CARDIOVASCULAR

Venous Insufficiency venous stasis ulcer

lesion that forms on the skin when the flow of venous blood is impaired

Coronary artery disease Diagnostic Findings

lipid profile studies electron beam computed tomography electrocardiography cardiac catheterization arteriography

COronary Artery disease Assessment Findings Signs and Symptoms

In mild CAD, clients are asymptomatic or complain of fatigue. The classical symptom is chest pain (angina pectoris) or discomfort during activity or stress. Such pain or discomfort typically is manifested as sudden pain or pressure that may be centered over the heart (precordial) or under the sternum (substernal). The pain may radiate to the shoulders and arms, especially on the left side, or to the jaw, neck, or teeth

Take another tablet in 5 minutes if chest pain is unrelieved. Keep the tablets in a tightly closed container.

Oatmeal rather than cold cereal. Egg substitute rather than scrambled eggs. Frozen yogurt rather than ice cream. Baked salmon rather than steak.

transmyocardial revascularization TMA

laser procedure that improves oxygenation of myocardial tissue by creating channels into which oxygenated blood seeps and is absorbed by the ischemic myocardium

Cardiac output:

* Cardiac output: the amount of blood pumped out of the left ventricle each minute * Stroke volume: the amount of blood pumped per contraction of the heart

OCCLUSIVE DISORDERS OF CORONARY BLOOD VESSELS

Coronary occlusion is the closing of a coronary artery, which reduces or totally interrupts blood supply to the distal muscle area. Coronary artery disease (CAD) precedes coronary occlusion, which, if untreated, leads to myocardial infarction (MI), which laypersons refer to as a heart attack. Symptoms usually do not occur until at least 60% of the arterial lumen is occluded.

Cardiac Risk Based on Highly Sensitive C-Reactive Protein Test

HS-CRP (MG/L) Less than 1.0 > LOW 1.0-2.9 > INTERMEDIATE Greater than 3.0 > HIGH

Blood supply to the heart:

Left and right coronary arteries supply oxygenated blood to cardiac muscle.

mitral valve prolapse Medical and Surgical Management

Many clients with mitral valve prolapse require no treatment. Such drugs as digitalis, beta-blockers, and calcium channel blockers control tachydysrhythmias; all but digitalis also control hypertension. Medications to reduce or inhibit platelet aggregation in cases where mitral valve prolapse is accompanied by atrial fibrillation include a single, daily, low-dose aspirin, warfarin (Coumadin), clopidogrel (Plavix), to prevent thrombus formation. If symptoms become severe, valve replacement is indicated. Antianxiety medication may be prescribed to prevent symptoms related to the sympathetic nervous system among those with mitral valve prolapse syndrome. Such clients also are advised to avoid caffeine to prevent tachycardia and heart palpitations. To compensate for symptoms associated with hypovolemia, liberal fluid and adequate sodium intake is recommended. Because alcohol can suppress antidiuretic hormone (ADH), leading to loss of extracellular fluid, clients with mitral valve prolapse syndrome are advised to restrict or eliminate its use.

Mitral Regurgitation (Insufficiency)

Mitral regurgitation, sometimes referred to as mitral insufficiency, occurs when the mitral valve does not close completely (Fig. 24-6). Some clients present with severe acute symptoms; others, whose heart muscle increases in size to compensate, remain asymptomatic or develop symptoms gradually over many years.

Pharmacologic Considerations

Often, medications are held for 24 hours before procedures. Confer with the primary provider regarding medications for chronic conditions; this is especially important for those who take heart, hypertension, or diabetes medications.

DISORDERS OF BLOOD VESSEL WALLS Assessment Findings S/S

Often, the condition first manifests itself when other factors impair venous return. The legs feel heavy and tired, particularly after prolonged standing. The client may say that activity or elevation of the legs relieves the discomfort. The leg veins look distended and tortuous and can be seen under the skin as dark blue or purple, snakelike elevations. The feet, ankles, and legs may appear swollen. The skin may be slightly darker in the areas of impaired circulation. There may be signs of skin ulcerations in various stages of healing. Capillary refill may be abnormal.

Peripheral Artery Disease

PAD, a condition that affects primarily the blood vessels that supply oxygen to lower limbs, which is the focus of this discussion. The same pathologic process, however, can affect the carotid, renal, and mesenteric arteries as well. Men are affected more than women by PAD in the lower extremities. As the disorder worsens, some affected individuals may develop critical limb ischemia, a complication characterized by open sores or infections that do not resolve, become gangrenous, and threaten the viability of the limb, making amputation necessary.

Two organisms that cause infectious conditions of the heart:

Streptococci Staphylococci

A client's lipid panel indicates an LDL of 182 mg/dL. What is an accurate analysis of the laboratory result?

The client's LDL is high; lifestyle changes should be encouraged.

Cardiac Rhythm

The electrical activity that produces the heart rhythm can be observed continuously with bedside cardiac monitoring.

Venous Thrombosis

The formation of blood clots within a vein

mitral stenosis Nursing Management

The nurse monitors the client's physical condition, prepares them for diagnostic testing, and provides posttreatment care. Discharge teaching includes information regarding drug therapy, activity modification, signs and symptoms of complications, and when to contact the primary provider

Venous Insufficiency

Venous insufficiency is a peripheral vascular disorder in which the flow of venous blood is impaired through deep or superficial veins (or both). The condition usually affects the lower extremities, most often the medial aspect of the leg or around the ankle.

Venous Insufficiency Pathophysiology and Etiology

Venous insufficiency may be a consequence of varicose veins or valvular damage from a previous venous thrombosis. When the forward movement of venous blood is affected, venous congestion develops from the accumulating blood volume.

A client with venous stasis in the lower extremities complains to the nurse that the elastic compression stockings are "too tight." What response by the nurse is most appropriate?

"I'll remove them and remeasure your extremities."

Sequence in transcatheter aortic valve implantation:

(A) the stenotic valve is opened with a balloon; (B) the balloon is deflated and a stent is positioned within the valve; (C) the stent expands to hold the valve leaflets open; and (D) the bioprosthetic replacement valve is implanted.

Regulation of the heart rate:

* Baroreceptors: the function is to sense the pressure from blood as it stretches vascular tissues * Chemoreceptors: structures that are sensitive to the pH and CO2 and oxygen levels of blood are located in the carotid bodies, aortic bodies, and medulla of the brain.

Cardiac cycle:

* Diastole: the majority of the blood supply flowing to coronary arteries to fill the ventricles * Systole: when the ventricles are filled, they contract.

Cardiopulmonary circulation:

* Largest veins: inferior vena cava and superior vena cava, bring venous (deoxygenated) blood from all areas of the body into the right atrium * Pulmonary artery (the only artery in an adult that carries deoxygenated blood): The pulmonary artery branches to deliver venous blood to the right and left lungs.

Arterial Occlusive Disease

-insufficient blood supply in the arteries (usually in legs); may be acute or chronic -narrowed blood vessels reduce blood flow to the limbs

Diagnosis of peripheral edema

0.9 or less

ABI (ankle brachial index) values to measure to detect peripheral artery disease

0.9-1.0 Normal 0.70- 0.89 Mild disease 0.40- 0.69 Moderate disease <0.40 Severe disease

Mitral Stenosis Diagnostic Findings

A chest radiograph reveals an enlarged left atrium and mitral valve calcification. In advanced stages, evidence of fluid congestion in the lungs (pulmonary edema) is found. A standard or esophageal echocardiogram demonstrates decreased movement of the mitral valve cusps and changes in the size of the atrial chamber. On ECG, the P wave is notched, showing that the left atrium takes longer to depolarize than the right atrium because of its increased size.

Venous Insufficiency Medical and Surgical Management

A major goal of therapy is to promote venous circulation. This is accomplished by applying elastic compression stockings, such as Jobst stockings, that maintain venous pressure at 40 mm Hg. The client wears the stockings at all times except when lying down. Because older adults may have difficulty applying elastic compression stockings, the primary provider may apply a nonelastic gauze dressing soaked in zinc paste and glycerin known as an Unna boot. Pneumatic compression pump therapy, similar to EECP, also may be implemented. The compression pump promotes venous p. 431 p. 432 blood flow more efficiently than compression stockings but is more expensive and time-consuming. Furthermore, it interferes with performance of daily activities during its use. Mild analgesics are recommended for pain. Vascular surgery can be performed in which the valves in larger veins are repaired or incompetent valves are bypassed using a length of vein with healthy valves from elsewhere in the body. A stasis ulcer is managed by keeping the skin and ulcer clean with soap and water or a diluted solution of a disinfectant such as Hibiclens. Necrotic tissue is debrided. Any infection is treated by applying Silvadene, an antibacterial cream, or an antibiotic ointment. The wound is covered with an occlusive transparent dressing such as Tegaderm that traps moisture, which speeds healing. Chronic, nonhealing skin lesions also are treated with topical hyperbaric oxygen (THBO) therapy. This approach delivers oxygen above atmospheric pressure directly to the wound rather than to the full body as with other disorders such as carbon monoxide poisoning. Oxygen accelerates the healing process. THBO is applied by covering the area with an inflatable boot that confines the oxygen at low hyperbaric pressure at the wound site. The boot remains in place for approximately 90 minutes a day for 4 consecutive days. The treatment is repeated after 3 days of nontreatment in a cycle over 8 to 10 weeks.

ABI Formula

ABI= Lower extremity Systolic pressure (÷) Brachial artery pressure

Assessment of Pulsus Paradoxus

Advise client to breathe normally throughout the assessment. Inflate BP cuff 20 mm Hg above systolic pressure. Deflate the cuff slowly, noting that sounds are audible during expiration, but not during inspiration. Note when the first BP sound (Korotkoff) is heard. Continue to deflate the cuff until BP sounds are heard during both inspiration and expiration. Measure the difference in millimeters of mercury between the first BP sound heard during expiration and the first BP sound heard during both inspiration and expiration.

arteriography Nursing care

After removal of the catheter, the nurse inspects the insertion site for bleeding, tenderness, hematoma formation, and inflammation. The client remains on bed rest for the rest of the day. They must avoid flexion, or bending, of the arm or leg used for catheter insertion. Vascular assessments distal to the insertion site continue at frequent intervals. Absent distal peripheral pulses, cool toes, and pale or cyanotic arms and legs indicate arterial occlusion, usually from a blood clot. These signs as well as a rapid or irregular pulse rate indicate a medical emergency that the nurse must report immediately to the primary provider.

Aneurysms

An aneurysm is the stretching and bulging of an arterial wall. Aneurysms of the aorta (aortic arch, thoracic, abdominal) are the most common, but aneurysms can be found in other arteries, such as those in the legs and brain.

Agents to Treat Valvular Heart Disorders

Antibiotics, Anticoagulants, Antiplatelets, Cardiac Glycosides, Antiarrhythmics, ACE Inhibitors (ACEI),

Arteries and ventricles:

Arteries: carry oxygenated blood from the heart Veins: return deoxygenated blood to the heart

Thrombosis, Phlebothrombosis, and Embolism Diagnostic Findings

Arteriography or venography (also called phlebography) using a contrast dye identifies the point of obstruction. Doppler ultrasonography is used to detect abnormalities in peripheral blood flow. Plethysmography measures volume changes in the venous or arterial system.

Aneurysms Pathophysiology and Etiology

Arteriosclerosis, hypertension, trauma, or a congenital weakness can affect the elasticity of the tunica media (middle layer of the artery wall), causing part of the vessel to bulge. Once formed, some aneurysms lay down layers of clots, blocking the vessel until blood flow stops. Most aneurysms enlarge until they rupture. Loss of a large volume of arterial blood leads to shock and death if not controlled. Some aneurysms tear and leak blood into surrounding cavities, such as the thorax or abdomen. Blood in a dissecting aneurysm is unavailable to arteries that branch off the aorta. When blood flow decreases or stops, tissue necrosis occurs.

Nursing Management

Assessment Determine the following: Client's description of pain: location, type, duration, intensity using a scale of 0 to 10, and whether it radiates to other areas Vital signs every 30 minutes until stable and then every 4 hours and as needed (p.r.n.) Presence of nausea, vomiting, diaphoresis, anxiety Oxygen saturation level with a pulse oximeter Cardiac rhythm via cardiac monitor or ECG Heart and lung sounds Presence and quality of peripheral pulses Results of serum cardiac markers A thorough history to establish baseline data about disorders such as diabetes mellitus, hypertension, recent streptococcal infection, or allergic reaction to streptokinase, and findings that may disqualify the client from thrombolytic therapy Drug history for prescribed, over-the-counter, and herbal products

The Client With a Valvular Disorder

Assessment Determine the following: Vital signs, noting tachycardia, rapid respirations, dyspnea, hypotension, or hypertension Any episodes of dizziness or fainting with or without confusion Chest pain and its characteristics Normal or abnormal lung and heart sounds Fluid intake and output Current weight and fluctuations during treatment Level of activity tolerance Social aspects (e.g., occupational activities) as they relate to physical energy requirements Knowledge of medical condition and current and future treatment protocols

Renaud syndrome Assessment Findings

Attacks are intermittent and of varying frequency but are especially common after exposure to cold. When the condition occurs in the hands, they become cold, blanched, and wet with perspiration. Numbness and tingling also may occur. The client may note awkwardness and fumbling, especially when attempting fine movements. After the initial pallor, the hands, especially the fingers, become deeply cyanotic and begin to ache. The hallmark symptoms of arterial insufficiency include ischemia, pain, and paresthesia. Placing the affected part in warm water or going to a warm area can relieve an attack. Eventually, the vasospasm is relieved, and blood rushes to the affected part. The skin in the deprived areas becomes flushed, swollen, and warm, and the person has a sensation of throbbing pain. In the early stages of the disease, the hands usually appear normal between attacks. The disease does not necessarily progress to cause severe disability. Symptoms often are mild and may even improve spontaneously. When the disease is severe and of long-standing, cyanosis of the fingers persists between attacks and skin changes gradually develop. Painful ulcers and superficial gangrene may appear at the fingertips. The fingers are especially vulnerable to infection. Healing of even minor lesions often is slow and uncertain.

