Semi-Finals: Medical-Surgical Nursing Iralyn Bernal

BSN 3A

NCM_112
CARDIOVASCULAR SYSTEM

The heart also has four chambers - two atria and two
ventricles
 The left atrium and the right atrium
 The left ventricle and the right ventricle

The heart chambers are guarded by valves

 The atrio-ventricular valves consists of the
The vascular system consists of the arteries, veins and tricuspid and bicuspid valves
capillaries
 The arteries are vessels that carry blood away from As the name suggests, the  The semi-
the heart to the periphery tricuspid valve has three cusps lunar valves
 The veins are the vessels that carry blood to the or leaflets while the bicuspid are the
heart valve has only two cusps or pulmonic
 The capillaries are lined with squamous cells, they leaflets. Both of these valves and aortic
connect the veins and arteries serve the primary function of valves
preventing the return of blood
The lymphatic system also is part of the vascular system back of
Both to the
thesemilunar
atria from the
valves
and the function of this system is to collect the extravasated ventricles.
have three cusps or leaflets and
fuid from the tissues and returns it to the blood check for the return of blood
back to the heart chambers.
Normal Anatomy The blood supply of the heart comes
from the coronary arteries
 The heart is located in the left side of the
mediastinum
1. Right coronary artery: supplies the right atrium and
right ventricle, inferior portion of the left ventricle, the
Consists of three (3) layers: epicardium, myocardium and
posterior septal wall and the two nodes- AV (90%) and
endocardium
SA node (55%)
 The epicardium covers the outer surface of the
heart
2. Left coronary artery: branches into the LAD and the
The myocardium is the middle muscular layer of
circumflex branch
the heart
 The LAD supplies blood to the anterior wall of the
 The endocardium lines the chambers and the
left ventricle, the anterior septum and the Apex of
valves
the left ventricle
 The layer that covers the heart is the pericardium
 The circumflex branch supplies the left atrium and
the posterior left ventricle
Pericardium
 There are two parts: parietal and visceral
pericardium
 The space between the two pericardial layers is the
pericardial space

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 Semi-Finals: Medical-Surgical Nursing Iralyn Bernal
BSN 3A

Heart rate
 Normal range is 60-100 beats per minute
 Tachycardia is greater than 100 bpm
 Bradycardia is less than 60 bpm
 Sympathetic system increase heart rate
 Parasympathetic system (Vagus) decrease heart
rate

Blood Pressure
 Cardiac output X peripheral resistance
 Control is neutral (central and peripheral) and
hormonal
 Baroreceptors in the carotid and aorta
 Hormones – ADH, aldosterone, epinephrine can
increase BP; ANF
The conducting system of the heart consists of the:
1. SA node – the pacemaker
CARDIAC ASSESSMENT
2. AV node – slowest conduction
Laboratory Procedures
3. Bundles of His – branches into the right and left
bundle branch
CARDIAC Proteins and enzymes
4. Purkinjie fibers – fastest conduction
 CK-MB (creatine kinase)
 Elevates in MI within 4 hours, peaks in 18
hours and then declines till 3 days
 Normal value is 0-7 U/L

 Lactic Dehydrogenase (LDH)

Laboratory Test Rationale

1. To assist in diagnosing MI
2. To identify abnormalities
3. To assess inflammation
4. To determine baseline value
5. To monitor serum level of medications
6. To assess the effects of medications
 Elevates in MI in 24 hours, peaks in 48-72
hours
 Normally LDH1 is greater than LDH2
.  In case of MI: LDH2 greater than LDH1
Your heart is a pump that sends (flipped LDH pattern)\
blood through your body. For The Heart sounds
1. S1- due to  Normal value is 70-200 IU/L
each heartbeat, electrical signals
travel through the conduction closure of the
pathway of your heart. It starts AV valves  Myoglobin
when your sinoatrial (SA) node (normal) lub  Rises within 1-3 hours
creates an excitation signal. 2. S2- due to  Peaks in 4-12 hours
This electrical signal is like the closure of  Returns to normal in a day
electricity traveling through the semi-  Not used alone
wires to an appliance in your lunar valves  Muscular and RENAL disease can have
home. (2nd sound) elevated myoglobin
dub
The excitation signal travels to: 3. S3- due to
1. Your atria (top heart increased
chambers), telling ventricular  Troponin I and T
them to contract. filling (not  Troponin I is usually utilized for MI
2. The atrioventricular considered  Elevates within 3-4 hours, peaks in 4-24
(AV) node, delaying normal) hours and persists for 7 days to 3 weeks!
the signal until your 4. S4- due to  Normal value for Troponin I is less than 0.6
atria are empty of forceful ng/mL
blood. atrial
3. The bundle of His contraction
(center bundle of nerve
fibers), carrying the
signal to the Purkinje 2
fibers.

 Remember to avoid IM injections before
obtaining blood sample!
 Early and late diagnosis can be made!
Serum Lipids
 Lipid profile measures the serum cholesterol,
triglycerides and lipoprotein levels
 Cholesterol- 200 mg/dL
 Triglycerides- 40- 150 mg/dL
 LDH-130 mg/dL
 HDL-30-70-mg/dL
 NPO post midnight (usually 12 hours)
Electrocardiogram (ECG)
 A non-invasive procedure that evaluates the
electrical activity of the heart
 Electrodes and wires are attached to the patient
Holter Monitoring
 A non-invasive test in which the client wears a
Holter monitor and an ECG tracing recorded
continuously over a period of 24 hours
 Instruct patient to resume normal activities and
maintain a diary of activities and any symptoms
that may develop
Semi-Finals: Medical-Surgical Nursing Iralyn Bernal
BSN 3A
Echocardiogram
 Non-invasive test that studies the structural and
functional changes of the heart with the use of
ultrasound
 No special preparation is needed
Stress Test
 A non-invasive test that studies the heart during
activity and detects and evaluates CAD
 Exercise test, pharmacologic test and emotional test
 Treadmill testing is the most commonly used stress
test
 Used to determine CAD, Chest pain causes, drug
effects and dysrhythmias in exercise
Pre-test: consent may be required, adequate rest, eat a light
meal or fast for 4 hours and avoid smoking, alcohol and
caffeine
Post-test: instruct client to notify the physician if any chest
pain, dizziness or shortness of breath. Instruct client to avoid
taking a hot shower for 10-12 hours after the test (avoid hot
shower vasodilation)
Pharmacological stress test
 Use of dipyridamole
 Maximally dilates coronary artery
 Side-effect: flushing of face
Pre-test: 4 hours fasting, avoid alcohol, caffeine
Post test: report symptoms of chest pain
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 Semi-Finals: Medical-Surgical Nursing Iralyn Bernal
BSN 3A

