UN 5 Cardiovascular System Disorder

Medical Surgical
Course code:
Cardiovascular Disorders ( CVD)
For Nursing students
BY: Ibrahim Ahmed (Bsc.N)

AVC
10/03/2023 BY: Ibrahim A ( BScN) 1

ANATOMY AND PHYSIOLOGY OVERVIEW OF CVS
CVS is composed of:

Heart
Blood vessels
Blood

The heart
The heart is a hollow, muscular organ located in

the center of the thorax, where it occupies the
space between the lungs
It weighs ~300g, although its weight and size are
influenced by age, gender, body weight, heart
disease etc

Functions of the heart
The heart pumps blood to the tissues, supplying them

with oxygen and other nutrients.
Its pumping action is accomplished by the rhythmic

contraction and relaxation of its muscular wall.
Ventricle ejects ~70 mL of blood per beat and has an

output of ~5 L/minute.

Layers of the heart
The heart is composed of three layers.

Inner layer, or endocardium: endothelial
tissue, lines the inside of the heart and valves.
Middle layer or myocardium: muscle fibers,
responsible for the pumping action.
Exterior layer or epicardium: surrounds the
other layers of the heart
Layers of heart …
The heart is encased in a thin, fibrous sac called
the pericardium (double layered).
The space between these two layers (pericardial
space) is filled with about 30 mL of fluid

Pumping heart

Heart Chambers
The heart has four chambers

◦ Right atrium
◦ Left atrium
◦ Right ventricle
◦ Left ventricle

Heart Chambers

Cardiac Chambers, Valves, and Circulation

Heart Chambers…
The right atrium and right ventricle, distributes
venous blood to the lungs via the pulmonary artery
for oxygenation.
Left atrium and left ventricle, distributes
oxygenated blood to the remainder of the body via
the aorta
The left atrium receives oxygenated blood from
the pulmonary circulation via the pulmonary veins.
Heart Valves
Valves of the heart permit blood to flow in only one

direction.
There are two types of valves:
1. Atrioventricular (AV) and

2. Semilunar valves

ATRIOVENTRICULAR VALVES
Separate the atria from the ventricles.
The tricuspid valve (right)

The mitral, or bicuspid valve, (left)

SEMILUNAR VALVES
The valve between the right ventricle and the

pulmonary artery is called the pulmonic valve;
The valve between the left ventricle and the aorta
is called the aortic valve.

Coronary Arteries
 The left and right coronary arteries and their branches
supply arterial blood to the heart.

 The heart has large metabolic requirements, extracting
~70% to 80% of the oxygen delivered.

 Resting coronary blood flow is roughly 225 ml/min
which results in 4- 5% of the total cardiac output.

Conduction system of the heart
Generate and coordinate the transmission of

electrical impulses to the myocardial cells.
The result is sequential atrioventricular

contraction, which leads to effective flow of
blood, thereby optimizing cardiac output.

Conduction system…
Three physiologic characteristics of the cardiac
conduction cells account for this coordination:
 Automaticity: Refers to an individual cell’s ability to “self-excite” without
any impulse from an outside source

 Excitability: Refers to the ability of a cell to respond to an electrical
stimulus.
 Conductivity: : Refers to the ability of each cell of the conduction system
to conduct individual electrical impulses from one cell to another.

The SA node
The sinoatrial (SA) node: primary pacemaker of the

heart, located at the junction of the superior vena cava
and right atrium.
The SA node in normal resting heart has an inherent

firing rate of 60 to 100 impulses per minute
The heart rate is determined by the myocardial cells with

the fastest inherent firing rate (SA node).

Conduction system…
 Under normal circumstances, the SA node has the
highest inherent rate, the AV node has the second

highest inherent rate (40 to 60), and the ventricular
pacemaker sites have lowest inherent rate (30 to 40)

Specialized excitatory and conductive system of the heart
1. Sino-atrial node (SA-node): in which the normal
(60-100 x/min) rhythmical self-excitatory impulse
is generated Located on the posterior wall of the R-
atrium inferior to the opening of the SVC
2. Internodal pathways: conduct impulse from the
SA-node to the AV-node
3. Atrioventricular node (AV-node): in which
impulse from the atria delayed to be conducted to
the ventricle.
 located just above tricuspid valve .
 Site of nodal delay. 40-60 x/min
 This node acts as an electrical gateway to the
Cont…d
4. Atrioventricular bundle (bundle of His):
which conducts impulse from the atria to the
ventricle.
5. Purkinje fibers: conduct cardiac impulse to the
ventricles

The auto rhythmic cells are
1. Sinoatrial (SA), or
sinus node
 Internodal
pathways
2. Atrioventricular (AV)
node
3. Atrioventricular (AV)
bundle (also called the
bundle of His)
4. Right & left bundle
branches
5. Purkinje fibers

The Impulse Travel in the heart
SA node

Internodal pathways

Atrioventricular node (AV node)

Impulse is delayed slightly

AV bundle (bundle of his)

Left and right bundle branches

Purkinje fibers

All parts of the ventricles

Contraction10/03/2023 BY: Ibrahim A ( BScN) 24
SA node
AV node
Bundle of His
Bundle Branches
Purkinje fibers

Cardiac Conduction

Cardiac cycle
Activities in the heart in a single beat
Contraction and relaxation of cardiac chambers
A single cardiac cycle comprised of
-Atrial diastole + atrial systole and
-Ventricular diastole + ventricular systole
75 cycles completed per minute
Duration of each cycle = 0.8 second
-Ventricular diastole = 0.5 second
-Ventricular systole = 0.3 second
◦ Systole-period of chamber contraction
◦ Diastole-period of chamber relaxation
An ECG is a recording of the electrical activity that initiates each
heartbeat.

1. Atrial contraction
Preceded by P wave (atrial excitation)

Pressure rise in atrium
Increase ventricular volume, small, transient at
rest
Mitral and tricuspid valves open
Contribute 10-20% to ventricular filling
End of atrial systole is also end of ventricular
diastole

2. Isovolumetric contraction
Initiated by ventricular excitation (QRS wave)

Mitral and tricuspid valves close because of pressure
gradient (aortic and pulmonic valves already closed)
Rapid rise in ventricular pressure
No change in ventricular volume (isovolumetric=
constant volume)
Decreasing aortic (and pulmonic) pressure
First heart sound begins

3. Ventricular ejection
Begins when ventricular pressure exceeds aortic (or

pulmonary artery)
Aortic (and pulmonic) valves open
Ventricular (and arterial) pressures increase to
maximum ("systolic pressure") and then decrease
slowly as the ventricular begin to relax
Initial low atrial pressure followed by increasing
atrial pressure as the atria fill with blood returning
via the veins from the peripheral vascular beds
Ventricular repolarization begins (T wave)

4. Isovolumetric relaxation
Begins when ventricular pressure drops below
aortic (or pulmonary artery)
Aortic (and pulmonic) valve closes (mitral and
tricuspid already closed)
Rapid fall in ventricular pressure
No change in ventricular volume
Decreasing arterial pressure
Increasing atrial pressure (venous "v" wave)
Second heart sound begins
5. Ventricular filling
Begins when ventricular pressure drops below
atrial pressure
Mitral (and tricuspid) valves open
Flow of blood from atrium to ventricle, initially
rapid, then slower as the ventricles fill
Ventricular pressure decreases and then rises
slowly as the ventricles fill

Cardiac cycle

Electrocardiography
An ECG is a recording of the electrical activity that
initiates each heartbeat from the surface of the
body using highly sensitive electrodes..
ECG provides events about arrhythmia,
hypertrophy, myocardial damage, ischemia and
necrosis
 The instrument used to record the changes is
an electrocardiograph

Cont,,,d
Depolarization: electrical activation of a cell
caused by the influx of sodium into the cell while
potassium exits the cell(converting the internal
charge of the cell to a positive one). Contraction
of the myocardium follows depolarization.
Re-polarization: return of the cell to resting state,
caused by reentry of potassium into the cell while
sodium exits the cell (this corresponds to
relaxation of myocardial muscle.)

Deflection Waves of ECG
1. P wave -initial wave, demonstrates the depolarization from SA
Node through both Atria; the Atria contract about 0.1 s after
start of P Wave
2. QRS complex-depolarization of AV node through both
ventricles; with a short delay after the end of atrial
contraction
3. T Wave –re-polarization of the ventricles (0.16 s)
Ventricles starts to relax.
4. PR (PQ) Interval -time period from beginning of atrial
contraction to beginning of ventricular contraction (0.16 s)
5. QT Interval -the time of ventricular contraction ( 0.36 s);
from beginning of ventricular depolarization to end of re-
polarization 10/03/2023 BY: Ibrahim A ( BScN) 37
60 seconds ÷0.8 seconds = resting heart rate of 75 beats/minute

Interpretation of ECG

HEART SOUNDS
Causes
1. Closure of valves (e.g. normal heart sounds)
2. Rapid acceleration of blood (e.g. opening snap of
mitral stenosis)
3. Turbulence (e.g. murmurs)

Cont…d
Heart sounds (lubb-dubb) are associated with closing of heart
valves
4-separate audible heart sounds (S1, S2, S3 and S4)
Means of identification
1. Auscultation: direct/immediate auscultation
Stethoscope mediated auscultation
2. Phonocardiographic based recording
S3
S4 S2
S1

Cont..d
S1: First heart sound
Causes:
sudden closure of AV-valves.
has ‘lub’ sound
Timing: occurs at the beginning of ventricular systole
Best site of auscultation
5th LIS, at midclavicular line
4th LIS, near the sturnum

Heart Sounds (cont’d)
S2: Second heart sound

Cause: Sudden closure of semilunar valves
 Has ‘dub’ sound.
Timing: occures at the beginning of ventricular diastole
Best site of auscultation
near the sternum
 Continuous heart sound: Lubb-Dubb, Lubb-Dubb

 Duration of Lubb-Dubb is shorter than that of Dubb-Lubb

Best sites of heart sound auscultation

Heart Sounds (cont’d)
S3: Third heart sound
Cause: rapid filling of the ventricles with blood during
ventricular diastole
It is audible in children and in adults during exercise
Best site of auscultation: at the apex of the heart beneath

the xiphoid process
S4: Fourth heart sound
Cause: rapid ventricular filling during atrial systole
Timing: during atrial systole
Best site of auscultation: at the apex of the heart Usually
not heard.
Heart Murmurs
sounds other than the typical "lub-dub"; typically

caused by disruptions in flow
1.incompetent valve -swishing sound just after the
normal "lub" or "dub"; valve does not completely
close, some regurgitation of blood
2.Stenotic valve -high pitched swishing sound when
blood should be flowing through valve; narrowing
of outlet in the open state

Important terms
 Ventricular volumes:
The volume of blood in the ventricles
 Ventricular end diastolic volume (VEDV):
The volume of blood in the ventricle at the end of ventricular
diastole
EDV = 130 ml
 Ventricular end systolic volume (VESV):
The volume of blood that remains in the ventricle at the end of
ventricular systole.
VESV = 60 ml
 Stroke volume (SV):
the volume of blood ejected from the ventricle during
ventricular systole.
SV = VEDV – VESV, 130 – 60 ml
SV= 70 ml

Cont...d
Cardiac output: the volume of blood ejected
from the heart per minute. CO = SV x HR,
6 L/min
Ejection fraction: the blood proportion that
enters the ventricles during diastole to the
amount ejected.
EF = VEDV/SV, 60% - 70%

Regulation of HR
Autonomic Regulation of Heart Rate
Sympathetic(NE) increases heart rate
Parasympathetic(ACh) decreases heart rate vagal tone-
parasympathetic inhibition of inherent rate of SA node,
allowing normal HR
Hormonal and Chemical Regulation of Heart Rate
o Epinephrine-by adrenal medulla during stress; increases HR
o Thyroxine-increases heart rate in large quantities

Cardiac Hemodynamics
An important determinant of blood flow in the CVS is

the principle that fluid flows from a region of higher
pressure to one of lower pressure.
These pressures are generated during cardiac cycle

Cardiac Cycle
It has two phases:

1. Diastole – ventricles relax & fill with blood (2/3
of the cardiac cycle.)
2. Systolic – heart contracts & pushes blood out of
the ventricles (1/3 of the cardiac cycle) to:
the lungs
systemic arteries
CONTROL OF STROKE VOLUME
SV is primarily determined by three factors:

1. Preload : the degree of stretch of the cardiac muscle
fibers at the end of diastole. (volume & speed of
venous return)
2. Afterload: the amount of resistance to ejection of

blood from the ventricle.
3. Contractility: is the force generated by the

contracting myocardium under any given condition

Blood Vessels
Composed of:
Arteries
Arterioles
Veins
Venules
Capillaries

Blood Vessels…
10/03/2023
10/03/2023 BY:FB
By Ibrahim A ( BScN) 55
Blood Functions - Distribution
Supplies Oxygen from lungs to cells
Supplies nutrients from digestive system to cells
Transports metabolic wastes from cells to disposal
sites
Transports hormones to target tissues/organs …