Normal Heart Sounds

Auscultation of the heart requires familiarization with normal and abnormal heart sounds. The first heart sound ("lub"), referred to as S1, is the closing of the mitral and tricuspid valves. S1 is heard loudest over the apex of the heart and occurs nearly simultaneously with the palpated pulse. The second heart sound ("dub"), referred to as S2, is the closing of the aortic and pulmonic valves. S2 is heard loudest with the stethoscope in the aortic area, which is at the second intercostal space to the right of the sternum

aortic regurgitation Medical and Surgical Management

Because aortic regurgitation is mild and only slowly progressive in most people, clients are sustained with cardiac glycosides or beta-blockers and diuretics. When taken appropriately, prophylactic antibiotics prevent recurrences of infective endocarditis. Clients are advised to modify their lifestyle to avoid excessive demands on the heart, such as those that may result from strenuous exercise and emotional stress. When a client becomes symptomatic, replacement of the diseased aortic valve is considered (see Chapter 29). The less the heart damage that occurs before surgery, the better the outcome. If the aorta is diseased, the procedure is more involved because repair involves a vascular graft.

Pulmonary Embolism

Blocking of a pulmonary artery due to a blood clot

Radiography and Radionuclide Studies

Chest radiography and fluoroscopy determine the size and position of the heart and condition of the lungs. These studies are also used to guide the insertion and confirm the placement of cardiac catheters, internal pacemaker wires, and internal cardiac defibrillators. Computed tomography (CT) scanning and magnetic resonance imaging are used to determine heart size and detect lung involvement. Radionuclides are radioactive chemical elements that are injected into and travel through the bloodstream. Their use sometimes is referred to as nuclear cardiology. The radionuclide technetium-99m is used to detect areas of myocardial damage. The radionuclide thallium-201 is used to diagnose ischemic heart disease during a stress test.

What discharge instructions for self-care should the nurse provide to a client who has undergone a PTCA? Select all that apply.

Clean the catheter insertion site with soap and water each day. Refrain from driving for at least 3 days after the procedure.

Arteriography

Coronary Arteriography The most common use of a left-sided cardiac catheterization is to determine the degree of blockage of the coronary arteries by performing arteriography while the catheter is in place. An arteriography is a diagnostic procedure that involves instilling contrast medium into an artery. In this case, it is instilled into the catheter and deposited into each coronary artery. Occlusive heart disease is indicated if one or more coronary arteries appear narrow or do not fill. Clients with coronary artery disease who are considered candidates for invasive treatment procedures must undergo cardiac catheterization and coronary arteriography.

Venous Insufficiency Diagnostic Findings

Doppler ultrasound demonstrates a reversed direction of blood flow, indicating valvular incompetence in superficial or deep veins. Photoplethysmography, a diagnostic test for venous pathology, measures light that is not absorbed by hemoglobin and consequently is reflected to the machine. When clients with venous insufficiency undergo photoplethysmography during exercise and rest, light reflection is greater during rest, showing that the client has decreased oxygen-bound hemoglobin and an increased volume of venous reflux (downward flow of venous blood). Air plethysmography measures venous pressure by filling a cuff with air after it is applied to the calf while the client is supine with the legs elevated. When the client stands, the pressure is measured again and venous pressure increases, indicating an increased volume of venous reflux.

Drug-Induced Stress Testing

Drugs may be used to stress the heart for clients with sedentary lifestyles or those with a physical disability, such as severe arthritis, that interferes with exercise testing. Drugs such as adenosine (Adenocard), dipyridamole (Persantine), or dobutamine (Dobutrex) may be administered singularly or in combination by the IV route. The drugs dilate the coronary arteries, similar to the vasodilation that occurs when a person exercises to increase the heart muscle's blood supply. When thallium, a radionuclide, is injected a few minutes later, a scan of the heart can detect compromised blood flow, which indicates coronary artery disease or evidence of well-perfused heart muscle.

Exercise Electrocardiography

During exercise electrocardiography, also known as a stress test, the electrical activity of the heart is assessed with an ECG monitor while the client walks on a treadmill, pedals a stationary bicycle, or climbs up and down stairs (Fig. 22-16). The speed of the treadmill, the force required to pedal the bicycle, or the pace of stair climbing is gradually increased. The goal is to increase the heart's workload to reach a predetermined target heart rate. The client's heart rate and rhythm are monitored continuously, and ECG waveforms are recorded periodically. The client's BP and respiratory rate also are assessed. The client is instructed to report the onset of chest pain, dizziness, leg cramps, or weakness. The stress test is aborted if the client develops chest pain, severe dyspnea, elevated BP, confusion, or arrhythmias. The primary provider interprets ECG tracings obtained during the test. Radionuclides also may be used during a stress test to provide additional information.

coronary artery disease Enhanced External Counterpulsation

Enhanced external counterpulsation (EECP) may be used as an adjunct to drug therapy and lifestyle modifications. This fairly new, noninvasive, and nonsurgical approach helps relieve angina. It requires 1- to 2-hour sessions in the primary provider's office, 5 days a week for approximately 7 weeks

Cardiac tissue:

Epicardium: outer layer Myocardium: middle layer, composed of muscle tissue Endocardium: inner layer, it has direct contact with the blood that passes through the heart Pericardium: is a saclike structure that surrounds and supports the heart

Cardiac Risk Associated With Blood Fat Levels

Good TOTAL CHOLESTEROL <200, Borderline moderate to elevated 200 - 239 HIgh 240 or > Low n/a GOOD HDL CHOLESTEROL 60 OR < High 60 0r > LOW < 40 Good LDL CHOLESTEROL < 100; below 70 if CAD present borderline 130-159/ HIGH 160 or > Low n/a TRIGLYCERIDES Good < 149 ideal is 100 borderline 100- 159 High 200 or higher 500 considered very high Low n/a

Heart Murmur Grades

Grade I: faint murmur, barely audible Grade II: soft murmur Grade III: easily audible but without a palpable thrill Grade IV: easily audible murmur with a palpable thrill Grade V: loud murmur, audible with stethoscope lightly touching the chest Grade VI: loudest murmur, audible with stethoscope not touching the chest

Assessing Blood Pressure and Pulse for Postural Changes

Have the client lie down for at least 3 minutes. Assess the client's BP and pulse. Assist the client to a sitting position. Be prepared to steady or assist the client should they become dizzy or faint. Reassess the BP and pulse within 30 seconds after the client sits. Repeat the assessments with the client standing. Determine the difference in systolic and diastolic BPs in the upright position from that recorded in the previous position. Determine the difference in the heart rate from that recorded in the previous position. Conclude that the client manifests postural changes if the BP is lower than 10 mm Hg from the previous measurement and the heart rate increases 10% or more from the previous measurement.

Hyperlipidemia

Hyperlipidemia, or high levels of blood fat, triggers atherosclerotic changes.

Lung Sounds

If the left side of the heart fails to pump efficiently, blood backs up into the pulmonary veins and lung tissue. The nurse auscultates the lungs for abnormal and normal breath sounds. With left-sided heart failure, auscultation reveals a crackling sound and possibly wheezes and gurgles. Wet lung sounds are accompanied by dyspnea and an effort to sit up to breathe. If uncorrected, left-sided heart failure is followed by right-sided heart failure because the circulatory system is a continuous loop.

Jugular Veins

If the right side of the heart fails to pump efficiently, blood becomes congested in the neck veins. With the client sitting at a 45-degree angle, the client turns their head to the left or right so the nurse can inspect the external jugular vein, Distention of this vein usually indicates increased fluid volume and pressure in the right side of the heart

Risk Factors for Coronary Artery Disease

Inherited Male sex Diabetes mellitus Increased lipid levels Genetic predisposition Hypertension Behavioral Smoking Sedentary lifestyle Obesity Competitive, aggressive personality High-fat diet

coronary arterie Invasive Perfusion Techniques

Invasive nonsurgical procedures that can reopen narrowed coronary arteries include percutaneous transluminal coronary angioplasty (PTCA), coronary stent, and atherectomy. Surgical procedures include coronary artery bypass graft (CABG) and transmyocardial revascularization (TMR).

Aneurysm

Is the stretching and bulging of an arterial wall. Aneurysms of the aorta (aortic arch, thoracic, abdominal) are the most common, but aneurysms can be found in other arteries, such as those in the legs and brain.

4 major heart arteries

L Anterior descending artery L circumflex artery Posterior descending artery Ramus or intermediate

Diagnostic Findings Serum Enzymes and Isoenzymes

Laboratory tests to diagnose MI include a series of serum cardiac markers, substances that are released by damaged myocardial cells during an infarct (Table 25-3). When tissues and cells break down, are damaged, or die, great quantities of certain enzymes are released into the bloodstream. Enzymes are complex proteins produced by living cells that function as catalysts, substances capable of producing chemical changes without being changed themselves. An isoenzyme is one of several forms of the same enzyme that may exist in cells and is capable of being identified separately from others. The following serum cardiac markers are measured initially and every 8 hours for 24 hours to determine elevated levels: Myoglobin, a biomarker that rises in 2 to 3 hours after heart damage Troponin and subunits known as troponin T and troponin I, enzymes in myocardial contractile tissue Creatine kinase (CK), formerly creatine phosphokinase, and its cardiospecific isoenzyme CK-MB Lactate dehydrogenase (LDH) and isoenzymes LDH1 and LDH2 Aspartate aminotransferase (AST), formerly called serum glutamic oxaloacetic transaminase (SGOT) Troponin is present only in myocardial tissue; therefore, it is the gold standard for determining heart damage in the early stages of an MI. The other enzymes can be elevated in response to cardiac or other organ damage. Therefore, the isoenzymes CK-MB, LDH1, and LDH2 are evaluated for their cardiac specificity.

Pulmonary Hypertension

Low systolic pressure is associated with pulmonary hypertension. A productive cough with pink-tinged frothy sputum can indicate a progression of the disorder and a need for treatment.

Nonmodifiable risk factors:

Male sex Diabetes mellitus Increased lipid levels Genetic predisposition Hypertension

Aneurysms Assessment Findings S/S

Many aneurysms go unnoticed until found during physical examination or the client has a massive hemorrhage. Some cause pain, discomfort, and symptoms related to pressure on nearby structures. For example, a thoracic aortic aneurysm can cause bronchial obstruction, dysphagia (difficulty swallowing), and dyspnea. An abdominal aortic aneurysm can produce nausea and vomiting from pressure exerted on the intestines, or it may cause severe back pain from pressure on the vertebrae or spinal nerves. Most clients are hypertensive. A pulsating mass may be felt or even seen around the umbilicus or to the left of midline over the abdomen. A bruit (purring or blowing sound) can be auscultated over the mass. Circulation to tissue may be impaired. Symptoms of a dissecting aneurysm vary and depend on whether a branching artery has been occluded or a tear has occurred in the aortic wall. Many clients become suddenly and acutely ill. Difference in the BPs of the left and right arms may be marked, or the BPs of the left and right legs may be unequal. Severe pain and signs of shock usually are present, but symptoms can be less severe in some instances. Because symptoms vary, diagnosis may be difficult.

skin

Many clients with cardiac disorders exhibit changes in skin color

Aneurysm Medical and Surgical Management

Medical treatment includes administering antihypertensive drugs to keep BP within normal range. Aneurysms are treated surgically whenever possible; no other cure exists. They are repaired by bypass or replacement grafting (see Chapter 29). A dissecting or ruptured aneurysm is a surgical emergency.

aortic stenosis Medical and Surgical Management

Medical treatment may begin while the client is asymptomatic and focuses on maintaining adequate cardiac output by supporting the heart's pumping activity. Digitalis, an antidysrhythmic drug particularly for atrial fibrillation with rapid ventricular response (see Chapter 26), and a diuretic may be prescribed. Sodium is restricted. Antibiotics are prescribed for clients with artificial heart valves, history of a heart valve infection, or congenital heart defects, to prevent recurrences of infective endocarditis, which can compound valvular damage. Nitrates or beta-adrenergic blockers are beneficial for relieving chest pain. Additional treatment eventually becomes critical because survival is jeopardized once symptoms develop. Surgery may be needed to correct a damaged or leaky valve that causes a heart murmur. Other treatment options are available depending on the client's risk factors. Balloon valvuloplasty is an invasive, nonsurgical procedure to enlarge a narrowed valve opening for clients whose conditions are too unstable for immediate surgery yet whose symptoms cannot be adequately controlled more conservatively. With this treatment option, a catheter with a deflated balloon is threaded through a peripheral blood vessel into the heart until the tip is located in the stenotic valve. When in position, the balloon is inflated to stretch the opening. Annuloplasty is a procedure that has the surgeon tightening the tissue around the valve by implanting an artificial ring. This allows the leaflets to come together and close the abnormal opening through the valve. Aortic valve replacement eventually becomes necessary to sustain life and relieve recurring symptoms. Traditionally, this has been performed via a transthoracic incision. There are two optional sources for replacement valves: (1) tissue valves, harvested from pigs (porcine), cows (bovine), or human cadavers; or (2) manufactured mechanical prostheses, made from metal (see Chapter 29). The latter require lifelong anticoagulant therapy to reduce the risk of blood clots forming, but tend to last longer than the tissue valves. Until recently, 30% to 40% of high-risk older adults were not candidates for replacement of the aortic valve using conventional, open heart surgery. Transcatheter aortic valve replacement (TAVR), or transcatheter aortic valve implantation (TAVI) are less invasive approaches. While visualizing the heart with transesophageal cardiography, a catheter is inserted in the femoral artery (or in some cases, the apex of the heart) and advanced to the stenotic valve. When the catheter traverses the aortic valve, the diseased leaflets are opened via an inflated balloon (balloon valvuloplasty). Once opened, a self-expanding stent is positioned to hold the valve leaflets out of the way. A porcine tissue replacement valve mounted within the framework of the stent then functions to restore blood flow into the aorta (Fig. 24-3). As with any procedure, there continue to be risks, but TAVI has improved the quality of life for those who previously faced their inoperable condition with a poor prognosis and ultimate death.