Cardiac catheterization (invasive procedure) Measuring CVP

 Insertion of a catheter into the heart and 1. Position the client supine with bed elevated at 45
surrounding vessels degrees
 Determines the structure and performance of the 2. Position the zero point of the CVP line at the level
heart valves and surrounding vessels of the right atrium. Usually this is at the MAL, 4th
 Used to diagnose CAD, assess coronary atery ICS
patency and determine extent of atherosclerosis 3. Instruct the client to be relaxed and avoid coughing
and straining.
Pretest: Ensure Consent, assess for allergy to seafood and
iodine, NPO, document weight and height, baseline VS,
blood tests and document the peripheral pulses
Pretest: Fast for 8-12 hours, teachings, medications to allay
anxiety
Intra-test: inform patient of a fluttery feeling as the catheter
passes through the heart; inform the patient that a feeling of
warmth and metallic taste may occur when dye is
administered
Post-test: Monitor VS and cardiac rhythm

 Monitor peripheral pulses, color and warmth and

sensation of the extremity distal to insertion site
 Maintain sandbag to the insertion site if required to
maintain pressure
 Monitor for bleeding and hematoma formation
 Maintain strict bed rest for 6-12 hours Assessment
 Client may turn from side to side but bed should
not be elevated more than 30 degrees and legs 1. Health History
always straight  Obtain description of present illness and the chief
 Encourage fluid intake to flush out the complaint
dyeImmobilize the arm if the antecubital vein is  Chest pain, SOB, Edema, etc.
used  Assess risk factors
 Monitor for dye allergy
2. Physical examination
 Vital signs- BP, PP, MAP
 Inspection of the skin
 Inspection of the thorax
 Palpation of the PMI, pulses
 Auscultation of the heart sounds

CVP (Central Venous Pressure)

 The CVP is the pressure within the SVC
 Reflects the pressure under which blood is returned
3. Laboratory and diagnostic studies
to the SVC and right atrium
 СВС cardiac catheterization
 Normal CVP is 0 to 8 mmHg/ 4-10 cm H20
 Lipid profile
 Elevated CVP indicates increase in blood volume,
 arteriography
excessive IVF or heart/renal failure
 Cardiac enzymes and proteins
 Low CVP may indicated hypovolemia,
hemorrhage and severe vasodilatation  CXR
 CVP
 EEG

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 Semi-Finals: Medical-Surgical Nursing Iralyn Bernal
BSN 3A

 Holter monitoring Coronary Artery Disease

 Exercise ECG

Implementation

1. Assess the cardio-pulmonary status

 VS, BP, Cardiac assessment

2. Enhance cardiac output

 Establish IV line to administer fluids

3. Promote gas exchange

 Administer 02
 Position client in semi-fowler's
 Encourage coughing and deep breathing exercises
Coronary Artery Disease (CAD) results from the focal
4. Increase client activity tolerance narrowing of the large and medium-sized coronary arteries
 Balance rest and activity periods due to deposition of atheromatous plaque in the vessel wall
 Assist in daily activities
Risk Factors
5. Promote client comfort 1. Age above 45/55 and Sex-Males and post-
 Assess the client's description of pain and chest menopausal females
discomfort 2. Family History
 Administer medication as prescribed 3. Hypertension
4. DM
6. Promote adequate sleep 5. Smoking
6. Obesity
7. Prevent infection 7. Sedentary lifestyle
 Monitor skin integrity of lower extremities 8. Hyperlipedimia
 Assess skin site for edema, redness and warmth,
Most important MODIFIABLE factors:
 Monitor for feve,
 Smoking
 Change position frequently
 Hypertension
8. Minimize patient anxiety  Diabetes
 Encourage verbalization of feelings, fears and  Cholesterol abnormalities
concerns
 Answer client questions. Pathophysiology
 Provide information about procedures and Fatty streak formation in the  There is
medications vascular intima decreased
 perfusion of
CARDIOVASCULAR SYSTEM DISORDERS T-cells and monocytes ingest myocardial
lipids in the area of deposition tissue and
Cardiac Diseases
 inadequate
 Coronary Artery Disease Atheroma myocardial
 Myocardial Infarction  oxygen
 Congestive Heart Failure Narrowing of the arterial lumen supply
 Infective Endocarditis   If 50% of
 Cardiac Tamponade Reduced coronary blood flow the left
 Cardiogenic Shock  coronary
Myocardial ischemia arterial
Vascular Diseases lumen is
 Hypertension reduced or 75% of the other coronary artery, this
 Buerger's disease becomes significant
 Varicose veins  Potential for Thrombosis and embolism
 Deep vein thrombosis
 Aneurysm

Angina Pectoris

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 Semi-Finals: Medical-Surgical Nursing Iralyn Bernal
BSN 3A