Blood Functions - Regulation
 Regulates body temperature

 Regulates the pH of body fluids
 Regulates blood volume to support efficient
circulation to cells, tissues, organs & systems
 Prevents blood loss
 Prevents infections

Formed Elements - Cells/Components
 Erythrocytes (RBCs)
Platelets
 Leucocytes (WBCs)

150,000 to 450,000/mm3
4,000 - 11,000/cm3)
4 - 6 million/mm3

Assessment of Cardiovascular System
62
Subjective and objective Data
1. Age 10. Edema
2. Gender 11. Nocturia
3. Chest pain 12. Dizziness or syncope
4. Dyspnea 13. Palpitation
5. Orthopnea 14. Height and current body
weight
6. Cough
15. Past cardiac history
7. Fatigue
16. Family cardiac history
8. Cyanosis or pallor
17. Personal habits
9. Leg pain
18. Environment
63
Other history to be taken
Lifestyle
Diet
Weight reduction
Exercise
Smoking
Cholesterol level
Screening for hypertension

Inspection of the skin:
Pallor
Cyanosis
Reduced skin turgor
Temperature
Moisture

Peripheral Cyanosis

Arterial Pulses cont’d…

Common diagnostic test for CVD
History
Physical examination
Blood tests
Urine analysis
Chest x-rays
ECG
Angiography
Cardiac catheterization etc

NURSING MANAGEMENT OF
PATIENTS WITH
CARDIOVASCULAR DISORDERS
(CVD)

Coronary Artery Disease (CAD)
 CAD is the most prevalent cardiovascular disease
Coronary Atherosclerosis
Arteriosclerosis is thickening or hardening of

arteries
Atherosclerosis is a type of arteriosclerosis caused

by a build-up of plaque (fatty substances,
cholesterol, cellular wastes) in the inner lining of an
artery.
CAD …
Coronary Atherosclerosis: blocks or narrows lumen

of coronary artery resulting in reduced blood flow
to the myocardium.
 The nature of coronary arteries makes it risky for
atherosclerosis
 Atherosclerosis is the major cause of CAD

BY: Ibrahim A ( BScN) 73 10/03/2023
CAD …
Risk factors:
Non modifiable Modifiable Risk factors
Family history of Major:
CAD High blood cholesterol
Gender Hypertension
Increasing age Cigarette smoking
Race Physical inactivity

CAD …
Minor
Obesity
DM
Stressful life style
Postmenopausal estrogen deficiency
High saturated fat intake etc
The risk of CAD is associated with:
A serum cholesterol level of >200mg/dL
A fasting triglyceride level of >150mg/dl

Pathophysiology
Fatty streaks in the intima of the arterial wall

Inflammation

Infiltration of T- lymphocytes and monocytes to ingest the lipids and die

Prolifiration of smooth muscle cells and formation of fibrous cap

Atheromas or plaques formation

Protrusion of Atheromas into the lumen of vessels

Obstruction to blood flow

Hemorrhage

Thrombus

Myocardial infarction

Lipids
High density lipoproteins (HDL)
 Caries lipids away from Low density
arteries and to the liver for lipoprotein (LDL)
metabolism  Contains more
 Higher in women than in
cholesterol
men
 Have increased
 Increase by physical
activity and estrogen affinity for arterial
 Decrease with age walls
77 10/03/2023 BY: Ibrahim A ( BScN)
CAD …

CAD …
Clinical Manifestations
S/S and complications depend on:
Location and degree of narrowing of the arterial

lumen
Thrombus formation
Obstruction of blood flow to the myocardium
 heart attack or sudden cardiac death

BY: Ibrahim A ( BScN) 82 10/03/2023
CAD…
Prevention
Control of the following four modifiable risk factors:
Increased Cholesterol
Cigarette Smoking
Hypertension
DM

Normal/optimal level of lipids
 LDL:- < 100 mg/dL for patients with CAD or a

CAD risk equivalent
 HDL > 40-60 mg /dL

CAD…
Contribution of smoking
i. CO readily combine with O2
 availability of O2 Decrease heart’s ability to pump
ii. Catecholamine production
HR,  BP, constriction of coronary arteries
iii. Platelet adhesion
 thrombus formation
People who stop smoking reduce their risk of heart disease by
30-50% with in the first year
Management/Treatment
 Many people are able to manage coronary artery

disease with lifestyle changes and medications.
 Other people with severe coronary artery disease
may need angioplasty or surgery.

CAD…
Management…
Referring to registered dietitian for dietary

measures
Weight reduction
Increased physical activity
Promoting cessation of tobacco use

Early detection and treatment of hypertension
Controlling DM  insulin & metformin

CAD…
Medications to decrease LDL, triglycerides & increase

HDL
Lovastatin
Prevastatin
Simvastatin
Fluvastatin
Atrovastatin
 Inhibit an enzyme HMG-CoA reductase which
catalyzes early step in the synthesis of cholesterol
CAD …
Nicotinic acid
Niacin: Decreased blood lipids
Fibric acids: primarily inhibits triglyceride
synthesis.
Fenofibrate
Colofibrate
Bile acid sequestrates : bind to bile acids to form an
insoluble substance and lowers LDLs
Cholestryramine
Colestipol HCL
Surgical intervention
1.Stenting: stent is introduced into blood vessel on

balloon catheter & advanced into the blocked area
 The balloon is then inflated and causes the stent to

expand until it fits the inner wall of the vessel
 The balloon is then deflated and drawn back

 The stent stays in place permanently, holding the
vessel open and improving the flow of blood.

Stent
Stent is a tube placed in the coronary arteries to keep it open (to treat CAD)
Treatment cont’d…
2. Angioplasty
A balloon catheter is passed through the guiding catheter
to the area near the narrowing. A guide wire inside the
balloon catheter is then advanced through the artery until
the tip is beyond the narrowing.
Balloon is inflated, compressing the plaque against the

artery wall
 Once plaque has been compressed and the artery has been
sufficiently opened, the balloon catheter will be deflated
and removed. 93 10/03/2023 BY: Ibrahim A ( BScN)
Angioplasty…

3. Bypass surgery Treatment cont’d…
 Healthy blood vessel is removed from leg, arm or

chest and used to create new blood flow path in the
heart
The “bypass graft” enables blood to reach the heart

by flowing around (bypassing) the blocked portion
of the diseased artery.
The increased blood flow reduces angina and the

risk of heart attack.
Coronary Bypass Surgery

ANGINA PECTORIS
Angina pectoris is a clinical syndrome usually
characterized by episodes or paroxysms of pain or
pressure in the anterior chest.
The cause is usually insufficient coronary blood
flow. The insufficient flow results in a decreased
oxygen supply to meet an increased myocardial
demand for oxygen in response to physical
exertion or emotional stress. In other words, the
need for oxygen exceeds the supply.
The severity of angina is based on the
precipitating activity and its effect on the activities
of daily living.
Patho-physiology
 Angina is usually caused by atherosclerotic disease.

Almost invariably, angina is associated with a significant
obstruction of a major coronary artery. The characteristics
of the various types of
 Several factors are associated with typical anginal pain:
 Physical exertion, which can precipitate an attack by
increasing myocardial oxygen demand
 Exposure to cold, which can cause vasoconstriction and
elevated blood pressure, with increased oxygen demand
 Eating a heavy meal, which increases the blood flow to the
mesenteric area for digestion, thereby reducing the blood
supply available to the heart muscle
Stress or any emotion-provoking situation,

Canadian Cardiovascular Society Classification of Angina
They classify as:

Class Activity Evoking Angina Limits To
Activity
I Prolonged Exertion None
II Walking >2 Blocks Slight
III Walking <2 Blocks Marked
IV Minimal Or Rest Severe
10/03/2023 BY: Ibrahim A ( BScN) 100

Types of Angina
 Stable angina: predictable and consistent pain that occurs
on exertion and is relieved by rest
 Unstable angina (also called pre-infarction angina or
crescendo angina): symptoms occur more frequently and
last longer than stable angina. The threshold for pain is
lower, and pain may occur at rest.
 Intractable or refractory angina: severe incapacitating
chest pain
 Variant angina (also called Prinzmetal’s angina): pain
at rest with reversible ST-segment elevation; thought to be
caused by coronary artery vasospasm
 Silent ischemia: objective evidence of ischemia but
patient reports no symptoms
Atypical angina is not associated with the listed factors. It may
occur at rest 10/03/2023 BY: Ibrahim A ( BScN) 101
pain , poorly localized and may radiate to the
neck, jaw, shoulders, and inner aspects of the
upper arms, usually the left arm.
feeling of indigestion to a choking
The pain is often felt deep in the chest behind the
upper or middle third of the sternum (retrosternal
area). The patient often feels tightness
The patient with diabetes mellitus may not have
severe pain with angina. Why?
SOB, pallor, diaphoresis, dizziness or
lightheadedness, and nausea and vomiting.
An important characteristic of angina is that it
abates or subsides with10/03/2023
rest orBY:nitroglycerin.
Ibrahim A ( BScN) 102
Medical Management
The objectives of the medical management of
angina are to፡
Decrease the oxygen demand of the myocardium
and
to increase the oxygen supply.
Medically, these objectives are met through
pharmacologic therapy and control of risk
factors.
10/03/2023 BY: Ibrahim A ( BScN) 103

PHARMACOLOGIC THERAPY
Among medications used to control angina are

nitroglycerin, beta-adrenergic blocking agents,
calcium channel blockers, and antiplatelet
agents.
Nitroglycerin፡ Nitrates remain the mainstay for
treatment of angina pectoris. A vasoactive agent,
nitroglycerin (Nitrostat, Nitrol, Nitrobid IV) is
administered to reduce myocardial oxygen
consumption, which decreases ischemia and relieves
pain.
Nitroglycerin dilates primarily the veins and, in higher
doses, also dilates the arteries.
10/03/2023 BY: Ibrahim A ( BScN) 104
Cont,,d
Beta-Adrenergic Blocking Agents.: Beta-blockers
such as propranolol (Inderal), metoprolol (Lopressor,
Toprol), and atenolol (Tenormin) appear to reduce
myocardial oxygen consumption by blocking the beta-
adrenergic sympathetic stimulation to the heart.
Calcium Channel Blocking Agents.፡ Calcium channel
blockers (calcium ion antagonists) have different
effects. Some decrease sinoatrial node automaticity and
atrioventricular node conduction, resulting in a slower
heart rate and a decrease in the strength of the heart
muscle contraction (negative inotropic effect).
10/03/2023 BY: Ibrahim A ( BScN) 105

Cont,,d
Antiplatelet and Anticoagulant Medications.
Aspirin.
Heparin.
Oxygen therapy
10/03/2023 BY: Ibrahim A ( BScN) 106

Myocardial Infarction (MI)
 MI refers to the process by which areas of

myocardial cells in the heart are permanently
destroyed.
 As the cells are deprived of oxygen, ischemia
develops, cellular injury occurs, and over time,
the lack of oxygen results in infarction, or cell
death.
107 10/03/2023 BY: Ibrahim A ( BScN)

MI..
Causes
 Reduced blood flow in a coronary arteries due to:
Thrombus (80-90% Cases)
Vasospasm
Atherosclerosis
 Decreased O2 supply
 Increased O2 demand
 In each case, imbalance exists b/n myocardial O2
demand & supply
10/03/2023 BY: Ibrahim A ( BScN) 108
Risk factors
 Advanced age
 Gender (men)
 Diabetes mellitus, Obesity (BMI >30 kg/m²)
 High blood pressure, Lack of physical activity
 Dyslipidemia/hypercholesterolemia - high LDL, low HDL
 Tobacco smoking, Alcohol, OCP + smoking
 Air pollution: CO, N2O,
 Family history of ischaemic heart disease or MI
10/03/2023 BY: Ibrahim A ( BScN) 109

Pathophysiology of MI
 Disruption of an atherosclerotic plaque in an epicardial
coronary artery clotting cascade total occlusion
of the artery
 Plaques can become unstable, rupture, and additionally
promote a thrombus that occludes the artery
 It leads to myocardial infarction (necrosis)
 Ischemic cascade: death of the heart cells near the occlusion
 A collagen scar forms and apoptosis
10/03/2023 BY: Ibrahim A ( BScN) 110

MI…
Myocardial Infarction
111 10/03/2023 BY: Ibrahim A ( BScN)

Myocardial Infarction
112 10/03/2023 BY: Ibrahim A ( BScN)

Pain
 Sudden & not relieved by rest or nitrate--hallmark
 Common locations: substernal or retrosternal,
radiating to the neck, jaw, and arms or to the back
 May occur while the patient is active or at rest,
asleep or walk
 Usually lasts for 20 minutes
113 10/03/2023 BY: Ibrahim A ( BScN)

Rough diagram of pain zones in myocardial infarction;
10/03/2023 BY: Ibrahim A ( BScN) 114

