NCM 102

ALTERATION IN OXYGENATION
Lecture Series 01

Anatomy And Physiology

Cardiovascular Physiology

• Circulatory system – includes a pump (the heart), interconnected tubes (blood vessels or
vascular system), and extracellular fluid and cells (blood)

Heart and heart wall layers

 The heart is located in the left side of the mediastinum.

The Layers of the Heart Wall

Epicardium – Essential layer of the heart – The layer that covers the heart is the
(visceral – Coronary arteries are found in this PERICARDIUM
pericardium) layer – There are two parts- parietal and visceral
– Middle and thickest layer of the heart pericardium
(CBQ) – The space between the two pericardial
Myocardium layers is the pericardial space
– Responsible for contraction of the
heart
– Innermost layer of the heart
Endocardium – Lines the inside of the myocardium
– Covers the heart valves

Chambers of heart
 Right atrium: collecting chamber for incoming systemic venous system
 Right ventricle: propels blood into pulmonary system
 Left atrium: collects blood from pulmonary venous system
 Left ventricle: largest thick-walled muscle that acts as a high-pressure
pump which propels blood into the systemic arterial system

The heart chambers are guarded by valves

- The atrio-ventricular valves- Tricuspid and bicuspid
- The semi-lunar valves- Pulmonic and aortic valves

The Blood supply of the heart comes from the Coronary arteries

NCM 102 Med-Surg Nsg. Cardiovascular Disorders Prepared by: Lindsay Carmelle
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- Right coronary artery
- Left coronary artery

Blood supply for the heart:

Coronary arteries – supply blood to myocardium
Coronary blood flow – blood flowing through the coronary arteries
Coronary sinus – drainage area for the blood; empties into right atrium

The main functions of this system are:

- to transport oxygen, hormones and nutrients to the tissues
- and to transport waste products to the lungs and kidneys for excretion

The CONDUCTING SYSTEM OF THE HEART

Consists of the
1. SA node- the pacemaker
2. AV node- slowest conduction
3. Bundle of His – branches into the Right and the Left bundle branch
4. Purkinje fibers- fastest conduction

The Heart sounds

1. S1- due to closure of the AV valves
2. S2- due to the closure of the semi-lunar valves
3. S3- due to increased ventricular filling
4. S4- due to forceful atrial contraction

Heart rate
- Normal range is 60-100 beats per minute
- Tachycardia is greater than 100 bpm
- Bradycardia is less than 60 bpm
- Sympathetic system INCREASES HR
- Parasympathetic system (Vagus) DECREASES HR (CBQ)

The Heart: Physiology

- The amount of blood the heart pumps out in each beat is called the STROKE VOLUME
- When this volume is multiplied by the number of heart beat in a minute (heart rate), it becomes
the CARDIAC OUTPUT
- When the Cardiac Output is multiplied by the Total Peripheral Resistance, it becomes the BLOOD
PRESSURE

Blood pressure = Cardiac output X Peripheral resistance

Blood pressure
- Control is neural (central and peripheral) and hormonal
- Baroreceptors in the carotid and aorta
- Hormones - ADH, Adrenergic hormones, Aldosterone and ANF

The Heart: Physiology

- The PRELOAD is the degree of stretching of the heart muscle when it is filled-up with blood

- The AFTERLOAD is the resistance to which the heart must pump to eject the blood

NCM 102 Med-Surg Nsg. Cardiovascular Disorders Prepared by: Lindsay Carmelle
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Vascular System
- The vascular system consists of the arteries, veins and capillaries
- The arteries are vessels that carry blood away from the heart to the periphery
- The veins are the vessels that carry blood to the heart
- The capillaries are lined with squamos cells, they connect the veins and arteries
- The lymphatic system also is part of the vascular system and the function of this system is to
collect the extravasated fluid from the tissues and returns it to the blood

Cardiac Assessment

1. Health History
- Obtain description of present illness and the chief complaint
- Chest pain, SOB, Edema, etc.
- Assess risk factors

2. Physical examination
- Vital signs- BP, PP, MAP
- Inspection of the skin
- Inspection of the thorax
- Palpation of the PMI, pulses
- Auscultation of the heart sounds