6. Dizziness and syncope

Laboratory Findings
1. ECG may show normal tracing if patient is pain-
free. Ischemic changes may show ST depression
and T wave inversion

2. Cardiac catheterization
 Provides the most definitive source of
diagnosis by showing the presence of the
atherosclerotic lesions
Chest pain resulting from coronary atherosclerosis or Nursing Management
myocardial ischemia 1. Administer prescribed medications
 Nitrates- to dilate the coronary arterie
Three Common Types of Assessment Findings
 Aspirin- to prevent thrombus formation
Angina 1. Chest pain-
 Beta-blockers- to reduce BP and HR
Angina
 Calcium-channel blockers- to dilate coronary
1. Stable Angina  The
artery and reduce vasospasm
 The typical angina that most
occurs during exertion,
2. Teach the patient management of anginal attacks
relieved by rest and
 Advise patient to stop all activities
drugs and the severity
does not change  Put one nitroglycerin tablet under the tongue
 (Trimetazidine) pain  Wait for 5 minutes
will relieve  If not relieved, take another tablet and •wait
for 5 minutes
2. Unstable angina  Another tablet can be taken (third tablet)
 Occurs unpredictably  If unrelieved after three tablets → seek
during exertion and medical attention
emotion, severity
increases with time 3. Obtain a 12-lead ECG
and pain may not be
relieved by rest and 4. Promote myocardial perfusion
drug  Instruct patient to maintain bed rest
 Administer 02 @ 3 lpm
3. Variant angina  Advise to avoid valsalva maneuvers (pag ere)
 Prinzmetal angina, Decrease heart rate until the heart stop
results from coronary  Provide laxatives or high fiber diet to lessen
artery constipation
VASOSPASMS, may  Encourage to avoid increased physical
occur at rest activities
characteristic symptom
5. Assist in possible treatment modalities
 Pain is described as mild to severe retrosternal
 PTCA-percutaneous transluminal coronary
pain, squeezing, tightness or burning
angioplasty
sensation
- To compress the plaque against the vessel
 Radiates to the jaw and left arm
wall, increasing the arterial lumen
 Precipitated by Exercise, Eating heavy meals,
 CABG-coronary artery bypass graft
Emotions like excitement and anxiety and
- To improve the blood flow to the
Extremes of temperature (5E)
myocardial tissue
 Relieved by rest and nitroglycerin
6. Provide information to family members to
2. Diaphoresis minimize anxiety and promote family cooperation
3. Nausea and vomiting
4. Cold clammy skin
5. Sense of apprehension and doom

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 Semi-Finals: Medical-Surgical Nursing Iralyn Bernal
BSN 3A

7. Assist client to identify risk factors that can be  Chest pain is described as severe, persistent,
modified crushing substernal discomfort
 Radiates to the neck, arm, jaw and back
8. Refer patient to proper agencies  Occurs without cause, primarily early
morning
 NOT relieved by rest or nitroglycerin
 Lasts 30 minutes or longer
Myocardial Infarction 2. Dyspnea
3. Diaphoresis
4. cold clammy skin
5. 5.N/V
6. restlessness, sense of doom
7. tachycardia or bradycardia
8. hypotension
9. S3 and dysrhythmias

Laboratory findings
1. ECG
 the ST segment is ELEVATED.
 T wave inversion, presence of Q wave

Death of myocardial tissue in regions of the heart with

abrupt interruption of coronary blood supply

Etiology and Risk factors

1. CAD
2. Coronary vasospasm
3. Coronary artery occlusion by embolus and
thrombus
4. Conditions that decrease perfusion-hemorrhage,
shock 2. Myocardial enzymes- elevated CK- MB, LDH and
Troponin levels
Risk factors 3. CBC- may show elevated WBC count
1. Hypercholesterolemia 4. Test after the acute stage- Exercise tolerance test,
2. Smoking thallium scans, cardiac catheterization
3. Hypertension
4. Obesity Nursing Interventions
5. Stress 1. Provide Oxygen at 2-1pm, Semi-fowler's
6. Sedentary lifestyle 2. Administer medications
 Morphine to relieve pain
Pathophysiology
 Nitrates, thrombolytics, aspirin and
anticoagulants
Interrupted coronary blood flow
 Stool softener and hypolipidemics

3. Minimize patient anxiety
Myocardial ischemia
 Provide information as to procedures and

drug therapy
Anaerobic myocardial metabolism for several hours
4. Provide adequate rest periods
 5. Minimize metabolic demands
Myocardial death
 Provide soft diet

 Provide a low-sodium, low cholesterol and
Depressed cardiac function
low fat diet
 6. Minimize anxiety
Triggers autonomic nervous system response 7. Reassure client and provide information as needed
 7. Assist in treatment modalities such as PTCA and
Further imbalance of myocardial O2 demand and supply CABG
8. Monitor for complications of MI- especially
Assessment findings dysrhythmias, since ventricular tachycardiacan
1. Chest pain happen in the first few hours after MI
9. Provide client teaching

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 Semi-Finals: Medical-Surgical Nursing Iralyn Bernal
BSN 3A

Medical Management
1. Analgesic
 The choice is morphine
 It reduces pain and anxiety
 Relaxes bronchioles to enhance
oxygenation
2. ACE inhibitors
 Prevents formation of angiotensin II
 Limits the area of infarction
3. Thrombolytics
 Streptokinase, Alteplase
 Dissolve clots in the coronary artery
allowing blood to flow