Cardiac markers:

Myoglobin Troponin T Troponin I CK-MB (creatine kinase) AST LDH1 LDH2

Drug therapy

Nitrates (e.g., nitroglycerin, isosorbide dinitrate): cause arterial vasodilation. Beta-adrenergic blockers: decrease consumption of myocardial oxygen by reducing heart rate. Calcium channel blockers: decrease consumption of myocardial oxygen by reducing heart rate. Angiotensin-converting enzyme inhibitors: cause blood vessels to enlarge or dilate and reduces BP. Diuretics: decrease work of heart by promoting excretion of sodium and water. Nicotinic acid (niacin): in pharmacologic doses helps increase HDL and lower LDL.

Renaud syndrome diagnostic findings

No specific laboratory studies can confirm Raynaud syndrome. Diagnosis is made by a history of the symptoms and examination of the involved part. Laboratory blood tests are ordered to confirm or rule out an accompanying connective tissue disorder

Aortic Regurgitation Pharmacologic Considerations

Nonselective beta-blockers can aggravate chronic obstructive pulmonary disease and contribute to hyperglycemia in insulin-dependent adults. Some diuretics deplete potassium, causing hypokalemia. Before administering beta-blockers, take the client's apical pulse. If the heart rate is less than 60 beats/min, withhold the drug and notify the primary health care provider. Closely monitor clients taking beta-blockers for signs and symptoms of overdosage: bradycardia, severe dizziness, drowsiness, and bluish discoloration of the palms, fingernails, or both. Notify the primary health care provider immediately if these symptoms appear.

What are the latest guidelines in treating a diagnosis of hypertension?

Normal BP S<. 130 D<. 85 High-normal BP S 30-139 D. 85-89 Grade 1 hypertension 140-159 90-99 Grade 2 hypertension S ≥160 D ≥100

Anticoagulant treatment

Parenteral anticoagulants: Heparin Low-molecular-weight heparins: Lovenox Arixtra Oral anticoagulants: Warfarin Eliquis Pradaxa Xarelto Antiplatelet agents: Aspirin: Ecotrin, Ascriptin Plavix Brilinta Integrilin

Peripheral Arteriography

Peripheral arteriography is used to diagnose occlusive arterial disease in smaller arteries. Contrast medium is injected into an artery, and radiographic films are taken. After the procedure, the chance for bleeding is greater than after a venipuncture; therefore, a pressure dressing is applied and client activity is restricted for about 12 hours. The nurse observes the client for bleeding and cardiac arrhythmias and assesses the adequacy of peripheral circulation by frequently checking the peripheral pulses.

OCCLUSIVE DISORDERS OF PERIPHERAL BLOOD VESSELS

Peripheral vascular disease (PVD) is a general term for disorders that affect blood vessels distant from the large central blood vessels supplying the myocardium or that circulate blood directly in and out of the heart. PVD includes disorders that affect arteries or veins. Common peripheral vascular disorders, which reduce blood flow by various mechanisms, include peripheral artery disease (PAD), Raynaud syndrome, thrombosis, phlebothrombosis, and embolism.

Phlebothrombosis

Phlebothrombosis is the development of a clot within a vein without inflammation.

Aneurysms Diagnostic Findings

Radiographs can demonstrate aneurysms when the arterial wall contains calcium deposits. Aortography identifies the size and exact location of the aneurysm.

Conduction system (sustains the electrical system of the heart):

SA node AV node Bundle of His Bundle branches Purkinje fibers

Assessment Findings

Signs and Symptoms Clients with PAD experience intermittent claudication, or pain and cramping in thigh, calf, or buttock muscles during activity such as walking or climbing stairs. The discomfort is relieved after resting for several minutes. One or both lower limbs feel cold to the touch. Upon exertion, many describe feeling numbness in the affected leg(s) accompanied by heaviness and fatigue. Some develop skin lesions that are slow to heal. Hair and toenail growth is slow. The skin over the leg(s) appears red in a dependent position but returns to normal color in one minute when elevated. Pulses in the lower extremities are difficult to palpate.

Conduction System

The conduction system, which plays a role in the cardiac cycle, sustains the electrical activity of the heart. It consists of the SA node, AV node, bundle of His, bundle branches, and Purkinje fibers

Aortic regurgitation Nursing Management

The nurse prepares the client for diagnostic procedures and monitors responses, reporting changes in heart rate and rhythm, dyspnea, chest pain, and loss of consciousness to the primary provider immediately. The nurse administers prescribed medications and evaluates the client's response. Ensuring that physical activity is balanced according to the client's tolerance is important. Before discharge, the nurse explains the need for antibiotic therapy before medical and dental procedures and teaches how to assess BP regularly as well as methods to control hypertension.

Infectious and Inflammatory Heart Disorders

The nurse provides the following instructions: Continue regular follow-up care because there will always be a risk for a recurrence. If there is a history of rheumatic fever, congenital valve disorders, or prosthetic valve replacements, see a primary provider if fever, malaise, or other symptoms of infection occur. There may be a need for antibiotics just before, and for a short time after, an event that might cause bacteremia, such as dental surgery. If an antibiotic is prescribed, take the full dose for the full-time because noncompliance with the drug regimen can hinder the complete destruction of the pathogen.

Thrombosis

Thrombosis is a state in which a thrombus has formed in a blood vessel.

Thrombosis, Phlebothrombosis, and Embolism Medical and Surgical Treatment

Treatment depends on whether an artery or a vein is occluded and the degree of occlusion (partial or complete).

Renaud Syndrome Medical and Surgical Management

Treatment involves avoiding factors that precipitate attacks. Smoking is contraindicated because it causes vasoconstriction. Drug therapy with peripheral vasodilators, such as isoxsuprine (Vasodilan), may be attempted, but results usually are less favorable than desired. Other drugs, such as nifedipine (Procardia), are being used investigationally. An IV infusion of prostaglandin E may provide temporary relief. Sympathectomy (cutting peripheral sympathetic nerves) may be performed; however, because of disappointing results, the procedure is performed less frequently than in the past. Gangrenous areas are amputated.

Heart valves:

Two AV valves: separate the atria from the ventricles Tricuspid valve: valve between the right atrium and the right Bicuspid valve/mitral valve: valve between the left atrium and left ventricle

Pathophysiology and Etiology Pathophysiology and Etiology

Valvular incompetence can result from damage to the valve cusps or papillary muscles. It may be a consequence of various disorders such as rheumatic carditis, endocarditis, syphilis, age-related stretching of the proximal aorta, and systemic inflammatory conditions. In 1997, the incidence of aortic and mitral regurgitation increased as a result of the use of fenfluramine (Pondimin) with phentermine (known as Fen-Phen), fenfluramine alone, and dexfenfluramine (Redux) alone for weight loss.

Ventricular Rupture

Ventricular rupture occurs when a soft necrotic area from a transmural or interventricular septal MI ruptures. Dyspnea, rapid right-sided heart failure, and shock result. Hemopericardium (blood in the pericardium) and cardiac tamponade follow.

Pharmacologic Considerations MRI

When a client's heart cannot tolerate physical exercise, medications may be used for stress testing. Dipyridamole, adenosine (both can lead to bronchospasm), and dobutamine may be used to chemically stress the heart. Often, cardiac meds are held for 24 hours before the test; be sure and instruct the client regarding medications as they are ordered for testing. Although only 30% of scans use a contrast medium, check the medical record for history of kidney failure or reduced function; gadolinium-based contrast medium has been associated with nephrogenic system fibrosis.

Pathophysiology and Etiology

When blood flow through arteries distal to the aortic arch becomes restricted, individuals experience manifestations of ischemia in the tissues where circulation is impaired. The primary cause is atherosclerosis, which—like its counterpathology, CAD—is secondary to obesity, hypertension, hyperlipidemia, diabetes mellitus, chronic smoking, and, in some cases, a family history of PAD or other atherosclerotic diseases. Hyperhomocysteinemia (increased blood level of homocysteine, an amino acid formed from protein-rich food containing methionine) is higher among those with PAD. Other than identifying it as a risk factor for PAD, however, the role of hyperhomocysteinemia in the disease and the effect of controlling its level have not been sufficiently explored

valvular regurgitation

When blood is pumped through the incompetent aortic valve, some leaks backward (valvular regurgitation) into the left ventricle. This backflow reduces cardiac output and causes fluid overload in the left ventricle, which becomes chronically stretched, hindering its ability to pump effectively (see Chapter 28). High fluid pressure in the left ventricle causes the mitral valve to shut early, which interferes with left atrial emptying. The blood in the left atrium backs up into the pulmonary circulation. Left ventricular enlargement increases the heart's need for oxygen. When the coronary arteries cannot supply the heart muscle with enough oxygen because of decreased cardiac output, the myocardium becomes ischemic and the client experiences angina. Dizziness, dyspnea on exertion, confusion, and left ventricular failure may develop.

Systole

When the ventricles contract (systole), the tricuspid and mitral valves close, preventing blood from returning to the atria. The pulmonary and aortic valves open as blood is ejected from the ventricles.

Hyperlipidemia:

high levels of blood fat triggers atherosclerotic changes. Factors such as gender, heredity, diet, diseases such as metabolic syndrome, and inactivity individually or collectively contribute to hyperlipidemia.

coronary arteries Medical and Surgical Management

ifestyle changes cessation, weight loss, stress management, and exercise. Blood glucose is kept regulated. When these methods are inadequate, drug therapy and other noninvasive, nonsurgical, or surgical interventions are indicated.

Types of Angina

stable, unstable, intractable, variant/printzmetal, microvascular

Thrombus

stationary blood clot

Atherectomy

surgical removal of plaque buildup from the interior of an artery

Coronary Stent

A coronary stent is a small metal coil with meshlike openings placed in the coronary artery during PTCA. The stent prevents the buildup of new tissue that reforms in the artery, prevents the coronary artery from collapsing shortly after the procedure, and keeps the lumen open for a longer period than traditional PTCA alone. The stent remains permanently in the enlarged artery, and endothelial tissue is incorporated into the mesh within 4 to 6 weeks. Restenosis usually is a problem even with the placement of a stent. Restenosis does not necessarily result from an accelerated atherosclerotic process but from an overgrowth of cells accompanying the inflammation caused by the local trauma to the tissue. Newly developed stents called drug-eluting stents are coated with an anti-inflammatory/antibiotic substance, either sirolimus (Rapamune) or paclitaxel (Taxol), which prevents the buildup of new tissue that clogs the artery. There have been some reports of allergic reactions and clots forming with the drug-eluting stents; but, along with aspirin or other antiplatelet drugs, they continue to be an improved technique for maintaining patency of previously obstructed arteries.

ABNORMAL HEART SOUNDS

A sound that follows S1 and S2 is called an S3 heart sound, or a ventricular gallop. When these three sounds are heard together, some say the cadence sounds like "Ken-tuck-y" or "lub-dub-dee." An S3, although normal in children, often is an indication of heart failure in an adult. An extra sound just before S1 is an S4 heart sound, or atrial gallop. Some say this sound resembles the word "Ten-nes-see" or "lub-lub-dub." An S4 sound often is associated with hypertensive heart disease. In addition to heart sounds, auscultation may reveal other abnormal sounds, such as murmurs and clicks caused by turbulent blood flow through diseased heart valves. A friction rub may cause a rough, grating, or scratchy sound that is indicative of pericarditis (inflammation of the pericardium).

Thrombosis, Phlebothrombosis, and Embolism

A thrombus is a stationary clot. Thrombosis is a state in which a thrombus has formed in a blood vessel. Thrombophlebitis is an inflammation of a vein accompanied by clot or thrombus formation (see Chapter 23). Phlebothrombosis is the development of a clot within a vein without inflammation. Phlebothrombosis and thrombophlebitis have similar symptoms and treatment. An embolus is a moving mass (clot) of particles, either solid or gas, in the bloodstream.

Gerontologic Considerations

Age-related effects, such as stiffening of the aorta and calcification and fibrotic thickening of the mitral and aortic valves, contribute to development of symptoms (e.g., increased systolic blood pressure [BP], dangerous arrhythmias [erratic heart rhythms or rates that are too fast or slow] sometimes referred to as dysrhythmias) and complications (e.g., increased myocardial oxygen demand, heart failure, and alterations in cardiac output) in the older adult with valvular heart disease. Older adults may experience a decreased thirst sensation, increasing the risk for dehydration and volume depletion, which may result in fatigue and weakness that can be confused with symptoms of valvular disease. Older adults may require lower doses of cardiac glycosides than younger clients because of age-related metabolic changes. The more medications older adults take, the more likely they are to have dangerous interactions. For older adults taking beta-blockers, monitor the heart rate and BP closely; the adverse effects of bradycardia and hypotension can cause confusion and falls.

Pathophysiology and Etiology

Aortic regurgitation occurs when the aortic valve does not close tightly and blood can leak backward. The valve's inability to close tightly is a condition called valvular incompetence.

mitral stenosis Medical and Surgical Management

Antibiotic therapy is prescribed to prevent future episodes of infective endocarditis. Preventing or relieving the symptoms of heart failure is essential. A daily aspirin, dipyridamole (Persantine), or other oral anticoagulant may be ordered to avoid clot formation. Arrhythmias (abnormal electrical impulse transmission through the conduction system), such as atrial fibrillation (quivering of the atrial muscle with insufficient force to pump blood), are treated with drugs or cardioversion. Cardioversion stops the heart momentarily to allow the sinoatrial node to reestablish itself as the pacemaker. Commissurotomy is a surgical technique to separate the fused valve leaflets (see Chapter 29). However, not all clients with mitral stenosis are suitable candidates for surgery. Those whose condition is so slight that it does not cause symptoms or so severe or of such long duration that profound changes in the heart and lungs have occurred usually are excluded. The earlier surgery is performed, the greater is the likelihood that it will relieve the symptoms. Percutaneous balloon valvuloplasty, also called valvotomy, is a nonsurgical alternative. When percutaneous balloon valvuloplasty is performed, a catheter with an uninflated balloon is passed through the femoral vein and threaded into the right atrium. The septum is then punctured between the right and left atria. When the catheter is in the mitral valve, it is inflated (Fig. 24-5). Clients often are discharged on the same day as the procedure. The atrial puncture allows some blood to shunt from the left atrium to the right, but the opening usually closes within 6 months. Complications, although rare, include mitral regurgitation (discussed next); residual atrial septal defect; perforation of the left ventricle; embolization; and MI. Management of the client after percutaneous balloon valvuloplasty includes the following: Echocardiogram within 72 hours to detect mitral regurgitation, left ventricular dysfunction, or pronounced atrial septal defect Oral anticoagulation therapy within 1 to 2 days for clients who have a history of atrial fibrillation or instituted for others if atrial fibrillation develops in the future Prophylactic antibiotic protocols to prevent infective endocarditis Yearly medical follow-up that includes echocardiography, chest radiography, and ECG

Arterial Embolism

Blood clots in the arterial bloodstream May originate in the heart Foreign substances Clinical manifestations/assessment Pain Absent distal pulses Pale, cool, and numb extremity Necrosis

Aortic regurgitation Diagnostic Findings

Cardiac catheterization reveals high left ventricular pressure and backward movement of blood. A chest radiograph reveals heart enlargement, and the aortic valve appears dilated. The ECG shows tall R waves; depressed ST segments indicate myocardial ischemia. A radionuclide scan comparing blood flow through the heart at rest and during exercise reveals the severity of the disease. Standard or transesophageal echocardiography provides images of atypical valvular and myocardial function. A computed tomography (CT) or magnetic resonance imaging (MRI) scan may be performed if the echocardiographic images are inconclusive.

