallop), and elevated jugular venous ● Laxatives
pressure. ○ Stool softeners to prevent valsalva
● Killip class III describes individuals with maneuver.
acute pulmonary edema. ● Anticoagulants- prevents clot.
● Killip class IV describes individuals in ● Thrombolytics- dissolves clot ; given to pt
cardiogenic shock or hypotension (measured within 6 hrs onset of MI or stroke.
as systolic blood pressure lower than 90 ● Antidysrhythmics
mmHg), and evidence of peripheral ○ Bradycardia → adm. Atropine
vasoconstriction (oliguria, cyanosis or Sulfate e.g. lidocaine, epinephrine,
sweating). norepinephrine for cardiac
stimulants.
STEMI-ST ELEVATION MYOCARDIAL INFARCTION ● Potassium salts
Patient has ECG evidence of acute MI with
characteristics changes in 2 contiguous lead on a 12 Therapeutic Management:
lead ECG. There is no significant damage to the ● IV fluids at slow rate to keep vein open for
myocardium administration of medications
● Clear liquid diet is prescribed initially to
NSTEMI- NON-ST ELEVATION MYOCARDIAL decrease 02 consumption and then
INFARCTION advanced to low sodium.
Patient has elevated cardiac biomarkers but no
definitive ECG evidence of acute MI Nursing Interventions:
● Respond to dysrhythmias with defibrillation,
Medical Management: cardiac massage or medications as
Goal - minimize myocardial damage, preserve appropriate.
myocardial function and prevent complications. Defibrillator is not used for:
● Morphine SO4 (monitor RR; <12 or <30) IV ○ Pulseless Electrical Activity (PEA)
to relieve pain and reduce anxiety It is a non shockable rhythm.
○ Note: Antidote = Naloxone ○ Asystole (heart stops beating)
(Narcan) Defibrillator is used for:
● Bed rest with cardiac precautions to reduce ○ VFIB ECG
demand for oxygen ■ Ventricular fibrillation
● Oxygen as necessary ■ Chaotic
● Cardiac monitoring for continued ○ VTACH ECG
surveillance of the heart's electrical activity ■ Ventricular tachycardia
(ECG- Electrocardiogram) ■ QRS complexes are
● Frequent monitoring of V/S wide.