3. Laboratory and diagnostic studies

- CBC
- Cardiac catheterization
- Lipid profile
- arteriography
- Cardiac enzymes and proteins
- CXR
- CVP
- ECG

NCM 102 Med-Surg Nsg. Cardiovascular Disorders Prepared by: Lindsay Carmelle
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 - Holter monitoring
- Exercise ECG

Laboratory Test Rationale

- To assist in diagnosing MI
- To identify abnormalities
- To assess inflammation
- To determine baseline value
- To monitor serum level of medications
- To assess the effects of medications

CK- MB (creatine kinase)

- Indicates myocardial damage
- Elevates in MI within 4-6 hours
- peaks in 18 hours and then declines till 3 days
- 0-5% of total CK (26-174U/L)
- Normal value is 0-7 U/L

Lactate Dehydrogenase (LDH)

- Elevates in MI in 24 hours
- peaks in 48-72 hours
- Normally LDH1 is greater than LDH2
- MI- LDH2 greater than LDH1 (flipped LDH pattern)
- Normal value is 70-200 IU/L

Myoglobin
- Oxygen binding protein
- Found in both skeletal and cardiac
- Level rises 1 hour after cell death
- Peaks in 4-6 hours
- Returns to normal w/in 24-36 hours
- Not used alone
- Muscular and RENAL disease can have elevated myoglobin

Troponin I and T
- Troponin I has a high affinity for myocardial injury
- Elevates within 3-4 hours, peaks in 4-24 hours and persists for 7 days to 3 weeks!
- Troponin I - <0.6 ng/mL
- Troponin T – 0-0.2ng/mL
- REMEMBER to AVOID IM injections before obtaining blood sample!
- Early and late diagnosis can be made!

SERUM LIPIDS
- Lipid profile measures the serum cholesterol, triglycerides and lipoprotein levels
- Cholesterol= 200 mg/dL
- Triglycerides- 40- 150 mg/dL
- LDL- 130 mg/dL
- HDL- 30-70- mg/dL
- NPO post midnight (usually 12 hours)

ELECTROCARDIOGRAM (ECG)
- A non-invasive procedure that evaluates the electrical activity of the heart
- Electrodes and wires are attached to the patient
- Tell the patient that there is no risk of electrocution
- Avoid muscular contraction/movement

NCM 102 Med-Surg Nsg. Cardiovascular Disorders Prepared by: Lindsay Carmelle
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Holter Monitoring
- A non-invasive test in which the client wears a Holter monitor and an ECG tracing recorded
continuously over a period of 24 hours
- Instruct the client to resume normal activities and maintain a diary of activities and any
symptoms that may develop

Echocardiogram
– Non-invasive test that studies the structural and functional changes of the heart with the use of
ultrasound
– No special preparation is needed

Stress Test
– A non-invasive test that studies the heart during activity and detects and evaluates CAD
– Exercise test, pharmacologic test and emotional test
– Treadmill testing is the most commonly used stress test
– Used to determine CAD, Chest pain causes, drug effects and dysrhythmias in exercise
– Pre-test: consent may be required, adequate rest , eat a light meal or fast for 4 hours and avoid
smoking, alcohol and caffeine
– Post-test: instruct client to notify the physician if any chest pain, dizziness or shortness of breath
– Instruct client to avoid taking a hot shower for 10-12 hours after the test
– Pharmacological stress test
 Use of dipyridamole
 Maximally dilates coronary artery
 Side-effect: flushing of face
 Pre-test: 4 hours fasting, avoid alcohol, caffeine
 Post test: report symptoms of chest pain

Cardiac Catheterization
– Insertion of a catheter into the heart and surrounding vessels
– Obtains information about the structure and performance of the heart valves and surrounding
vessels
– Used to diagnose CAD, assess coronary artery patency and determine extent of atherosclerosis

PRE PROCEDURE
 Ensure Consent
 assess for allergy to seafood and iodine
 Withhold solid food 6-8 hours and liquids for 4 hours
 document weight and height, baseline VS, blood tests and document the peripheral pulses

NCM 102 Med-Surg Nsg. Cardiovascular Disorders Prepared by: Lindsay Carmelle
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  inform client that a local anesthetic will be administered before insertion
 Client may feel fatigued because of the need to lie for 2 hours
 Prepare IV line if prescribed
 Prepare insertion site by shaving and cleaning with an antiseptic solution if prescribed
 Administer pre medication

INTRATEST
 inform patient of a fluttery feeling as the catheter passes through the heart
 inform the patient that a feeling of warmth and metallic taste may occur when dye is
administered.