Other s/s
 SOB, dyspnea, tachypnea, crackles, pulmonary edema
 Nausea & Vomiting
 Cool, clammy, diaphoretic, and pale appearance
 Peripheral vasoconstriction
 Tachycardia, bradycardia, and dysrhythmias.
 Fever
 Headache, visual disturbances, altered speech, altered
motor function, and further changes in LOC
115 10/03/2023 BY: Ibrahim A ( BScN)
Other s/s …
 Discomfort, palpitations.
 S3, S4, and new onset of a murmur.
 Increased jugular venous distention
 Blood pressure changes.
 Decreased urinary output
 Anxiety, restlessness, light-headedness
10/03/2023 BY: Ibrahim A ( BScN) 116

MI…
Diagnosis
HX
Physical Examination
Lab tests e.g. – Increased myoglobin
ECG changes
117 10/03/2023 BY: Ibrahim A ( BScN)

MI…
Medical Mgt
Goals:-
Minimizing myocardial damage
Preserving myocardial function
Preventing complications
10/03/2023 BY: Ibrahim A ( BScN) 118

MI…
Pharmacologic therapy
 Thrombolytics e.g. streptokinase
 Analgesics e.g. morphine sulphate & meperidine
 ACE inhibitors e.g. captopril
 Antidysrhythmic drugs
 B- blockers, Calcium channel blockers
 Stool softeners: Bisacodyl
 Nutritional Mgt, support & physical activity
 Risk reduction by education of individuals & group
10/03/2023 BY: Ibrahim A ( BScN) 119
Nursing Diagnoses
◦ Pain related to poor O2 supply to the myocardium
◦ Risk for impaired gas exchange related to fluid overload

from left ventricular dysfunction
◦ Risk for altered peripheral tissue perfusion related to

decreased CO from left ventricular dysfunction
◦ Anxiety related to fear of death
◦ Deficient knowledge about post-MI self-care
10/03/2023 BY: Ibrahim A ( BScN) 120

MI…
Nursing Interventions
Relieving pain
– Oxygen administration
– Morphine & thrombolytics administration as prescribed
– Monitoring V/S every 1-2 hrs
– Physical rest in bed with backrest elevated
Preventing impaired gas exchange
• Regular & careful assessment of respiratory status
• Encourage deep breathing & coughing
• Frequent positioning
• Elevate head of bed 10/03/2023 BY: Ibrahim A ( BScN) 121

MI…
Reducing anxiety
Developing trusting & caring relationship with patient
Ensuring quite environment
Teaching relaxation techniques
Using humor(fun) & assisting the patient to laugh
Addressing the patient’s spiritual need
Music therapy
10/03/2023 BY: Ibrahim A ( BScN) 122

MI…
Potential Complications
Acute pulmonary edema
HF
Cardiogenic shock
Dysrhythmias and cardiac arrest
Pericardial effusion & cardiac tamponade
Myocardial rapture
10/03/2023 BY: Ibrahim A ( BScN) 123

INFECTIOUS DISORDERS OF THE HEART
Rheumatic heart disease, Infective endocarditis,

myocarditis, and pericarditis are among the most
common infections of the heart.
The ideal management is prevention
10/03/2023 BY: Ibrahim A ( BScN) 124

Acute Rheumatic Fever (ARF) and
Rheumatic Heart Disease (RHD)
 RF is an inflammatory disease of the heart
potentially involving all the layers of the heart.
 The resulting damage to the heart from RF is

called rheumatic heart disease, a chronic
condition characterized by scaring and deformity
of the heart valves.
125 10/03/2023 BY: Ibrahim A ( BScN)

Rheumatic Heart Disease…
Rheumatic heart disease affects the heart valves.
As blood flows, bacteria can infect the heart valves
Mitral and aortic valves are most commonly

affected by the rheumatic endocarditis, less
commonly tricuspid valve
10/03/2023 BY: Ibrahim A ( BScN) 126

Etiology and Epidemiology
 ARF occurs most often in school age children (5-

18yrs) following 0.3% to 3% of cases of group A-
beta hemolytic streptococcal pharyngitis
 Spread/transmission contact with oral or

respiratory secretions
127 10/03/2023 BY: Ibrahim A ( BScN)

Risk factors
Malnutrition
Overcrowding
Low socio- economic status
Familial tendency
Skin (subcutaneous) nodules
Lungs ( fibrous pleurisy)
Joints (polyarthritis)
10/03/2023 BY: Ibrahim A ( BScN) 128
Pathophysiology
 As blood flows, bacteria that lie in URT can infect the heart
valves, leading to symptoms or

 Without proper treatment of rheumatic fever, the disease
progresses to RHD and leads to autoimmune attack on heart
valves.
 Leukocytes accumulate in the affected tissues and form
nodules, which eventually replaced by scar tissue.
 Rheumatic myocarditis develops, which temporarily
weakens the contractile power of the heart.
10/03/2023 BY: Ibrahim A ( BScN) 129

 Fever
 Arthritis
Joint pain, swelling, redness and warmth
 Abdominal pain
 Skin rash (erythematic mariginatum)
 Skin nodules
 Sydenham’s chorea
 Nose bleeds
 SOB, chest pain, murmur, cardiomegaly
130 10/03/2023 BY: Ibrahim A ( BScN)
Clinical Manifestations…
Skin
nodules
131 10/03/2023 BY: Ibrahim A ( BScN)

Arthritis
 Most common feature: present in 80% of patients
 Painful, migratory, short duration, excellent

response for salicylates
 Usually >5 joints affected and large joints preferred
Knees
Ankles
Wrists
Elbows
Shoulders
132 10/03/2023 BY: Ibrahim A ( BScN)
Carditis
 Most serious manifestation which affect any cardiac
tissue
 May lead to death in acute phase or at later stage
 Clinical signs:
 High pulse rate
 Murmurs
 Cardiomegaly
 Rhythm disturbances
 Pericardial friction rubs
 Cardiac failure
 Mitral and aortic regurgitation most common
 Chest pain
133 10/03/2023 BY: Ibrahim A ( BScN)
Diagnosis
 History
 Physical Exam
 Lab tests
 ECG
 Chest X-ray
 Synovial fluid analysis
134 10/03/2023 BY: Ibrahim A ( BScN)

Jones Criteria for the diagnosis of ARF
 Two major or
 One major and two minor
Major criteria
Minor criteria
 Carditis
 Fever
 Polyarthritis  Previous occurrence of RF

 Chorea or RHD
 Arthralgia
 Erythematic mariginatum
 Prolonged PR interval
 Subcutaneous nodules
 Lab findings
10/03/2023 BY: Ibrahim A ( BScN) 135

Medical Mgt
Objectives
Eradicating causative organisms
Preventing additional complications
Pharmacologic therapy includes:
Long term antibiotic treatment

ASA
Corticosteroids
136 10/03/2023 BY: Ibrahim A ( BScN)
According to DACA of Ethiopia
For Rheumatic fever
 Benzanthine penicillin G, IM 1.2 mil units stat
For those allergic to penicillins
 Erythromycin 250mg PO QID for 10 days Plus

 Aspirin up to 2g QID for 4-6 weeks And/or
 Prednisolone up to 30 mg PO QID
137 10/03/2023 BY: Ibrahim A ( BScN)

For Rheumatic heart disease /RHD (Secondary
prophylaxis)
First line: Benzanthine penicillin G, 1.2 mil units

IM every 3-4 wks, for a minimum of 10years or
until the age of 40years
Alternatives
Penicillin, 250 mg PO daily Or
Sulfadiazine 1gm PO once daily

138 10/03/2023 BY: Ibrahim A ( BScN)
Nursing Mgt
Patient education about
 The disease
 Its treatment
 The preventive steps needed to avoid potential

complications
**Antibiotics administration before invasive

procedures 139 10/03/2023 BY: Ibrahim A ( BScN)
Infective Endocarditis
It is an infection of the valves and endothelial surface

of the heart
Causes
Bacteria
Streptococci (60%)
Staphylococci (20%)
Rickettsiae
Fungi
Chlamydia
140 10/03/2023 BY: Ibrahim A ( BScN)
Infective endodarditis…
Risks/incidence
 More common in older people
 IV/injection drug users, immunosuppressive drugs
 The combination of invasive procedure, bacteremia, and
cardiac defect
 Those with prosthetic (artificial) heart valves, previous
endocarditis, congenital malformations
 Pts with RHD or mitral valve prolapsed (insufficiency).
10/03/2023 BY: Ibrahim A ( BScN) 141

A mitral valve vegetation caused by bacterial endocarditis
10/03/2023 BY: Ibrahim A ( BScN) 142

Pathophysiology
 Bacteria or other infectious microorganism can

enter the bloodstream during certain procedures
 Bacteria can grow and form infected clots that
break off and travel to the brain, lungs, kidneys, or
spleen.
 Direct invasion of the endocardium by microbes.
 Causes deformity of the valve leaflets, and
sometimes affect other cardiac structures.
10/03/2023 BY: Ibrahim A ( BScN) 143
Duke criteria for the clinical Dx of IE.
 Major criteria:
 Positive blood culture –typical M/O investigation
 Positive echocardiogram
 Definitive vegetation:
 Intracardiac mass of valve and supporting
10/03/2023 BY: Ibrahim A ( BScN) 144

Definitive vegetation---
New valvular regurgitation Abscess
Partial dehiscence of prosthetic valve
10/03/2023 BY: Ibrahim A ( BScN) 145

Minor criteria:
 Predisposition –predisposing heat condition ,

-IV drug abuse
 Fever
 Embolic phenomena
 Microbiologic evidence –positive blood culture but not

meeting major criteria
 Echocardiogram consist but not meeting major criteria

10/03/2023 BY: Ibrahim A ( BScN) 146
Definitive diagnosis
Two major criteria:
One major and three minor criteria
Five minor criteria alone
10/03/2023 BY: Ibrahim A ( BScN) 147

 Fever
 Chills, anorexia, weight loss
 Arthralgias, myalgias, back pain, weakness, malaise, fatigue
 Clubbing of fingers
 Splinter hemorrhages occur in nail beds
 Petechiae in conjuctiva & mucus membranes
 Cardiomegally & heart failure
 Cerebral ischemia, stroke, headache
 Embolization to brain, kidneys, liver, limb & spleen
148 10/03/2023 BY: Ibrahim A ( BScN)

Clinical Manifestations …
 Abnormal urine color, Blood in the urine
 Excessive sweating (Night sweats)
 Shortness of breath with activity
 Swelling of feet, legs, abdomen
 Bleeding in the retina (Roth's spots)
10/03/2023 BY: Ibrahim A ( BScN) 149

Petechiae
1. Nonspecific
2. Often located on extremities or mucous membranes
150 10/03/2023 BY: Ibrahim A ( BScN)

Splinter Hemorrhages
1. Linear reddish-brown lesions found under the nail bed

2. Usually do NOT extend the entire length of the nail
151 10/03/2023 BY: Ibrahim A ( BScN)
Osler’s Nodes
1. More specific
2. Painful and erythematous nodules
3. Located on pulp of fingers and toes
4. More common in subacute IE
152 10/03/2023 BY: Ibrahim A ( BScN)
Janeway Lesions
1. More specific
2. Nonpainful Erythematous, blanching
macules
3. Located on palms and soles
153 10/03/2023 BY: Ibrahim A ( BScN)
Diagnosis
 History
 Physical examination
 Blood culture (positive in 90-95% of patients)
 ESR
 Chest X-ray
 ECG
 Increased WBCs
 U/A
154 10/03/2023 BY: Ibrahim A ( BScN)
Prevention
 Antibiotics prophylaxis before and after dental, oral,

respiratory, urinary or esophageal procedures
 Continued medical follow-up
Medical Mgt
 Appropriate parenteral antibiotics for 2-6 wks

Eg. vancomycin and ceftriaxone, pencillin, aminoglycoside
 Antifungal agents like amphotericin- if fungal endocarditis

 Antipyretics: PCM
Surgical Mgt
 Surgical valve repair or replacement for sever valve case

155 10/03/2023 BY: Ibrahim A ( BScN)
Nursing Management
 Monitoring
Body temp
S/S of systemic embolization
S/S of pulmonary infarction & infiltrates
 Assess for S/S of organ damage such as stroke, HF,
MI, meningitis, glomerulonephritis &
spleenomegally
 Pre & post –op care if the patient received surgical

treatment
156 10/03/2023 BY: Ibrahim A ( BScN)
Nursing Management…
 Bed rest
 Teach the family and patient about:
Any activity restriction & medications & s/s of
infection
Need of prophylactic antibiotics before and after

dental, respiratory, GI & GU procedures
 Provide emotional support
10/03/2023 BY: Ibrahim A ( BScN) 157

 Blood clots or emboli to brain, kidneys, lungs, etc

 Brain abscess, Stroke
 Congestive heart failure
 Glomerulonephritis
 Neurological changes
 Dysrhythemias
 Severe valve damage
10/03/2023 BY: Ibrahim A ( BScN) 158

Heart failure (HF)
159 10/03/2023 BY: Ibrahim A ( BScN)