M- orphine sulfate
O-xygen
N- itroglycerine
A-spirin
T-hrombolytics
A-nticoagulants
S-tool softeners
○ Cardiac monitor: pt is
 unresponsive: check the carotid ● Toxicity: dysrhythmia (PVCs), xanthopsia
pulse and breathing. (yellow vision), muscle weakness
● Administer analgesics as ordered
Nursing Care:
● Administer 02 as necessary
● Check apical pulse prior to administration;
● Provide gradual increase in activity below 60 or above 120, withhold the dose
● Provide emotional support to client and and notify the physician
family ○ Apical pulse can be auscultated at
● Reduce anxiety and accept client's fears the 5th ICS mid clavicle.
● Avoid sexual activity ● Should not be exposed to light (should be in
● ↓ hr ↓ bp ↓ O2 sat = Cardiac Arrest amber glass) to prevent loss of
patency/effectiveness of drug
● Administer oral preparation with meals to
For sexual activity: reduce GI irritation
● F - atigue ● Monitor client for hypokalemia, which
● U - nfamiliar partners (wont be able to potentiates the effects of digitalis
handle the partner due to unanticipated ● Digoxin: monitor blood level during therapy
movements) (normal: 0.5 to 2.5 mg/ml)
● S - tress
● H - eavy meal
● A - lcohol intake ANTIDYSRHYTHMICS
● E - xtreme temperature
● Used to treat abnormal variations in cardiac
Note: less fatiguing sexual position, must be able to
rate and rhythm
climb 2 flight of stairs before resuming sexual activity. ● Decreases cardiac output
● Pulse Pressure Examples:
○ Subtraction of systolic to diastolic. - Disopyramide PO4 (Norpace)
○ Normal value: 40 mmHg - Lidocaine HCI
○ Wide: >40 mmHg - Phenytoin (Dilantin)
○ Narrow: <40 mmHg - Procainamide HCI (Pronestyl)
- Propranolol (Inderal)
● Pulse Deficit
- Ca ion antagonists (diltiazem, nifedipine, verapamil)
○ Subtraction of apical pulse (5th
ICS) to radial pulse (radial artery). Major S/E:
● Mean Aterial Pressure (MAP) ● Dizziness
○
𝑆𝑦𝑠𝑡𝑜𝑙𝑖𝑐 + 2(𝑑𝑖𝑎𝑠𝑡𝑜𝑙𝑖𝑐)
mmHg ● N/V
3 ● Heart Block
● Toxicity: diarrhea, CNS disturbance, sensory
disturbances
III. PHARMACOLOGY RELATED TO ● Anticholinergic effect (sympathetic)- such as
CARDIOVASCULAR SYSTEM DISORDERS dry mouth
● Blood dyscrasias: decreased WBC, RBC,
platelet synthesis (aplastic anemia)
CARDIAC GLYCOSIDES Nursing Care:
● Use cardiac monitoring during IV
● Used to improve the pumping ability of the administration
heart, thus increasing cardiac output. ● Report any changes in HR and rhythm
● (+) inotropic - ↑ workload (contractions) ● Monitor blood levels during therapy
● WOF: ● Administer with meals to reduce Gl irritation
○ Digitalis Toxicity (>2.0 mg/mL) ● Monitor ECG during course of therapy
S/E: nausea & vomiting, visual
disturbances, ↓ K (potassium)
Examples:
- Digitalis CARDIAC STIMULANTS
- Digitoxin
- Digoxin (Lanoxin) ● Used to increase heart rate.
- Cardiac Glycosides ● To treat ↓ bp ↓ hr
● Stimulates the heart to increase heart rate.
Major S/E: Examples:
● N/V, diarrhea, anorexia - Atropine SO4
● Malabsorption of all nutrients - Epinephrine HCI (Adrenalin)
● Bradycardia (check the apical pulse, HR <60 - Isoproterenol HCI (Isuprel)
do not give to pt)
Major S/E: Major S/E:
● Tachycardia ● Orthostatic Hypotension
● Headache ● Dizziness
● CNS Stimulation ● Cardiac rate alteration
● Cardiac dysrhythmias ● Sexual disturbances (failure of erection due
● Atropine: anticholinergic effects e.g. dry to loss of vascular tone)
mouth, blurred vision, urinary retention as a ● Blood dyscrasias
result of decreased parasympathetic ● Drowsiness
stimulation
Nursing care:
Nursing care: ● Monitor BP during course of therapy
● Use cardiac monitoring during IV ● Follow a low sodium diet
administration. ● Change position slowly
● Monitor ECG during course of therapy. ● Continue to take medicines as prescribed
● Utilize safety precautions during ● Avoid engaging in hazardous activities
administration. ● Reserpine: assess client for mental
depression; implement suicidal precautions.

