Cardiovascular Disorders Module-1

Laoag City, Ilocos Norte
CARDIO AND PERIPHERAL

VASCULAR MODULE
WILJOHN M. DE LA CRUZ, M.A.N.

THRICIA BLESS S. VENTURA, RN
Professor
Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response,
Cellular Aberrations, acute and chronic and Peri-operative Nursing
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Objectives:
 Review the anatomy, physiology, and functions of cardiovascular, and peripheral
system.
 Define the different disorders.
 Understand the causes and/or risk factors associated with the disorders.
 Trace the pathophysiology of common disorders, relating their manifestations to the
pathophysiologic process.
 Identify indicated diagnostic procedures appropriate for the different disorders.
 Discuss appropriate management for specific patient and family members with
ethical considerations as to medical, surgical, pharmacological and nursing
management.
Introduction
The cardiovascular system, including the heart and blood vessels, is

responsible for the circulation of blood to all tissues of the body while carrying away carbon
dioxide and waste products. Cardiac muscle shares many attributes with skeletal and smooth
muscles but represents a separate muscle group with distinct structure, function, and regulation.
Key in this function is the self-activating nature of particular cardiac cells that normally provide
an ordered contraction of the cardiac chambers. Blood vessels contain smooth muscle cells
regulated by a variety of signal molecules and also play an important role in maintenance of
blood pressure and oxygen/nutrient distribution. Diseases of these blood vessels, especially
hypertension and atherosclerosis, cause much of the illness and most of the deaths in the
developed world.
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Since you have a background of the anatomy and physiology of

the cardiovascular and peripheral systems. Before a deeper
discussion, I want you to answer the following exercise at your
best.
Activity 7 Self- Assessment
Instruction: Match each term in Column A with its description in Column B. Write
the correct letter only.
Column A Column B
1. Circulation A. carry blood away from the heart

2. Heart B. pumps blood
3. Arteries C. connect arteries and veins
4. Vein D. transport of materials in living things
5. Capillaries E. carry blood back to the heart
6. Cardiac output F. thin, transparent outer layer walls of the heart
7. Sinoatrial node G. pacemaker of the heart
8. Epicardium H. determining by computing Stroke volume x Heart rate
9. Right ventricle I. receives blood from left atrium and ejects blood to the
systemic circulation
10. Left ventricle J. receives blood from the right atrium and ejects blood to the
lungs
K. the receives oxygenated blood from the four
pulmonary veins and serves as a reservoir during
ventricular systole.
L. situated in the septum between the two atria,
anterior to the opening of the coronary sinus
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In this part I want you to answer the following questions related to our next topic.
Be at your FINEST and answer them well. Enjoy!
Activity 8 Exploring your Understanding
1. An understanding of the structure and function of the heart in health and in disease is
essential to develop cardiovascular assessment skills. In your own understanding simplify
the route of blood flow through the heart (blood circulation of the heart).
2. For your own understanding, describe what will happen if the heart will stop beating?
Give one disorder as your example. Your answer must not exceed to 150 words.
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In this part of our lesson we will be discussing the overview of the anatomy,
physiology and functions of the cardiovascular and peripheral system, model
diseases, identifying the risk/etiology, tracing the pathophysiologic process,
clinical manifestations, appropriate diagnostic procedures and management.
Anatomy, Physiology and Functions of Cardiovascular and

Peripheral System
What is HEART?
 Pumping organ of the body.

 Size: clenched fist/closed fist.
 Shape: cone – shaped ( with base &
apex)
 Weight: Males: 10.5 – 12.5 oz (300
– 350 grams)
Females 9 – 10.5 0z (250 – 300
grams)
 Location: between the two lungs,
lying in the thoracic cavity,
specifically the mediastinal cavity,
where 2/3 of it is situated to the left
of the midline.
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ANATOMICAL STRUCTURE OF THE HEART
A. PERICARDIUM – strong non

distensible sac which loosely
encloses the heart and attaches to
the large blood vessels at the base
of the heart and to diaphragm at
the apex
 It protects the heart from
trauma and infection.
 Layers:
 Fibrous pericardium
– outer membrane,
prevents over
stretching of the heart,
provides protection &
anchors the heart in the
mediastinum.
 Serous pericardium –
outer layer, more delicate membrane that forms a double layer around the
heart.
Parietal layer – outer layer of the serous pericardium which is fused
to the fibrous pericardium.
Visceral layer – lines the surface of the heart.
B. HEART WALL
 EPICARDIUM – thin, transparent outer layer of the walls of the heart.

 MYOCARDIUM – cardiac muscle tissue, responsible for the heart’s pumping
action. It consists of specialized cardiac muscle cells (myofibrils).
 ENDOCARDIUM – innermost lining of the heart chambers & covers the
valves of the heart.
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C. CHAMBERS OF THE HEART

 The FOUR chambers of the
heart are as follows: Right
Atrium, Right Ventricle,
Left Atrium, and Left
Ventricle.
 The RIGHT ATRIUM –
receives blood from
superior vena cava, inferior
vena cava, and the
coronary sinus.
 The RIGHT
VENTRICLE – receives
venous blood from the
right atrium, and ejects this
blood into the lungs via the
pulmonary artery through
the semilunar valve.
 The LEFT ATRIUM –
receives oxygenated blood from the four pulmonary veins and serves as a
reservoir during ventricular systole.
 The LEFT VENTRICLE – receives blood from the left atrium and ejects
blood into the systemic arterial circulation via the aorta.
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D. VALVES OF THE HEART

 The two types of cardiac valves are the atrioventricular (AV) valves and the
semilunar valves.
 The AV valves are the tricuspid valve & bicuspid valve.
 TRICUSPID VALVE – the valve between the right atria and the right
ventricle, it contains 2 leaflets or cusps.
 BICUSPID
VALVE – the
valve between the
left atrium and
the left ventricle,
it contains 2
leaflets or cusps
 The AV valve is held in

place by the chorda
tendinae cordis, which
in turn are anchored to
the ventricular wall by
the papillary muscles.
The chorda tendinae
cordis supports the AV valves during ventricular systole to prevent valvular
prolapse into the atrium.
 The semilunar valves are the aortic valve and the pulmonic valve.
 AORTIC VALVE – lies between the LV and the aorta.
 PULMONIC VALVES – lies between the RV & pulmonary artery.
These valves open during ventricular systole, and they close during
ventricular diastole.
E. CORONARY ARTERIES
 The coronary arteries originate from the aorta, behind the cusps of the aortic
valve, in an area known as VALSALVA’s SINUS.
 Coronary artery blood flow to the myocardium occurs during diastole, when
coronary vascular resistance is reduced. During diastole, blood enters the
coronary artery, which is called DIASTOLIC FILLING.
 The two main coronary arteries are:
 Left Coronary Artery (LCA) divides into two branches namely, the
circumflex coronary artery (CCA) and left anterior descending artery
(LADA).
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 CCA – supplies the left atrium, posterior lateral surface of

the left ventricle.
 LADA – supplies the anterior wall of the left ventricle, the
anterior intraventricular septum, the anterior papillary
muscles and the apex of the heart.
 Right Coronary Artery (RCA) – supplies the right atrium, right
ventricle a portion of the septum, SA node, AV node, and inferior portion
of the left ventricle.
F. CONDUCTION SYSTEM
1. SA Node (Sinoatrial
node) – located in the atrial
wall just inferior to the
opening of the superior
vena cava.
-The normal
pacemaker of the
heart and triggers
electrical impulses at
rate of 60 – 100 times
beat per minute.
2. AV node (Atrioventricular node) – situated in the septum between the two

atria, anterior to the opening of the coronary sinus.
- Receives electrical impulses from SA node & generates action potentials
in case the SA node is damaged or injured but a slower pace of 40 – 50
beats per minute.
3. AV bundle (atrioventricular bundle)/Bundle of his