Nursing Intervention After Acute Episode Diminished contractile proteins

1. Maintain bed rest for the first 3 days 
2. Provide passive ROM exercises Poor contraction
3. Progress with dangling of the feet at side of bed 
4. Proceed with sitting out of bed, on the chair for 30 Decreased blood ejection
minutes TID 
5. Proceed with ambulation in the room →toilet → Increased blood remaining in the venricle
hallway TID 
Ventricular stretching and dilatation
Cardiac rehabilitation
 To extend and improve quality of life
 Physical conditioning Associated Factors
 Patients who are able to walk 3-4 mph are usually 1. Heavy alcohol intake
ready to resume sexual activities 2. Pregnancy
3. Viral infection
Cardiomyopathies 4. Idiopathic

Pathophysiology

 Systolic Dysfunction

Hypertrophic Cardiomyopathies

Heart muscle disease associated with cardiac dysfunction

1. Dilated Cardiomyopathy
2. Hypertrophic Cardiomyopathy
3. Restrictive cardiomyopathy

Dilated Cardiomyopathies Increased size of myocardium


Reduced ventricular volume

Resistance to ventricular filling

Diastolic dysfunction

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 Semi-Finals: Medical-Surgical Nursing Iralyn Bernal
BSN 3A

3. Edema
4. Chest pain
5. Palpitations
6. dizziness
7. Syncope with exertion

Laboratory Findings
1. CXR- may reveal cardiomegaly
2. ECHOCARDIOGRAM
3. ECG
4. Myocardial Biopsy

Medical Management
1. Surgery
2. pacemaker insertion
3. Pharmacological drugs for symptom relief
Associated factors
1. Genetic
Nursing Management
2. Idiopathic
1. 1.Improve cardiac output
 Adequate rest
Pathophysiology
 Oxygen therapy
 Low sodium diet
3. Increase patient tolerance
 Schedule activities with rest periods in
between
4. Reduce patient anxiety
 Support
 Offer information about transplantations
 Support family in anticipatory grieving
Restrictive Cardiomyopathies Infective Endocarditis

Associated factors
1. Infiltrative diseases like amyloidosis Infection of the heart valves and the endothelial surface of
2. Idiopathic the heart
 Can be acute or chronic
Pathophysiology
Risk factors
1. Prosthetic valves
Rigid ventricular wall 2. Congenital malformation
 3. Cardiomyopathy
Impaired stretch and diastolic filling 4. IV drug users
 5. Valvular dysfunctions
Decreased output
Etiologic factors
 Diastolic dysfunction 1. Bacteria- Organism depends on several factors
2. Fungi
Cadiomyopathies: Assessment findings
1. PND- paroxysmal nocturnal dyspnea Pathophysiology
2. Orthopnea
Direct invasion of microbes

Microbes adhere to damaged valve surface and 9
proliferate
 Semi-Finals: Medical-Surgical Nursing Iralyn Bernal
BSN 3A

Assessment findings
1. Intermittent HIGH fever
2. anorexia, weight loss
3. cough, back pain and joint pain
4. splinter hemorrhages under nails
5. Osler's nodes- painful nodules on fingerpads
6. Roth's spots- pale hemorrhages in the retina
7. Heart murmurs
8. Heart failure

Prevention
 Antibiotic prophylaxis if patient is undergoing
procedures like dental extractions, bronchoscopy,
Etiology of CHF
surgery, etc.
1. CAD
2. Valvular heart diseases
Laboratory Exam
3. Hypertension
 Blood Cultures to determine the exact organism 4. MI
5. Cardiomyopathy
6. Lung diseases
Nursing management 7. Post-partum
1. regular monitoring of temperature, heart sounds 8. Pericarditis and cardiac tamponade
2. manage infection
3. long-term antibiotic therapy

Medical management New York Heart Association

1. Pharmacotherapy Class 1
 IV antibiotic for 2-6 weeks  Ordinary physical activity does NOT cause chest
 Antifungal agents are given - pain and fatigue
amphotericin B  No pulmonary congestion
2. Surgery
 Asymptomatic
 Valvular replacement
 NO limitation of ADLS
Congestive Heart Failure
Class 2
 SLIGHT limitation of ADLS
 NO symptom at rest
 Symptom with INCREASED activity
 Basilar crackles and S3

Class 3
 Markedly limitation on ADLS
 Comfortable at rest BUT symptoms present in
LESS than ordinary activity

Left ventricular pump failure


A syndrome of congestion of both pulmonary and systemic Back up of blood into the pulmonary veins
circulation caused by inadequate cardiac function and 
inadequate cardiac output to meet the metabolic demands of Increased pulmonary capillary pressure
tissues 
 Inability of the heart to pump sufficiently Pulmonary congestion
 The heart is unable to maintain adequate circulation
to meet the metabolic needs of the body Left ventricular failure
 Classified according to the major ventricular 
dysfunction- Left or Right Decreased cardiac output

Decreased perfusion to the brain, kidney and other
tissues

Oliguria, dizziness

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 Semi-Finals: Medical-Surgical Nursing Iralyn Bernal
BSN 3A

Class 4 3. Instruct to avoid OTC drugs, Stimulants, smoking

 SYMPTOMS are present at rest and alcohol
4. Provide a LOW fat and LOW sodium diet
Pathophysiology 5. Provide potassium supplements
6. Instruct about fluid restriction
7. Provide adequate rest periods and schedule
activities
8. Monitor daily weight and report signs of fluid
retention
Left Sided CFT Assessment Findings
1. Dyspnea on exertion Congestive Heart Failure
2. PND
3. Orthopnea
4. Pulmonary crackles/rales
5. cough with Pinkish, frothy sputum
6. Tachycardia
7. Cool extremities
8. Cyanosis
9. decreased peripheral pulses
10. Fatigue
11. Oliguria
12. signs of cerebral anoxia