Cardiac output

Cardiac output is the amount of blood pumped out of the left ventricle each minute. In a healthy adult, cardiac output ranges from 4 to 8 L/min (the average is approximately 5 L/min). Volume varies according to body size. The heart adjusts cardiac output to the body's changing needs. During active exercise, athletes may have a cardiac output that is five to seven times the normal amount. Cardiac output can be increased in two ways: by increasing the heart rate and by increasing the stroke volume. Stroke volume is the amount of blood pumped per contraction of the heart. The stroke volume averages about 65 to 70 mL. The following formula is used to calculate cardiac output: Cardiac output = heart rate × stroke volume

Focus assessment criteria for a client with cardiovascular problems:

Client history, General examination/physical appearance, Pain, VS, Cardiac rhythm, Heart sounds, Peripheral pulses, Skin Peripheral edema, WT, Jugular veins, Lung sounds, Sputum Mental status, Diagnostic tests used for heart disease, Lab tests Radiography and radionuclide studies, MRI, Echocardiography Electrocardiography, Cardiac catheterization, Arteriography

Peripheral Artery Disease Medical and Surgical Management

Clients are encouraged to lose weight, exercise daily, and cease smoking. Diabetics must strive to keep their blood sugar levels under control. Several classes of drugs, such as antihypertensive, lipid-lowering, antiplatelet, and antithrombotic medications, help to slow the progression of symptoms and reduce the risk of complications. Percutaneous and surgical revascularization procedures are performed when clients develop advanced disease.

Sputum

Clients with cardiac disease may have a productive or nonproductive cough. The nurse notes the type and frequency of the cough and the amount and appearance of the sputum. These findings can be important in diagnosing heart failure or other pulmonary complications.

Cardiac Cycle

During the cardiac cycle, the majority of the blood flowing to coronary arteries to fill the ventricles is supplied during diastole. When the ventricles are filled, they contract, which is called systole.

Echocardiography

Echocardiography uses ultrasound waves to determine the functioning of the left ventricle and to detect cardiac tumors, congenital defects, and changes in the tissue layers of the heart.

Peripheral Edema

Edema occurs when blood is not pumped efficiently or plasma protein levels are inadequate to maintain osmotic pressure. When blood has nowhere else to go, the extra fluid enters the tissues. Particular areas for examination are the dependent parts of the body, such as the feet and ankles.

Angiocardiography

In angiocardiography, a radiopaque contrast medium is injected into a vein, and its course through the heart is recorded by a series of radiographic pictures taken in rapid succession. The pictures reveal the size and shape of the heart chambers and great vessels and the sequence and time of their filling with dye. Angiocardiography is used particularly to diagnose congenital abnormalities of the heart and great vessels. It usually is performed when simpler diagnostic measures fail to provide the necessary information. The client fasts for at least 3 hours before the test. A sedative and an antihistaminic medication usually are administered before the client is taken to the radiography department.

Mitral Valve Prolapse

In mitral valve prolapse, the valve cusps enlarge, become floppy, and bulge backward into the left atrium (Fig. 24-7). Mitral regurgitation may occur, but not in all cases. Mitral valve prolapse is the leading cause of mitral regurgitation. It is more common in young women than men. Despite its high incidence, it is considered to be a benign disease for most affected people.

Mitral Stenosis Assessment Findings S/S

It may take 20 to 40 years for a client who has had rheumatic fever to develop mitral stenosis. The normal valve opening is 4 to 5 cm2; symptoms develop when the valve area is less than 2.5 cm2. At that time, clients report fatigue and dyspnea after slight exertion. Symptoms become disabling approximately 10 years after onset; they are accentuated when unusual demands are placed on the heart (e.g., fever, emotional stress, pregnancy). Later, clients experience heart palpitations caused by tachyarrhythmias (rapid arrhythmias). With the onset of pulmonary hypertension, clients may become more dyspneic at night and must sleep in a sitting position. They may develop a cough productive of pink, frothy sputum. Crackles heard in the bases of the lungs are a sign of pulmonary congestion. Changes in heart sounds may be the earliest indication of mitral valve stenosis. S1 may be extremely loud if the cusps are fused or muffled or absent if the cusps have calcified and are immobile. A murmur, described as sounding like a rumbling underground train, can be heard at the heart's apex, especially when the client assumes a left lateral position. The systolic BP is low from reduced cardiac output. If backward pressure through the pulmonary circulation is sufficient to affect the right ventricle, the client's face is flushed, neck vein distention is evident, the liver is enlarged, and there is peripheral edema.

Modifiable risk factors:

Smoking Sedentary lifestyle Obesity Competitive, aggressive personality High-fat diet

Types of angina:

Stable angina Unstable angina Variant (Prinzmetal) angina Microvascular angina (cardiac syndrome X)

Aortic Stenosis

Stenosis means narrowing. Aortic stenosis is a narrowing of the opening in the aortic valve when the valve cusps become stiff and rigid. It is a common valvular disorder in the United States, especially among older adults.

CAD Self-Care Following Percutaneous Transluminal Coronary Angioplasty

The nurse provides the following instructions before the client is discharged: Avoid lifting more than 10 lb for at least 3 days if the groin was used for catheter insertion. Avoid lifting more than 1 lb for at least 3 days if a site in the upper extremity was used. Refrain from riding a bicycle, driving a vehicle, or mowing the lawn for at least 3 days. Refrain from sexual activity for 1 week. Shower rather than bathe until the cutaneous catheterization site heals. Clean the site with soap and water; eliminate any dressing. Relieve discomfort at the site with a mild analgesic such as acetaminophen (Tylenol); numbness at the site is temporary and not unusual. Expect to see a bruise, which may last 1 to 3 weeks, at the catheter insertion site. Report any signs of bleeding, infection, or impaired circulation: fever, swelling, redness, bloody or purulent drainage, acute pain in the extremity, and cold or pale skin. Notify the cardiologist immediately if there is pain or tightness in the chest, which could indicate obstructed blood flow through the coronary artery.

DISORDERS OF BLOOD VESSEL WALLS Varicose Veins

Varicose veins or varicosities are dilated, tortuous veins. Both men and women suffer equally from this disorder. The saphenous leg veins commonly are affected because they lack support from surrounding muscles. Varicose veins also may occur in other body parts, such as the rectum (hemorrhoids) and esophagus (esophageal varices). Varicose veins may be accompanied by a smaller variation called spider veins, which appear closer to the surface of the skin.

aortic stenosis Diagnostic Findings

Ventricular enlargement is evident on a chest radiograph. An echocardiogram validates ventricular thickening and diminished transvalvular size. On an electrocardiogram (ECG), the height of the R wave may be increased, reflecting the large mass and force of contracting muscle. During left-sided cardiac catheterization, the pressure of blood in the left ventricle is higher than usual.

A client is given a prescription for sublingual nitroglycerin to be taken when chest pain develops. What nursing instructions are appropriate? Select all that apply.

You may feel dizzy within minutes of taking the medication. Take another tablet in 5 minutes if chest pain is unrelieved. Keep the tablets in a tightly closed container.

Atherosclerosis:

a condition in which the lumen of arteries fill with fatty deposits called plaque

Venous insufficiency

a peripheral vascular disorder in which the flow of venous blood is impaired through deep or superficial veins (or both). The condition usually affects the lower extremities, most often the medial aspect of the leg or around the ankle.

Cardiogenic Shock

abnormal heart rhythms/ Cardiogenic shock, which has a high mortality rate, occurs when 40% of the left ventricle has lost the ability to pump effectively

CAD:

arteriosclerotic and atherosclerotic changes in the coronary arteries supplying the myocardium

Cardiac Biomarkers

blood test that measures the presence and amount of several substances released by the heart when it is damaged or under stress; also called cardiac enzyme test

Thrombolytic Therapy

injection of a medication either intravenously or intra-arterially to dissolve blood clots. The goal for administering thrombolytic agents, IV drugs that dissolve blood clots, is a "door-to-needle" time of 30 minutes, but no more than 90 minutes. Drugs such as streptokinase and recombinant tissue plasminogen activator (tPA) dissolve the thrombus occluding the coronary artery, restoring the circulation of oxygenated blood to the myocardium. If administered within the first 2 hours after the onset of symptoms, an MI can be greatly minimized. Even if the client is seen within 12 to 24 hours of the onset of the occlusion, reestablishing coronary artery blood flow can reduce the zone of necrosis. A thrombolytic can be administered within the specified timelines unless the client is disqualified on the basis of criteria that identify possible concomitant risks for neurologic complications and bleeding

PAD

is a condition that affects primarily the blood vessels that supply oxygen to lower limbs. Can affect the carotid, renal, and mesenteric arteries.

PVD

is a general term for disorders that affect blood vessels distant from the large central blood vessels supplying the myocardium or that circulate blood directly in and out of the heart.

Metal Devices That Pose Contraindications in Magnetic Resonance Imaging (MRI)

* Within the Body Wound staples Implanted pacemakera Implanted cardiac defibrillatora Artificial heart valve or stents Metallic pins, screws, platesb Implanted drug delivery device Aneurysm clips Transdermal patchesc Implanted brain/spinal nerve stimulator Tattooed eyeliner * On the Body (Must Be Removed) Watch Jewelry Hearing aid Hair clips or pins Pocket knife Keys Credit cards or bank cards Body piercings Removable dental work

Diagnostic Tests

*Laboratory tests may be performed daily or every few days. *Blood chemistries, such as fasting blood glucose and serum electrolyte, cholesterol, and triglyceride levels, may be used as part of the diagnostic process. *Serum cholesterol and lipid tests and isoenzyme analyses *When tissues and cells break down, are damaged, or die, large quantities of certain enzymes are released into the bloodstream. Enzymes can therefore be elevated in response to cardiac or other organ damage.

Inflammatory conditions of the heart:

*Rheumatic fever and rheumatic carditis *Infective endocarditis *Myocarditis *Cardiomyopathy -Dilated: the cavity of the heart is stretched (dilated) -Hypertrophic: the muscle of the left ventricle and septum thickens, causing heart enlargement -Restrictive: heart muscle stiffens, which interferes with its ability to stretch and fill with blood *Pericarditis

Inflammatory disorders of the peripheral blood vessels

- Thrombophlebitis: is an inflammation of a vein accompanied by clot or thrombus formation. The veins deep in the lower extremities are most commonly affected. - Thromboangiitis obliterans/Buerger disease: is an inflammation of blood vessels associated with clot formation and fibrosis of the blood vessel wall. It affects primarily the small arteries and veins of the legs and can occasionally involve the arms.

Venous Occlusive Disease

-Also called SINUSOIDAL Obstruction Disease (SOS) Small blood vessel that leads into the liver or inside become blocked. -Venous thrombosis is treated with bed rest, elevation of the extremity, local heat, analgesics for pain, and intermittent subcutaneous injections or continuous IV heparin therapy followed by oral anticoagulants once the heparin has achieved a therapeutic effect. DVT may necessitate surgical removal of the clot (thrombectomy).<remove arteries and vein clots

Four cardiac valves: promote the forward circulation of blood to sustain adequate cardiac output

-Aortic: (semilunar valve) has three cusps. The left ventricle pumps blood from the heart through the aortic valve. When the left ventricle contracts, the aortic valve opens to allow the unrestricted passage of oxygenated blood into the arterial vascular system. -Mitral: lies between the left atrium and left ventricle, it is a bicuspid valve. It opens to allow oxygenated blood to fill the left ventricle and closes tightly to prevent blood from reentering the left atrium after the left ventricle is filled. -Tricuspid: is located between the right atrium and right ventricle. Its role is to make sure blood flows in a forward direction from the right atrium to the ventricle. -Pulmonic: is located in the right ventricle of the heart. It prevents regurgitation of deoxygenated blood from the pulmonary artery back to the right ventricle. It is a semilunar valve with three cusps.

Raynaud Syndrome

-Extreme vasoconstriction producing cessation of flow to fingers and toes. -Raynaud syndrome is characterized by brief spasms of the arteries and arterioles in the fingers (most common site), toes, nose, ears, or chin. The spasms last approximately 15 minutes and cause temporary ischemia (impaired oxygenation) to the tissues. The vessels then dilate widely, apparently to compensate for the restriction. Patchy areas of necrosis occur with prolonged ischemia. The underlying cause of Raynaud syndrome is not entirely clear. In some clients, it seems idiopathic (no explainable reason); in others, it is secondary to connective tissue diseases, such as scleroderma, systemic lupus erythematosus, or rheumatoid arthritis (see Chapter 63). The anatomy of the arteries and arterioles is normal. One theory explaining the vasospasms is impaired release of prostaglandins (chemicals stored in cellular membranes). Some prostaglandins cause vasoconstriction; others cause vasodilation. The type that accompanies an inflammatory response causes vasodilation.