- The only electrical connection between the atria and the ventricles.
- Relay impulses from AV node to the ventricles.
4. Right and Left Bundle Branches

 Branch of the bundle of His that run through the interventricular septum
towards the apex of the heart.
5. Purkinje Fibers/ conduction Myofibers. Large diameter conduction myofibers

rapidly conduct the action potential to the apex of the ventricular myocardium and
then upward to the remainder of the ventricular myocardium.
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G. ELECTROPHYSIOLOGIC PROPERTIES OF THE HEART

 Automaticity – the ability of the heart to initiate impulses repetitively and
spontaneously (also called rhythmicity).
 Excitability – the ability of cardiac cells to respond to a stimulus by initiating
a cardiac muscle.
 Conductivity – the ability of cardiac cells to respond to an impulse by
transmitting the impulse along cell membranes.
 Contractility – the ability of cardiac cells to respond to an impulse contracting.
 Refractoriness – the ability of the cardiac cells to respond to a new stimulus
while it is still in contraction in response to a previous stimulus.
H. THE CARDIAC CYCLE

 The two phases of the cardiac
cycle are diastole and systole.
Relaxation and filling of the
atria and ventricles occur
during diastole. Contraction
and emptying of the atria and
ventricles occur during systole.
 Normally, the complete cardiac
cycle occurs about 70 to 80
times per minute, measured as
the heart rate (HR).
I. HEART SOUNDS
1. The first heart sound (S1) is heard as the atrioventricular valves close and is heard
loudest at the apex of the heart.
2. The second heart sound (S2) is heard when the semilunar valves close and is heard
loudest at the base of the heart.
3. A third heart sound (S3) may be heard if ventricular wall compliance is decreased
and structures in the ventricular wall vibrate heart; this can occur in conditions such
as congestive heart failure or valvular regurgitation. However, a third heart sound
may be normal in individuals younger than 30 years.
4. A fourth heart sound (S4) may be heard on atrial systole if resistance to ventricular
filling that is present; this is an abnormal finding, and causes include cardiac
hypertrophy, disease, or injury to the ventricular wall.
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J. PHYSIOLOGY OF CARDIAC OUTPUT

 CARDIAC OUTPUT – the volume of blood ejected by each ventricle into
the aorta or pulmonary trunk per minute.
 It is determined by computing Stroke volume x heart rate.
 The average Cardiac output is 5L/minute.
 STROKE VOLUME – the
amount of blood ejected by
ventricle during each systole.
 The average SV is 70 ml/beat.
 Factors that affect Stroke
volume:
 PRELOAD
- Degree of myocardial
stretch at the end of
diastole & just before
contraction
- Determined by the
amount of blood
returning to the heart
from venous &
pulmonary system
STARLING'S LAW
- The more the heart is filled during diastole, the more forcefully it contracts
 CONTRACTILITY
- Force generated by the contracting enhanced by myocardium
- Catecholamines, sympathetic activity and with medications such as
the 3 D's (Digoxin, Dopamine, Dobutamine)
 AFTERLOAD
- Pressure or resistance that the ventricles must overcome to eject blood
through the semi-lunar valves.
- Directly proportional to the BP & Diameter of blood vessels
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Figure 1. Cardiac
output is influenced by
heart rate and stroke
volume, both of which
are also variable.
Main Components of Vascular System

1. Arteries- carry blood away
from the heart.
3 Layers of the
Arteries
a. Tunica Intima-
inner layer made up
of the endothelium
(simple squamous
epithelium)
b. Tunica Media-
middle layer of the
connective tissues,
smooth muscles or
elastic fibers.
c. Tunica Adventitia- the outer layer, made up of connective tissue and serves to
protect and anchor vessel.
2. Capillaries- -connect the arterioles with the venules, where exchange of gases,
nutrients and metabolic waste products occur.
3. Veins- thin-walled vessels which transport deoxygenated blood from the capillaries
back to the heart.
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Factors that Affect Arterial Circulation

a. Blood flow- refers to the volume of blood transported in a vessel, in an organ or
throughout the entire circulation over a given period of time.
- Commonly expressed as liters or milliliters per minute.
b. Peripheral Vascular Resistance (PVR) - refers to the opposing forces or

impedance to blood flow as the arterial channels become more and more distant
from the heart.
3 Factors that affects PVR

a. Blood viscosity
b. Length of the vessel
c. Diameter of the vessel
c. Blood Pressure- force exerted against the walls of the arteries by the blood as it is
pumped from the heart.
-most accurately referred to as Mean Arterial Pressure (MAP)
Factors Influencing Arterial Blood Pressure
1. SNS and PNS – primary mechanisms that regulate BP.

SNS – exerts major effect on peripheral resistance by causing vasoconstriction
PNS – causes vasodilation of the arterioles, lowering blood pressure.
2. Baroreceptors and chemoreceptors in the aortic arc, carotid sinus and other
LV’s
3. Kidneys help maintain BP by excreting or conserving sodium water
4. Temperatures (Cold – vasoconstriction, Warmth – produces vasodilation)
5. Chemical, Hormones and Drugs
- Epinephrine  vasoconstriction and increased HR
- Prostaglandins  dilate BV diameter by relaxing Vascular smooth muscle
- Endothelin  a chemical released by the inner lining of vessels is a potent
vasoconstrictor
- Nicotine  vasoconstriction
- Alcohol and histamine  vasodilation
5. Dietary Factors – intake of salt, saturated fats and cholesterol elevate BP by affecting
BV and vessel diameter.
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You have already finished the overview of the anatomy, physiology and functions
of the cardiovascular and peripheral system. Anyway, this is only a simple recall.
At this time, we will begin to discuss coronary heart, cardiac and peripheral
disorders. If you have queries or concerns my messenger and contacts are free, just
let me know.
Care of Clients with Coronary Heart Disease and Cardiac Disorders