CORONARY VASODILATORS
● Used to decrease cardiac work and
myocardial O2 requirement by their
vasodilator action.
● sympathetic stimualtion to the heart
Examples:
- Nitrates (sublingual): Isosorbibe dinitrate (Isordil)
- Nitroglycerine nitrates (oral): Isordil
- Nitrate (topical): Nitroglycerine ointment,
nitroglycerin transdermal (route: spray and patch- 10
to 12 hrs)
- Ca ion antagonists (Ca channel blockers): Dilitiazem,
- Nifedipine, verapamil
- Isoproterenol HCI (Isuprel)
Major S/E
● Tachycardia
● Headache
● Flushing/ orthostatic hypotension
● Dizziness
Nursing care:
● Encourage client to change position slowly
● Note slight stinging, burning, and tingling
under the tongue; indicates potency of drug.
● Avoid placing the drug in the heat, light,
moisture or plastic; store in original amber
glass container.
● Take sublingual prep every 5 minutes, not to
exceed 3 tablets in 15 minutes for chest
pain, if pain persists, go to ER (indicative for
MI)
● Use safety precautions.
ANTIHYPERTENSIVES
● Used to promote dilation of peripheral blood
vessels, thus decreasing BP and afterload.
Examples:
- Clonidine (catapres)
- Hydralazine HCI (apresoline)
- Methyldopa (aldomet)
- Propranolol (Inderal)
- Captopril (capoten)
BETA ADRENERGIC BLOCKING AGENTS
● Appear to reduce myocardial oxygen
consumption by blocking the beta-adrenergic
● Most medications ends in “LOL” the two L
can stand for Low BP and Low HR, meaning
it lowers bp and hr.
● (-) chronotropic- ↓ heart rate
● (-) inotropic- ↓ workload/ force
● (-) dromotropic- ↓ beat/ CO (cardiac output)
Functions of Adrenergics:
● Alpha 1
○ Contracts heart
○ Constricts blood vessels
● Alpha 2
○ Relaxes heart
○ Dilates blood vessels
● Beta 1
○ Contracts heart
○ Constricts blood vessels
● Beta 2
○ Relaxes and dilates the lungs
Beta 1 blockers- relaxes heart and dilates blood
vessels.
Beta 2 blockers- constricts lungs, thus, it is
contraindicated to pt w/ asthma and COPD due to
bronchoconstriction.
Examples:
- Propranolol
- (Inderal), metoprolol (Lopressor, Toprol), and
atenolol (Tenormin)
- Captopril (capoten)- an ACE inhibitor
Side Effects and possible contraindications:
● Hypotension
● Bradycardia ↓ hr
● Advanced atrioventricular block
● Decompensated heart failure
● Other side effects include worsening of
hyperlipidaemia, depression, fatigue,
 decreased libido, and masking of symptoms
of hypoglycemia
● Contraindicated to patients with asthma and
COPD due to bronchoconstriction.
● Monitorly check the bp, hr, and blood
glucose level.
Nursing care:
● Monitor ECG, blood pressure, and heart rate
after adm.
● Teach the patient not to stop taking them
abruptly, because angina may worsen and
MI may develop.
● Assess blood glucose levels more often and
to observe for signs and symptoms of
hypoglycemia for patients with DM.
CALCIUM CHANNEL BLOCKING AGENTS
(CALCIUM ION ANTAGONISTS)
● Decrease sinoatrial node automaticity and
atrioventricular node conduction, resulting in
a slower heart rate and a decrease in the
strength of the heart muscle contraction
● Relax the blood vessels, causing a decrease
in blood pressure and an increase in
coronary artery perfusion
● Increase myocardial oxygen supply by
dilating the smooth muscle wall of the
coronary arterioles; they decrease
myocardial oxygen demand.
● Helps in lowering hr and bp by relaxing the
heart. ↓ hr ↓ bp
Examples:
- Amplodipine (Norvasc)
- Verapamil (Calan, Isoptin, Verelan)
- Diltiazem (Cardizem, Dilacor, Tiazac)
DIURETICS
● Used to increase urine output which reduces
hypervolemia.
● Removes fluid overload in the body
(Diuresis).
● Do not give when pt has hypotension. It
could gradually decrease their bp due to
frequent urination and can be fatal.
Examples:
- Thiazides: Chlortiazide (diuril), Methylchlothiazides
(enduron)
- Potassium sparers: Spironolactone (Aldactone)-
given when potassium drops.
- Loop diuretics/ K wasting: Furosemide (Lasix)-
given when potassium levels are high.
Normal value of Potassium: 3.5-5.0 mEq/L
Major side effects
● GI irritation
● Hypernatremia- high sodium levels
● Orthstatic hypotension
● Hyperuricemia
● DHN - dehydration
● All diuretics except K sparers: hypokalemia,
increased urinary excretion of MG and zinc
● K sparers: hyperkalemia, hypomagnesemia,
increased urinary excretion of Ca
● WOF: Arrythmia due to ↓ K
Nursing Care:
● MIO - Monitor Intake and Output.
● Weigh daily
● Administer the drug in the morning
○ To prevent frequent urination at
night if it is taken at night.
● Assess v/s especially pulse and BP
● Encourage intake of foods high in Ca, Mg,
zinc and K
● Assess client for signs of fluid and electrolyte
imbalance.
● Instruct client to change positions slowly-
due having an orthostatic hypotension.
● Thiazides and loop diuretics: monitor blood
sugar in diabetes; may cause
hyperglycemia.
PERIPHERAL VASOCONSTRICTORS
● Used to elevate BP.
Examples:
- Levarterenol bitartrate (levophed)
- Phenylephrine HCI (Neo-synephrine)
Major side effects
● hypertension
● Headache
● GI disturbance
Nursing Care:
● Assess V/S
● Monitor BP
● Do not leave patient unattended
● Increase intake of food high in fiber to
reduce the potential of constipation.
ANTICOAGULANTS
● Used to prevent clot formation and clot
extension.
Examples:
- Heparin Na
- Route: SQ, Infusion, Injection.
- Lab: APTT (Activated Partial
Thromboplastin Clotting Time)
- Warfarin Na (Coumadin), Dicumarol
- Route: Oral
- Lab: INR (International Normalized Ratio)
Normal value: 2-3
Major side effects ANTILIPIDEMICS
● Fever, chils
● Skin rash ● Used to lower serum lipid levels by reducing
● Hemorrhage cholesterol or triglyceride synthesis or both.
● Diarhea Examples:
- Niacin (nicobid)
Nursing Care: - Lovastatin (mevacor)
● Monitor blood works during course of - Gemfibrozil (lopid)
therapy - Simvastatin (zocor)- best taken at night
● Assess for signs of bleeding
● Have appropriate antidote available: Vitamin Major side effects
K for Warfarin and Protamine SO4 for ● Nausea and vomiting
Heparin ● diarrhea
● Avoid administration of salicylates during ● musculoskeletal disturbances
anticoagulant therapy ● hepatic disturbances
● Avoid IM injections of other drugs if possible ● skin rash
● Instruct client to: ● Reduce absorption of fat and fat soluble
○ Report any signs of bleeding vitamins (ADEK) as well as vitamin b12 and
○ Avoid use of alcohol during therapy iron
○ Use electric razor and soft ● Visual disturbances
toothbrush ● flushing
○ Avoid taking OTC drugs containing
aspirin
○ Eat a consistent diet of vitamin K
ANGIOTENSIN CONVERTING ENZYME INHIBITOR
containing foods.
ACE INHIBITORS