POST TEST
 Monitor VS and cardiac rhythm
 Monitor dysrrhytmia and chest pain
 Monitor peripheral pulses, color and warmth and sensation of the extremity distal to insertion
site
 Apply sandbag or compression device to insertion site if required to maintain pressure
 Maintain strict bed rest for 6-12 hours
 Client may turn from side to side but bed should not be elevated more than 15 degrees
 Notify physician if client complains of tingling, cool, pale, cyanosis and loss of peripheral pulses
 Keep the leg straight to prevent occlusion
 Monitor for bleeding and hematoma formation
 Encourage fluid intake to flush out the dye
 Immobilize the arm if the antecubital vein is used
 Monitor for dye allergy
 Encourage fluid intake to promote renal excretion of dye
 Monitor nausea, vomiting, rash and other sign of HPS rxn

CVP
– The CVP is the pressure within the SVC
– Reflects the pressure under which blood is returned to the SVC and right atrium
– is measured with a central venous line in the SVC and balloon flotation catheter in the pulmonary
artery
– Normal CVP is 3 to 8 mmHg/ 4-10 cm H2O

Increased CVP
1. increase in blood volume as a result of Na and water retention, excessive IVF or heart/renal
failure

Decreased CVP
2. May indicate decrease in circulating blood volume and may be to hypovolemia, hemorrhage
and severe vasodilatation

Measuring CVP
1. Position the client supine with bed elevated at 45 degrees (CBQ)
2. Position the zero point of the CVP line at the level of the right atrium. Usually this is at the MAL,
4th ICS
3. Instruct the client to be relaxed and avoid coughing and straining.
 note disease that activity that increases intra-thoracic pressure such as coughing and straining
 If the client is on the ventilator reading should be taken at the point of end expiration

NCM 102 Med-Surg Nsg. Cardiovascular Disorders Prepared by: Lindsay Carmelle
I. Nate, R.N.
 Cardiac Implementation
1. Assess the cardio-pulmonary status
- VS, BP, Cardiac assessment
2. Enhance cardiac output
- Establish IV line to administer fluids
3. Promote gas exchange
- Administer O2
- Position client in SEMI-Fowler’s
- Encourage coughing and deep breathing exercises
4. Increase client activity tolerance
- Balance rest and activity periods
- Assist in daily activities
- Provide strict bed rest if indicated
- Soft foods
- Assistance in self-care
5. Promote client comfort
- Assess the client’s description of pain and chest discomfort
- Administer medication as prescribed
 Morphine for MI
 Nitroglycerine for Angina
 Diuretics to relieve congestion (CHF)
6. Promote adequate sleep
7. Prevent infection
- Monitor skin integrity of lower extremities
- Assess skin site for edema, redness and warmth
- Monitor for fever
- Change position frequently
8. Minimize patient anxiety
Encourage verbalization of feelings, fears and concerns
Answer client questions. Provide information about procedures and medications

CARDIOVASCULAR DISORDERS

Cardiac Diseases
 Coronary Artery Disease
 Myocardial Infarction
 Congestive Heart Failure
 Infective Endocarditis
 Cardiac Tamponade

Vascular Diseases
 Hypertension
 Buerger’s disease
 Aneurysm
 Varicose veins
 Deep vein thrombosis

Cardiac Diseases

Coronary Artery Disease (CAD)

- results from the focal narrowing of the large and medium-sized coronary arteries due to deposition
of atheromatous plaque in the vessel wall

Risk Factors
1. Age above 45/55 and Sex- Males and post-menopausal females
2. Family History
3. Hypertension
4. DM
5. Smoking
6. Obesity
7. Sedentary lifestyle
8. Hyperlipedimia

Most important MODIFIABLE factors:

- Smoking
- Hypertension
- Diabetes

NCM 102 Med-Surg Nsg. Cardiovascular Disorders Prepared by: Lindsay Carmelle
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 - Cholesterol abnormalities

Pathophysiology
- There is decreased perfusion of myocardial tissue and inadequate myocardial oxygen supply
- If 50% of the left coronary arterial lumen is reduced or 75% of the other coronary artery, this
becomes significant
- Potential for Thrombosis and embolism

Artery walls have three layers.