Heart failure (HF)
 HF, often referred to as congestive HF (CHF), is

the inability of the heart to pump sufficient blood
to meet the needs of the tissues for oxygen and
nutrients
 It is a problem with contraction (systolic

dysfunction) or filling of the heart (diastolic
dysfunction) and may or may not cause pulmonary
or systemic congestion
160 10/03/2023 BY: Ibrahim A ( BScN)
Heart failure…
Incidence
 The incidence of HF increases with age.
 Nearly 5 million people in the US have HF, with
more than one-half million new cases diagnosed
each year.
 High prevalence in blacks
 Most common reason for hospitalization of older
people.
10/03/2023 BY: Ibrahim A ( BScN) 161
Classification of HF
Systolic Vs Diastolic dysfunction
 Systolic Dysfunction: the ventricle is unable to

contract forcefully enough during systole
 Diastolic dysfunction: the left ventricle is
unable to relax adequately during diastole
Based on the side of the heart involved
 left heart failure
 right heart failure
162 10/03/2023 BY: Ibrahim A ( BScN)
Left heart failure
 LHF results from LV dysfunction,

 Increased Pulmonary pressure
 Fluid extravagation from the plmonary capillary
bed into the interstitial spaces & then to the alveoli
 Pulmonary congestion & Edema
163 10/03/2023 BY: Ibrahim A ( BScN)

Pathophysiology of Left sided HF
 LV dysfunction, causes blood to back up in the left

atrium and pulmonary veins
 The increased left ventricular end-diastolic blood
volume increases the left ventricular end-diastolic
pressure
 Decreases blood flow from the left atrium into the left
ventricle during diastole
 The blood volume and pressure in the left atrium
increases,
10/03/2023 BY: Ibrahim A ( BScN) 164
Pathophysiology…
 Decreases blood flow from the pulmonary vessels

 Pulmonary venous blood volume and pressure rise,
forcing fluid from the pulmonary capillaries into
the pulmonary tissues and alveoli,
 Impairment of gas ex-change.
 Backward failure
10/03/2023 BY: Ibrahim A ( BScN) 165

Or Pathophysiology…
 The decrease in SV stimulation of the sympathetic

nervous system impedes perfusion to many organs.
 Blood flow to the kidneys decreases reduced urine
output (oliguria).
 Renal perfusion pressure falls release of renin
aldosterone secretion Sodium and fluid retention
increases intravascular volume.
 sometimes called forward failure.
10/03/2023 BY: Ibrahim A ( BScN) 166

II. Right sided failure (cor pulmonale)
RHF results from a diseased RV that causes back

ward flow of blood to the RA and venous
circulation.
Causes
 Left ventricular failure (the usual cause)
 CAD e.g. RV MI
 Pulmonary hypertension
167 10/03/2023 BY: Ibrahim A ( BScN)
Pathophysiology
RV failure

Inability of RV to empty
completely
Systemic Congestion

Increased volume &  Peripheral edema
pressure in the systemic
 Hepatomegally
veins
  Spleenomegally
Systemic venous congestion  Congestion of the GI tract
168 10/03/2023 BY: Ibrahim A ( BScN)

Functional classification- Class I: no limitation is experienced in
NYHA any activities there are no symptoms
from ordinary activities
Class II:
slight, mild limitation of activity; the patient is comfortable
at rest or with mild exertion
Class III:
marked limitation of any activity; the patient is comfortable
only at rest
Class IV:
any physical activity brings on discomfort and symptoms occur at rest
169 10/03/2023 BY: Ibrahim A ( BScN)

Framingham Criteria for Diagnosis of CHF
Major Criteria
◦ Paroxysmal nocturnal dyspnea
◦ Neck vein distention
◦ Rales
◦ Cardiomegaly
◦ Acute pulmonary edema
◦ S3 gallop
◦ Positive hepatojugular reflux
10/03/2023 BY: Ibrahim A ( BScN) 170

Cont,d
Minor Criteria
 Extremity edema
 Night cough
 Dyspnea on exertion
 Hepatomegaly
 Pleural effusion
 Vital capacity reduced by one-third from normal
 Tachycardia (120 bpm)
Major Or Minor
◦ Weight loss 4.5 kg over 5 days’ treatment
10/03/2023 BY: Ibrahim A ( BScN) 171

Common causes of CHF
 CAD Compensatory mechanisms for

 Cardiomyopathy ed CO:
 Systemic or pulmonary Increased HR
hypertension Improved SV (stroke Volume)
 Valvular heart disease Arterial vasoconstriction
 ed CO (anemia, hypoxia) Sodium & water retention
 Rheumatic heart disease Myocardial hypertrophy
 Congenital heart disease
172 10/03/2023 BY: Ibrahim A ( BScN)

Cont,d
Loss of pumping efficiency by the heart.

Occurs when CO is insufficient to maintain
blood flow required by body
I. Underlying causes
 Myocardial lesions
- Cardiomyopathy
- Myocarditis
- Myocardial infarction
10/03/2023 BY: Ibrahim A ( BScN) 173
Cont…d
 Valvular & Endocardial lesions
- Endocarditis
- Congenital valvular- heart disease
- RHD (Rheumatic Heart Disease)
Pericardial – lesions
- Pericarditis
- Cardiac-tamponade
10/03/2023 BY: Ibrahim A ( BScN) 174

II. Precipitating (secondary) causes.
H = Hypertension
E = Infective Endocarditis
A = Anemia
R = Rheumatic –fever (Recurrence)
T = Thyrotoxicosis
F = Fetus (pregnancy)
A = Arrhythmias
I = Infections
L = Lung problems (pathologies)
S = Stress, salts, etc.
10/03/2023 BY: Ibrahim A ( BScN) 175
Left sided HF
Decreased CO
Dizziness
 Fatigue,
Tachycardia, palpitation
 Decreased activity
Apical impulse displacement
tolerance
Pallor
 Oliguria during the
Cyanosis
day
Weak peripheral pulse
 Nocturia
Cool extremities at rest
 Angina
 Confusion, restlessness 10/03/2023 BY: Ibrahim A ( BScN) 176
C/M LHF cont’d…
Pulmonary congestion
 Cough -hacking, worsen at night

 Dyspnea, orthopnea, paroxysmal nocturnal
dyspnea (cardiac asthma)
 Crackles/ rales or wheezes in lungs

 Tachypnea
 Dullness
 Murmurs
 S3/S4
177 10/03/2023 BY: Ibrahim A ( BScN)
C/Ms Right sided HF
Systemic Congestion
 Jugular vein distension (JVD)

 Hepatomegally & spleenomegally
 Anorexia, nausea
 Dependent edema -legs & sacrum
 Ascites
 Nocturia
 Weight gain
 Change in BP 178 10/03/2023 BY: Ibrahim A ( BScN)
C/Ms Cont’d…
179 10/03/2023 BY: Ibrahim A ( BScN)

Diagnosis
 History
 Physical Examination
 Lab tests
 ECG
 Chest X-ray
 Pulse oximetry
 B-type natriuretic peptide(BNP)
 Cardiac catheterization
180 10/03/2023 BY: Ibrahim A ( BScN)
Medical Mgt
Objectives
 To eliminate or reduce etiologic or contributing
factors
 To reduce the workload on the heart by reducing
afterload & preload
181 10/03/2023 BY: Ibrahim A ( BScN)

Pharmacologic Therapy
I. ACE - inhibitors (ACE-Is)

 Promotes vasodilatation & diuresis
 Include:
 Captopril
 Enalapril
 Lisinopril
II. Angiotensin II receptor blockers (ARBs): Losartan
 Decreases BP & systemic vascular resistance
III. Hydralazine
 Decreases systemic vascular resistance
IV. Beta blockers e.g. propranolol
182 10/03/2023 BY: Ibrahim A ( BScN)

Pharmacologic Therapy Cont’d…
IV. Digitalis e.g. digoxin

 Increases the force of myocardial contraction & slow
conduction through the AV node
V. Diuretics
 Thiazides e.g. chlorothiazide, hydrochlorothiazide
 Loop diuretics e.g. furosemide (lasix)
 Potassium sparing e.g. spironolactone
 Combination agents e.g. spironolactone + hydrochlorothiazide
183 10/03/2023 BY: Ibrahim A ( BScN)

IV. Other medications

 Anticoagulants
 Antianginal medications
 Avoiding NSAID-b/c they increase vascular
resistance and decrease renal perfusion
10/03/2023 BY: Ibrahim A ( BScN) 184

Nutritional therapy
Low sodium diet (< 2g -3g /day)
Avoid excessive fluid intake
Tell the patient’s family which foods are high in

sodium
185 10/03/2023 BY: Ibrahim A ( BScN)

DACA of Ethiopia
Digoxin 0.125-0.375 mg po daily Plus
Furosemide , 40-240 mg, po divided in to 2-3 doses daily
Plus
Potassium chloride, 600 mg po once or twice daily
And/or
Enalopril 5-40 mg po once or divided in to two dose daily
And/or
Spironolactone 25-100mg po once daily or divided into two
186 10/03/2023 BY: Ibrahim A ( BScN)

Monitoring and managing potential complications
Hypokalemia
Hyperkalemia
Hypotension
Renal dysfunction
187 10/03/2023 BY: Ibrahim A ( BScN)

NURSING DIAGNOSES
Activity intolerance related to imbalance between oxygen

supply and demand because of decreased CO
Excess fluid volume related to excess fluid or sodium intake

and retention of fluid because of HF and its medical therapy
Risk for impaired skin integrity related to edema
Anxiety related to breathlessness and restlessness from

inadequate oxygenation
Powerlessness related to inability to perform role

responsibilities because of chronic illness and hospitalizations
Noncompliance related to lack of knowledge

10/03/2023 BY: Ibrahim A ( BScN) 188
1. Maintaining normal body 2. Improving activity tolerance:

fluid:
Avoid prolonged bed rest
Daily measurement of
Moderate physical exercise
abdominal girth
for a total of 30 min with 3-
Administering drugs as
5 times per week
prescribed
Monitoring patient’s
Monitoring intake & out put
response to activity
and daily body weight
Restriction of sodium diets

& fluid
189 10/03/2023 BY: Ibrahim A ( BScN)
Nsg mgt…cont’d…
3. Maintaining skin integrity 4. Improving self care

 Monitor signs of edema  Assisting the patient with all
 Meticulous skin care ADLs
 Pad bony prominences  Teaching the family about self
 Passive ROM to extremities care activities
every 4 hours to facilitate
venous return
 Turning & repositioning the
patient q 2hrs
190 10/03/2023 BY: Ibrahim A ( BScN)
Hypertension
191 10/03/2023 BY: Ibrahim A ( BScN)

INTERVENTIONS OF PATIENTS WITH VASCULAR
DISORDERS
10/03/2023 BY: Ibrahim A ( BScN) 192

Blood pressure
In normal circulation, pressure is exerted by the
flow of blood through the heart and blood vessels.
High blood pressure can result from a change in
cardiac output, peripheral resistance, or both.
High BP can be viewed in three ways: as a sign, a
risk factor for atherosclerotic CVD, or a disease
10/03/2023 BY: Ibrahim A ( BScN) 193

Normal regulation of BP
Arterial BP= CO X SVR
SVR
 Is the force opposing the movement of blood
CO
 Is the product of stroke volume & heart rate
194 10/03/2023 BY: Ibrahim A ( BScN)

INTERVENTIONS OF PATIENTS WITH VASCULAR
DISORDERS
10/03/2023 BY: Ibrahim A ( BScN) 195

BP Regulation Involves:
1. Nervous System Regulation
I. Autonomic Nervous System
II. Baroreceptors (pressero receptors)
2. Renal System
3. Endocrine system
 Defect in one of the regulating mechanisms may

result in HTN
196 10/03/2023 BY: Ibrahim A ( BScN)

Hypertension
Hypertension-is defined as:
systolic BP (SBP) > 140 mmHg and
diastolic BP (DBP) > 90mmHg
based on the average of two or more correct BP
measurements taken during two or more
contacts with the health care provider
197 10/03/2023 BY: Ibrahim A ( BScN)

Types of hypertensions
 Primary / idiopathic /essential/ hypertension
Hypertension with mulifactorial etiology with
no identifiable cause
 Secondary hypertension
 Hypertension result from an identifiable
cause
10/03/2023 BY: Ibrahim A ( BScN) 198

Types of hypertension…
 White coat hypertension
Hypertension in people who are usually
normotensive except when their blood
pressure is measured by health care
professionals which occurs due to
intermittent vaso vagal response; which if
treated leads to sever hypotension
10/03/2023 BY: Ibrahim A ( BScN) 199
Types of hypertension…
 Isolated systolic hypertension
Hypertension that occur when SBP is
140mmHg or higher and DBP remain less
than 90mmHg
Hypertensive crisis/ Persistent sever
HPN/resistant HPN/malignant HPN
10/03/2023 BY: Ibrahim A ( BScN) 200
Hypertension con’t
Hypertension characterized hypertensive urgency
or emergency in which the DBP is 110mmHg to
120mmHg with sign of TOD which occur if left
untreated or resistant to treatment
Hypertensive emergency: hypertension that needs
immediate reductions of blood pressure to prevent
target organ damage(TOD)
10/03/2023 BY: Ibrahim A ( BScN) 201

Hypertension …
Hypertensive urgency: a condition in
which there is a desire to reduce with in
few hours as in the case of sever
hypertensions
10/03/2023 BY: Ibrahim A ( BScN) 202