Thrombosis, Phlebothrombosis, and Embolism Nursing Management

-The nurse obtains a history of symptoms and identifies characteristics of the pain. The nurse examines the extremities and compares skin color, temperature, capillary refill time, and tissue integrity; they also measure each calf. The nurse palpates peripheral pulses or uses a Doppler ultrasound device if pulses cannot be palpated. They mark the location of each peripheral artery with a soft-tipped pen to facilitate its relocation. The nurse immediately reports any change in the quality of a peripheral pulse or its sudden absence. Outlining any color change (line of demarcation) above or below the occluded area with a soft-tipped pen is useful to establish a baseline for future comparison. -The nurse monitors the client's response to anticoagulation therapy. If heparin is administered, the nurse assesses IV infusions hourly. They monitor aPTT, PT, and INR when concurrent oral anticoagulation is prescribed. These values help determine therapeutic response and daily dosage. The nurse is alert for signs of bleeding and keeps protamine sulfate on hand for reversing heparin and vitamin K on hand for reversing oral anticoagulants. Additional nursing management is directed at increasing arterial or venous blood flow, relieving pain, and preventing complications. Thorough teaching before discharge is essential. To prevent a recurrence of thrombosis, phlebothrombosis, or embolism, the nurse informs clients to avoid prolonged periods of inactivity (especially sitting), elevate the legs periodically, and walk or do isometric leg exercises frequently if sitting is unavoidable. They recommend wearing antiembolism stockings to prevent venous stasis (especially if the client has venous leg ulcers). The nurse instructs the client to apply these stockings before assuming a dependent position or after elevating the extremities for several minutes. The client needs to remove and reapply antiembolism stockings twice a day or as recommended by the primary provider. The nurse informs those who must take continued anticoagulants to observe for signs of unusual bleeding and keep appointments for laboratory tests.

Cardiac Cycle

-The term cardiac cycle refers to the sequence of electrical and mechanical events in the atria and ventricles that result in a heartbeat (Fig. 22-4). First, the atria fill and then contract simultaneously to fill the resting, relaxed ventricles (diastole) with blood. When the pressure from accumulating blood increases in the ventricles, they contract (systole), and after a brief pause, the cycle begins again. The contraction of the left ventricle can be felt as a wavelike impulse (the pulse) in peripheral arteries. The pause between pulsations is ventricular diastole. -The sequence in the cardiac cycle begins when (A) blood from the venae cavae and pulmonary veins fills the atria. Near the end of atrial filling, an electrical stimulus causes (B) the atria to contract, allowing the atrial blood to fill the ventricles (C) when the atrioventricular valves open. A continuation of electrical stimulation causes ventricular contraction leading to the ejection of blood (D) through the pulmonic and aortic valves. After a brief pause, the cycle repeats.

Surgical Management

-Vascular repair, surgical hemostasis of major wounds, closure of bleeding ulcers, & chemical scarring (chemosclerosis) of varicosities. CABG surgery is done to revascularize the myocardium surgically. In clients who are experiencing cardiogenic shock, a ventricular assist device may be implanted or cardiomyoplasty (a procedure for grafting skeletal muscle to the heart) or an alternative called a heart wrap may be used

Thrombosis, Phlebothrombosis, and Embolism Assessment Findings S/S

-When an arterial clot is present, symptoms arise from ischemia to the tissues that depend on the obstructed vessel for their oxygenated blood supply. With total occlusion, the extremity suddenly becomes white, cold, and extremely painful. Arterial pulsations are absent below the obstructed area. Numbness, tingling, or cramping also may be present, and surrounding blood vessels spasm. Loss of sensation and ability to move the part follows. Symptoms of shock frequently result if a large vessel is obstructed. When a small vessel is occluded, symptoms of ischemia, such as pallor and coldness, occur but are less severe. Unless blood flow is restored, gangrene develops -Clients with phlebothrombosis may have few, if any, symptoms because inflammation is absent. Signs and symptoms of DVT usually include mild fever and pain, swelling, and tenderness of the affected extremity. A thrombus may become a mobile embolus and lodge in a distal blood vessel, such as the pulmonary capillaries, causing symptoms related to the organ to which circulation has become impaired.

Nursing Management transmyocardial revascularization TMA

-assesses the characteristics of chest pain and administers prescribed drugs that dilate the coronary arteries or reduce the work of the heart. - encourage rest and administer oxygen to improve the available oxygen supply to the heart muscle. If drugs, rest, and oxygen do not relieve the pain, the nurse notifies the primary provider. -The nurse helps clients learn how to reduce modifiable CAD risk factors, which can improve not only cardiac health but also overall well-being. -balancing caloric intake with physical activity to achieve or maintain a healthy body weight can significantly reduce risks. The nurse arranges a consultation with a dietitian and provides written material about a heart-healthy diet (see Nutrition Notes). They refer clients to smoking cessation programs and discuss medications that can help (see Chapter 71). The nurse teaches about the administration and side effects of antianginal drugs (Client and Family Teaching 25-2). They emphasize that severe, unrelieved chest pain indicates a need to be examined by a primary provider without delay. The nurse advises the client to report changes in the usual pattern of angina, such as increased frequency or severity or occurrence with rest or during sleep.

The Client at Risk for Cardiovascular Disease

A healthy diet and lifestyle forms the cornerstone of CVD prevention and treatment. The following recommendations for risk reduction are appropriate for all people over the age of 2 years; they may be intensified for clients with established CVD. Attain or maintain healthy weight by balancing calorie intake with physical activity. Excess body weight increases LDL cholesterol levels, blood glucose levels, and BP and lowers HDL levels. p. 419 p. 420 Consume an overall healthy diet rich in a variety of fruits and vegetables. Fruits and vegetables are rich in vitamins, minerals, and fiber and low in calories. Select whole grains for at least half of all grain choices. Whole grains are rich sources of fiber; soluble fiber helps lower LDL cholesterol, and insoluble fibers are associated with lower CVD risk. Eat fatty fish at least twice a week. Fatty fish such as salmon, swordfish, and king mackerel provide omega-3 fatty acids that are associated with a reduced risk of both sudden death and death from CAD. Limit the intake of saturated fat, trans fat, and cholesterol by choosing lean meats, using plant proteins, choosing fat-free dairy products, and limiting the intake of partially hydrogenated fats found in stick margarines, shortenings, and commercially baked products. Diets low in saturated fat, trans fat, and cholesterol lower CVD risk mostly by lowering LDL cholesterol. Limit food and beverages high in added sugars, such as desserts, candy, and carbonated beverages. Added sugars contain empty calories devoid of nutrients. Limit salt intake by eating and preparing foods with little or no salt. Compare sodium in foods like soup, bread, and frozen meals, and choose the foods with lower numbers. Add spices or herbs to season food without adding salt. Generally, as salt intake increases, so does BP. Drink alcohol in moderation, if at all. Moderate alcohol intake (less than 1 drink/day for women, 2 drinks/day for men) increases HDL cholesterol levels, but it is not recommended that people begin drinking for the purpose of reducing their risk of CVD. Antioxidant supplements, such as those containing vitamins C and E, beta carotene, and selenium, are not recommended because clinical trials have failed to confirm beneficial effects from their use. People are urged to consume dietary sources of antioxidants, such as fruits, vegetables, whole grains, and vegetable oils.

Ventricular Aneurysm

A ventricular aneurysm is a bulging of the portion of the heart affected by the MI. This area of poorly contractile tissue predisposes the heart to failure. Blood trapped in the projection tends to form thrombi, which may be released into the arterial circulation, or the aneurysm may burst, resulting in hemorrhage and death.

Cardiac Rehabilitation

After a significant cardiac event such as an MI or heart surgery, clients are encouraged to participate in a medically supervised cardiac rehabilitation program, which combines exercise and educational activities to speed recovery and reduce or prevent recurring episodes. Cardiac rehabilitation usually begins before discharge but continues on an outpatient basis. The plan is designed according to the client's unique needs. Some clients may achieve the goals of therapy by meeting two to three times a week for 1 hour or more over a few weeks. Other clients may require therapy for 3 to 4 months. Activities and educational topics include the following: Gradual exercise that increases according to the client's tolerance Establishment of physical limitations such as the maximum amount the client can lift Recognition and management of depression Medication regimen: importance of drug therapy, dose, time taken, adverse drug effects Smoking cessation When and how to resume sexual activity (Client and Family Teaching 25-3) Diet modifications, how to read food labels, what food labels indicate How to monitor pulse rate and BP Symptoms to report to a primary provider as soon as possible How to avoid or minimize stressors Importance of continued medical supervision

Ambulatory Electrocardiography

Ambulatory ECG, or Holter monitoring, is the recording of an ambulatory client's cardiac rate and rhythm over 24 to 48 hours as the client performs daily activities. The Holter monitor, which is worn on a belt or carried on a strap about the neck, consists of a tape recorder connected to ECG leads attached to the client's chest (Fig. 22-15). During the test period, the client keeps a diary of activities and associated symptoms. At the end of the recording period, the monitor is returned to the hospital or primary provider and the tape is analyzed. The client's written notes are compared with the recorded information. Ambulatory ECG helps to detect dysrhythmias (rhythm abnormalities) and myocardial ischemia that occur sporadically during activity or rest.

Thrombolytic Therapy Pharmacologic Considerations

Aminocaproic acid (Amicar) is suggested as an antidote to control excessive bleeding when thrombolytics are administered. Aminocaproic acid binds to plasminogen and prevents its conversion to plasmin. Although this drug is theoretically beneficial, the action of most thrombolytics is generally complete by the time the drug can be administered (Jang & Nelson, 2012). Hemorrhage associated with thrombolytics may be controlled by infusing platelets, fresh frozen plasma (FFP), or cryoprecipitate—the latter of the two contain concentrated clotting factors. Frozen blood products take 30 minutes to thaw. FFP must be obtained from an ABO compatible blood type; it is preferred for platelets and cryoprecipitate as well

Myocardial Infarction

An infarct is an area of tissue that dies (necrosis) from inadequate oxygenation. An MI, or heart attack, occurs when there is prolonged total occlusion of coronary arterial blood flow. The larger the necrotic area is, the more serious the p. 420 p. 421 damage. An infarct that extends through the full thickness of the myocardial wall is called a transmural infarction or Q-wave MI. A partial-thickness infarct is called a subendocardial infarction or a non-Q-wave MI. Each coronary artery supplies oxygenated blood to a different area of the myocardium. The location of the infarction depends on the area where the blood supply to the myocardium is interrupted by the respective occluded coronary artery

Aortography

Aortography detects aortic abnormalities such as aneurysms (abnormal dilation of a blood vessel wall) and arterial occlusions. When aortography is performed, contrast medium is injected and radiographic films are taken of the abdominal aorta and major arteries in the legs. Distribution of the contrast medium also may be observed as it circulates to other vessels, such as the renal arteries.

Mitral regurgitation (insufficiency) Medical and Surgical Management

Asymptomatic clients are monitored through physical examination and annual echocardiograms. Exercise is not limited until mild symptoms develop. An angiotensin-converting enzyme (ACE) inhibitor such as quinapril (Accupril), an angiotensin receptor blocker (ARB) such as losartan (Cozaar), or a nitrate such as isosorbide dinitrate (Isordil) reduces afterload, preserving the left ventricle's ability to eject blood effectively. Digitalis, calcium channel blockers, beta-blockers (Carvedilol), or other antiarrhythmic drugs control tachycardia. Some clients are given drugs to prevent intracardiac thrombi, a common complication of blood stasis that accompanies atrial fibrillation. Prophylactic antibiotics are prescribed to prevent recurrences of infective endocarditis. An intra-aortic balloon pump, which provides counterpulsation to the contraction of the left ventricle, can be used in an emergency to stabilize a client in left ventricular failure (see Chapter 28). Surgery to correct mitral regurgitation includes annuloplasty, repair of the valve leaflets and their fibrous ring. The implantation of a biologic or mechanical prosthetic valve to restore unidirectional blood flow may accompany annuloplasty.

aortic stenosis, Assessment Findings Signs and Symptoms

Asymptomatic for decades, When symptoms develop, they include dizziness, fainting, and angina because of insufficient cardiac output. At first, the client experiences dyspnea and fatigue during activity. With ventricular enlargement, heart pulsations are displaced laterally or distally on the chest wall from the usual point of maximum impulse (PMI) at the fifth intercostal space medial to the left midclavicular line. The carotid pulse feels weak because of a low stroke volume. The S2 heart sound is split; that is, there is a definite separation between the sounds of the aortic valve and pulmonic valve closing. Usually, these sounds occur in unison or are so closely timed that they seem as one. While listening at the second intercostal space to the right and left of the sternum, the S1 and split S2 sounds like "lub-t-dub." The split persists throughout inspiration and expiration and does not disappear when the client sits up during auscultation. This finding distinguishes the split S2 from a normal, physiologic splitting. Sometimes, auscultation identifies other abnormal sounds (e.g., systolic murmur, click). Box 24-1 explains grading of heart murmurs.