1. The inner layer provides a slippery surface.
2. The middle layer is strong, elastic and muscular.
3. The outer, fibrous, layer adds strength and contains tiny blood vessels that supply blood to the
arteries themselves.

Narrowing or obstruction of the coronary arteries is the main cause of a group of disorders known
as ischaemic heart disease.

Coronary Artery Disease.

- Acute Coronary Syndrome (ACS) is the phrase used when referring to any cardiac condition
involving the coronary arteries.
- Angina is a feeling of tightness or pain across the chest that may spread outwards to the
shoulders, upper arms and back.
May occur with exercise or strong emotion and can be worse after a meal or in cold weather.
Symptoms usually disappear after 1-2 minutes rest.
- Heart attack (myocardial infarction or MI) is when part of the heart muscle dies. This is
usually caused by a blood clot (coronary thrombosis), which has blocked one of the coronary
arteries supplying the heart and depriving the tissues of oxygen.

Coronary Artery Disease treatment

 Angioplasty & Stent
 Coronary Artery Bypass Graft.

- Treatment for C.A.D involves the removal or treatment of risk factors.

- Sometimes procedures to enlarge or bypass coronary artery narrowing are required.
- If Coronary Disease is not treated and the coronary artery becomes blocked the result may be a
heart attack.

Angioplasty
- Coronary angioplasty involves inserting a balloon into a diseased (blocked/narrowed) coronary
artery through an artery in the groin or arm.
- Commonly a metal support (stent) is inserted into the artery to help keep it open.

NCM 102 Med-Surg Nsg. Cardiovascular Disorders Prepared by: Lindsay Carmelle
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 C. A. B. G.
- Veins and sometimes arteries are grafted from the aorta to a point on the coronary artery beyond
the area of disease. This enables an adequate blood supply to reach those parts of the heart
suffering from ischaemia

Valve Replacements
- Aortic Valve Replacement (AVR)
- Mitral Valve Replacement (MVR)

Angina Pectoris
- Chest pain resulting from coronary atherosclerosis or myocardial ischemia

Angina Pectoris: Clinical Syndromes

Three Common Types of Angina

1. Stable Angina
- The typical angina that occurs during exertion, relieved by rest and drugs and the severity
does not change

2. Unstable angina
- Occurs unpredictably during exertion and emotion, severity increases with time and pain may
not be relieved by rest and drug

3. Variant angina
- Prinzmetal angina, results from coronary artery VASOSPASMS, may occur at rest

ASSESSMENT FINDINGS
1. Chest pain - ANGINA
- The most characteristic symptom
- PAIN is described as mild to severe retrosternal pain, squeezing, tightness or burning sensation
- Radiates to the jaw and left arm
- Precipitated by Exercise, Eating heavy meals, Emotions like excitement and anxiety and
Extremes of temperature
- Relieved by REST and Nitroglycerin
2. Diaphoresis
3. Nausea and vomiting
4. Cold clammy skin
5. Sense of apprehension and doom
6. Dizziness and syncope

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

NCM 102 Med-Surg Nsg. Cardiovascular Disorders Prepared by: Lindsay Carmelle
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 2. Cardiac catheterization
3. Provides the MOST DEFINITIVE source of diagnosis by showing the presence of the
atherosclerotic lesions
- Decreased cardiac output
- Impaired gas exchange
- Activity intolerance
- Anxiety