Types of hypertension …
Accelerated hypertension
Sever hypertension with SBP 180mmHg
and DBP 110mmHg with retinopathy of
grade III (flame hemorrhage, dot and blot
hemorrhage, and hard and soft exudates)
10/03/2023 BY: Ibrahim A ( BScN) 203

A. Old classification system
Category systolic Diastolic
Blood presure ˂ 80
Optimal ˂ 120 ˂ 85
Normal ˂ 130 85 - 89
High normal 130 - 139
Hypertention
HPN stage I 140 – 159 9o- 99
HPN stage II 160 – 179 100 – 109
HPN stage III ≥ 180 ≥ 110
Isolated systolic hypertension
Stage I 140 – 159 ˂90
Stage II ≥ 160 ≥90
10/03/2023 BY: Ibrahim A ( BScN) 204

B. Modern classification
Category Systolic mmHg Diastolic mmHg Recommendation
Normal <120 And <80 Health awareness
Pre hypertension 120-139 Or 80-89 No need of drug
Stage I mild 140-159 Or 90-99 Thiazide
hypertension
Stage II/ moderate 160-179 Or 100-109 Two drugs

hypertension
Stage III/ sever ≥ 180 ≥ 110 Two drugs

HPN
10/03/2023 BY: Ibrahim A ( BScN) 205

Classification of BP for Adults (age > 18 years)
Category Systolic BP Diastolic BP

(mmHg) (mmHg)
Normal <120 And <80
Pre-hypertension 120-139 Or 80-89
Stage 1 or Mild HTN 140-159 Or 90-99
Stage 2/Moderate HTN 160-179 Or 100-109
Stage 3 Sever HTN > 180 Or > 110
10/03/2023 BY: Ibrahim A ( BScN) 206

10/03/2023 BY: Ibrahim A ( BScN) 207
Etiology of Hypertension(HTN)
Can be primary (essential) or secondary hypertension

I. Primary (Essential) hypertension
 Accounts for 90-95% of all cases
 Has no known causes
 Onset usually between the age of 30 & 50yrs
 Associated risk factors include:
 Advanced age
 Family history
 Obesity
 High sodium intake
 Cigarette smoking
 Sedentary lifestyle
 Excessive alcohol intake
 Diabetes
 Stress and increased serum lipid level
208 10/03/2023 BY: Ibrahim A ( BScN)
II. Secondary hypertension
 Has specific cause
 Accounts for <5% of cases
 Brain tumors
 Identifiable causes include:
 Pregnancy
 Coarctation or congenital
 Medications:
abnormalities of aorta
Estrogen
 Renal disease
Glucocorticoids
 Renovascular HTN
Sympathomimetics
 Pheochromocytoma
(e.g. dopamine,
 Cushing’s syndrome dobutamine)
209 10/03/2023 BY: Ibrahim A ( BScN)
Clinical manifestations
 HTN is often called “silent killer”

 With severe hypertension symptoms developed
secondary to effect on blood vessels in various
organs and tissues or to increased work load of
the heart
210 10/03/2023 BY: Ibrahim A ( BScN)

These C/Ms may include:
Headache  Faintness (sudden fall)

 Most common symptom  Sudden hemiplegia
 Occurs in occipital region Stroke or TIA
Nocturia  Blurring of vision
Increased BUN & creatinine Epistaxis
 Occasionally, retinal
Speech & vision alternation
changes
Dizziness
 Hemorrhages
Weakness
 Exudates
 small infarction
211 10/03/2023 BY: Ibrahim A ( BScN)
Hypertensive crises
 Present as hypertensive urgency or hypertensive

emergency
 Systolic reading of 180 mm Hg or higher OR
diastolic reading of 110 mm Hg or higher, on two
separate occasions at minutes interval
 needs immediate emergency medical treatment
10/03/2023 BY: Ibrahim A ( BScN) 212

Hypertensive Urgency
 there is no associated organ damage.

 Patients may or may not experience one or more of
these symptoms:
Severe headache,
Shortness of breath,
Nosebleeds, and
Severe anxiety.
 Treatment requires readjustment and/or additional

dosing of oral medications, without hospitalization
10/03/2023 BY: Ibrahim A ( BScN) 213
Hypertensive emergency
Is hypertension with acute impairment of one or

more organ systems that can result in irreversible
organ damage.
It generally occurs at blood pressure levels
exceeding 180 systolic OR 120 diastolic, but can
occur at even lower levels in patients whose blood
pressure had not been previously high.
10/03/2023 BY: Ibrahim A ( BScN) 214

manifestations
retinal hemorrhage or an exudate , Papilloedema

headache, vomiting, and/or subarachnoid or
cerebral hemorrhage.
hematuria, proteinuria and acute renal failure
10/03/2023 BY: Ibrahim A ( BScN) 215

Diagnosis
History
Measuring blood pressure (at least 1week apart)
Ophthalmologic examination
Lab tests
ECG
Echocardiography & chest X-ray
216 10/03/2023 BY: Ibrahim A ( BScN)

Medical Management
Goals
Preventing death and complications
Achieving and maintaining the arterial BP at:
 140/90 mmHg or lower
 <130/80 mmHg for people with DM & chronic kidney
diseases
The managements of hypertension include:
Lifestyle modifications
Pharmacologic therapy
217 10/03/2023 BY: Ibrahim A ( BScN)
Management…
Indications of Life style modification:

 person with either border line or sustained HTN
Lifestyle modifications
Weight reduction
Moderation of alcohol intake
Regular physical activity
Reduction of sodium intake
Smoking cessation
218 10/03/2023 BY: Ibrahim A ( BScN)

Medical Management…
Indications of drug therapy:

 BP remaining > 140/90mmHg after 3-6
months of life style changes
 Presence of target organ damage
 Presence of other complications or risk factors
10/03/2023 BY: Ibrahim A ( BScN) 219

Management approach
Blood pressure Risk group A risk group B(at Risk group C
stage (mmHg) (no risk factor, least 1 risk (TOD/CCD) and/or
no TOD/CCD) factor, no DM, DM with or
no TOD/CCD) without risk factors
High normal Lifestyle Lifestyle Drug therapy

modification modification
Stage 1 Lifestyle Lifestyle Drug therapy

modification modification (up
(up to 6 to 6 months)
months)
Stage 2 and 3 Drug therapy Drug therapy Drug therapy
10/03/2023 BY: Ibrahim A ( BScN) 220

Management approach
Blood pressure Risk group A risk group B(at Risk group C
stage (mmHg) (no risk factor, least 1 risk (TOD/CCD) and/or
no TOD/CCD) factor, no DM, DM with or
no TOD/CCD) without risk factors
High normal Lifestyle Lifestyle Drug therapy

modification modification
Stage 1 Lifestyle Lifestyle Drug therapy

modification modification (up
(up to 6 to 6 months)
months)
Stage 2 and 3 Drug therapy Drug therapy Drug therapy
10/03/2023 BY: Ibrahim A ( BScN) 221

Drugs used for the treatment of HTN include:
Vasodilating drugs
hydralazine
β-adrenergic blocking drugs
Atenolol
Metoprolol
Propranolol
Antiadrenergic drugs (centrally acting)
Methyldopa
222 10/03/2023 BY: Ibrahim A ( BScN)
Medical Management…
Indications of drug therapy:

 BP remaining > 140/90mmHg after 3-6
months of life style changes
 Presence of target organ damage
 Presence of other complications or risk factors
10/03/2023 BY: Ibrahim A ( BScN) 223

Drugs …
Alpha (α)-adrenergic blocking drugs

doxazosin
Prazosin
Calcium channel blockers
Nifidipine
Verapamil
Diltiazem
10/03/2023 BY: Ibrahim A ( BScN) 224

Drugs …
Angiotensin-converting enzyme (ACE) inhibitors
Captopril
Enalapril
Lisinopril
Angiotensin II receptor antagonists
Losartan
Valsartan
Irbesartan
Diuretics
Furosemide (Lasix)
Hydrochlorothiazide
225 10/03/2023 BY: Ibrahim A ( BScN)
Sodium &
Water
retention
BP
Angiotensin II
receptor blocker
226 10/03/2023 BY: Ibrahim A ( BScN)
DACA of Ethiopia
Any one of the following classes of drugs could be

used as first step agents:
Diuretics
Beta Blockers
Calcium antagonists
ACE-Is
227 10/03/2023 BY: Ibrahim A ( BScN)

First line drugs for non-emergency conditions
Hydrochlorothiazide, 12.5-50 mg/day PO And/or
Nifedipine 10-40 mg, PO TID And/or
Propranolol 40-160 mg PO divided in to 2-4 doses
Alternative
Enalopril, 2.5-40 mg PO, once or divided in to two

doses daily An/Or
Methyldopa, 250-2000 mg PO in divided doses.
228 10/03/2023 BY: Ibrahim A ( BScN)

Drugs used to treat hypertensive crisis include:
 Nitroprusside, nifedipine, propranolol, captopril, hydralyzine
1. Treatment of Hypertensive Emergency
 Hydralazine, 5 mg IV every 15-min
 Depending on the underlying condition/TOD, furosemide,
40 mg IV can be used.
2. Treatment of Hypertensive Urgency
 Nifedipine, 20-120 mg p.o in divided doses per day. OR
 Captopril, 25-50 mg p.o three times daily

10/03/2023 BY: Ibrahim A ( BScN) 229
10 Commandments for BP Control
1.Know your blood pressure.
 Have it checked regularly
2. Know what your weight should be.
 Keep it at that level or below
3. Don’t use excessive salt in cooking or at meals.
 Avoid salty foods

10/03/2023 BY: Ibrahim A ( BScN) 230
10 Commandments---
4. Eat a low-fat diet
 According to AHA regulations
5. Don’t smoke cigarettes
 Or use tobacco products
10/03/2023 BY: Ibrahim A ( BScN) 231

10 Commandments---
6.Take your medicine exactly as prescribed
 Don’t run out of pills.
7. Keep your appointments with the doctor.
8. Follow your doctors advice about exercise

regularly .
10/03/2023 BY: Ibrahim A ( BScN) 232

10 Commandments----
9. Make certain family members have their
blood pressure checked.
10. Live a normal life in every other way!
10/03/2023 BY: Ibrahim A ( BScN) 233

Nursing Diagnoses
Activity intolerance due to exacerbation of

symptoms with activity
Pain related to hypoxia
Deficient knowledge regarding the relation between

the treatment regimen and control of the disease
process
Noncompliance with therapeutic regimen related to

side effects of prescribed therapy
10/03/2023 BY: Ibrahim A ( BScN) 234
1. Improving activity tolerance
2. Alleviating pain (headache)
3. Advice about adherence to treatment
4. Nutritional advice
5. Avoiding potential complications
235 10/03/2023 BY: Ibrahim A ( BScN)

Prevention
British Hypertension Society suggestions:
Dietary changes - - DASH diet
Weight reduction
Regular aerobic exercise (e.g., walking)
Reducing dietary sugar intake
Reducing sodium (salt)
Discontinuing tobacco use and alcohol consumption
Reducing stress
236 10/03/2023 BY: Ibrahim A ( BScN)
DASH Eating Plan
Low in saturated fat, cholesterol
Eating fruits, vegetables, and low fat diary

products
Reduced red meat, sweets, and sugar containing

beverages
Rich in magnesium, potassium, protein, and fiber
Low sodium intake
Can reduce BP in 2 weeks

237 10/03/2023 BY: Ibrahim A ( BScN)
 Left ventricular hypertrophy
 Myocardial infarction
 HF
 Cerebrovasular accident (stroke or brain

attacks)
 Renal insufficiency & failure
 Retinal hemorrhage
238 10/03/2023 BY: Ibrahim A ( BScN)

DISEASES OF THE VEINS
Varicose vein (varicosities)
Enlarged, weakened, twisted and dilated veins that have
permanently lost ability to carry blood from the legs
back up to the heart against the force of gravity.
Most commonly occurs in lower extremities

Veins in which the one-way valves aren't working well.
They don't close properly, causing some of the blood to pool in

the legs
10/03/2023 BY: Ibrahim A ( BScN) 240
Causes/risk factors
Heredity
Sex (Pregnancy)
Obesity, aging
Standing for long periods
Traumatic injury to the leg
abdominal straining, and crossing legs
Post phlebitic obstruction
Venous and arteriovenous malformations
10/03/2023 BY: Ibrahim A ( BScN) 241

Pathophysiology
 Varicose veins may be considered primary (without
involvement of deep veins) or secondary (resulting
from obstruction of deep veins).
A reflux of venous blood in the veins results in
venous stasis.
 If only the superficial veins are affected, the person
may have no symptoms but may be troubled by the
appearance of the dilated veins.
10/03/2023 BY: Ibrahim A ( BScN) 242
Tired, Feeling of heaviness, aching, swollen legs
Nighttime leg cramps and leg restlessness
Visible, enlarged veins
Mild swelling of ankles especially in evening
Skin at the ankle discolored

Skin ulcers near the ankle
Increased susceptibility to injury and infection
10/03/2023 BY: Ibrahim A ( BScN) 243