● Most medications ends in “PRIL”

ANTIANEMICS ● Lowers blood pressure by inhibiting the
lungs from releasing ACE or enzymes that
● Used to promote RBC production converts angiotensin I into angiotensin II,
Examples: which is responsible for narrowing of the
- Ferrous SO4 blood vessels.
Examples:
Major side effects - Captopril
● Iron supplements: N/V, constipation, black - Lisinopril
stools, stained teeth (liquid prep)
● Vitamin replacements: local irritation, allergic Side Effects:
reactions, diarrhea ● Coughing (due to lungs being involved)

Nursing Care: Nursing Mgt:

● For iron replacements: Monitor bp regularly.
○ Use Z track procedure for IM
administration ANGIOTENSIN RECEPTOR BLOCKERS/
○ Administer liquid prep through a ANGIOTENSIN II RECEPTOR ANTAGONIST
straw after diluting with water or (ARBS)
fruit juice; encourage good oral
hygiene
● Ends in “SARTAN”
○ Administer oral prep on an empty
● Blocks the angiotensin II receptors which
stomach, if possible, for optimum
makes blood vessels narrow, thus, no
absorption; ascorbic acid (vit C)
constriction of blood vessels will occur.
increases absorption
○ Encourage intake if high fiber foods
Examples:
to reduce the potential of
- Losartan
constipation
○ Antidote for iron toxicity:
Deferoxamin mesylate (desferol) Additioal:
● For vitamin replacements: RAAS- Renin Angiotensin Aldosterone System
○ Vitamin B12: inform client that this ● A hormone system that regulates blood
drug cannot be administered orally; pressure, fluid and electrolyte balance, and
therapy is for life systemic vascular resistance.
○ Folic acid instruct client on dietary
sources of folic acid (fresh fruits
vegetables and meat).
 Signs & Symptoms:
many people have a balloon leaflet but no symptoms
others have symptoms of:

● Fatigue
● shortness of breath
● lightheadedness
● dizziness
● syncope
● palpitations
● chest pain
● anxiety

Medical management
● eliminate caffeine and alcohol from the diet
● stop smoking
● antiarrhythmic medications may be
prescribed
● chest pain that the respond to nitrates may
respond to calcium channel blockers or beta
blockers.
IV. VALVULAR HEART DISEASE

MITRAL STENOSIS
Valvular heart disease causes abnormalities in blood
flow across the cardiac valves. ● Impedes blood flow from the le to the lv
during the ventricular diastole.
Two types of Functional Derangements:

1. Valvular regurgitation/ insufficiency/

incompetence
- Valve leaflets fail to close securely,
permitting backward flow.
- Incompetent valve.