Right Sided CFT Assessment Findings

1. Peripheral dependent, pitting edema
2. Weight gain
3. Distended neck vein
4. hepatomegaly
5. Ascites
Heart fails to pump adequately resulting to a decreased
6. Body weakness
cardiac output and decreased tissue perfusion
7. Anorexia, nausea
8. Pulsus alternans
Etiology
1. Massive MI
Laboratory Findings
2. Severe CHF
1. CXR may reveal cardiomegaly
3. Cardiomyopathy
2. ECG may identify Cardiac hypertrophy
4. Cardiac trauma
3. Echocardiogram may show hypokinetic heart
5. Cardiac tamponade
4. ABG and Pulse oximetry may show decreased O2
saturation
Assessment Findings
5. PCWP is increased in LEFT sided CHF and CVP is
1. Hypotension
increased in RIGHT sided CHF
2. oliguria (less than 30 ml/hour)
3. tachycardia
Nursing Intervention
4. tachypnea
1. Assess patient's cardio- pulmonary status
5. narrow pulse pressure
2. Assess VS, CVP and PCWP. Weigh patient daily
6. weak peripheral pulses
to monitor fluid retention
7. cold clammy skin
3. Administer medications-usually cardiac glycosides
6. changes in sensorium/LOC
are given-DIGOXIN or DIGITOXIN, Diuretics,
7. pulmonary congestion
vasodilators and hypolipidemics are prescribed
4. Provide a LOW sodium diet. Limit fluid intake as
Laboratory Findings
necessary
5. Provide adequate rest periods to prevent fatigue  Increased CVP (Normal is 4-10 cmH2O)
6. Position on semi-fowler's to fowler's for adequate
chest expansion Nursing Intervention
7. Prevent complications of immobility 1. Place patient in a modified Trendelenburg (shock)
position
Nursing Intervention after the Acute Stage 2. Administer IVF, vasopressors and inotropics such
1. Provide opportunities for verbalization of feelings as dopamine and dobutamine
2. Instruct the patient about the medication regimen- 3. Administer O2
digitalis, vasodilators and diuretics 4. Morphine is administered to decreased pulmonary
congestion and to relieve pain

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 Semi-Finals: Medical-Surgical Nursing Iralyn Bernal
BSN 3A

5. Assist in intubation, mechanical ventilation, PTCA,
CABG, insertion of Swan-Ganz cath and IABP
6. Monitor urinary output, BP and pulses
7. cautiously administer diuretics and nitrates
3. Monitor ECG, urine output and BP
4. Monitor for recurrence of tamponade
Pericardiocentesis
 Patient is monitored by ECG
 Maintain emergency equipments
 Elevate head of bed 45-60 degrees
 Monitor for complications- coronary artery rupture,
dysrhythmias, pleural laceration and myocardial
trauma

Cardiac Tamponade

Hypertension

A condition where the heart is unable to pump blood due to

accumulation of fluid in the pericardial sac (pericardial
effusion)
 This condition restricts ventricular filling resulting
to decreased cardiac output
 Acute tamponade may happen when there is a
sudden accumulation of more than 50 mlfluid in
the pericardial sac

Causative factors
1. Cardiac trauma
2. Complication of Myocardial infarction
3. Pericarditis
4. Cancer metastasis
A systolic BP greater than 140 mmHg and a diastolic
pressure greater than 90 mmHg over a sustained period,
Assessment Findings
based on two or more BP measurements.
1. BECK's Triad- Jugular vein distention, hypotension
and distant/muffled heart sound
Types of Hypertension
2. Pulsus paradoxus
1. Primary or ESSENTIAL
3. Increased CVP
4. decreased cardiac output  Most common type
5. Syncope 2. Secondary
6. anxiety  Due to other conditions like
7. dyspnea Pheochromocytoma, renovascular
8. Percussion- Flatness across the anterior chest hypertension, Cushing's, Conn's, SIADH

Laboratory Findings Classification of Hypertension by JNC – VII

1. Echocardiogram
2. Chest X-ray

Nursing Intervention
1. Assist in pericardiocentesis
2. Administer IVF

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 Semi-Finals: Medical-Surgical Nursing Iralyn Bernal
BSN 3A

 Calcium channel blockers

 ACE inhibitors
 A2 Receptor blockers
 Vasodilators

Nursing Interventions
1. Provide health teaching to patient
 Teach about the disease process
 Elaborate on lifestyle changes
 Assist in meal planning to lose weight
 Provide list of LOW fat, LOW sodium
diet of less than 2-3 grams of Na/day
 Limit alcohol intake to 30 ml/day
 Regular aerobic exercise
 Advise to completely Stop smoking
Pathophysiology 2. Provide information about anti- hypertensive drugs
 Multi-factorial etiology  Instruct proper compliance and not abrupt
cessation of drugs even if pt becomes
 BP=CO (SV X HR) x TPR
asymptomatic/ improved condition
 Any increase in the above parameters will increase
 Instruct to avoid over-the-counter drugs
BP
that may interfere with the current
1. Increased sympathetic activity
medication
2. Increased absorption of Sodium, and water in
3. Promote Home care management
the kidney
3. Increased activity of the RAAS  Instruct regular monitoring of BP*
4. Increased vasoconstriction of the peripheral Involve family members in care
vessels  Instruct regular follow-up
5. insulin resistance 4. Manage hypertensive emergency and urgency
properly
Assessment Findings
1. Headache Vascular Diseases
2. Visual changes
3. chest pain
4. dizziness
5. N/V

Risk factors for Cardiovascular Problems in

Hypertensive patients
Major Risk factors
1. Smoking
2. Hyperlipidemia
3. DM
4. Age older than 60
5. Gender- Male and post menopausal
6. Family History

Diagnostic Studies
1. Health history and PE Aneurysm
2. Routine laboratory- urinalysis, ECG, lipid profile,
BUN, serum creatinine, FBS
3. Other lab- CXR, creatinine clearance, 24-huour
urine protein