ATHEROSCLEROSIS

Atherosclerosis is a condition in which the lumen of arteries fills with fatty deposits called plaque. The plaque is chiefly composed of cholesterol, a fatty (lipid) substance. Atherosclerosis is a more modifiable contributor than arteriosclerosis to vascular disease. Therefore, it is the focus of attention and research into the mechanisms that contribute to plaque formation and its reduction to decrease vascular disease.

cardiac catherization nursing care

Before the procedure, the client needs to consult the primary provider about which prescribed medications to take or omit the day of the cardiac catheterization. Food and fluids usually are withheld; however, if the test is late in the day, light food may be permitted. Allergies must be identified; those of primary concern before a cardiac catheterization are iodine, shellfish, radiographic dye, and latex. IV fluids are administered before the test to maintain hydration and to administer any necessary medications. A sedative may be administered before the test. For a diagnostic cardiac catheterization, conscious sedation using midazolam (Versed) may be used. Conscious sedation allows the client to be sleepy and comfortable, but sufficiently awake to respond to questions and positional changes. A local anesthetic is administered at the site where the catheter is inserted. General anesthesia is reserved for a cardiac catheterization that will involve cardiac surgery. After the test, the catheter is removed and the site is covered with a pressure dressing to control bleeding. The usual length of stay following cardiac catheterization is at least 5 to 9 hours or overnight. After the test, the nurse monitors BP and pulse frequently to detect complications. They also check the dressing over the insertion site frequently for signs of bleeding. The nurse palpates the pulse in various locations and checks the color and temperature in the extremity to confirm that blood is circulating well. Instructions for the client and family include the following: Keep the extremity straight for several hours and avoid movement. Report any warm, wet feeling that may indicate oozing blood, numbness, tingling, or sharp pain in the extremity. Drink a large volume of fluid to relieve thirst and promote the excretion of the dye. Follow discharge instructions for home care

Coronary Artery Bypass Graft Surgery CABG surgery

CABG surgery (see Chapter 29) is a technique for revascularizing the myocardium. A section from a healthy leg vein or chest artery is used to reroute the flow of oxygenated blood from the aorta or a chest artery to below the obstruction in the diseased p. 418 p. 419 coronary artery. More than one graft may be necessary if several coronary arteries are occluded. The procedure is performed through a 10- to 12-inch midsternal incision, which is closed with wire, staples, or sutures. The heart is stopped during traditional CABG surgery, but blood is circulated through a heart-lung machine so that oxygen continues to be delivered to cells, tissues, and organs while CO2 is removed. When the vascular reconnections are completed, heart function is restored. The client remains on a ventilator for approximately 24 hours. It may be several weeks before the client can return to work. Results after CABG surgery tend to last longer than PTCA, stenting, or atherectomy.

Cardiac Catheterization

Cardiac catheterization is a diagnostic test performed in an operative setting. It can be done for a variety of purposes. In this procedure, a long, flexible catheter is inserted from a peripheral blood vessel in the groin, arm, or neck into one of the great vessels (inferior or superior vena cava which is attached to the heart) and then into the heart. Cardiac catheterization may be carried out on the left side of the heart by way of an artery or on the right side by way of a vein.

Stable angina

Cause: Elevated heart rate or BP Eating a large meal, S/S: Chest pain that lasts 15 minutes, TX: Rest, sublingual nitrates, antihypertensives, lifestyle changes

unstable angina

Cause: Progressive, worsening S/S: Chest pain of increased frequency, severity, and duration poorly relieved by rest or oral nitrates Client at risk of MI within 18 months of angina's onset TX: Sedation, IV nitroglycerin, oxygen, antihypertensives, anticoagulant or antiplatelet therapy, revascularization procedures

VARIANT (PRINZMETAL) ANGINA

Causes: Arterial spasm in normal or diseased coronary arteries S/S: Chest pain 12 and 8 a.m, sporadic over 3-6 months, and diminishes over time; ST elevation rather than depression on ECG TX: Nitrates or calcium channel blockers

MICROVASCULAR ANGINA (CARDIAC SYNDROME X)

Causes: Constriction of myocardial capillaries too small for standard cardiac tests to detect S/S: Prolonged chest pain that accompanies exercise and is not always relieved by medication TX: Heart-healthy habits and trials with medications like a nitrate, beta-blocker, or calcium channel blocker

The Client With a Valvular Heart Disorder

Clients with valvular disorders often need to limit sodium intake because decreasing the volume of blood decreases cardiac workload. Because approximately 75% of sodium in the typical American diet comes from processed foods, encourage clients to substitute homemade foods for convenience products and commercially prepared items. Foods to avoid include canned fish, meat, poultry, soup, vegetables, and vegetable juices; smoked and processed meats; sauerkraut; commercial mixes; instant rice and pasta mixes; casserole mixes; frozen dinners, entrees, pizzas, and vegetables with sauces; most fast foods; condiments such as catsup, relish, pickles, barbecue sauce, soy sauce, and Worcestershire sauce; and seasoning salts. Salt substitutes replace sodium with potassium or other minerals and may taste bitter. Low-sodium salt substitutes may contain up to half as much sodium as regular table salt. Clients should not use either type without a primary provider's approval. Clients with valvular disorders may need to restrict fluid because volume affects cardiac emptying. Foods that liquefy at room temperature (e.g., ice cream, ice milk, gelatin, ice pops, sherbet) are counted as liquids when fluid intake is restricted.

Electrocardiography

Electrocardiography is the graphic recording of the electrical currents generated by the heart muscle. The test performed during electrocardiography is called an ECG. During an ECG, color-coded electrodes matched to corresponding lead wires connect the client to the recording machine. The electrodes are coated with conductive gel and applied to the skin surface of the wrists, ankles, and chest (Fig. 22-13). A computerized ECG machine immediately interprets the tracings, or rhythm strips, which serve as a screening device. A primary provider later interprets the rhythm strips to aid in diagnosing heart disease

The normal anatomy and physiology of the cardiovascular system.

Heart chambers: Right and left atria Right and left ventricles

Regulation of Heart Rate

Heart rate fluctuates according to stimulation from the autonomic nervous system, baroreceptors, and chemoreceptors. The autonomic nervous system affects heart rate through sympathetic and parasympathetic nervous system innervation. When released by sympathetic nerve fibers, adrenergic neurotransmitters such as norepinephrine and epinephrine excite the SA node in the conduction system, increasing heart rate. These same neurotransmitters also stimulate beta-adrenergic receptors in the atria and ventricles, increasing the force of myocardial contraction. Conversely, the heart rate slows when parasympathetic nerve fibers from the cardiac branches of the vagus nerve release the cholinergic neurotransmitter acetylcholine. Parasympathetic neurostimulation, however, usually does not affect the force of contraction.

Characteristics of Normal Sinus Rhythm

Heart rate is between 60 and 100 beats/min. The SA node initiates the impulse (upright P wave before each QRS complex). Impulse travels to the AV node in 0.12-0.2 second (the PR interval). The ventricles depolarize in 0.12 second or less (the QRS complex). Each impulse occurs regularly (evenly spaced).

Proteins that transport lipids (cholesterol)

LDL has a lower ratio of protein to cholesterol. Or "bad cholesterol" because it sticks to arteries, exceeds recommended amounts (less than 100 mg/dL). HDL has a higher ratio of protein to cholesterol. Or "good cholesterol" because it carries cholesterol to the liver for removal, is lower than desirable (more than 60 mg/dL).

Magnetic Resonance Imaging

Magnetic resonance imaging (MRI) is a diagnostic tool used to identify disorders that affect many different structures in the body without performing surgery (Fig. 22-10). The principle underlying MRI is that many elements within the human body, such as hydrogen, are magnetic. The MRI machine's magnetic field excites the hydrogen atoms, creating a radio signal. The radio signal is converted to an image on a computer monitor. Because magnetism is used, clients undergoing an MRI are not exposed to radiation as would occur with tests involving X-rays. Ferrous-based materials, nickel alloys, and most stainless steel materials are not compatible with an MRI because they may be pulled toward the magnetic source. Therefore, an MRI is prohibited on clients with various metal devices within their body. External metal objects such as body piercings, some types of hearing aids, and the like must be removed (Box 22-2). Nonferromagnetic materials are either safe or identified as "MR-conditional," but when questionable, the safety of various items can be checked by consulting lists provided by the Food and Drug Administration (Shellock, 2016).

mitral valve prolapse Assessment Findings

Many clients with mitral valve prolapse are asymptomatic. When symptoms are present, they include chest pain, palpitations, and fatigue. The chest pain differs from that of angina: Its onset does not correlate with physical exertion, its duration is prolonged, and it is not easily relieved. Some clients also experience symptoms that resemble anxiety or panic, such as a rapid and irregular heart rate, shortness of breath, light-headedness, difficulty concentrating, and fear that the symptoms indicate impending death. Auscultation of heart sounds reveals a characteristic "click" during ventricular systole caused by tightening of the chordae tendineae. A systolic murmur is associated with mitral regurgitation. The presumptive diagnosis of mitral valve prolapse is strong if the murmur disappears or diminishes when the client squats during auscultation. Additional symptoms of mitral regurgitation also may be manifested. Echocardiography shows abnormal movement of one or more mitral valve leaflets during systole. The electrocardiogram ECG (resting, exercise, chemical, or ambulatory) is essentially normal, eliminating MI as a cause for the chest pain. ECG, however, may detect other causes.

Mitral regurgitation (insufficiency) Pathophysiology and Etiology

Mitral regurgitation is associated with rheumatic carditis and mitral valve prolapse (discussed next). It also is linked with damage to the papillary muscles, impaired myocardial function after MI, connective tissue disorders, stretching of the valve opening from an enlarged left ventricle, and malfunction of a replaced valve. It also can develop after balloon valvuloplasty. Use of the weight loss drugs identified in the discussion of aortic regurgitation also has been associated with mitral valve regurgitation. When the mitral valve becomes incompetent (i.e., does not close completely), blood flows backward into the left atrium during ventricular systole and leaks into the left ventricle during atrial diastole. The heart usually can compensate for a small amount of blood that is regurgitated backward and forward by increasing the size of the left ventricle and left atria. The larger size facilitates ejection of blood from the heart, in which case pulmonary congestion does not occur. If the regurgitation occurs rapidly, however, the heart is less able to compensate. Forward output from the left ventricle is diminished, and the client develops signs of cardiogenic shock (see Chapter 17). Accumulation of blood in the left atrium results in pulmonary congestion.

Renaud's syndrome Nursing Management

Once an episode of pain occurs, there are several ways that the attack can be aborted. If warming the hands in water is impossible, the nurse encourages the client to imagine warming them in some way such as holding them near a roaring fire. The mind can alter the physiology of blood flow. Another technique is to teach clients to imitate the exercise snow skiers use called the McIntyre maneuver: while standing, clients swing their arms behind and then in front of their bodies at a rate of about 180 times per minute. The swinging motion distributes blood to the distal areas of the fingers. Teaching for clients with Raynaud syndrome and their family members is important. The nurse instructs clients to avoid situations that contribute to ischemic episodes, explaining that injuries may heal slowly. If clients smoke, they must stop because nicotine causes vasoconstriction and increases the frequency of episodes. The nurse advises clients to wear wool socks and mittens during cold weather. Clients should avoid over-the-counter decongestants, cold remedies, and drugs for symptomatic relief of hay fever because of their vasoconstrictive qualities. The nurse advises clients to wear work gloves during household chores such as gardening and washing dishes to prevent accidental injury. Client teaching also includes information about how to perform nail care to avoid injury, such as soaking the hands or feet before trimming nails, trimming nails straight across, and seeing a podiatrist for the treatment of corns or calluses. If a sympathectomy is done, the nurse emphasizes that the areas of altered sympathetic stimuli no longer perspire and explains that applying cream to prevent excessive skin dryness may be helpful.

mitral valve prolapse Nursing Management

One measure to relieve chest pain is to have the client lie flat with the legs elevated and supported against a wall or couch at a 90-degree angle for 3 to 5 minutes to facilitate volume changes in the heart. Other recommendations include increasing activity when tachycardia occurs to eliminate the initiation of extra, ineffective beats; make up for reduced cardiac output; and lower levels of catecholamines. To relax or decrease shortness of breath, the nurse instructs the client to breathe deeply and slowly and then exhale through pursed lips. Client teaching also includes instructions to avoid caffeinated beverages and over-the-counter medications that contain stimulating chemicals to avoid contributing to an already rapid heart rate. If hypertension is not a problem, the nurse encourages the client to drink adequate fluids and continue moderate use of salt to maintain intravascular fluid volume. Alcohol is discouraged, however, because of its dehydrating effects and because withdrawal after chronic use can cause cardiac stimulation. The nurse warns clients who are prescribed minor tranquilizers not to stop the medication abruptly or they may experience stimulating withdrawal symptoms. Additional nursing management depends on other assessment data

Mitral Stenosis

Pathophysiology and Etiology Mitral stenosis means that the valve does not open properly to facilitate filling of the left ventricle (Fig. 24-4). It is primarily a sequela (a condition that follows a disease) of rheumatic carditis (see Chapter 23). Mitral stenosis worsens with each recurrence of endocarditis. The inflammation causes the cusps to stick together and form a thick, rigid, calcified scar at the commissures, the area where the cusps contact each other and the chordae tendineae fuse and shorten. The mitral valve cannot open completely, leading to incomplete emptying of the left atrium. Pooled blood from incomplete emptying contributes to clot formation, which puts the client at risk for arterial emboli. The left atrium enlarges because it has to contract more forcibly to empty. Pressure from overfilling is conveyed backward through the blood vessels to the lungs, creating pulmonary hypertension and the potential for pulmonary edema (see Chapter 21). Pulmonary hypertension increases the work of the right ventricle as it pumps against the high pressure in the pulmonary vascular system. Because blood flows in a circuit, the disease on the left side of the heart eventually affects the right side. The right ventricle may enlarge in response to its increased workload. When the contraction of the right ventricle can no longer overcome the pulmonary resistance, right-sided heart failure develops. Excess blood accumulates in the venous circulation, the liver becomes congested, and edema occurs in the legs.

Resting/Exercise ECG

Resting ECG is performed as a baseline before doing an exercise ECG. Exercise ECG is more diagnostic than resting ECG because it demonstrates how the heart functions when subjected to activity.

Use of Short-Acting Nitroglycerin

Sit down and rest before self-administering nitroglycerin. Decreased activity may relieve chest pain; sitting will prevent injury should the nitroglycerin lower BP and cause fainting. Place one nitroglycerin tablet under the tongue if 2 to 3 minutes of rest fails to relieve pain. Expect to feel dizzy or flushed or to develop a headache. Let the tablet dissolve slowly; there should be slight tingling or burning under the tongue. Take a second nitroglycerin tablet in 5 minutes if chest pain is still present. Take a third nitroglycerin tablet in 5 more minutes if chest pain is still present. Call 911 if chest pain continues; do not drive to an emergency department. Discuss the chest pain with the primary provider if self-management relieved it or its usual characteristics changed. Keep a few nitroglycerin tablets in a dark, dry container with you at all times; consult with the pharmacist about a sealed metal container that you can wear around the neck. Do not place other medications in the container with the nitroglycerin. Replace nitroglycerin tablets every 6 months or after any container has been opened six times.