Clinical Manifestations…
Appearance of spider veins (telangiectasia) in the affected

leg.
Redness, dryness, and itchiness of areas of skin (stasis

dermatitis or venous eczema).
Cramps when making a sudden move as standing up.
Minor injuries to the area may bleed more and/or take long
time to heal.
Lipodermatosclerosis (skin above the ankle may shrink )
10/03/2023 BY: Ibrahim A ( BScN) 244

Varicose vein
10/03/2023 BY: Ibrahim A ( BScN) 245

10/03/2023 BY: Ibrahim A ( BScN) 246
Varicose vein and spider vein pictures
10/03/2023 BY: Ibrahim A ( BScN) 247

Diagnosis
History
Venography (with x-ray)
Venous Duplex Ultrasound
Clot
10/03/2023 BY: Ibrahim A ( BScN) 248

Medical management
Conservative Treatment
Wearing compression stockings
Alleviate swelling & pain
Help heal any skin inflammation or ulcerations
Sclerotherapy
10/03/2023 BY: Ibrahim A ( BScN) 249

compression stockings
Sclerotherapy
10/03/2023 BY: Ibrahim A ( BScN) 250

Surgery
Micro-Surgery
Phlebectomy (to remove the affected veins)
Ligation and stripping
10/03/2023 BY: Ibrahim A ( BScN) 251

Nursing management
Discourage Bed rest and encourage ambulation
Foot of the bed elevated or Elevating legs
Discourage standing and sitting for long period
Promoting comfort and understanding
Analgesics can be given
Inspect & care for dressing if surgery has

performed
10/03/2023 BY: Ibrahim A ( BScN) 252

Prevention
 Exercise - e.g. Swimming

 controlling weight and diet
 Don't wear tight clothes around waist, legs or groin
 Avoid long periods of sitting or standing
 Don't sit with legs crossed
10/03/2023 BY: Ibrahim A ( BScN) 253

DISORDERS OF THE TISSUE PERFUSION
AND HEMATOLOGICAL SYSTEM
10/03/2023 BY: Ibrahim A ( BScN) 254

RBC Disorders
10/03/2023 BY: Ibrahim A ( BScN) 255

Anemia
Anemia is a qualitative or quantitative deficiency of

hemoglobin, in red blood cells that transports oxygen.
It is a lower than normal number of red blood cells,

usually measured by a decrease in the amount of
hemoglobin.
Is the most common disorder of blood which leads to

hypoxia in organs.
Not specific disease but a sign of underlying disorder.

10/03/2023 BY: Ibrahim A ( BScN) 256
Classification
Anemia can be classified in a variety of

ways, based on:
Production vs destruction or loss
The morphology of RBCs
underlying etiologic causes
10/03/2023 BY: Ibrahim A ( BScN) 257

Potential causes
1. Loss of RBCs—bleeding, (eg. GIT, uterus, nose, or wound)
2. Decreased production of RBCs (ineffective hematopoiesis

): deficiency in cofactors for erythropoiesis; bone marrow
suppression or lack of erythropoietin.
3. Hemolysis: overactive RES (e.g. hypersplenism) or

production of abnormal RBCs (eg, sickle cell anemia)
10/03/2023 BY: Ibrahim A ( BScN) 258

Causes & risk Factors
Blood loss, nutritional deficits, diseases,

medication, and problems with the bone marrow,
heavy menstrual periods

 Pregnancy
 older age
10/03/2023 BY: Ibrahim A ( BScN) 259

Several factors influence anemia-associated

symptoms:
The speed with which the anemia has developed
The duration of the anemia (ie, its chronicity)
The metabolic requirements of the individual
Other concurrent disorders or disabilities
10/03/2023 BY: Ibrahim A ( BScN) 260

Types and potential causes
Vit-B12 deficiency Anemia

 Pernicious anemia
Folate deficiency Anemia
Iron deficiency Anemia
Anemia due to chronic disease
Hemolytic anemia like Sickle cell anemia
Aplastic anemia
Idiopathic anemia
10/03/2023 BY: Ibrahim A ( BScN) 261
Specific types of anemia
1. Vitamin B12 deficiency Anemia

Caused by a lack of vitamin B12.
Also called Macrocytic anemia.
Vitamin B12 is essential for normal nervous system

function and blood cell production.
For vitamin B12 to be absorbed by the body, it must

bind to intrinsic factor, a protein secreted by cells in
the stomach.
10/03/2023 BY: Ibrahim A ( BScN) 262
Causes
diet low in vit B12 (e.g. strict vegetarian)
Chronic alcoholism
Abdominal or intestinal surgery
Crohn's disease
Intestinal malabsorption disorders
Hook worm
Pernicious anemia
10/03/2023 BY: Ibrahim A ( BScN) 263

2. Folate-deficiency anemia
Folate, also called folic acid, is necessary for RBC

formation and growth.
Referred to as megaloblastic anemia
Folate is not stored in the body in large amounts,
Occurs in about 4 out of 100,000 people.
Folate - obtained from green leafy vegetables and

liver.
10/03/2023 BY: Ibrahim A ( BScN) 264

Cause/Risk factors
Poor dietary intake of folic acid or Eating

overcooked food
Malabsorption diseases: celiac disease (sprue)
Certain medications e.g. phenytoin
Third trimester of pregnancy
Alcoholism
10/03/2023 BY: Ibrahim A ( BScN) 265

3. Iron deficiency anemia
it is the most common form of anemia
Decrease number of RBC in blood due to too

little iron
RBCs are not providing adequate oxygen to body

tissues
Girls going through puberty are high risk because

of onset of menstruation
10/03/2023 BY: Ibrahim A ( BScN) 266

Causes
Too little iron in the diet
Poor absorption of iron by the body
Loss of blood (including from heavy menstrual bleeding)
Risky groups
♣ Women of child-bearing age
♣ Pregnant or lactating women
♣ Infants, children, and adolescents in rapid growth
♣ People with a poor dietary intake of iron
♣ Blood loss: peptic ulcer, long term ASA use, colon ca
10/03/2023 BY: Ibrahim A ( BScN) 267

4. Hemolytic anemia
Inadequate number of circulating RBCs caused by

premature destruction.
It can be autoimmune, hereditary or mechanical
The bone marrow is unable to compensate for

premature destruction.
Types: Sickle-cell anemia, Idiopathic autoimmune

hemolytic anemia, Thalassemia, etc
10/03/2023 BY: Ibrahim A ( BScN) 268

Normal and Sickle shaped RBC
10/03/2023 BY: Ibrahim A ( BScN) 269

Causes
 Abnormal hemoglobin: Sickle cell anemia,

Thalassemia
 Enzyme deficiencies: Glucose-6-phosphate
dehydrogenase deficiency
 Acquired Hemolytic Anemia: Antibody-related
 Iso-antibody/transfusion reaction
 Autoimmune hemolytic anemia
10/03/2023 BY: Ibrahim A ( BScN) 270

Cause …
Liver disease
Trauma/ Mechanical heart valve
Hypersplenism
Infection
Certain medications
Inherited disorders
10/03/2023 BY: Ibrahim A ( BScN) 271

Common Symptoms of sickle cell anemia and
also other types of anemia
Paleness
 Susceptibility to infections
Yellow eyes/skin
 Ulcers on the lower legs
Fatigue  Jaundice
 Bone pain
Breathlessness
 Attacks of abdominal pain
Rapid heart rate  Fever
Delayed growth and puberty

10/03/2023 BY: Ibrahim A ( BScN) 272
Cont,d
The patient may also have:
 Bloody urine (hematuria )
 Frequent urination
 Excessive thirst
 Chest pain
 Poor eyesight/blindness
 Painful erection (priapism)
10/03/2023 BY: Ibrahim A ( BScN) 273

There are several types of crises:
۩ Hemolytic crisis
۩ Splenic sequestration crisis
۩ Aplastic crisis
10/03/2023 BY: Ibrahim A ( BScN) 274

5. Idiopathic Aplastic Anemia
Is a failure of the bone marrow to properly form all

types of blood cells
Results from injury to the stem cell
Also called pancytopenia
Cause is unknown, but is thought to be an

autoimmune process.
10/03/2023 BY: Ibrahim A ( BScN) 275

It may be related to:
Chemotherapy,
Radiation therapy,
Toxins,
Drugs,
Pregnancy,
Congenital disorder or
Systemic lupus erythematosus , etc
10/03/2023 BY: Ibrahim A ( BScN) 276

Assessment and Diagnostic Findings
Physical Exam & history
CBC
Hgb concentration, Hct,
ESR, RBC folate level, serum vit B12, RFT
Iron tests (serum level, binding capacity, % saturation)
Bone marrow aspiration and biopsy
Urinary casts or blood in the urine
Elevated bilirubin, WBC count
Erythropoietin levels
10/03/2023 BY: Ibrahim A ( BScN) 277
Treatments for anemia
Treatment depends on severity and the cause.
Treatment goals:
to get RBC counts or Hgb levels back to normal
to treat the underlying cause of the anemia
10/03/2023 BY: Ibrahim A ( BScN) 278

Iron deficiency anemia
Iron supplements- for several months or longer
If the underlying cause of iron deficiency is loss of

blood, the source of bleeding must be located and
stopped.
Meat, poultry, fish, eggs, dairy products, or iron-

fortified foods are the best sources of iron found in food.
Ferrous sulfate
10/03/2023 BY: Ibrahim A ( BScN) 279

Vitamin B12 deficiency anemias
Pernicious anemia is treated with injections —

often lifetime injections — of vitamin B12.
Folic acid deficiency anemia is treated with folic

acid supplements
10/03/2023 BY: Ibrahim A ( BScN) 280

Anemia of chronic disease
There's no specific treatment for this type of anemia.
It can be focused on treating the underlying disease.
Iron and vitamin supplements don't help
If symptoms become severe, a blood transfusion or

injections of synthetic erythropoietin, may help
stimulate RBC production.
10/03/2023 BY: Ibrahim A ( BScN) 281

Aplastic anemia
Blood transfusions to boost levels of RBC
Bone marrows transplantation-
Immune-suppressing medications after bone

marrow transplantation
10/03/2023 BY: Ibrahim A ( BScN) 282

Hemolytic anemias
Avoiding suspect medications

Treating related infections
Drugs that suppress immune system like steroids
or gamma globulin .
Spleen removal
10/03/2023 BY: Ibrahim A ( BScN) 283

Sickle cell anemia
Rx for this incurable anemia include:
♣Administration of oxygen
♣Pain-relieving drugs
♣Oral and intravenous fluids
♣Blood transfusions
♣Folic acid and antibiotics
♣A bone marrow transplant
♣cancer drug hydroxyurea (Droxia)
10/03/2023 BY: Ibrahim A ( BScN) 284
Prevention of anemia
 Eat foods high in iron

 Eat and drink foods that help your body absorb iron,
 Don't drink coffee or tea with meals.
 Make sure to consume enough folic acid and vit. B12.
 Make balanced food choices.
 Avoid food fads and dieting
 Talk to doctor about taking iron pills (supplements):
ferrous and ferric.
10/03/2023 BY: Ibrahim A ( BScN) 285
Possible complications of Anemia
Diminishes the capability to perform physical

activities.
Hypoxemia
Brittle or rigid fingernails,
Cold intolerance,
Possible behavioral disturbances in children.
Exacerbation of pre-existing cardio-pulmonary
problems
10/03/2023 BY: Ibrahim A ( BScN) 286
Polycythemias
 Polycythemia፡ refers to an increased volume of
RBCs. It is a term used when the hematocrit is
elevated (to more than 55% in males, more
than 50% in females). Dehydration (decreased
volume of plasma) can cause an elevated
hematocrit, but not typically to the level to be
considered polycythemia.
 Polycythemia is classified as either primary or
secondary.
10/03/2023 BY: Ibrahim A ( BScN) 287

POLYCYTHEMIA VERA
Polycythemia vera, or primary polycythemia, is a
proliferative disorder in which the myeloid stem
cells seem to have escaped normal control
mechanisms.
The bone marrow is hypercellular, and the RBC,
WBC, and platelet counts in the peripheral blood
are elevated. However, the RBC elevation is
predominant; the hematocrit can exceed 60%.
This phase can last for an extended period (10
years or longer).
The spleen resumes its embryonic function of
hematopoiesis and enlarges.
10/03/2023 BY: Ibrahim A ( BScN) 288
Splenomegaly (enlarged spleen)

headache, dizziness, tinnitus, fatigue,
paresthesias, and blurred vision) or from
increased blood viscosity (angina, dyspnea, and
thrombophlebitis), particularly if the patient
has atherosclerotic blood vessels. Another
common and bothersome
problem is generalized pruritus, which may be
caused by histamine release due to the increased
number of basophils.
10/03/2023 BY: Ibrahim A ( BScN) 289

Treatment
Phlebotomy፡ by removing enough blood
(initially 500 mL once or twice weekly) to
deplete the patient’s iron stores,
Anagrelide (Agrylin) inhibits platelet
aggregation
10/03/2023 BY: Ibrahim A ( BScN) 290