Medical Management
1. Lifestyle modification
2. Drug therapy
3. Diet therapy

Drug therapy
 Diuretics
 Beta blockers

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 Semi-Finals: Medical-Surgical Nursing Iralyn Bernal
BSN 3A

Refers to arterial insufficiency of the extremities usually

secondary to peripheral atherosclerosis.
Dilation involving an artery formed at a weak point in the
 Usually found in males age 50 and above
vessel wall
 The legs are most often affected
 Saccular - when one side of the vessel is affected
 Fusiform - when the entire segment becomes
Risk factors for Peripheral Arterial occlusive disease
dilated
Non-Modifiable
1. Age
Risk Factors
2. gender
 Atherosclerosis 3. family predisposition
 Infection - syphilis Modifiable
 Connective tissue disorder 1. Smoking
 Genetic disorder - Marfan's Syndrome 2. HPN
3. Obesity
4. Sedentary lifestyle
Pathophysiology 5. DM
6. Stress
Assessment
 Asymptomatic Assessment Findings
 Pulsatile sensation on the abdomen 1. Intermittent Claudication - the hallmark of PAOD
 Palpable bruit  This is PAIN described as aching,
cramping or fatiguing discomfort
Dissecting aneurysm consistently reproduced with the same
 degree of exercise or activity
Tear in the intima and media with dissection of blood  This pain is RELIEVED by REST
through the layers  This commonly affects the muscle group
below the arterial occlusion
2. Progressive pain on the extremity as the disease
Laboratory
advances
 CT scan
3. Sensation of cold and numbness of the extremities
 Ultrasound 4. Skin is pale when elevated and cyanotic/ruddy
 X-ray when placed on a dependent position
 Aortography 5. Muscle atrophy, leg ulceration and gangrene
Medical Management Diagnostic Findings
 Anti-hypertensives 1. Unequal pulses between the extremities
 Synthetic graft 2. Duplex ultrasonography
3. Doppler flow studies
Nursing Management:
 Administer medications Medical Management
 Emphasize the need to avoid increased abdominal 1. Drug therapy
pressure  Pentoxyfylline (Trental) reduces blood
 No deep abdominal palpation viscosity and improves supply of O2
 Remind patient the need for serial ultrasound to blood to muscles
detect diameter changes  Cilostazol (Pletaal) inhibits platelet
aggregation and increases vasodilatation
Peripheral Arterial Occlusive Disease 2. Surgery- Bypass graft and anastomoses

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Nursing Interventions
1. Maintain Circulation to the extremity
 Evaluate regularly peripheral pulses,
temperature, sensation, motor function and
capillary refill time
 Administer post-operative care to patient
who underwent surgery
2. Monitor and manage complications
 Note for bleeding, hematoma, decreased
urine output
 Elevate the legs to diminish edema
 Encourage exercise of the extremity while
on bed
 Teach patient to avoid leg-crossing
3. Promote Home management
 Encourage lifestyle changes
 Instruct to AVOID smoking
 Instruct to avoid leg crossing
Buerger’s Disease
A disease characterized by recurring inflammation of the
medium and small arteries and veins of the lower
extremities
 Thromboangiitis obliterans
 Occurs in MEN ages 20-35
Risk Factors: Smoking
Pathophysiology
 Cause is UNKNOWN
Inflammation of the arteries
  A localized episode of vasoconstriction of
Thrombus formation

Occlusion of the vessels
 Probably an Autoimmune disease
Semi-Finals: Medical-Surgical Nursing Iralyn Bernal
BSN 3A
Assessment Findings
1. Leg PAIN
 Foot cramps in the arch (instep
claudication) after exercise
 Relieved by rest
 Aggravated by smoking, emotional
disturbance and cold chilling
2. Digital rest pain not changed by activity or rest 207
of rest
3. Intense RUBOR (reddish-blue discoloration),
progresses to CYANOSIS as disease advances
4. Paresthesia
Diagnostic Studies
1. Duplex ultrasonography
2. Contrast angiography
Nursing Interventions
1. Assist in the medical and surgical management
 Bypass graft
 amputation
2. Strongly advise to AVOID smoking
3. Manage complications appropriately
Nursing Interventions
Post-operative care: after amputation
 Elevate stump for the FIRST 24 HOURS to
minimize edema and promote venous return
 Place patient on PRONE position after 24hours
 Assess skin for bleeding and hematoma
 Wrap the extremity with elastic bandage
Raynaud’s Disease
A form of intermittent arteriolar
 Vasoconstriction that results in coldness, pain and
pallor of the fingertips or toes
Cause: Unknown
 Most commonly affects WOMEN, 16- 40 years old
Assessment Findings
1. Raynaud's phenomenon
the small arteries of the hands and feet that
causes color and temperature changes
 W-B-R
 Pallor- due to vasoconstriction, then
 Blue- due to pooling of Deoxygenated
blood
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 Semi-Finals: Medical-Surgical Nursing Iralyn Bernal
BSN 3A

 Red- due to exaggerated reflow/hyperemia

2. tingling sensation Pathophysiology
3. Burning pain on the hands and feet
Factors
Medical management 
 Drug therapy with the use of CALCIUMchannel Venous stasis
blockers 
 To prevent vasospasms Increased hydrostatic pressure

Nursing Interventions Assessment findings

1. instruct patient to avoid situations that may be  Tortuous superficial veins on the legs
stressful  Leg pain and Heaviness
2. instruct to avoid exposure to cold and remain  Dependent edema
indoors when the climate is cold
3. Instruct to avoid all kinds of nicotine4. instruct Laboratory findings
about safety. Careful handling of sharp objects  Venography
 Duplex scan pletysmography