Mental Status

Some clients with cardiac disorders may be alert and oriented; others may be alert, confused, or disoriented. Confusion or disorientation can result from a decrease in the oxygen supply to the brain (cerebral ischemia) as a result of poor circulation. Chest pain and impaired breathing can create anxiety. The nurse reports extremes of emotion or disturbances in thought processes to the primary provider because such effects could interfere with the client's safety, diagnostic testing, and prescribed therapy.

Mitral regurgitation (insufficiency) Diagnostic Findings

Standard transthoracic or transesophageal echocardiography is the best technique to identify structural changes in the mitral valve. Chest radiography shows enlarged chambers on the left side of the heart. Radionuclide angiography, an imaging procedure using an intravenously injected radioactive substance, shows the heart's chambers in motion and provides information on the volume of regurgitated blood. Echocardiography reflects cardiac enlargement, papillary muscle or chordae tendineae dysfunction, and factors that contribute to various associated arrhythmias

Disorders that commonly affect heart valves:

Stenosis is a narrowing of the opening in the aortic valve when the valve cusps become stiff and rigid. Treatment: stenosis that causes any symptoms (particularly shortness of breath on exertion, angina, or fainting), or if the valve begins to fail, then it is replaced. Replacement of the abnormal valve is the best treatment for nearly everyone, and the prognosis after valve replacement is excellent. Regurgitation: occurs when the aortic valve does not close tightly, and blood can leak backward. Treatment: Sometimes valve repair or replacement. If regurgitation is mild, no specific treatment may be required. However, the regurgitation may gradually worsen, so echocardiography is done periodically to help determine whether surgery becomes necessary. Surgery must be done before the heart muscle becomes permanently weakened. Valve prolapse: the valve cusps enlarge, become floppy, and bulge backward into the left atrium. Treatment: Sometimes beta-blockers. Most people with valve prolapse do not need treatment. If the heart is beating too fast, a beta-blocker may be taken to slow the heart rate and to reduce palpitations and other symptoms

DISORDERS OF BLOOD VESSEL WALLS Diagnostic Findings

The Brodie-Trendelenburg test is performed for diagnostic purposes. The client lies flat and elevates the affected leg to empty the veins. A tourniquet is then applied to the upper thigh, and the client is asked to stand. If blood flows from the upper part of the leg into the superficial veins when the tourniquet is released, the valves of the superficial veins are considered incompetent. Ultrasonography and venography are also used to detect impaired blood flow.

Arrhythmias medical management

Treatment is directed toward reducing tissue hypoxia, relieving pain, treating shock (if present), and alleviating arrhythmias if they occur

Miscellaneous Laboratory and Diagnostic Tests

The WBC count, C-reactive protein, and erythrocyte sedimentation rate increase on about the third day following MI because of the inflammatory response that the injured myocardial cells triggered. Blood glucose level may be elevated because of the body's response to a major stressor. After an MI, characteristic changes appear on the ECG within 2 to 12 hours. They may, however, take as long as 3 days to develop. These changes include T-wave inversion, ST-segment elevation, and a Q wave

DISORDERS OF THE AORTIC VALVE

The aortic valve has three cusps, or leaflets, and each cusp is described as a semilunar valve because each cusp appears like a half-moon. The left ventricle pumps blood from the heart through the aortic valve. When the left ventricle contracts, a nondiseased aortic valve opens to allow the unrestricted passage of oxygenated blood into the arterial vascular system. The coronary arteries supplying the myocardium are the first blood vessels perfused. After ejection of left ventricular blood, the aortic valve closes tightly to prevent backflow of blood. Two valvular conditions interfere with unidirectional blood flow from the left side of the heart: aortic stenosis and aortic regurgitation.

Mitral Valve Prolapse Pathophysiology and Etiology

The cause of mitral valve prolapse is not completely understood, and it often is classified as idiopathic (having no known cause). It also has been suggested that the tissue changes result from an inherited connective tissue disorder that affects the mitral valve and other connective tissues in the body. It has been observed that some clients develop mitral valve prolapse in association with CAD, although there is speculation that no etiologic relationship actually exists. There is, however, strong evidence that mitral valve prolapse accompanies the valvular changes of rheumatic carditis, and structural changes predispose the valve to further damage if infective endocarditis develops. Some people develop mitral valve prolapse syndrome, symptoms that cannot be attributed to valvular disease alone. It is associated with autonomic nervous system dysfunction. This association may explain why some clients have increased levels of catecholamines (i.e., epinephrine, norepinephrine), abnormal catecholamine regulation, and decreased intravascular volume, which causes symptoms that mimic severe anxiety (tachycardia, palpitations, breathlessness, dizziness). Decreased circulatory volume may contribute to the client's symptomatology by triggering an abnormal renin-angiotensin-aldosterone response (see Chapter 16). Changes in the mitral valve tissue layers cause the cusps to distend. The billowing cusps stretch the papillary muscles as they balloon backward into the left atrium. The stretching of the papillary muscles causes local ischemia and atypical chest pain. As the papillary muscles provide less support to the mitral valve, valvular incompetence occurs. The left atrium and ventricle eventually may enlarge and subsequently progress to heart failure.

aortic regurgitation Assessment Findings S/S

The client remains asymptomatic as long as the left ventricle can sustain adequate circulation. Tachycardia is one of the first signs of cardiac compensation. When valve damage affects the left ventricle, the client becomes aware of forceful heart contractions (palpitations). At first, palpitations occur only when lying flat or on the left side. In later stages, the client experiences dyspnea and chest pain. During physical examination, skin may be flushed and moist, especially in the upper body. The radial pulse may be very strong, with quick, sharp beats followed by a sudden collapse of force, a characteristic called a water-hammer pulse or Corrigan pulse. Often, pulse pressure is wide because systolic BP tends to be extremely high, whereas diastolic BP usually remains low or normal. The enlarged heart displaces the PMI. The chest may heave or rock from the forceful contractions of the enlarged left ventricle. A heart murmur, caused by the turbulence of blood falling back through the dilated aortic valve, also may be heard.

Mitral regurgitation (insufficiency). Assessment Findings S/S

The client typically experiences chronic fatigue and dyspnea on exertion. Heart palpitations may occur caused by the forceful contraction of the left ventricle as it attempts to empty the excess blood from its chamber. The S1 heart sound is diminished because of incomplete closure of the mitral valve. An S3 heart sound, if heard, is an early sign of impending heart failure. Hypertension may develop when reduced cardiac output triggers the renin-angiotensin-aldosterone cycle (see Chapter 16). Tachycardia is a compensatory mechanism when stroke volume decreases. A loud, blowing murmur often is heard throughout ventricular systole at the heart's apex. If pulmonary congestion occurs, the client develops shortness of breath and moist lung sounds typical of left ventricular failure

Venous Insufficiency Assessment Findings S/S

The foot or feet appear swollen. Testing for pitting is difficult because the congested fluid cannot be displaced. Superficial veins are dilated and obvious during inspection. Skin color is not uniform; there usually is a red or darkly pigmented area. If a lesion is present, its margin usually is irregular. Serous fluid may have collected in a pocket beneath the skin, or the area has beads of fluid on its surface that return after being wiped away. If an infection is present, the drainage may change from clear to opaque. Most clients report moderate pain. Pedal and tibial pulses may be difficult to palpate because of the congestion of venous fluid.

Cardiopulmonary Circulation

The largest veins, the inferior vena cava and superior vena cava, bring venous (deoxygenated) blood from all areas of the body into the right atrium. The right atrium fills with blood, and the tricuspid valve opens. Blood then travels into the right ventricle and is pumped into the pulmonary artery (the only artery in an adult that carries deoxygenated blood). The pulmonary artery branches to deliver venous blood to the right and left lungs. The lungs exchange the oxygen in inspired air for the CO2 in the venous blood. The CO2 is transferred into the alveoli and exhaled. The pulmonary veins then bring the oxygenated blood into the left atrium. The oxygenated blood flows out of the left atrium through the bicuspid, or mitral, valve and into the left ventricle. The left ventricle then pumps the blood through the aorta to all the body's cells and tissues.

Blood Supply to the Heart

The left and right coronary arteries supply oxygenated blood to cardiac muscle (Fig. 22-3). The openings to the coronary arteries called the coronary ostia (singular, ostium) lie at the base of the aorta. When the left ventricle is filling with blood, the coronary ostia dilate and fill with blood. Thus, the myocardium is the first tissue of the body to receive oxygen-rich blood with each heartbeat.

DISORDERS OF THE MITRAL VALVE

The mitral valve, which lies between the left atrium and left ventricle, is a bicuspid valve. The two cusps are attached on the ventricular surface to strands of fibrous tissue called chordae tendineae, which are projections from papillary muscles (see Fig. 22-2, Chapter 22). The papillary muscles contract in unison with the ventricle, pull on the chordae tendineae, and prevent the cusps from ballooning into the left atrium. The functions of the mitral valve are to open widely to allow oxygenated blood to fill the left ventricle and close tightly to prevent blood from reentering the left atrium after the left ventricle is filled. As long as the mitral valve remains structurally sound, blood exits the left ventricle through the aortic valve, where the aorta receives a 50- to 70-mL bolus of oxygenated blood referred to as the stroke volume. The valve may become rigid (stenotic), incompetent (inadequate closure), or prolapsed (floppy). Mitral valve prolapse is the most commonly diagnosed valvular disorder.

Thrombosis, Phlebothrombosis, and Embolism Pharmacologic Considerations

The most common test used to monitor heparin is activated partial thromboplastin time (aPTT) or partial thromboplastin time (PTT). PTT and aPTT are the same; however, in aPTT, an activator is added that speeds up the clotting time and results in a narrower reference range. The aPTT is considered a more sensitive version of the PTT. The dose is adjusted to attain a therapeutic range of 1.5 to 2.5 times the normal. When oral anticoagulant therapy begins, so does the importance of monitoring prothrombin time (PT) and international normalized ratio (INR). Therapeutic PT levels are 1.5 to 2.5 times the control value and the normal range for INR is 2.0 to 3.0. Monitoring continues monthly while the oral anticoagulant is taken.

Venous Insufficiency Nursing Management

The nurse assesses the appearance of the extremities and the quality of circulation. If an ulcer is present, they measure it and describe its appearance. If the client has pain, the nurse asks the client to rate it and administers an analgesic if warranted. The nurse measures the diameter of the calf and ankle and the length of the leg from heel to knee to obtain accurately fitting compression stockings. They help apply the stockings each morning before the client lowers the legs to the floor and implements wound care according to primary provider directives. The nurse teaches the client to do the following: Purchase more than one pair of compression stockings so one pair is worn while the other pair is laundered. Dry elastic stockings by laying them flat rather than hanging them, which stretches elastic. Lose weight if necessary. Elevate the legs periodically for at least 15 to 20 minutes. Walk or do isometric calf muscle pumps hourly to promote venous circulation. Raise the foot of the bed to promote venous circulation during sleep. Avoid morning showers or sitting in front of a fire because heat dilates blood vessels and contributes to venous congestion. Wear shoes with laces rather than slippers or sandals to reduce pooling of blood in the feet.

DISORDERS OF BLOOD VESSEL WALLS Nursing Management

The nurse assesses the skin, distal circulation, and peripheral edema, asking the client to rate the level of discomfort and ability to do active and isometric leg exercises. (See Chapter 14 for routine perioperative care.) When a surgical approach is used, the client returns with a gauze dressing covered by elastic roller bandages on the operative leg(s). The nurse monitors for swelling in the operative leg(s) and its effect on circulation. The nurse removes and rewraps the roller bandage to facilitate blood flow and inspects the dressing for signs of active bleeding. In the immediate postoperative period, the nurse elevates the foot of the bed to aid venous circulation to the heart and reminds the client to alternately contract and relax the lower leg muscles. If active exercise is inadequate, the nurse consults with the primary provider about using pneumatic venous compression stockings, which cover the leg from foot to thigh and periodically inflate and release air, simulating isometric muscle contraction. The nurse helps the client ambulate as soon as possible to promote venous circulation, reduce edema, and prevent venous thrombosis. When bleeding is no longer a problem, the nurse applies elastic antiembolism stockings in place of the elastic roller bandage and provides adequate fluid to decrease potential thrombosis. When teaching the client and family, the nurse identifies factors that impair venous circulation: wearing elastic girdles or tight belts, using round garters or rolling and twisting nylon stockings, standing or sitting for prolonged periods, and sitting with the knees crossed. The nurse describes appropriate foot and nail care to facilitate tissue integrity, explaining that any open areas on the feet or lower legs require examination and treatment by the primary provider. The nurse recommends active or isometric exercises and elevation of the extremities frequently during the day. They demonstrate how to apply and remove elastic support stockings and refers the client to the dietitian if weight loss is indicated.

Mitral regurgitation (insufficiency Nursing Management

The nurse closely monitors BP, heart rate and rhythm, heart sounds, and lung sounds. If sodium is restricted, the nurse works with the client and dietitian to find palatable seasonings and foods and weighs the client to determine changes in fluid volume. They administer medications to treat symptoms and report signs of left- or right-sided heart failure immediately. The nurse emphasizes the need for prophylactic antibiotics and periodic health assessments. Refer to Nursing Care Plan 24-1 for more specific interventions.

Peripheral Artery Disease Nursing Management

The nurse explains the rationale for lifestyle changes in diet, exercise, and adherence to medication self-administration. The action, dosage, administration schedule, and side effects of each drug are explained as well as any blood tests that are required for monitoring safety. The nurse palpates and compares lower extremity peripheral pulses bilaterally. The skin on the extremities is assessed, and the nurse teaches the client to notify the primary provider if cyanosis, skin lesions, or gangrene is detected. The nurse sets an example for daily skin and foot care, including washing and drying the feet well, applying moisturizing lotion, changing cotton socks daily, and wearing supportive shoes. Regular attention by a podiatrist is recommended for thick nails that are difficult p. 428 p. 429 to trim, corns, calluses, or blisters that may form. The nurse stresses the danger of applying direct heat to the lower extremities and shows the client how to avoid positions that interfere with blood flow, such as crossing the legs at the knee. Besides the prescribed exercise regimen, the nurse recommends sedentary exercises such as extending the knees and ankle pumping and rotation to promote circulation, followed by periods of rest.