1. CORONARY ATHEROSCLEROSIS
- Progressive disease
characterized by atheroma
(plaque) formation, which
affects the intimal and medial
layers of large and midsize
arteries.
RISK FACTORS
a. Non modifiable
1. Age – more than 50% of
heart attack victims are
65 or older.
2. Gender – men are
affected by CHD at an
earlier age than women.
3. Genetic factors – a family history of CHD in a male first-degree relative
younger than age 55 or a female first degree relative younger than 65 y/o.
b. Modifiable
1. Hypertension- consistent blood pressure readings greater than 140 mmHg
systolic or 90 mmHg diastolic.
2. Diabetes – associated with higher blood lipid levels, HPN and obesity.
3. Abnormal blood lipids- high levels of LDL promote atherosclerosis- LDL
deposits cholesterol on arterial walls.
4. Cigarette Smoking
5. Physical Inactivity
6. Diet
7. Risk factors unique to women- premature menopause, oral contraceptive
use and hormone replacement therapy.
8. Obesity
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LABORATORY/ DIAGNOSTIC TEST/S

a. Total serum cholesterol
b. C- reactive protein
c. Exercise ECG Testing- used to assess the response to increase cardiac workload
induced by exercise.
d. Electron Beam Computed Tomography (EBCT) - creates a three-dimensional
image of the heart and coronary arteries that can reveal plaque and other
abnormalities.
MANAGEMENT
a. Risk Factors Management
 Smoking Cessation
 Diet- reduce saturated fats and cholesterol intake
- increase intake of foods that helps raise HDL levels
- moderate alcohol consumption
 Exercise- regular physical exercise reduces the risk of CHD in several
ways: (1) lowers VLDL, LDL and triglyceride levels and raises HDL
levels (2) reduces BP and insulin resistance.
 Hypertension- reduce sodium intake, regular exercise, stress
management and medications.
 diabetes- weight loss and blood glucose management
 Obese/overweight – loss weight thru a combination of reduced calorie
intake and exercise.
b. Pharmacological Management
 Anti-hyperlipidemic Agents
 Statins
 Bile acid sequestrants
 Nicotinic acid
 Fibrates
NURSING DIAGNOSES AND INTERVENTIONS
a. Imbalance Nutrition: More than body requirements

1. Encourage assessment of food intake and eating patterns to help identify
areas that can be improved.
2. Provide guidance regarding specific food choices with healthy alternatives.
3. Refer to a clinical dietitian for diet planning and further teaching.
4. Encourage gradual but progressive dietary changes.
5. Encourage reasonable goals for weight loss.
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b. Ineffective Health Maintenance

1. Discuss the immediate benefits of smoking cessation.
2. Help the client identify specific sources of psychosocial and physical
support for smoking cessation, dietary and lifestyle changes.
3. Discuss the benefits of regular exercise for cardiovascular health and
weight loss.
4. Provide information and teaching about prescribed medications such as
cholesterol-lowering drugs.
2. ANGINA PECTORIS
- Chest pain resulting from reduced
coronary blood flow, which causes
a temporary imbalance between
myocardial blood supply and
demand.
Three Types:
a. Stable Angina- most common
and predictable form of an gina.
- Occurs when the work of the
heart is increased by physical
exertion, exposure to cold or by stress.
b. Prinzmetal’s (Variant) Angina- occurs unpredictably (unrelated to activity)
and often at night.
c. Unstable Angina- occurs with increasing frequency, severity and duration.
CAUSES
a. Atherosclerosis
b. Vessel constriction
c. Hyper metabolic conditions- exercise, stimulant abuse, hyperthyroidism and
emotional stress
d. Anemia
e. Heart failure
f. Ventricular hypertrophy
g. Pulmonary diseases
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MANIFESTATIONS
a. Chest pain- cardinal sign
- Classic sequence is activity-pain, rest-relief
- Pain is described as a tight, squeezing, heavy pressure or constricting
sensation.
- Begins beneath the sternum and may radiate to the jaw, neck,
shoulder or arm.
b. Dyspnea
c. Pallor
d. Tachycardia
e. Anxiety and fear
f. Indigestion
g. Nausea and Vomiting
h. Upper back pain
Classification of Angina According to Severity:

a. Class I- does not occur with ordinary physical activities
- Prompted by strenuous, rapid or prolonged physical exertion.
b. Class II- may develop with rapid or prolonged walking or stair climbing
c. Class III- limits ordinary physical activities.
d. Class IV- may have angina at rest as well as with any physical activity.

a. Electrocardiography- changes are seen during angina episodes- ST segment is
depressed or down sloping and the T wave may flatten or invert.
b. Stress electrocardiography/ exercise stress test- uses ECG to monitor the
cardiac response to an increased workload during progressive exercise.
c. Radionuclide Testing- safe, noninvasive technique to evaluate myocardial
perfusion and left ventricular function.
- The amount of radioisotope injected is very small, no special radiation
precautions are required during or after the scan.
- Thallium-201 or a technetium-based radio compound is injected
intravenously and the heart is scanned with a radiation detector.
- Ischemic or infracted cells of the myocardium do not take up the
substance normally, appearing as a “cold spot” on the scan.
d. Echocardiography- noninvasive test that uses ultrasound to evaluate cardiac
structure and function.
e. Coronary Angiography- gold standard in evaluating the coronary arteries.
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- Guided by fluoroscopy, a catheter is introduced into the femoral or brachial

artery is threaded into the coronary artery and dye is injected into each
coronary opening.
Nursing Care:
Before Procedure
1. Explain the procedure.
2. No food or fluids are allowed
for 6-8 hours before the test.
3. Assess for allergies to seafood,
iodine or iodine contrast dyes.
4. Assess for use of NSAIDS and
history of kidney disease.
5. Discontinue oral
anticoagulants, heparin may be
ordered to prevent thrombi.
6. An IV of D5W is started at
KVO (for emergency drugs)
During the Procedure

1. Client is positioned on a padded table that tilts.
2. A local anesthetics is used at the catheter insertion site.
3. ECG leads are applied and V/s are monitored.
4. The client lies supine and is asked for cough, deep breathe frequently. Procedure
takes 30 mins to 3 hours.
5. Tell the client that a hot, flushing sensation may be felt for a while when the dye
is injected.
After the Procedure

1. Monitor v/s every 15 minutes for the 1st hour and then every 30 minutes until
stable.
2. Assess client for complaints of chest heaviness, shortness of breath, abdominal
or groin pain.
3. Monitor catheter inserted at site for bleeding or hematoma.
4. Administer pain medications as prescribed.
5. Instruct client to remain on bed rest for 6-12 hours.
6. Encourage oral fluids unless contraindicated.
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MANAGEMENT
a. Pharmacological Management
1. Nitrates- nitroglycerin and longer acting nitrate preps
- Sublingual NTG is the drug of choice- acts within 1-2 mins
- Longer acting NTG preps (oral tablets, ointment or transdermal
patches) are used to prevent attacks of angina, NOT to treat an ACUTE
attack.
2. Beta blockers- propranolol, metoprolol, nadolol and atenolol- considered
first line drugs to treat stable angina.
3. Calcium channel blockers- reduce myocardial oxygen demand and
incease myocardial blood and oxygen supply. (Ex: Verapamil, Diltiazem,
Nifedipine)
4. Aspirin- low dose aspirin is often prescribed to reduce the risk of platelet
aggregation and thrombus formation.
b. Health Promotion Management

1. Encourage client to stop smoking.
2. Encourage regular aerobic exercise.
3. Diet – low sodium, low fat, low cholesterol, high fiber, avoid saturated
a. Ineffective Tissue Perfusion: Cardiac

1. Keep prescribed NTG tablets at the client’s side so one can be taken at the
onset of pain.
2. Start oxygen at 4 to 6 L/min per nasal cannula or as prescribed.
3. Space activities to allow rest between them.
4. Teach about prescribed medications to maintain myocardial perfusion and
reduce cardiac work.
5. Instruct to take SL NTG before engaging in activities that precipitate angina.
6. Encourage to implement and maintain a progressive exercise program under
the supervision of the primary care provider or a cardiac rehabilitation
professional.
7. Refer to a smoking cessation program as indicated.
b. Risk for Ineffective Therapeutic Regimen Management
1. Assess knowledge and understanding of angina.
2. Teach about angina and atherosclerosis as needed, building on current
knowledge base.
3. Provide written and verbal instructions about prescribed medications and
their use.
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4. Stress the importance of taking chest pain seriously while maintaining a

positive attitude.
5. Refer to a cardiac rehabilitation program or other organized activities and
support groups for clients with coronary heart disease.
3. ACUTE CORONARY SYNDROME