SECONDARY POLYCYTHEMIA
Secondary polycythemia is caused by excessive

production of erythropoietin.
This may occur in response to a reduced amount of
oxygen, which acts as a hypoxic stimulus, as in cigarette
smoking, chronic obstructive pulmonary disease, or
cyanotic heart disease, or in nonpathologic conditions
such as high altitude.
Secondary polycythemia can also occur from neoplasms
(eg, renal cell carcinoma) that stimulate erythropoietin
production.
10/03/2023 BY: Ibrahim A ( BScN) 291

Venous Thrombosis
 A blood clot that forms in the lumen of a blood vessel.
 A thrombus may form in an artery, but it is more

common in veins.
 due to the lower pressure and reduced blood flow

found in the venous circulation.
10/03/2023 BY: Ibrahim A ( BScN) 292

Factors for the formation of a thrombus
 Stasis of blood due to:

 poor blood flow
 Immobility
 heart failure
 myocardial infarction
 Hypotension
10/03/2023 BY: Ibrahim A ( BScN) 293

Factors-----
 Damage to blood vessels from:
Surgical trauma
IV drugs
catheters or
 immune response
10/03/2023 BY: Ibrahim A ( BScN) 294

Factors-----
 Hypercoagulability of blood resulting from:
Pregnancy
 malignancies
coagulation disorders
dehydration
 use of oral contraceptives

10/03/2023 BY: Ibrahim A ( BScN) 295
Treatment
 Ambulation
 use of elastic stockings
 exercise or elevation of legs
 Anticoagulation therapy (warfarin, heparin)
 Thrombolytic therapy to dissolve clots (streptokinase).
10/03/2023 BY: Ibrahim A ( BScN) 296

Embolism
 An embolism is a thrombus that breaks loose and travels

through circulation.
 Common sites for lodging of emboli - the small

pulmonary blood vessels of the lungs .
 Lodge in cerebral or coronary blood vessels are rapidly

fatal .
 A bolus of fat from breakage of long bones or air

injection ,foreign matter into the blood stream
10/03/2023 BY: Ibrahim A ( BScN) 297

occurrence
Commonly legs but where else
 Abdominal wall
 Anus
 Vulva
 Esophagus
10/03/2023 BY: Ibrahim A ( BScN) 298
causes
Primary:
 Congenital abnormality (most common)
Secondary cause:
 Anything that raises intra-abdominal pressure or raise
pressure in superficial/deep venous system
 -pregnancy
 -abdominal/pelvic mass
 -ascites
 -Obesity
 -Constipation thrombosis of deep
10/03/2023 BY: Ibrahim A ( BScN) 299

Treatment
Anticoagulant drugs.
Aspirin- a potent inhibitor of platelet aggregation

through its inhibition of the enzyme cyclo-oxygenase.
Thrombolytic drugs (fibrinolytic or clot-dissolving

drugs) e.g. streptokinase
10/03/2023 BY: Ibrahim A ( BScN) 300

Thrombophlebitis
The formation of a clot ,associated with
inflammation of the lining of a vein.

Causes:
 Venous stasis.
 Injury to vessel wall.
 Hypercoagulable state
10/03/2023 BY: Ibrahim A ( BScN) 301

Clinical risk factors
Old (age >60y) - blood group A
Malignancy - Birth control
Trauma -travel
Obesity - obstetrics
-Surgery smoking
10/03/2023 BY: Ibrahim A ( BScN) 302

Treatment
Bed rest
 leg elevation
elastic stockings
Anticoagulant
follow-up
10/03/2023 BY: Ibrahim A ( BScN) 303

WBC disorder
 Leukocytosis:
Absolute increase in number of leukocytes in

peripheral blood.
without reference to cell type or level of

maturity.
In adults, greater than 10,000-11,000/mm3.
10/03/2023 BY: Ibrahim A ( BScN) 304

WBC disorder----
 Neutrophilic leucocytosis :
 Majority of cases of leukocytosis are due to an increase
in cells of neutrophilic series.
 Neutrophilia – absolute neutrophil count of
8,000/mm3 or higher
 Mechanisms of neturophilia
 Increased production by bone marrow (acute)
 _ Increased release from stores (chronic) – shift to left
 _ Shift from marginal pool to circulating pool
10/03/2023 BY: Ibrahim A ( BScN) 305

WBC disorder----
 Pathologic increase
 Total WBC: 15,000-30,000/mm3 (may be

higher)
Inflow exceeds outflow and neutrophilia develops
– result of inflammatory stimulus
 Infectious Disease – Bacterial most common
 Intoxication: metabolic and chemical

Tissue Necrosis
10/03/2023 BY: Ibrahim A ( BScN) 306
Leucopenia
Reduction in white count <4,000/mm3
Most frequently due to decrease in neutrophil

(neutropenia)
Neutropenia: absolute count <1,500/mm3
 Severe granulocytopenia: agranulocytosis
 Increased susceptibility to infection

10/03/2023 BY: Ibrahim A ( BScN) 307
Causes of neutropnia
Infectious Agents- peripheral utilization of
neutrophils or interference with production
 Bacteria: typhoid, paratyphoid, brucellosis
Viral: Measles, Rubella, Influenza, Hepatitis
 Protozoa: Malaria, Kala-azar

10/03/2023 BY: Ibrahim A ( BScN) 308
Leukemia
 Is a malignant disease of hematopoietic tissue.
 The accumulation of abnormal white cells (neoplastic or

leukemic) in the bone marrow :
 Leading to bone marrow failure
 A raised circulating white cell count (leukocytosis)
 infiltrate organs ( e.g liver, spleen, lymph nodes, brain)
10/03/2023 BY: Ibrahim A ( BScN) 309

Leukemia----
Cancer of the white blood cells.
Acute or Chronic.
Affects ability to produce normal blood cells.
Bone marrow makes abnormally large number

of immature white blood cells called blasts
10/03/2023 BY: Ibrahim A ( BScN) 310

Etiology and Risk Factors
 Unknown.
 Oncogenes mutation and tumor suppressor gene
alteration.
 Chromosomal abnormality
 Gene rearrangement
 Immunodeficiency
 Chronic bone marrow dysfunction

10/03/2023 BY: Ibrahim A ( BScN) 311
Etiology-----
Environmental factors:
 Ionizing radiation
 Chemical drugs:
- Benzene,
- Chloramphenicol,
- Phenylbutazone
-Cytotoxic alkylating
10/03/2023 BY: Ibrahim A ( BScN) 312

Classifications of leukemia
Acute Chronic
Age All ages Adults
Clinical onset Sudden Insidious
Leukemic cells Immature Mature
Anemia Mild to severe Mild
Thrombocytopenia Mild to severe Mild
WBC Variable Increased
Organomegaly Mild prominent
10/03/2023 BY: Ibrahim A ( BScN) 313

Symptoms
When there are excessive white blood cells -->

Infections
When there are few red blood cells: Paleness -->

Anemia
When there are few platelets --> Excessive

bleeding
10/03/2023 BY: Ibrahim A ( BScN) 314

Tests for Diagnosis
Finger prick
Blood sample
Bone marrow sample
Spinal Tap/Lumbar Puncture
10/03/2023 BY: Ibrahim A ( BScN) 315

Developmental stages
 Stage 1- Normal
 Stage 2- Symptoms
 Stage 3- Diagnosis
 Stage 4- Worsening
 Stage 5a- Anemia
 Stage 5b- Infection
10/03/2023 BY: Ibrahim A ( BScN) 316

Treatment leukemia
Chemotherapy
Immunotherapy
Radiation
Bone marrow transplant
10/03/2023 BY: Ibrahim A ( BScN) 317

Lymphomas
Malignant transformation of cells residing

predominantly in lymphoid tissue.
 It is broadly classified:
Hodgkin’s disease
Non-Hodgkin’s lymphomas
10/03/2023 BY: Ibrahim A ( BScN) 318

Hodgkin’s disease
 It has bimodal age incidence (20-30&>50years)
 In developing countries young adults are commonly
affected
 Male to female ratio=2:1
10/03/2023 BY: Ibrahim A ( BScN) 319

Clinical manifestations
Non-tender, firm enlargement of superficial
lymph nodes.
Cervical (60-70%), axillary (10-15%),
inguinal (l6-12%) commonly affected.
10/03/2023 BY: Ibrahim A ( BScN) 320

manifestations -----
 Mild splenomegaly .
 Constitutional symptoms (fever, wt loss, sweating .
 Purities
 Pain, weakness, fatigue, anorexia,
10/03/2023 BY: Ibrahim A ( BScN) 321

Diagnosis
 Lymph node biopsy -histological examination of an

excised lymph node.
10/03/2023 BY: Ibrahim A ( BScN) 322

Clinical stage
Stage 1. Only affecting one lymph node area

Stage 2. Two or more lymph nodes on the same
side
Stage 3.disease involving lymph nodes above
and below diaphragm, spleen involved.
Stage 4.extra nodal site involved ( liver ,b. marrow
10/03/2023 BY: Ibrahim A ( BScN) 323

Treatment
Radiotherapy
Chemotherapy :
 MOPP=mustine, vincristine (oncovine) ,procarbatine ,
predinisolone
 ABVD=Adramycin,bleomycin,viblastin,decarbazine
Note :This therapy is given alone or combinations MOPP

& ABVD hybrid for 6 or 4 cycles after full remission
10/03/2023 BY: Ibrahim A ( BScN) 324

Prognosis
 Depends on stage
 Five years survival being:
 Stage I and II=85%
 Stage III =70%
 Stage IV =50%
10/03/2023 BY: Ibrahim A ( BScN) 325

Non Hodgkin’s lymphoma (NHL)
 Predisposing factors /diseases :

 HIV infection
 Immuno-suppression
 Celiac disease, dermatitis
 Infections (e.g. Helicobacter infections)
10/03/2023 BY: Ibrahim A ( BScN) 326

Clinical feature
Superficial lymphadenitis
Constitutional symptoms
Oro-pharyngeal involvements
Anemia
Organo-megally
10/03/2023 BY: Ibrahim A ( BScN) 327

Laboratory findings
CBC
Cytopnia
Lymphoma cells
Bone marrow biopsy
10/03/2023 BY: Ibrahim A ( BScN) 328

Laboratory----
Uric acid level elevated
Liver enzymes abnormally elevated
10/03/2023 BY: Ibrahim A ( BScN) 329

Treatments
No therapy if no symptoms
Local radio therapy =stage I&II
Combination chemotherapy for advanced case
BMT( bone marrow transplantation)
10/03/2023 BY: Ibrahim A ( BScN) 330

Shock
10/03/2023 BY: Ibrahim A ( BScN) 331

Shock
Shock is a serious, life-threatening medical condition

where insufficient blood flow reaches the body tissues.
Reduced blood flow hinders oxygen and nutrients

delivery to the tissues, and can stop the tissues from
functioning properly.
It is a medical emergency and one of the most common

causes of death for critically-ill people.
10/03/2023 BY: Ibrahim A ( BScN) 332

Stages of shock
There are four stages of shock, although shock is a

complex and continuous condition
◦ Initial stages
◦ Compensatory (Compensating)
◦ Progressive (Decompensating)
◦ Refractory (Irreversable)
10/03/2023 BY: Ibrahim A ( BScN) 333

Initial stage
Changes attributed to this stage occur at the cellular

level and not detectable clinically.
10/03/2023 BY: Ibrahim A ( BScN) 334

Compensatory Stage
Blood pressure remains within normal limits.
Vasoconstriction, increased HR and contractility to

maintain adequate cardiac output (SNS)
The patient displays the “fight or flight” response.
The body shunts blood to the brain and heart
Skin is cold and clammy, bowel sounds are

hypoactive, and urine output decreases
10/03/2023 BY: Ibrahim A ( BScN) 335

Compensatory…
Anaerobic metabolism and metabolic acidosis.
Respiratory rate increases causing compensatory

respiratory alkalosis.
Mental status changes, such as confusion
If treatment begins in this stage of shock, the

prognosis for the patient is good
10/03/2023 BY: Ibrahim A ( BScN) 336

Progressive Stage
The mechanisms that regulate BP can no longer compensate

and the MAP falls below normal limits,
The overworked heart becomes dysfunctional;
ischemia and myocardial depression
The autoregulatory function of the microcirculation fails,

increased capillary permeability, vasoconstriction
Interstitial edema and return of less fluid to the heart.
10/03/2023 BY: Ibrahim A ( BScN) 337

Irreversible Stage
Organ damage is so severe that the patient does not respond to
treatment and cannot survive.
Despite treatment, blood pressure remains low.
Complete renal and liver failure, compounded by the release of

necrotic tissue toxins, metabolic acidosis.
Anaerobic metabolism contributes to a worsening lactic acidosis.
Reserves of ATP are almost totally depleted.
Multiple organ dysfunctions progressing to complete organ

failure and death is imminent.
10/03/2023 BY: Ibrahim A ( BScN) 338

Summary of Clinical Findings in Shock
10/03/2023 BY: Ibrahim A ( BScN) 339

Pathophysiology of shock
10/03/2023 BY: Ibrahim A ( BScN) 340

Types of shock
There are four common types of shock:
1. Hypovolaemic,
2. Cardiogenic,
3. Distributive and
4. Obstructive shock
10/03/2023 BY: Ibrahim A ( BScN) 341