Medical management
 Pharmacological therapy
 Leg vein stripping
 Anti-embolic stockings
Venous Diseases Nursing management
1. Advise patient to elevate the legs
2. Caution patient to avoid prolonged standing or
sitting
3. Provide high-fiber foods to prevent constipation
4. Teach simple exercise to promote venous return
5. Caution patient to avoid knee-length stockings and
constrictive clothings
6. Apply anti-embolic stockings as directed
7. Avoid massage on the affected area

Deep Vein Thrombosis

These are dilated veins usually in the lower extremities

Varicose veins

Inflammation of the deep veins of the lower extremities and

the pelvic veins
 The inflammation results to formation of blood
clots in the area
Predisposing Factors
 Pregnancy Predisposing factors
 Prolonged standing or sitting  Prolonged immobility
 Constipation (for hemorrhoids)  Varicosities
 Incompetent venous valves  Traumatic procedures

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 Semi-Finals: Medical-Surgical Nursing Iralyn Bernal
BSN 3A

2. Decreased RBC production

Complication 3. Increased RBC destruction
 Pulmonary thromboembolism
Hypoproliferative Anemia
Assessment findings Iron Deficiency Anemia
 Leg tenderness
 Leg pain and edema
 Positive Homan’s Sign

Laboratory findings
 Venography
 Duplex scan

Medical management
 Antiplatelets
 Anticoagulants
 Vein stripping and grafting
 Anti-embolic stockings Iron Deficiency Anemia
 Results when the dietary intake of iron is
inadequate to produce hemoglobin

Nursing management Etiologic Factors

1. Provide measures to avoid prolonged immobility 1. Bleeding- the most common cause
 Repositioning Q2 2. Mal-absorption
 Provide passive ROM 3. Malnutrition
 Early ambulation 4. Alcoholism
2. Provide skin care to prevent the complication of leg
ulcers Pathophysiology
3. Provide anti-embolic stockings  The body stores of iron decrease, leading to
4. Administer anticoagulants as prescribed depletion of hemoglobin synthesis
5. Monitor for signs of pulmonary embolism  The oxygen carrying capacity of hemoglobin is
reduced→ tissue hypoxia
Blood Disorders
Anemia Assessment Findings
1. Pallor of the skin and mucous membrane
2. Weakness and fatigue
3. General malaise
4. Pica
5. Brittle nails
6. Smooth and sore tongue
7. Angular cheilosis

Laboratory findings
1. CBC-Low levels of Hct, Hgb and RBC count
2. low serum iron, low ferritin
3. Bone marrow aspiration- MOST definitive

Medical management
Anemia 1. Hematinics
 Nutritional anemia 2. Blood transfusion
 Hemolytic anemia
 Aplastic anemia Nursing Management
 Sickle cell anemia 1. Provide iron rich-foods
 Organ meats (liver)
A condition in which the hemoglobin concentration is lower  Beans
than normal  Leafy green vegetables
 Raisins and molasses
Three broad categories 2. Administer iron
1. Loss of RBC- occurs with bleeding

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 Semi-Finals: Medical-Surgical Nursing Iralyn Bernal
BSN 3A

 Oral preparations tablets- Fe fumarate, 1. fatigue

sulfate and gluconate 2. pallor
 Advise to take iron ONE hour before meal 3. dyspnea
 Take it with vitamin C 4. bruising
 Continue taking it for several months 5. splenomegaly
 Oral preparations-liquid 6. retinal hemorrhages
 It stains teeth
 Drink it with a straw Laboratory Findings
1. CBC- decreased blood cell numbers
 Stool may turn blackish- dark in color
2. Bone marrow aspiration confirms the anemia-
 Advise to eat high-fiber diet to counteract
hypoplastic or acellular marrow replaced by fats
constipation
 IM preparation Medical Management
 Administer DEEP IM using the Z- track 1. Bone marrow transplantation
method 2. Immunosupressant drugs
 Avoid vigorous rubbing 3. Rarely, steroids
 Can cause local pain and staining 4. Blood transfusion

Nursing management
1. Assess for signs of bleeding and infection
2. Instruct to avoid exposure to offending agents

Aplastic Anemia Megaloblastic Anemia

Anemias characterized by abnormally large RBC secondary

to impaired DNA synthesis due to deficiency of Folic acid
and/or vitamin B12

A condition characterized by decreased number of RBC as Folic Acid Deficiency

well as WBC and platelets
Causative factors
Causative Factors 1. Alcoholism
1. Environmental toxins- pesticides, benzene 2. Mal-absorption
2. Certain drugs- Chemotherapeutic agents, 3. Diet deficient in uncooked vegetables
chloramphenicol, phenothiazines, Sulfonamides
3. Heavy metals
4. Radiation
Decreased folic acid

Pathophysiology
Impaired DNA synthesis in the bone marrow
Toxic cause a direct bone marrow depression 
 Impaired RBC development, impaired nuclear
Acellular bone marrow maturation but cytoplasmic maturation continues
 
Decreased production of blood elements Large size
Pathophysiology of Folic acid deficiency
Assessment Findings

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 Semi-Finals: Medical-Surgical Nursing Iralyn Bernal
BSN 3A

Vitamin B12 Deficiency

Causative factors
1. Strict vegetarian diet
2. Gastrointestinal malabsorption
3. Crohn's disease
4. Gastrectomy

Vitamin B12 deficiency

Pernicious Anemia
 Due to the absence of intrinsic factor secreted by
the parietal cells
 Intrinsic factor binds with Vit. B12 to promote
absorption

Assessment findings
1. weakness
2. fatigue A severe chronic incurable hemolytic anemia that results
3. listless from heritance of the sickle hemoglobin gene.
4. neurologic manifestations are present only in Vit.
B12 deficiency Causative factor
 Genetic inheritance of the sickle gene
 HbS gene