- A condition of unstable cardiac
ischemia.
- It includes unstable angina and
acute myocardial ischemia.
PRECIPITATING FACTORS
a. Rupture or erosion of
atherosclerotic plaque with
formation of a blood clot that
does not fully occlude the
vessel.
b. Coronary artery spasm
c. Progressive vessel obstruction by atherosclerotic plaque or restenosis following
a percutaneous revascularization procedure
d. Inflammation of a coronary artery
e. Increased myocardial oxygen demand and/or decreased supply
MANIFESTATIONS
a. Chest pain- usually substernal or epigastric, radiates to the neck, left shoulder
and/ or left arm
b. Dyspnea
c. Diaphoresis
d. Pallor
e. Cool skin, tachycardia and hypotension
a. Cardiac muscle troponins- cardiac specific troponin T and cardiac specific
troponin I are sensitive indicators of myocardial damage. May be elevated in
ACS.
b. Creatine kinase (CK) and CK-MB- are likely to be within normal limts or
demonstrate transient elevation, returning to normal levels within 12 to 24
hours.
c. ECG- particularly when done during the acute episode of chest pain is a
valuable diagnostic tool for ACS.
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MANAGEMENT
1. Fibrinolytic drugs
- Streptokinase
- APSAC- anisoylated plasminogen streptokinase
- t-PA, tenecteplase, retaplase(rPA)
2. Nitrates and Beta blockers
3. Anticoagulants- inhibit blood clotting and reduce the risk of thrombus
formation- heparin.
4. Antiplatelet drugs- suppress platelet aggregation (aspirin, clopidogrel)
- IV antiplatelet drugs- abciximab, eptifibatide, tirofiban- used
when an invasive coronary revascularization procedure is
anticipated
b. Revascularization procedures
- Used to restore blood flow and oxygen to ischemic tissue.
- Non-surgical techniques include transluminal coronary angioplasty, laser
angioplasty, coronary atherectomy and intracoronary stents.
Percutaneous Coronary Revascularization (PCR)

- Used to restore blood flow to the ischemic myocardium in clients with
CHD.
Nursing Care
Before:
1. Assess knowledge of the procedure and expectations of treatment.
2. Discuss possible sensations during the procedure.
3. Perform a comprehensive assessment, including hydration status (skin and
mucous membrane moisture, turgor) and peripheral circulation (color, warmth,
sensation, pulses, and capillary refill).
After:
1. Complete a head-to-toe assessment.
2. Monitor v/s and cardiac rhythm continuously.
3. Monitor for and threat or report chest pain as indicated.
4. Maintain bed rest as ordered in the High back rest at 30 degrees or less.
5. Monitor distal pulses, color, movement, sensation of the affected leg and
insertion site every 15 minutes for the first hour, every 30 minutes for the next
hour, every hour for the next 8 hours, then every 4 hours.
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Percutaneous
transluminal
coronary angioplasty
(PTCA)
- a balloon-tipped
catheter is threaded
over the guide
wire, with the
balloon positioned
across the area of
narrowing.
- the balloon is
inflated to
compress the
plaque followed by
placement of a
stent.
Coronary Artery
Bypass Grafting
- It involves using
a section of a vein or an
artery to create a
connection (or bypass)
between the aorta and
the coronary artery
beyond the obstruction.
- The internal
mammary artery in the
chest and the saphenous
vein from the leg are the
vessels most commonly used.
- A median sternomy commonly is used to access the heart.
- Heart is stopped during surgery
- Cardiopulmonary bypass (CPB) is used to maintain perfusion to the rest of the
organs during open-heart surgery.
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Transmyocardial Laser Revascularization

- A laser is used to drill tiny holes into the myocardial muscle itself to provide
collateral blood flow to ischemic muscle.
4. HEART FAILURE
- Myocardium weakens and enlarges, loses its ability to pump blood through the
heart and into the systemic circulation.
- Inability of the heart to pump enough blood to meet the needs of tissues for
oxygen and nutrients.
- Decreased heart contractility/ Pump failure.
- Inadequacy of the heart to pump blood throughout the body.
- Insufficient perfusion of body tissues (decreased cardiac output).
COMMON CAUSES OF HEART FAILURE

 Hypertension
 CAD
 Cardiomyopathy
 Substance abuse (Alcohol, Cocaine, Amphetamines)
 Valvular disease
 History of myocardial infarction
 Congenital defects
 Cardiac infections & inflammations
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AA CLASSIFICATION OF HEART FAILURE

Patients at high risk for Developing left ventricular
STAGE A Dysfunction but without structural heart disease or symptoms of heart
failure
Patients with left ventricular dysfunction or structural heart disease who
STAGE B have not developed symptoms of
heart failure
Patients with left ventricular dysfunction or structural heart disease with
STAGE C current or prior symptoms of heart
failure
Patients with refractory end-stage heart failure requiring specialized
STAGE D
interventions
TWO MAJOR TYPES OF HEART FAILURE

1. Systolic heart failure- alteration in ventricular contraction which is
characterized by weakened heart muscle.
2. Diastolic heart failure- characterized by a stiff and non- compliant heart
muscle making it difficult for the ventricle to fill. The signs and symptoms of
HF can be related to which ventricle is affected.
LEFT-SIDED HEART FAILURE

 Pulmonary venous blood volume and
pressure increase, forcing fluid from
the pulmonary capillaries into the
pulmonary, tissues and alveoli,
causing pulmonary, interstitial
edema and impaired Gas exchange.
 Pulmonary congestion occurs
 Signs and symptoms:
Pulmonary/Lung (Left=Lung)
 Dyspnea, cough, pulmonary
crackles/rales, and low
oxygen saturation levels.
 Orthopnea, difficulty
breathing when lying flat.
 Frothy, pink (blood-tinged)
sputum: pulmonary congestion (pulmonary edema)
 An extra heart sound, the S3, or "ventricular gallop," may be detected
on auscultation.
 The dominant feature in HF is inadequate tissue perfusion.
Page 24 of 43
Compensatory Mechanisms
 Compensatory mechanisms act to restore cardiac output to near-normal levels.
- Sympathetic nervous system stimulation
 Arterial vasoconstriction
 Increases afterload
 Increased left cardiac workload
 Increased heart rate
 Improved stroke volume
 Arterial vasoconstriction
- Renin-angiotensin system activation
 A decrease in renal perfusion due to low cardiac output causes the
release of renin by the kidneys.
 Renin promotes the formation of Angiotensin I, a benign, inactive
substance.
 Angiotensin- converting enzyme (ACE) in the lumen of
pulmonary blood vessels converts angiotensin I to angiotensin II a
potent vasoconstrictor, which then increase blood pressure and
afterload.
 Angiotensin II also stimulates the release of aldosterone from the
adrenal cortex, resulting in sodium and fluid retention by the renal
tubules and stimulation of antidiuretic hormone. These
mechanisms lead to the fluid volume overload commonly seen in
HF.
COMMON NURSING DIAGNOSES

a. Impaired gas exchange related to ventilation perfusion imbalance
b. Decreased CO related to altered contractility, preload & afterload
c. Activity intolerance related to an imbalance between 02 supply and demand
d. Potential for pulmonary edema, pneumonia, dysrhythmias
MANAGEMENT
1. Patients with orthopnea usually prefer not to lie flat. They may need pillows to
prop themselves up in bed, or they may sit in a chair and even sleep sitting up.
2. Monitor vital signs and look for changes.
3. Record fluid intake and output—weigh daily to assess for fluid overload.
4. Position patient in semi-Fowler's position to oxygen as ordered because it ease
breathing
5. Administer oxygen as ordered because it helps to decrease workload of heart.
6. Administer diuretic as prescribed.
7. Tell the patient to eat foods low in sodium to avoid fluid retention.
Page 25 of 43
RIGHT-SIDED HEART FAILURE