Hypovolemic shock
This is the most common type of shock and is caused by

insufficient circulating volume.
Cause and risk factors

Internal: Fluid Shifts
External: Fluid Losses
 Hemorrhage
 Trauma
 Severe Burns
 Surgery
 Ascites
 Vomiting
 Dehydration
 Diarrhea
 Diuresis 10/03/2023 BY: Ibrahim A ( BScN) 342

Pathophysiologic events in hypovolemic shock
10/03/2023 BY: Ibrahim A ( BScN) 343

Body response to HVS
 The human body responds to acute hemorrhage by
activating 4 major physiologic systems .
 The hematologic system
 The cardiovascular system
 The renal system and
 The neuroendocrine system
10/03/2023 BY: Ibrahim A ( BScN) 344

Hematologic System response
 Activating the coagulation cascade
 contracting the bleeding vessels (via local thromboxane

A2 release)
 Platelets are activated which form an immature clot on

the bleeding source
 damaged vessels expose collagen, which

subsequently causes fibrin deposition and
stabilization of the clot.
10/03/2023 BY: Ibrahim A ( BScN) 345
Cardiovascular System response
Increases the heart rate
increasing myocardial
contractility and
 constricting peripheral bloodvessels
10/03/2023 BY: Ibrahim A ( BScN) 346

Cardiovascular System----
 This occurs secondary to an increase in release of
norepinephrine and a decrease in baseline vagal tone
(regulated by the baroreceptors in the carotid arch,
aortic arch, left atrium, and pulmonary vessels).
 The cardiovascular system also responds by

redistributing blood to the brain, heart, and kidneys
and away from skin, muscle, and GI tract.
10/03/2023 BY: Ibrahim A ( BScN) 347

Renal System response
 The kidneys respond an increase in rennin secretion from
the juxtaglomerular apparatus.
 Renin –angiotensinogen- angiotensin-I- angiotensin II-
blood vessels constriction stimulates aldostron-water and salt

retntion
10/03/2023 BY: Ibrahim A ( BScN) 348

Neuroendocrine System ------
 Causes an increase in circulating antidiuretic hormone

(ADH)
 ADH indirectly leads to an increase in reabsorption of

water and salt (NaCl) by the distal tubule, the collecting
ducts, and the loop of Henle.
10/03/2023 BY: Ibrahim A ( BScN) 349

Cardiogenic shock
This type of shock is caused by the failure of the

heart to pump effectively.
Cause
Myocardial infarction
Arrhythmias
Cardiomyopathy
Congestive heart failure (CHF)
Cardiac valve problems
10/03/2023 BY: Ibrahim A ( BScN) 350
Pathophysiologic events in cardiogenic shock
10/03/2023 BY: Ibrahim A ( BScN) 351

Distributive shock
As in hypovolaemic shock there is an insufficient

intravascular volume of blood.
This form of "relative" hypovolaemia is the result of
dilation of blood vessels which diminishes systemic
vascular resistance.
10/03/2023 BY: Ibrahim A ( BScN) 352

Distributive shock
Examples of this form of shock are:
A. Septic shock: is a type of shock caused by infection
Cause
Infections leading to vasodilatation caused by:
– Gram negative bacteria i.e. E.coli, Proteus species,
– Gram-positive cocci, such as streptococci
– Certain fungi
May be related to:
◦ Immunosuppression, Extremes of age, Malnourishment,
Chronic illness, Invasive procedures

10/03/2023 BY: Ibrahim A ( BScN) 353
Distributive shock …
B. Anaphylactic shock - Caused by a severe anaphylactic
reaction to an allergen, antigen, drug or foreign

protein causing the release of histamine which causes
widespread vasodilation, leading to hypotension and
increased capillary permeability.
May be due to:
Penicillin sensitivity
Transfusion reaction
Bee sting allergy
Latex sensitivity
10/03/2023 BY: Ibrahim A ( BScN) 354
Distributive shock …
C. Neurogenic shock : is the rarest form of shock
Cause
Trauma to the spinal cord resulting in the sudden loss
of autonomic and motor reflexes below the injury
level
Spinal anesthesia
Depressant action of medications
Glucose deficiency 10/03/2023 BY: Ibrahim A ( BScN) 355
Pathophysiologic events in circulatory shock
10/03/2023 BY: Ibrahim A ( BScN) 356

Obstructive shock
– In this situation the flow of blood is obstructed which
impedes circulation and can result in circulatory arrest.
Causes
Cardiac tamponade
Constrictive pericarditis
Tension pneumothorax
Massive pulmonary embolism
Aortic stenosis- obstruct the ventricular outflow tract
10/03/2023 BY: Ibrahim A ( BScN) 357

Clinical manifestations of shock
Hypovolemic Cardioge Obstructiv Distributive shock
Type of shock
nic e Septic shock Neurogenic Anaphylact

ic
 Anxiety, restlessness, S/S of S/S of S/S of S/S of Skin eruption

altered mental state hypovolaemi hypovolaemic hypovolaemic hypovolaemic Localized
 Hypotension c shock shock PLUS shock PLUS shock PLUS edema
 A rapid, weak, PLUS Distended Pyrexia and warm and dry Weak & rapid
thready pulse Distended jugular veins, fever, or skin pulse
 Cool, clammy, jugular Pulsus hyperthermia- Breathlessness
Sign and Symptoms
mottled skin veins, paradoxus in the initial & cough

 Rapid and shallow Absent pulse stage
respirations Vasodilation &
 Hypothermia increased
 Thirst and dry mouth cardiac output
 Fatigue
 Dilated pupil
10/03/2023 BY: Ibrahim A ( BScN) 358

Diagnosis
 Clinical(Hx and PE)

 CBC
 Blood cultures
10/03/2023 BY: Ibrahim A ( BScN) 359

Treatment of shock
In the early stages, shock requires immediate intervention

to preserve life, even before a diagnosis is made.
Re-establishing perfusion to the organs is the primary

goal through restoring and maintaining the circulating
blood volume to effective cardiac function, and
preventing complications.
10/03/2023 BY: Ibrahim A ( BScN) 360

Treatment…
Raising blood pressure to be able to transport "safely";
If surgery is required, it should be performed within the

first hour to maximize the patient's chance of survival.
10/03/2023 BY: Ibrahim A ( BScN) 361

Treatment…
1. Hypovolaemic shock
If caused by bleeding
 Control bleeding
 Restore volume with infusions of balanced salt

solutions
 Blood transfusions -for loss of large amounts of blood
(e.g. >20% of blood volume)
10/03/2023 BY: Ibrahim A ( BScN) 362

Treatment…
If due to burns, diarrhoea, vomiting, etc:
Infusions of electrolyte solutions that balance the lost

fluid
Prevent metabolic acidosis
As soon as the airway is maintained and oxygen

administered the next step is to commence replacement
of fluids via the intravenous route
10/03/2023 BY: Ibrahim A ( BScN) 363

Treatment…
The most common fluids used are:

 Crystalloids - Such as sodium chloride (0.9%), Ringer's
lactate
 Blood - Essential in severe hemorrhagic shock
 Colloids
10/03/2023 BY: Ibrahim A ( BScN) 364

Treatment…
2. Cardiogenic shock
Depending on the type of MI, one can infuse fluids or in shock
refractory to infusing fluids give drugs
Inotropic agents- (like calcium, Digoxin, Dopamine, Dobutamine,)
Fluid replacement with intravenous infusions;
Use of vasopressing drugs to induce vasoconstriction;
Use of anti-shock trousers
10/03/2023 BY: Ibrahim A ( BScN) 365

Treatment…
3. Distributive shock
 Treating infection with antibiotics and supportive care
 Anaphylaxis is treated with adrenaline & Corticosteroids
Neurogenic shock
Trendelenburg position to shunt blood back to the body's core
Vasopressors like adrenaline, noradrenaline,

dubutamine, dopamine, ephederine etc.
10/03/2023 BY: Ibrahim A ( BScN) 366

Trendelenburg position
10/03/2023 BY: Ibrahim A ( BScN) 367

Treatment…
4. Obstructive shock
The only therapy consists of removing the obstruction.
Pneumothorax/haemothorax is treated by inserting chest tube
Pulmonary embolism requires thrombolysis or embolectomy
Tamponade is treated by draining fluid from the pericardial

space through pericardiocentesis
10/03/2023 BY: Ibrahim A ( BScN) 368

Group assignment(10%)
Be in a group of ten students
Your assignment has presentation and one
randomly selected student will present it.
Your assignment must have cover page,
introduction, definition, cause and risk factors,
sign and symptom, diagnosis, treatment both
pharmacologic & non pharmacologic, nursing
diagnosis
Plagiarism will result in zero mark
Assignmnt must submitt with in 5 days.
10/03/2023 BY: Ibrahim A ( BScN) 369
Questions
 ventricular dysrhythmias: ( group 1 & 2)

-Premature ventricular Complex
-Ventricular Tachycardia
-Ventricular Fibrillation
-Ventricular asystole
10/03/2023 BY: Ibrahim A ( BScN) 370

Atrial dysrhythmias: ( group 3,4 & 5)
sinus Bradycardia
sinus Tachycardia
Degree AV block
Atrial Fibrillation
Atrial Flutter
10/03/2023 BY: Ibrahim A ( BScN) 371
Cont,d
Reading Assignment
Bleeding disorders- hemophilia
10/03/2023 BY: Ibrahim A ( BScN) 372

Thank
you!!
10/03/2023 BY: Ibrahim A ( BScN) 373

UN 5 Cardiovascular System Disorder

Uploaded by

Document Information

Original Description:

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

UN 5 Cardiovascular System Disorder

Uploaded by

Copyright:

Available Formats

Medical Surgical

BY: Ibrahim Ahmed (Bsc.N)

10/03/2023 BY: Ibrahim A ( BScN) 1

CVS is composed of:

10/03/2023 BY: Ibrahim A ( BScN) 2

The heart is a hollow, muscular organ located in

10/03/2023 BY: Ibrahim A ( BScN) 3

The heart pumps blood to the tissues, supplying them

Its pumping action is accomplished by the rhythmic

Ventricle ejects ~70 mL of blood per beat and has an

10/03/2023 BY: Ibrahim A ( BScN) 4

The heart is composed of three layers.

10/03/2023 BY: Ibrahim A ( BScN) 6

10/03/2023 BY: Ibrahim A ( BScN) 7

The heart has four chambers

10/03/2023 BY: Ibrahim A ( BScN) 8

10/03/2023 BY: Ibrahim A ( BScN) 9

10/03/2023 BY: Ibrahim A ( BScN) 10

Valves of the heart permit blood to flow in only one

1. Atrioventricular (AV) and

10/03/2023 BY: Ibrahim A ( BScN) 13

Separate the atria from the ventricles.

The tricuspid valve (right)

10/03/2023 BY: Ibrahim A ( BScN) 14

The valve between the right ventricle and the

10/03/2023 BY: Ibrahim A ( BScN) 15

 The left and right coronary arteries and their branches

supply arterial blood to the heart.

~70% to 80% of the oxygen delivered.

10/03/2023 BY: Ibrahim A ( BScN) 16

Generate and coordinate the transmission of

The result is sequential atrioventricular

10/03/2023 BY: Ibrahim A ( BScN) 17

any impulse from an outside source

 Conductivity: : Refers to the ability of each cell of the conduction system

to conduct individual electrical impulses from one cell to another.

10/03/2023 BY: Ibrahim A ( BScN) 18

The sinoatrial (SA) node: primary pacemaker of the

The SA node in normal resting heart has an inherent

The heart rate is determined by the myocardial cells with

10/03/2023 BY: Ibrahim A ( BScN) 19

 Under normal circumstances, the SA node has the

highest inherent rate, the AV node has the second

10/03/2023 BY: Ibrahim A ( BScN) 20

10/03/2023 BY: Ibrahim A ( BScN) 22

10/03/2023 BY: Ibrahim A ( BScN) 23

10/03/2023 BY: Ibrahim A ( BScN) 25

10/03/2023 BY: Ibrahim A ( BScN) 26

10/03/2023 BY: Ibrahim A ( BScN) 28

Preceded by P wave (atrial excitation)

10/03/2023 BY: Ibrahim A ( BScN) 29

Initiated by ventricular excitation (QRS wave)

10/03/2023 BY: Ibrahim A ( BScN) 30

Begins when ventricular pressure exceeds aortic (or

10/03/2023 BY: Ibrahim A ( BScN) 31

10/03/2023 BY: Ibrahim A ( BScN) 33

10/03/2023 BY: Ibrahim A ( BScN) 34

10/03/2023 BY: Ibrahim A ( BScN) 35

10/03/2023 BY: Ibrahim A ( BScN) 36

10/03/2023 BY: Ibrahim A ( BScN) 38

10/03/2023 BY: Ibrahim A ( BScN) 39

10/03/2023 BY: Ibrahim A ( BScN) 40

10/03/2023 BY: Ibrahim A ( BScN) 41