Pernicious Anemia Factors

Assessment Findings 
 Beefy, red, swollen tongue Cause defective haemoglobin to acquire a rigid, crystal-
 Mild diarrhea like C-shaped configuration
 Extreme pallor 
 Paresthesias in the extremities Sickled RBCs will adhere to endothelium

Laboratory findings Pile up and plug the vessels
1. Peripheral blood smear-shows giant RBCs, WBCs 
with giant hypersegmented nuclei Ischemia results
2. Very high MCV 
3. Schilling's test Pain, swelling and fever
4. Intrinsic factor antibody test

Medical Management Pathophysiology

1. Vitamin supplementation  Decreased 02, Cold, Vasoconstriction can
 Folic acid 1 mg daily precipitate sickling process
1. Diet supplementation
 Vegetarians should have vitamin intake
2. Lifetime monthly injection of IM Vit B12

Nursing Management
1. Monitor patient
2. Provide assistance in ambulation Assessment Findings
3. Oral care for tongue sore 1. jaundice
4. Explain the need for lifetime IM injection of vit 2. enlarged skull and facial bones
B12 3. tachycardia, murmurs and cardiomegaly
4. Primary sites of thrombotic occlusion: spleen,
Hemolytic Anemia: Sickle Cell lungs and CNS
5. Chest pain, dyspnea

Assessment Findings
1. Sickle cell crises
 Results from tissue hypoxia and necrosis
2. Acute chest syndrome

19

 Manifested by a rapidly falling
hemoglobin level, tachycardia, fever and
chest infiltrates in the CXR
Medical Management
1. Bone marrow transplant
2. Hydroxyurea
 Increases the HbF
3. Long term RBC trnasfusion
Nursing Management
1. manage the pain
 Support and elevate acutely inflamed joint
 Relaxation techniques
 analgesics
2. Prevent and manage infection
 Monitor status of patient
 Initiate prompt antibiotic therapy
3. Promote coping skills
 Provide accurate information
 Allow patient to verbalize her concerns
about medication, prognosis and future
pregnancy
4. Monitor and prevent potential complications
 Leg ulcer
o Aseptic technique
5. Monitor and prevent potential complications
 Priapism
o Sudden painful erection
o Instruct patient to empty bladder,
then take a warm bath
Polycythemia
Polycythemia
 Refers to an INCREASE volume of RBCs
 The hematocrit is ELEVATED to more than 55%
 Clasified as Primary or Secondary
Polycythemia Vera
 Primary Polycythemia
 A proliferative disorder in which the myeloid stem
cells become uncontrolled
Semi-Finals: Medical-Surgical Nursing Iralyn Bernal
BSN 3A
Causative factor -unknown
Pathophysiology
 The stem cells grow uncontrollably
 The bone marrow becomes HYPERcellular and all
the blood cells are increased in number
 The spleen resumes its function of hematopoiesis
and enlarges
 Blood becomes thick and viscous causing sluggish
circulation
 Overtime, the bone marrow becomes fibrotic
Assessment findings
1. Skin is ruddy
2. Splenomegaly
3. headache
4. dizziness, blurred vision
5. Angina, dyspnea and thrombophlebitis
Laboratory findings
1. CBC- shows elevated RBC mass
2. Normal oxygen saturation3 Elevated WBC and
Platelets
Complications
1. Increased risk for thrombophlebitis, CVA and MI
2. Bleeding due to dysfunctional blood cells
Medical Management
1. To reduce the high blood cell mass-phlebotomy
2. Allopurinol
3. Dipyridamole
4. Chemotherapy to suppress bone marrow
Nursing Management
1. Primary role of the nurse is EDUCATOR
2. Regularly asses for the development of
complications
3. Assist in weekly phlebotomy
4. Advise to avoid alcohol and aspirin
5. Advise tepid sponge bath or cool water to manage
pruritus
Leukemia
Malignant disorders of blood forming cells characterized by
uncontrolled proliferation of white blood cells in the bone
marrow-replacing marrow elements.
 The WBC can also proliferate in the liver, spleen
and lymph nodes.
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 Semi-Finals: Medical-Surgical Nursing Iralyn Bernal
BSN 3A

 The leukemias are named after the specific lines of
blood cells afffected primarily
- Myeloid
- Lymphoid
- Monocytic
 The leukemias are named also according to the
maturation of cells
- Acute: The cells are primarily immature
- Chronic: The cells are primarily mature or
diferentiated
Leukemia
 ACUTE myelocytic leukemia
 ACUTE lymphocytic leukemia
 Bone marrow aspiration biopsy reveals a large
percentage of immature cells – blasts
 Erythrocytes and platelets are decreased
Medical Management
1. Chemotherapy
2. Bone marrow transplantation
Nursing Management
1. Manage and prevent infection
 Monitor temperature
 Assess for signs of infection
 Be alert if the neutrophil count drops
below 1,000 cells/ mm3

 CHRONIC myelocytic leukemia 2. Maintain skin integrity

 CHRONIC lymphocytic leukemia 3. Provide pain relief
4. Provide information as to therapy – chemo and
Etiologic Factors bone marrow transplantation
 UNKNOWN
 Probably exposure to radiation
 Chemical agents
 Infectious agents
 Genetic

Pathophysiology of Acute Leukemia

Uncontrolled proliferation of immature cells

Suppress bone marrow function

Severe anemia, thrombocytopenia and granulocytopenia

Pathophysiology of Chronic Leukemia

Uncontrolled proliferation of differentiated cells


Slow suppression of bone marrow function

Milder symptoms

Assessment Findings: Acute Leukemia

 Pallor
 Fatigue
 Dyspnea
 Hemorrhages
 Organomegaly
 Headache
 vomiting

Assessment Findings: Acute Leukemia

 less severe symptoms
 organomegaly

Laboratory Findings
 Peripheral WBC count varies widely

21