 Right side of the heart cannot eject blood and cannot accommodate all the blood
that normally returns to it from the venous circulation.
 Increased venous pressure leads to Jugular vein distention and increased capillary
hydrostatic pressure throughout the venous system.
 Edema of the lower extremities (dependent system edema)
 Hepatomegaly (enlargement of the liver)
 Ascites (accumulation of fluid in the peritoneal al cavity)
 Weight gain due to retention of fluid.
"Inability of the right heart to empty its blood volume results in blood backing up
into the systemic circulation. LV failure is the most common cause of right
ventricular (RV) failure. Sustained pulmonary hypertension also causes RV failure".
NURSING INTERVENTIONS
1. Monitor heart rate and for dysrhythmias by using a cardiac monitor.
2. Assess for edema in dependent areas and in the sacral, lumbar, and posterior
thigh regions in the client on the bed rest.
3. Avoid the unnecessary IV administration of fluids.
4. Monitor weight to determine a response to treatment.
5. Assess for hepatomegaly and ascites, and measure and record abdominal girth.

a. Atrial natriuretic peptide and brain natriuretic peptide- are hormones
released by the heart muscle in response to changes in blood volume.
- Blood levels of these hormones increase in heart failure.
b. Serum electrolytes- are measured to evaluate fluid and electrolyte status.
c. Urinalysis, BUN, Serum creatinine- are obtained to evaluate renal function.
d. Liver function tests- ALT, AST, LDH, serum bilirubin, total protein and
albumin levels
-are obtained to evaluate possible effects of heart failure on liver function.
e. Arterial blood gases (ABGs)- used to evaluate gas exchange in the lungs and
tissues.
f. Chest x-ray- may show pulmonary vascular congestion and cardiomegaly in
heart failure.
g. ECG- used to identify changes associated with ventricular enlargement,
myocardial ischemia or infarction.
h. Radionuclide imaging- used to evaluate ventricular function and size.
Page 26 of 43
MANAGEMENT
1. ACE INHIBITORS ( e.g. enalapril, catopril, moexipril, ramipril, lisinopril,
quinapril)
2. Angiotensin II Receptor Blockers (ARBs) they do not block the
production of angiotensin II instead they block its ACTION.
- Candesartan, losartan, valsartan, irbesartan, telmisartan
3. Beta blockers- improve cardiac function in heart failure by inhibiting SNS
activity. It is used in low doses.
4. Diuretics- relieve symptoms related to fluid retention.
- Loop/High ceiling diuretics
- Thiazide diuretics
5. Vasodilators- relax smooth muscle in blood vessels, causing dilation.
6. Digitalis glycosides/cardiac glycosides- has a positive inotropic effect on
the heart.
- digoxin (lanoxin), digitoxin
- watch out for DIGITALIS TOXICITY
7. Anti-arrthymics- amiodarone
b. Other treatments
Circulatory Assistance Devices
Intra-aortic balloon pump
Left ventricular assist device
Page 27 of 43
Care of Clients with Peripheral Vascular Disorders

1. HYPERTENSION
- An abnormal elevation of BP; systolic pressure above 140 mmHg and or diastolic
pressure above 90 mmHg for at least two readings.
Classification of Blood Pressure for Adults

Classification Systolic BP (mm Hg) Diastolic BP (mm Hg)
Normal < 120 < 80
Prehypertension 120 – 139 80 – 89
Stage 1 Hypertension 140 – 159 90 – 99
Stage 2 Hypertension > 160 > 100
TYPES
1. PRIMARY/ESSENTIAL HYPERTENSION
- Persistently elevated systemic blood pressure.
- Accounts 90-95% of all cases of HPN.
- More than 90% of these which has no identified cause
- Cause is unknown
NONMODIFIABLE RISK FACTORS

a. Family History/ Genetic Factor
b. Age- incidence of hypertension rises with increasing age.
c. Race- more common and more severe in blacks than in people of other ethnic
backgrounds.
MODIFIABLE RISK FACTORS

a. High sodium intake associated with fluid retention
b. Obesity central obesity
c. Excess alcohol consumption
d. Insulin resistance hyperinsulemia is linked with HPN
e. Stress physical and emotional stress cause transient elevation of BP.
2. SECONDARY HYPERTENSION
- Elevated blood pressure resulting from an identified underlying process.
- It accounts for only 5-10% of identified cases of HPN.
Page 28 of 43
CAUSES
a. Kidney disease – most common identifiable cause of HPN
b. Coarctation of the aorta – narrowing of the aorta
c. Endocrine disorders – adrenal glands d/o’s such as Cushing’s syndrome,
hyperthyroidism
d. Neurologic disorders – increased ICP causes an elevated BP
e. Drug Use – (e.g. estrogen and oral contraceptives, cocaine and
methamphetamines)
f. Pregnancy - PIH
MANIFESTATIONS
a. Headache usually in the back of the head and neck, maybe present on
awakening, subsiding during the day.
b. Epistaxis
c. Dizziness
d. Tinnitus
e. Unsteadiness
f. Blurred vision examination of the retina of the eye may reveal narrowed
arterioles, hemorrhages, exudates and papilledema (swelling of the optic nerve)
g. Nocturia
h. Nocturia
i. Nausea and vomiting
Complications: CHD, Stroke, Nephrosclerosis, Renal Impairement Hypertensive

Encephalopathy
LABORATORY AND DIAGNOSTIC TEST/S

a. Urinalysis – hematuria, proteinuria and casts often indicate kidney disease.
b. Blood Glucose
c. Lipid profile
d. ECG
e. BUN and Creatinine elevated may indicate kidney disease
f. Intravenous pyelography – x-ray examination of the kidneys, ureters, bladder that uses
iodinated contrast medium injected into veins.
g. Renal ultrasonography
h. CT scan/MRI
Page 29 of 43
MANAGEMENT
a. LIFESTYLE MODIFICATIONS
1. DIET- focus on reducing sodium intake, maintaining adequate potassium and
calcium intakes and reducing total and saturated fat intake.
- The DASH (Dietary Approaches to Stop Hypertension) diet has proven
beneficial effects in lowering BP.
 Grains- 7-8 servings/day
 Vegetables- 4-5 servings/day
 Fruits- 4-5 servings/day
 Nonfat/low fat dairy products- 2 to 3 servings/day
 Meats, poultry and fish- 2 or less 3 oz servings per day
 Nuts, seeds and dry beans- 4 to 5 servings per week
 Fats and oils- 2 to 3 servings/day
 Sweets- 5 servings per week (should be low in fat)
- Weight loss is recommended for clients who are obese.
- A balanced diet such as the DASH diet is recommended for weight loss.
2. PHYSICAL ACTIVITY
- Regular exercise reduces BP as contributes to weight loss, stress
reduction and feelings of overall wellbeing.
- engage in aerobic exercise for 30-45 minutes per days of the week- 5-6
days
- Isometric exercise (such as weight training) may not be appropriate
because it can raise the systolic BP.
3. ALCOHOL AND TOBACCO USE