Aneurysm Nursing Management

The nurse helps control hypertension by keeping activity and stress to a minimum. The client should avoid straining during bowel movements, coughing, and holding the breath while changing positions. The nurse monitors BP, pulse, hourly urine output, skin color, level of consciousness, and characteristics of pain for signs of hemorrhage or dissection. They prepare the client for diagnostic testing and surgical interventions. Afterward, the nurse monitors for shock and adequate tissue perfusion. (See Chapter 29 for nursing management of a client undergoing cardiovascular surgery.)

Nursing Process for the Client Undergoing Cardiac or Vascular Surgery.)

The nurse informs clients about diagnostic tests or treatment procedures. The nurse who prepares the client for invasive, nonsurgical procedures performed with a percutaneous catheter cleanses and removes hair from skin insertion sites (one for the coronary catheter and the other for an arterial line through which BP will be directly monitored). The nurse withholds anticoagulant therapy before the procedure to decrease the chance of hemorrhage. They monitor all vascular sites for bleeding after a procedure and assesses distal pulses. The nurse also observes mental status because cerebral emboli can occur. They monitor urine output and administer analgesics for discomfort. Any of the following data are reported immediately: severe chest pain; abnormal heart rate or rhythm; mental confusion or loss of consciousness; hypotension; urine output of less than 30 to 50 mL/hour; or a cold, pulseless extremity.

Discharge Instructions for Clients Having Cardiac Catheterization

The nurse instructs the client as follows: Rest for the next 3 days and avoid heavy lifting, strenuous activity, or sports during this time. Do not drive or climb stairs for the next 24 hours. Do not take a tub bath until the puncture site is healed. Change the bandage in 24 hours; continue changing the bandage until a crust or scab forms over the puncture site. You may experience some soreness at the puncture site; however, if it becomes worse, notify your primary provider. If pain or swelling of the puncture site occurs, notify your primary provider. If the puncture site begins to bleed, hold pressure over the site and call 911 or another emergency services number.

Aortic Stenosis Nursing Management

The nurse monitors subjective and objective symptoms and explains the purposes and techniques of diagnostic tests. They administer prescribed medications and monitor for therapeutic or adverse responses and institute measures to ensure adequate cardiac output and tissue oxygenation. The nurse assists the client to adhere to dietary modifications to reduce fluid volumes and the work placed on the heart (

Sexual Guidelines After Myocardial Infarction

The nurse provides the following information to the client: Check with primary provider before resuming sexual activity; those with an "uncomplicated" heart attack (no heart failure, shock, severe arrhythmias, or residual chest pain) may resume sex in about 1 week or when able to perform mild or moderate activity such as walking up two flights of stairs without experiencing angina. Avoid sex with anyone other than your usual partner. Avoid positions that require supporting your own weight. Get adequate rest before sexual intercourse. For women, apply an over-the-counter estrogen cream or other friction-reducing substance on or in the vagina to promote lubrication. Have sex in the same environment as before the MI. Postpone sex for 2 to 3 hours after eating a heavy meal or consuming alcohol. Use a short-acting nitrate, if the primary provider approves, before intercourse; avoid combining a medication for erectile dysfunction with a nitrate. Begin with moderate sexual foreplay. Use medium water temperatures when bathing or showering before or after sexual activity.

Diagnostic Findings

The tentative diagnosis begins with taking a history of the client's symptoms and examining the lower extremities. Blood tests that reveal elevated total cholesterol, high LDL, above-normal triglyceride, and increased homocysteine contribute to the diagnosis. One of the simplest tests involves measuring the ankle-brachial index, a comparison of the systolic pressure in the brachial artery with that in the posterior tibial artery using Doppler ultrasound at rest or after exercise (Fig. 25-13). The severity of the disorder is determined by dividing the systolic BP in the ankle by the systolic pressure in the arm. When the quotient (result of the division) is 0.9 or less, the data support a diagnosis of PAD. Clients may also undergo angiography using a CT scan or magnetic resonance imaging. Invasive angiography using a contrast agent may be used to detect the specific location of blocked arteries or determine improvement after endovascular procedures.

The image is recorded and kept as a permanent record

This technique is also known as transthoracic echocardiography.

Thrombophlebitis

Thrombophlebitis is an inflammation of a vein accompanied by a clot or thrombus formation.

Thrombosis, Phlebothrombosis, and Embolism Pathophysiology and Etiology

Thrombosis in the venous system most often occurs in the lower extremities and usually is associated with disorders or circumstances that cause venous stasis (inactivity, immobility, or trauma to a blood vessel). Orthopedic surgical procedures increase the incidence of deep vein thrombosis (DVT) of the lower extremities. Atherosclerosis, endocarditis, pooling of blood in a ventricular aneurysm, and arrhythmias such as atrial fibrillation can precipitate arterial thrombosis and subsequent embolization. When a thrombus forms or an embolus reaches a blood vessel too small to permit its passage, blood flow is partly or totally occluded.

DISORDERS OF BLOOD VESSEL WALLS Medical and Surgical Management

Treatment of mild varicose veins includes exercising (walking, swimming), losing weight (if needed), wearing elastic support stockings, and avoiding prolonged periods of sitting or standing. Defective smaller veins may be occluded using skin surface laser treatments. Deeper varicose veins may be sclerosed or occluded by injecting a chemical that sets up inflammation in the vein wall. Endovascular radiofrequency, in which a catheter with a heated probe is inserted into the vein, is another alternative. Eventually, adhesions form, and blood flow must find an alternate route through collateral veins. Surgical treatment for severe or multiple varicose veins consists of vein ligation with or without vein stripping. A vein ligation is a procedure in which the affected veins are ligated (tied off) above and below the area of incompetent valves, but the dysfunctional vein remains. For better results, a vein stripping is performed; in this procedure, the ligated veins are severed and removed. The entire great saphenous vein, which extends from the groin to the ankle, or the small saphenous vein may be removed.

DISORDERS OF BLOOD VESSEL WALLS Pathophysiology and Etiology

Varicose veins have a familial tendency. The valves of the veins become incompetent in early adulthood, resulting in varicosities. In others, anything that constricts or interferes with venous return contributes to the formation of varicose veins. Prolonged standing compromises venous return as blood pools distally with gravity. Obesity and pressure on blood vessels from an enlarging fetus, liver, or abdominal tumor contribute to venous congestion. Thrombophlebitis may lead to varicose veins because the inflammatory process may damage vein valves. Normally, the action of leg muscles during movement and exercise aids venous return (Fig. 25-15). When valves in veins become incompetent, blood accumulates rather than being propelled efficiently to the heart. The congestion stretches the veins. Over time, they cannot recoil and remain chronically distended. Venous hypertension then forces some fluid to move into the interstitial spaces of surrounding tissue. Venous congestion and local edema may diminish arterial blood flow, impairing cellular nutrition. Even minor skin or soft tissue injuries easily become infected and ulcerated. The healing of such lesions is slow and uncertain.

Coronary stent:

a small metal coil with meshlike openings placed in the coronary artery during PTCA. The stent prevents the buildup of new tissue that reforms in the artery, prevents the coronary artery from collapsing shortly after the procedure, and keeps the lumen open for a longer period.

Symptomatic Treatment

alleviates symptoms but does not influence course of disease, An IV infusion is initiated to provide fluid while eating is restricted. The IV route also is used to administer parenteral medications. Drug therapy includes analgesics for pain, nitrates or other vasodilating drugs to improve blood flow, diuretics to reduce circulating blood volume, sedatives to promote rest and reduce anxiety, anticoagulants to prevent additional thrombus formation, and drugs to treat arrhythmias (see Drug Therapy Table 25-1). Oxygen is ordered to treat or prevent hypoxemia. Complete bed rest is prescribed initially but not recommended for uncomplicated MIs after the first 12 hours. Activity is adjusted according to the extent of the MI, complications, and response to therapy. When chest pain is controlled, a clear liquid diet is allowed and progressed to a heart-healthy diet thereafter (see Nutrition Notes). Clients who regularly consumed caffeine before an MI and consumed three to five cups of coffee per day afterward did not affect their mortality (Ding et al., 2014; Mukamal et al., 2009). A stool softener is prescribed to prevent increased BP from straining with the passage of stool. Permanent smoking cessation is imperative. The intra-aortic balloon pump may be used for clients who develop severe left ventricular failure

coronary artery disease Drug Therapy

arterial vasodilation, such as nitrates (e.g., nitroglycerin, isosorbide dinitrate). Beta-adrenergic blockers, which decrease consumption of myocardial oxygen by reducing heart rate, also are used. Calcium channel blockers may be used as well, although research has shown that they may be less beneficial than beta-adrenergic blockers (Drug Therapy Table 25-1). Drugs such as angiotensin-converting enzyme inhibitors and diuretics, as well as stress management, are used to control hypertension. Nicotinic acid (niacin) in pharmacologic doses (i.e., not the dosage in multivitamins) helps increase HDL and lower LDL. Daily intake of food sources or supplements of folate or folic acid, vitamin B6 (pyridoxine), and vitamin B12 (cyanocobalamin) reduce homocysteine levels; however, available evidence is not sufficient to recommend folate and other vitamin B supplements as a means to reduce CVD risk, according to the AHA.

BLOOD FLOW THROUGH THE HEART

body --> superior and inferior vena cava --> RA --> triuspid --> RV --> pulmonary SL valve --> pulmonary trunk --> pulmonary arteries --> capillary bed of lungs --> pulmonary veins --> LA --> bicuspid --> LV --> aortic SL valve --> ascending aorta --> aortic arch --> descending aorta --> systemic veins --> coronary sinus

ARTERIOSCLEROSIS

hardening of the arteries

Pericarditis

inflammation of the sac surrounding the heart

Peripheral Pulses

cataroid, femoral, brachial, radial, ulnar, popliteal, posterior tibial, dorsalis pedis

Mitral Insufficiency

causes backflow of blood into the left atrium due to incomplete closure of valve

Raynaud syndrome:

characterized by periodic constriction of the arteries that supply the extremities. The disorder is most common in young women.

Cardiac Telemetry

continuous monitoring of a patient's heart rate and rhythm via EKG electrodes, sends ECG information over radio waves to a monitor that is distant from the client.

Varicose veins or varicosities

dilated, tortuous veins, found mainly in the saphenous veins. May occur in other body parts, such as the rectum (hemorrhoids) and esophagus (esophageal varices). Varicose veins may be accompanied by a smaller variation called spider veins, which appear closer to the surface of the skin.

Coronary Artery Disease

disease of the arteries surrounding the heart, CAD refers to arteriosclerotic and atherosclerotic changes in the coronary arteries supplying the myocardium. It may not be diagnosed until clients are in late middle age or older, but the vascular changes most likely begin much earlier.

coronary artery disease Percutaneous Transluminal Coronary Angioplasty

percutaneous transluminal coronary angioplasty (PTCA), sometimes referred to as balloon angioplasty, is performed. In PTCA, which uses sedation and local anesthesia, a balloon-tipped catheter is inserted through the skin and threaded from a peripheral artery into the diseased coronary artery While passage of the catheter is monitored under fluoroscopy, the catheter is positioned in the area of stenosis, and the balloon is inflated with carbon dioxide (CO2) for anywhere from several seconds to several minutes. Inflation of the balloon compresses the atherosclerotic plaque against the arterial wall, increasing the diameter of the artery. Arterial rupture, MI, and abrupt reclosure are complications of PTCA. Because the artery tends to reocclude in 40% to 50% of clients who undergo PTCA, a coronary stent (see discussion below) is usually placed in the artery during the procedure; otherwise, PTCA may need to be repeated. Clients who have not had an accompanying MI but have had PTCA or any procedure that uses a percutaneous catheter are provided with the discharge instructions for self-care shown

Atherectomy, or removal of fatty plaque:

plaque is removed by either inserting a cardiac catheter with a cutting tool at the tip or by performing laser angioplasty.

Arteriosclerosis:

refers to the loss of elasticity or hardening of the arteries that accompanies the aging process.

Diastole

the tricuspid and mitral valves are open and allow blood to flow freely from the atria to the ventricles. The aortic and pulmonary valves are closed.

PTCA, or balloon angioplasty:

uses sedation and local anesthesia, a balloon-tipped catheter is inserted through the skin and threaded from a peripheral artery into the diseased coronary artery. The catheter is positioned in the area of stenosis, and the balloon is inflated with CO2 for anywhere from several seconds to several minutes. Inflation of the balloon compresses the atherosclerotic plaque against the arterial wall, increasing the diameter of the artery.

narrowing of the aortic valve

valve is an age-related degenerative change from progressive calcium deposits in valve cells. The muscular wall of the left ventricle enlarges In others, aortic stenosis results directly from valvular damage related to rheumatic carditis and infective endocarditis

transesophageal echocardiography (TEE)

which, as the name implies, involves passing a tube with a small transducer internally from the mouth to the esophagus (Fig. 22-12). The transducer can obtain images of the posterior heart and its internal structures from the esophagus, which lies behind the heart. TEE provides superior views that are not possible using standard transthoracic echocardiography. It is also an adjunct for assessing intraoperative complications in the heart during cardiothoracic surgery. Clients whose chests are rotund or who are obese are candidates for TEE. Because the throat is anesthetized locally, the nurse cautions the client to avoid eating or drinking until sensation and the gag reflex return, which may take 1 hour or longer after removal of the tube containing the transducer.

Contraindications for Thrombolytic Therapy

●Pregnancy Risk Category C.● Any prior intracranial hemorrhage (hemorrhagic stroke). Known structural cerebral vascular lesion (arteriovenous malformation). Active internal bleeding. History of significant closed head or spinal trauma within past 2 months. Acute pericarditis or bacterial endocarditis, Brain tumors, Severe hepatic or renal disorders. Use cautiously in clients who have severe hypertension, cerebral vascular disorders, recent GU or GI bleeding, major surgery within past 10 days, or in older adult clients