2. Valvular stenosis
- Valve orifice becomes restricted impending
forward flow. Fails to open.

Causes:
● Rheumatic heart fever
● Valve destruction by infective endocarditis
● Inborn defects of connective tissue
● congenital malformation

MITRAL VALVE PROLAPSE

● Is a deformity that usually produces no

symptoms.
● Progresses into Mitral Regurgitation.
● Occurs more frequently in women than in
men.
● a portion of a mitral valve leaflet balloons Blood accumulates in the left atrium.
back into the atrium during systole. Signs & Symptoms:
● Blood then regurgitates from the left ventricle ● dyspnea
back into the left atrium. ● tachycardia
● orthopnea
● mild hemoptysis

Medical management
● antibiotic prophylaxis therapy
● anticoagulants
MITRAL REGURGITATION ● Surgical replacement of the aortic valve

● Permits retrograde blood flow from the LV to

the LA as a result of incomplete valve AORTIC REGURGITATION
closure.
● Produces reflux of blood from the aorta into
the lv during ventricular relaxation.
● Leads to heart failure.

Early symptoms
● Palpitations
● Fatigue
● Dyspnea on exertion
● Angina

Management
● Antibiotic prophylaxis
● Aortic valvuloplasty or valve replacement.

Early symptoms ADDITIONAL

● Weakness and fatigue caused by the
reduction in forward flow Therapeutic interventions:
● Exertional dyspnea
● Palpitations For Mitral Valve Disease
● Diuretics
Management ● Digoxin
● Mitral valve replacement ● Antidysrhythmics
● Valvuloplasty ● Vasodilator
● Anticoagulants

For Aortic Valve Disease

AORTIC STENOSIS ● Surgical Intervention

● Obstructs blood flow from the LV into the Surgical therapy

aorta during ventricular systole, resultin in
cardiomegaly.
● Mitral valvotomy – opening of the mitral
valve
● Mitral Commissurotomy/ mitral split –
splits the valve leaflets at the point of fusion
along the commissures

MITRAL VALVE REPLACEMENT:

● Uses lifelong warfarin due to the artificial
replacement valve which leads to build up of
clots near its surroundings.

Triad of symptoms
● Angina
● Syncope
● LV failure

Management
● Antibiotic prophylaxis
 ● Valvuloplasty – repair of the valve. produced by GAS (Group A
beta-hemolytic streptococc) and is
detected by ASO titers.
● Throat cultures
● ECG, CXR, 2D ECHO
● Cardiac catheterization

Treatment
● Penicillin G or erythromycin
● Salicylates corticosteroids
● Annuloplasty – prosthetic ring is inserted in ● ACE inhibitors, Digoxin, Diuretics
the valve annulus to stabilize and repair the ● Strict bed rest for about 5 weeks
valve orifice. ● Sodium restrictions
● Corrective surgery (valvuloplasty or valve
replacement)

Nursing interventions
● Teaching about the disease its treatment and
the preventive steps needed to avoid
potential complications.
● Prophylactic antibiotics before invasive
procedure.
V. INFLAMMATORY HEART DISORDERS

RHEUMATIC HEART DISEASE

● A systemic inflammatory disease of

childhood involving the heart joints CNS skin
and subcutaneous tissue.
● Cause: Group A beta-hemolytic streptococci
● Incidence is highest in children of low
socioeconomic group between 5 and 15
years old.
● Sydenham Chorea- muscle twitching ENDOCARDITIS

● Infection of the endocardium heart valves or

cardiac prosthesis resulting from bacterial or
fungal invasion.
● Other names
1. Ineffective and dough carditis
2. Bacterial endocarditis