- Limit alcohol intake to no more than 1 oz of ethanol (1/2 oz for women
and lighter weight people) per day.
- cessation of cigarette smoking
4. STRESS REDUCTION
- Regular, moderate exercise is the treatment of choice for reducing stress.
- Relaxation techniques as also recommended to relax both the mind and
body.
Page 30 of 43
b. Pharmacological Management
1. DIURETICS
- Preferred treatment for systolic HPN in older adults.
- First line of drugs for treating mild hypertension.
- Prevents tubular reabsorption of sodium thus promoting sodium and water
excretion and reducing blood volume.
Types:
 Potassium Wasting Diuretics
- Thiazides- Hydrochlorothiazide, Chlorothiazide
- Thiazide-like- Chlorthalidone, Indapamide
- Loop/High Ceiling- Athacrynic Acid, Furosemide, Torsemide
 Potassium- Sparing Diuretics- Aldactone
 Thiazide w/ Potassium Sparing Diuretics
- Amiloride & Hydrocholothiazide (Moduretic)
- Spironolactone & Hydrochlorothiazide (Aldactazide)
- Dyazide and Maxzide (Triamterene + Hydrochlorothiazide)
2. BETA BLOCKERS
- Reduce BP by preventing beta-receptor stimulation in the heart thereby
decreasing heart rate and CO.
- It also interferes with rennin release by the kidneys, decreasing the
effects of angiotensin and aldosterone.
- the “OLOL DRUGS”
3. ACE INHIBITORS
- Lower BP by preventing conversion of angiotensin I to angiotensin II.
- the “PRIL DRUGS”
- also blocks the release of aldosterone
4. ANGIOTENSIN II RECEPTOR BLOCKERS (ARBs)

- They act by blocking the effect of angiotensin II on receptors.
- the “SARTAN DRUGS”
- Candesartan (Atacand), Lozartan (Cozaar), Irbesartan (Avapro),
Eprosartan (Teveten), Olmesartan (Benicar), Telmisartan (Micardis),
Valsartan (Diovan)
Page 31 of 43
5. CALCIUM CHANNEL BLOCKERS

- Inhibit the flow of calcium ions across the cell membrane of vascular
tissue and cardiac cells. In doing so, they relax arterial smooth muscle,
lowering peripheral resistance through vasodilation.
- Amlidipine (Norvasc), Diltiazem (Cardizem), Felidipine (Plendil),
Nicardipine (cardene), Nifedipine (Procardia), Verapamil (Isoptin),
Nisoldipine (Sular), Israldipine (DynaCirc)
6. CENTRALLY ACTING SYMPATHOLYTICS

- Stimulate the alpha receptors in the CNS to suppress sympathetic
outflow to the heart and blood vessels. A fall in CO and vasodilation
result, reducing blood pressure.
- Conidine (Catapres), Methyldopa (Aldomet), Guanfacine (Tenex),
Reserpine
- Adverse Effects: Dry mouth and sedation.
7. VASODILATORS
- Reduce BP by relaxing vascular smooth muscle and decreasing
peripheral vascular resistance.
- Hydralazine (Apresoline), Minoxidil (Loniten) Nitroprusside,
Diazoxide
a. Ineffective Health Maintenance

1. Assist with identifying current behaviors that contribute to hypertension.
2. Assist in developing a realistic health maintenance plan.
3. Help the client and family identify strengths and weaknesses in maintaining
health.
b. Imbalanced Nutrition: More than Body Requirements

1. Assess usual daily food intake, and discuss possible contributing factors to
excess weight.
2. Mutually determine with the client a realistic target weight. Regularly
monitor weight.
3. Refer to a dietitian for information about low-fat, low-calorie food and
eating plans.
4. Recommend participating in an approved weight loss program.
Page 32 of 43
c. Excess Fluid Volume

1. Monitor I & O, and weigh daily or weekly.
2. Monitor for peripheral edema. Sacral edema in the bedridden client.
3. Refer to a dietitian for teaching about a restricted sodium diet.
2. ARTERIAL DISORDERS
a. ARTERIOSCLEROSIS – hardening of the arteries. It affects the tunica media.
b. ATHEROSCLEROSIS – narrowing/occlusion of lumen of arteries due to
accumulation of fatty plaques in the tunica intima.
The Clinical Manifestation of Arterial Disorders:

1. Pain. Intermittent claudication. This is leg pain on activity and exercise, it is relieved
by rest.
2. Coldness or cold sensitivity.
3. Impaired arterial pulsations.
4. Color changes. Cyanosis on dependency of legs.
5. Ulceration and gangrene.
6. Sexual dysfunction. Decreased penile circulation due to occlusion of terminal aorta.
A. Buerger’s Disease (Thromboangitis Obliterans)

- Characterized by recurring
inflammation of the
intermediate and small arteries
and veins of the lower and
upper extremities.
- May affect either the upper or
lower extremities – it often
affects a leg or foot.
- It also involves inflammation and fibrosis of nerves.
Causes/Risk Factors
- Unknown
- More common among males between 20-35 years old
- Cigarette smoking (most common cause)
- DM due to lack insulin resulting to increase blood sugar
- Obesity – obese individuals have hyperlipidemia (atherosclerosis)
- Polycythemia – increase RBC
Page 33 of 43
Manifestations
- Intermittent claudication (most characteristics) pain in the calf muscles after
walking or exercise.
- Coolness of extremities
- Thickening of blood nails.
- Cyanosis of legs
- Paresthesia (abnormal sensation (numbness, burning) loss of sensation
- Ulceration, muscle atrophy & gangrene.
Diagnostic Test
1. Leg Arteriography – visualization of an artery (they will inject contrast
medium/dye into the bloodstream).
2. Doppler Studies – to locate and determine the extent of the disease
3. Angiography/MRI – used to evaluate the extend of the disease
4. X-ray examination
5. UTZ
Nursing Interventions
1. Eliminate cigarette smoking and avoid standing for long periods.
2. Slow progressive physical activity.
3. Don’t elevate the affected leg because it will increase the pain (non - elevation is
the most important).
4. For presence of ulcers & gangrene – gentle washing with soap & tepid water, rinse
thoroughly, pat dry with soft towel.
5. Diet should be rich in vitamin B & C to improve CV status & skin integrity.
6. Administration of medication as prescribed such as Vasodilators (e.g. alpha
adrenergic antagonist – vasodilan (isoxsuprine Hcl), Calcium channel blockers, anti
– platelet agents & analgesic)
7. Surgery – Amputation (it is performed in clients with gangrene).
B. Raynaud’s Disease/Phenomenon
(Arteriospastic Disease)
- A form of intermittent
arteriolar vasoconstriction
that results in coldness,
pain, and pallor of the
fingertips or toes.
Page 34 of 43
Causes/ Risk Factors:

- Unknown
- Most common in women between 16 and 40 years of age
- Exposure to cold & stress
- Occupationally related to trauma & pressure to fingers, exposure to heavy
metals.
Manifestations
- Blue –white- red disease (affected digits initially turn blue as blood flow is
reduced to vasospasm. Then white as circulation is more severely limited.
Finally very red as the fingers are warmed and the spasm resolves.
- Tingling sensation
- Burning pain on the hands & feet
- Fingertips thickened, nails become brittle with repeated attacks
Diagnostic Test – no specific test
1. Avoidance of cold, mechanical & chemical injury.
2. Clients are instructed to keep their hands warm, wearing gloves when outside in
cold weather, kitchen gloves when handling cold items.
3. Cessation of smoking.
4. Swinging the arms back and forth can sometimes stop attacks
5. Stress reduction measures ( exercise, relaxation techniques, massage therapy,
aroma therapy and counseling)
6. Teach lifestyle habits that contribute to vascular health. (reducing dietary fat,
Increasing activity level and maintaining normal body weight)
7. Use of vasodilators, calcium channel blockers, anti-inflammatory, analgesics.
C. ARTERIAL OCCLUSION
- Peripheral artery may be acutely
occluded by development of a
thrombus (blood clot) or by an
embolism. Blood flow to the
tissue supplied by the artery is
impaired, resulting in acute tissue
ischemia and a risk for necrosis
and gangrene.
Page 35 of 43
1. Arterial thrombosis
- Thrombus is a blood clot that adheres to the vessel wall. Thrombi tend to
develop in areas where intravascular factors stimulate coagulation (e.g. where
a vessel lumen is partially obstructed and its wall is damaged and roughened
by atherosclerosis). Other disorders, such as infection or inflammation of the
vessel wall or pooling of blood (e.g. in an aneurysm).
2. Arterial embolism
- Embolism is sudden obstruction of a blood vessel by debris. A thrombus can
break loose from the arterial wall to become a thromboembolus.
- Other substances also can become emboli: atherosclerotic plaque, masses of
bacteria, cancer cells, amniotic fluid, and bone marrow fat and foreign objects
such as air bubbles or broken intravenous catheters.
Manifestations (related to tissue ischemia)

a.Painful, pale and cool or cold
b. Distal pulses are absent
c. Paresthesias (numbness and tingling) develop in the extremity
d. Cyanosis and mottling are common
e. paralysis and muscle spasms in the affected extremity
Diagnostic Test
a. Arteriography – used to confirm the diagnosis, locate the occlusion, and
determine its extent.
1. Protect the extremity, keeping it horizontal or lower than the heart
2. Maintain intravenous fluids as ordered. Adequate circulating blood volume is
necessary to maintain cardiac output and tissue perfusion.
3. Following surgery, avoid raising the knee gatch, placing pillows under the knees
or sitting with 90 degree hip flexion.
4. Provide emotional support especially if the client is anxious. Assess the level of
anxiety at least every 8 hours.
5. Decrease sensory stimuli as much as possible.
6. Speak slowly and clearly and avoid unnecessary interruptions when listening.
7. Administer anticoagulant as prescribed to prevent further clot propagation and
recurrent embolism.
8. Monitor activated partial thromboplastin (aPTT) during heparin therapy and
prothrombin time (PT) or International Normalized Ratio (INR) during oral
anticoagulant therapy.
Page 36 of 43
9. Protect from injury. Use side rails or other measures as needed to prevent falls;
avoid parenteral injections and other invasive procedures.
10. Surgery:
a. Embolectomy (within 4 to 6 hours) the treatment of choice for acute arterial
occlusion by an embolus to prevent tissue necrosis and gangrene.
b. Thromboendarterectomy done to remove thrombus and plaque in the
artery.
3. VENOUS THROMBOSIS (aka THROMBOPHLEBITIS)

- Condition in which a blood clot
(thrombus) forms on the wall of a vein,
accompanied by inflammation of the vein
wall and some degree of obstructed
venous blood flow.
- Venous thrombi are common than
arterial thrombi because of lower
pressures and flow within the venous
system.
- Thrombi can form in either superficial or
deep veins.
- Deep venous thrombosis (DVT) is a common complication of hospitalization, surgery,
and immobilization.
Pathologic Factors, called Virchow’s triad
a. Vessel wall injury/ damage
b. Venous stasis (stasis of blood)
c. Altered blood coagulation
Risk Factors for Venous stasis

a. Bed rest or immobilization
b. Obesity
c. History of varicosities
d. Spinal cord injury
e. Age (greater than 65 years)
Assessment
a. Obstruction of the deep veins comes edema and swelling of the extremity because
the outflow of venous blood is inhibited
b. Limb pain, a feeling of heaviness, functional impairment, ankle engorgement, and
edema.
Page 37 of 43
Diagnostic Tests
a. Duplex venous ultrasonography – a non-invasive test used to visualize the vein
and measure the velocity of blood flow in the veins.
b. Plethysmography – a noninvasive test that measures changes in blood flow
through the veins. Most valuable in diagnosing thromboses of larger or more
superficial veins.
c. Magnetic resonance imaging (MRI) – noninvasive means of detecting DVT. It
is particularly useful when thrombosis of the venae cava or pelvic veins is
suspected.
d. Ascending contrast venography – uses an injected contrast medium to assess
the location and extent of venous thrombosis. Although invasive, expensive and
uncomfortable, contrast venography is the most accurate tool for venous
thrombosis.
Medical Management
1. Anticoagulant therapy
a. Administration of a medication to delay the clotting time of blood, prevent
the formation of a thrombus in postoperative patients, and forestall the
extension of a thrombus after it has formed)
b. Oral Anticoagulant Warfarin (Coumadin)
2. Thrombolytic
a. Alteplase (Activase, t-PA)
b. Urokinase (Abbokinase)
c. Streptokinase (Streptase)
Surgery
a. Venous thrombectomy – done
when thrombi lodge in the
femoral vein and their removal
is necessary to prevent
pulmonary embolism or
gangrene. Successful thrombus
removal rapidly improves
venous circulation.
Page 38 of 43
1. If the patient is receiving anticoagulant therapy, the nurse must frequently monitor
the aPTT, prothrombin time (PT) and INR.
2. Elevation of the affected extremity, graduated compression stockings, and
analgesic agents for pain relief are adjuncts the therapy. They help improve
circulation and increase comfort.
3. Warm, moist- packs applied to the affected extremity reduce the discomfort
associated with DV.
4. The patient is encouraged to walk once anticoagulation therapy has been initiated.
The nurse should instruct the patient that walking is better than standing or sitting
for long periods.
5. Nursing alert: For ambulatory patients, graduated compression stockings are
removed at night and reapplied before the legs are lowered from the bed to the floor
in the morning.
Prevention
1. Preventive measures include the application of graduated compression stockings.
2. In surgical patients is administration of subcutaneous unfractionated or low
molecular- weight heparin (LMWH).
3. Lifestyle changes as appropriate, which may include weight loss, smoking
cessation, and regular exercise.
4. VARICOSITIES / Varicose veins