Common Causes:
● IV drug abuse
● Prosthetic Heart Valves
● Mitral Valve Prolapse
Signs and symptoms ● Rheumatic Heart Disease
● Strep infection
● mitral or artic murmurs Other predisposing factors
● Pericardial friction rubs ● Congenital abnormalities (TOF, CoA)
● Pleuritic chest pain ○ Tetralogy of Fallot
● Dyspnea, tachypnea ■ Has 4 defects: Right
● Nonproductive cough Ventricular Hypertrophy
● Bibasilar crackles (RVH), Pulmonary
● Edema Stenosis, Ventricular
Septal Defect, and
Diagnostic tests Overriding Aorta.
● WBC, ESR ○ Coarctation of Aorta
● Hemoglobin hematocrit ■ The hallmarks of
● Cardiac enzymes coarctation of the aorta
● ASO titers are absent leg pulses and
○ Antistreptolysin O, a substance a difference in blood
 pressure between the accident or brain attack), meningitis, heart
arms and legs. failure, myocardial infarction, glomerular
■ Children with this nephritis, and splenomegaly
condition are usually
cyanotic. Health teaching
● Activity restrictions, occasions, and signs
and symptoms of infection
● The need for prophylactic antibiotics before,
and possibly after dental, respiratory
gastrointestinal or genito-urinary procedures.

MYOCARDITIS

● Focal or diffuse inflammation of the

● Subarctic and valvular aortic stenosis myocardium that causes infiltrates in the
● Pulmonary stenosis myocardial in in the myocardial interstitium
● Ventricular septal defects and injury to adjacent myocardial cells at
typical of infarction.
Causes
● Infections
● Hypersensitive Immune Reactions
● Radiation Therapy
● Toxins
● Chronic alcoholism

Causes:
● Invasion of myocardial tissue by organisms
(viral, bacterial parasitic-protozoan fungal, or
metazoal)
Signs and symptoms ● Production of toxins (lead, chemicals
● Malaise, weakness fatigue cocaine)
● Weight loss, anorexia ● Autoimmune reaction (RF,SLE)
● Arthralgia- joint stiffness/pain. ● Radiation therapy
● Intermittent low grade fever night sweat ● Chronic alcoholism
chills
● Valvular insufficiency Types of myocarditis
● Loud regurgitant murmurs ● Primary myocarditis – with unknown etiology
● Secondary myocarditis – with identifiable
Diagnostic test cause (i.e drug hypersensitivity, or toxicity,
● Three or more blood cultures drawn from infection)
three different sites with at least 1-3 hours Types:
between each draw ● Acute myocarditis
● WBC ● Chronic myocarditis
● ESR
● Anemia (Normocytic, Normochromic) Signs and symptoms
● Echocardiography ● Fatigue, Dyspnea, palpitations, fever
● Treatment ● Mild continuous pressure or soreness in the
● Penicillin and aminoglycoside chest
● Aspirin or acetaminophen ● Tachycardia S3 and S4 gallop
● Bedrest, sufficient fluid intake ● Murmurs, Pericardial friction rub
● Corrective surgery if refractory heart failure ● CHF- Congestive Heart Failure
develops
● Replacement of infected prosthetic valve Diagnostic Tests
● Elevated CK-MB, AST, LDH
Nursing interventions ● Increase WBC & ESR
● Monitor the patient's temperature ● Antibody titer (+)
● Assess heart sound ● ECG, CXR, 2D-ECHO
● Monitor for signs and symptoms of systemic ● Radionuclide scanning
embolization ● Cultures of stool, throat, and body fluids
● Monitor for signs and symptoms of ● Endomyocardial biopsy
pulmonary infarction
● Assess signs and symptoms of organ Management
damage such as stroke (IE, cerebrovascular ● Antibiotics antipyretic
 ● Supplemental oxygen therapy
● Restrictive activity
● Sodium restriction & diuretics
● ACE inhibitors, digoxin
● Antiarrythmic drugs
● Temporary pacemaker- done by open heart
surgery.
● Anticoagulant to prevent thromboembolism
● Corticosteroids, immunosuppressants
● Cardiac assist devices or transplantation
● Hypotension
● Pulsus paradoxus ( ↓ bp during inspiration),
neck vein distention.
● Fluid retention, ascites, hepatomegaly
● Kussmaul’s sign
○ Observation of a jugular venous
pressure (JVP, the feeling of the
jugular vein that rises with
inspiration)
○ A right sided heart failure.

Nursing management
● Assess the patient's temperature
● Assess signs and symptoms of heart failure
and dysrhythmia
● Cardiac monitoring

PERICARDITIS

● Inflammation of the fibrosis (pericardium)

that envelops, support and protects the heart

Types: Diagnostic Tests

● Acute pericarditis ● To diagnose the condition:
● Chronic constrictive pericarditis ● ECG
● 2D ECHO- will determine if the pt has
Causes cardiac tamponade.
● Bacterial fungal or viral infection ● CXR
● Neoplasm
● High-dose-rate to digest high-dose radiation To identify underlying cause:
to the chest ● ESR, WBC, BUN
● Uremia ● Blood C/S
● Hypersensitivity or autoimmune disease ● ASO titers
● Previous cardiac injury such as MI, trauma, ● PPD
core surgery ○ Purified Protein Derivative- a skin
● Drugs (Procainamide, Hydralazine) test for Tuberculosis .
● Aortic Aneurysm
● Myxedema Management
● Idiopathic factors ● Bed rest as long as fever and pain persist
● Treatment of underlying causes if identifiable
● NSAIDs, corticosteroids
● Antibacterial, Antifungal, Antiviral therapy
● Partial or total pericardiectomy

Nursing management
● Alert to the possibility of cardiac tamponade
● Pain management with analgesics
positioning, and psychological support
● Reservations condition improves gradual
increase of activities and courage
● Monitor the patient for heart failure.

Signs and symptoms HEART FAILURE

● Pericardial friction rubs
● Sharp, sudden chest pain ● Inability of the heart to meet the demands of
● Shallow rapid respiration the body
● Mild fever, Tachycardia ● Clinical syndrome resulting from structural or
● Dyspnea, orthopnea functional cardiac disorders that impair the
● Heart failure ability of the ventricles to feel or eject blood.
● Muffled, distant heart sounds ○ MI
● Pallor ○ Valvular defects
● Clammy skin ○ HON
 ○ Anemia ● Peripheral cyanosis
○ Hyperthyroidism ● Cheyne-stokes respirations
○ Obesity ● Frothy, blood tinged sputum
○ Circulatory overload
HEART FAILURE
● Right heart failure will be evident in the Goal: relieve patient symptoms improved functional
systemic circulation status, quality of life, and to extend survival. Increase
● Left heart failure will be evident in the cardiac contractility, reduce preload and afterload.
pulmonary system
Medical management
● Rest to reduce cardiac workload
● Morphine SO4 therapy to reduce anxiety and
dyspnea
● Oxygen by mask or cannula
● ACE inhibitors or beta blockers
● Diuretic such as Furosemide (Lasix)
● Vasodilators
● Digitalis/digoxin
● Low sodium diet to more than 2 g per day
● Avoidance of smoking
● Excessive intake of fluid and alcohol
● Weight reduction if indicated
● Regular exercise
Classification of heart failure
● Stage A high risk of left ventricular Congestive heart failure therapeutic interventions
dysfunction ● K supplements
● Stage B with left ventricular dysfunction who ● Rotating tourniquets
has no symptoms ○ 3 rotations using 3 BP apparatus
● Stage C with left ventricular dysfunction with every after 15 mins.
symptoms ○ To prevent/stop blood from
● Stage D with refractory end-stage heart congesting.
○ Starts from right going to left.
Right ventricular failure
● Abdominal pain
● Fatigue
● Bloating
● Nausea
● Dependent, pitting edema; ankle edema
(first sign of CHF); often subsides at night
when legs are elevated
● Ascites from increased pressure within the
portal system- Ascites is the fluid overload in
the peritoneum.
● Hepatomegaly- “enlarged liver” ● Paracentesis- a procedure that removes
● Respiratory distress peritoneal fluid in the abdomen.
● Increased CVP (Central Venous Pressure) ● Sodium restricted diet
● Diminished urinary output ● Hemodynamic monitoring through CVP or
Swanz-Ganz catheter
RIGHT SIDED HEART FAILURE
● H – epatomegaly Nursing interventions
● E – dema ● Maintain the client in high fowler's position
● A – scites ● Auscultating lungs sound
● D – istended neck vein ● Elevate extremities
● C – oughing and dyspnea ● Frequently monitor vital signs
● H – emoptysis ● Change position frequently- ideal for pt w/
● O – rthopnea right sided heart failure.
● P – ulmonary congestion ● MIO and daily wait
● Assessing symptoms of fluid overload (eg.
Signs and symptoms of Left Ventricular Heart Orthopnea, paroxysmal nocturnal dyspnea,
Failure and dyspnea on exertion) and evaluating
● Dyspnea from fluid within the lungs changes.
● Orthopnea
● Fatigue
● PND- Paroxysmal Nocturnal Dyspnea
● Crackles