- Irregular, tortuous veins with
incompetent valves.
- Varicosities may develop in any vein,
and may be called by other names, such
as hemorrhoids in the rectum and
varices in the esophagus.
- Usually affect the veins of the lower
extremities; the long saphenous vein is
often affected.
Predisposing factors:
a. Hereditary
b. Age
c. Congenital weakness of veins
d. Thrombophlebitis
e. Heart disease
f. Pregnancy
Page 39 of 43
g. Obesity
h. Prolonged immobility - Prolonged standing (e.g. beauticians, salespeople, nurses)
Manifestations
1. Pain especially after prolonged standing (severe aching leg pain)
2. Dilated tortuous skin veins
3. Warm to touch (feelings of heat in the legs)
4. Heaviness in legs
Diagnostic Tests
1. Doppler ultrasonography or duplex Doppler ultrasound – to identify specific
locations of incompetent valves. This test is useful before surgery to identify valves that
allow reflux of blood from the femoral, popliteal, or peripheral deep veins into the
superficial veins.
2. Trendelenburg’s test – to determine the underlying cause of superficial venous
insufficiency. The leg is elevated, then an elastic tourniquet is placed around the distal
thigh. The varicosities then observed as the client stands. The vein distend quickly < 35
seconds.
 Draining of blood on lower extremities
 Then stand, observe Saphenous veins how they fill up
o Gradually = (-) Trendelenburg Test; (-) Varicose Veins
o Abruptly = (+) Trendelenburg Test’ (+) Varicose Veins
Nursing Management
1. Elevate legs above heart level – to promote venous return – 1 to 2 pillows
2. Measure circumference of leg muscles to determine if swollen.
3. Wear anti embolic or knee high stockings. Women – panty hose
4. Do not cross legs.
5. Administer medicine as prescribed (e.g. Analgesics)
6. Surgery:
a. Vein Stripping – Ligation of
Saphenous Veins
b. Sclerotherapy – Injecting of solution

at site of varicosities, formation of
hematoma
Page 40 of 43
In this portion you will answering case study related to our previous
discussion. Answer them enthusiastically. Enjoy learning!
Activity 9 Case Study

Instruction: Below are case situation related to our previous topic. Please answer them and
send back via canvas after you finished.
SITUATION: A 40 years of age and works as a newspaper editor rushed to the emergency
department of GRBASMH complaining of chest pain radiating into both arms, accompanied
by diaphoresis and shortness of breath. He has been having episodes of transient substernal and
shoulder pain over the past week. Upon history taking, he is being treated for hypertension and
is currently taking 100 mg metoprolol twice per day. He does not exercise and he smoked a
pack of cigarette daily for 20 years. He reports considerable job stress and overweight with a
body mass index of 35. His vital signs are as follows; BP 190/100 mmHg, body temperature
of 98.6 F, heart rate 97 bpm and respiratory rate 21 bpm. The physician diagnosed him with
Angina pectoris and admitted at the CCU.
Study Questions
1. What is the correlation between cigarette smoking to the following;
a. Coronary Heart Diseases (e.g. Coronary atherosclerosis)
b. Cardiac Disorders (e.g. Heart failure and etc.)
c. Peripheral Vascular Disorders (e.g. HPN and etc.)
2. Distinguish between the symptoms of angina and Myocardial Infarction.
3. The patient ask the nurse, “What is causing this pain?” What is the best response by the
nurse?
4. List specific nursing measures regarding medications, diet, activity, lifestyle changes,
and emotional support that should be implemented for the patient.
5. Discuss the nursing diagnosis of self-concept in regard to patients with angina. How
does this major problem impact their perception of self? Their relationships with
others?
Page 41 of 43
This part can be in the form of a QUIZ/

EXAMS or any Summative
Assessment. This will be conducted
online via CANVAS. For more details I
will make an announcement ahead in the
Canvas.
Thank You!
CONGRATULATIONS !
You already finished the MODULE . Hope you learned a lot.

You may now proceed to your Final examination. Goodluck and
Enjoy learning!
Page 42 of 43
PRELIMINARY EXAMINATION/
FINAL OUTPUT
For your test/final output it will

be conducted online using the
canvas. For more details wait
for further announcement.
Thank You!
Page 43 of 43

Cardiovascular Disorders Module-1

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Laoag City, Ilocos Norte

CARDIO AND PERIPHERAL

WILJOHN M. DE LA CRUZ, M.A.N.

The cardiovascular system, including the heart and blood vessels, is

Since you have a background of the anatomy and physiology of

Activity 7 Self- Assessment

1. Circulation A. carry blood away from the heart

Activity 8 Exploring your Understanding

Anatomy, Physiology and Functions of Cardiovascular and

 Pumping organ of the body.

ANATOMICAL STRUCTURE OF THE HEART

A. PERICARDIUM – strong non

 EPICARDIUM – thin, transparent outer layer of the walls of the heart.

C. CHAMBERS OF THE HEART

D. VALVES OF THE HEART

 The AV valve is held in

 CCA – supplies the left atrium, posterior lateral surface of

2. AV node (Atrioventricular node) – situated in the septum between the two

3. AV bundle (atrioventricular bundle)/Bundle of his

4. Right and Left Bundle Branches

5. Purkinje Fibers/ conduction Myofibers. Large diameter conduction myofibers

G. ELECTROPHYSIOLOGIC PROPERTIES OF THE HEART

H. THE CARDIAC CYCLE

J. PHYSIOLOGY OF CARDIAC OUTPUT

Main Components of Vascular System

Factors that Affect Arterial Circulation

b. Peripheral Vascular Resistance (PVR) - refers to the opposing forces or

3 Factors that affects PVR

Factors Influencing Arterial Blood Pressure

1. SNS and PNS – primary mechanisms that regulate BP.

Care of Clients with Coronary Heart Disease and Cardiac Disorders

LABORATORY/ DIAGNOSTIC TEST/S

NURSING DIAGNOSES AND INTERVENTIONS

a. Imbalance Nutrition: More than body requirements

b. Ineffective Health Maintenance

Classification of Angina According to Severity:

LABORATORY/ DIAGNOSTIC TEST/S

- Guided by fluoroscopy, a catheter is introduced into the femoral or brachial

During the Procedure

After the Procedure

b. Health Promotion Management

NURSING DIAGNOSES AND INTERVENTIONS

a. Ineffective Tissue Perfusion: Cardiac

4. Stress the importance of taking chest pain seriously while maintaining a

3. ACUTE CORONARY SYNDROME

Percutaneous Coronary Revascularization (PCR)

Transmyocardial Laser Revascularization

COMMON CAUSES OF HEART FAILURE

AA CLASSIFICATION OF HEART FAILURE

TWO MAJOR TYPES OF HEART FAILURE

LEFT-SIDED HEART FAILURE

COMMON NURSING DIAGNOSES

RIGHT-SIDED HEART FAILURE

LABORATORY/ DIAGNOSTIC TEST/S

Intra-aortic balloon pump

Left ventricular assist device

Care of Clients with Peripheral Vascular Disorders

Classification of Blood Pressure for Adults

NONMODIFIABLE RISK FACTORS

MODIFIABLE RISK FACTORS

Complications: CHD, Stroke, Nephrosclerosis, Renal Impairement Hypertensive

LABORATORY AND DIAGNOSTIC TEST/S

3. ALCOHOL AND TOBACCO USE

4. ANGIOTENSIN II RECEPTOR BLOCKERS (ARBs)