Nursing Management
1. Administer prescribed medications
 Nitrates- to dilate the venous vessels decreasing venous return and to some extent dilate the
coronary arteries
 Aspirin- to prevent thrombus formation
 Beta-blockers- to reduce BP and HR
 Calcium-channel blockers- to dilate coronary artery and reduce vasospasm
2. Teach the patient management of anginal attacks
 Advise patient to stop all activities
 Put one nitroglycerin tablet under the tongue
 Wait for 5 minutes
 If not relieved, take another tablet and wait for 5 minutes
 Another tablet can be taken (third tablet)
If unrelieved after THREE tablets seek medical attention
3. Obtain a 12-lead ECG
4. Promote myocardial perfusion
 Instruct patient to maintain bed rest
 Administer O2 @ 3 lpm
Advise to avoid valsalva maneuvers
 Provide laxatives or high fiber diet to lessen constipation
 Encourage to avoid increased physical activities
5. Assist in possible treatment modalities
 PTCA- percutaneous transluminal coronary angioplasty
 To compress the plaque against the vessel wall, increasing the arterial lumen
 CABG- coronary artery bypass graft
 To improve the blood flow to the myocardial tissue
6. Provide information to family members to minimize anxiety and promote family cooperation
7. Assist client to identify risk factors that can be modified
8. Refer patient to proper agencies

Myocardial infarction
- Death of myocardial tissue in regions of the heart with abrupt interruption of coronary blood
supply

NCM 102 Med-Surg Nsg. Cardiovascular Disorders Prepared by: Lindsay Carmelle
I. Nate, R.N.
 FIGURE 13-1 Different degrees of damage occur to the heart muscle after a
myocardial infarction. The diagram shows the zones of necrosis, injury, and ischemia.

ETIOLOGY and Risk factors

1. CAD
2. Coronary vasospasm
3. Coronary artery occlusion by embolus and thrombus
4. Conditions that decrease perfusion- hemorrhage, shock

Risk factors
1. Hypercholesterolemia
2. Smoking
3. Hypertension
4. Obesity
5. Stress
6. Sedentary lifestyle

Pathophysiology
- Interrupted coronary blood flow myocardial ischemia  anaerobic myocardial metabolism for
several hours  myocardial death  depressed cardiac function  triggers autonomic nervous
system response  further imbalance of myocardial O2 demand and supply

Assessment Findings
1. Chest Pain
- Chest pain is described as severe, persistent, crushing substernal discomfort
- Radiates to the neck, arm, jaw and back
- Occurs without cause, primarily early morning
- NOT relieved by rest or nitroglycerin
- Lasts 30 minutes or longer
2. Dyspnea
3. Diaphoresis
4. cold clammy skin
5. N/V
6. restlessness, sense of doom
7. tachycardia or bradycardia
8. hypotension
9. S3 and dysrhythmias

Laboratory Findings
1. ECG- the ST segment is ELEVATED, T wave inversion, presence of Q wave
2. Myocardial enzymes- elevated CK-MB, LDH and Troponin levels

NCM 102 Med-Surg Nsg. Cardiovascular Disorders Prepared by: Lindsay Carmelle
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 3. CBC- may show elevated WBC count
4. Test after the acute stage - Exercise tolerance test, thallium scans, cardiac catheterization
Pain
- Decreased cardiac output
- Impaired gas exchange
- Activity intolerance
- Altered tissue perfusion
- Constipation

Nursing Intevention
1. Provide Oxygen at 2 lpm, Semi-fowler’s
2. Administer medications
- Morphine to relieve pain
- Nitrates, thrombolytics, aspirin and anticoagulants
- Stool softener and hypolipidemics
3. Minimize patient anxiety
- Provide information as to procedures and drug therapy
- Allow verbalization of feelings
- Morphine can be administered
4. Provide adequate rest periods
- Bed rest during acute stage
5. Minimize metabolic demands
- Provide soft diet
- Provide a low-sodium, low cholesterol and low fat diet
6. Assist in treatment modalities such as PTCA and CABG
7. Monitor for complications of MI- especially dysrhythmias, since ventricular tachycardia can
happen in the first few hours after MI
8. Provide client teaching

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

Nursing Interventions After Acute Episode

1. Maintain bed rest for the first 3 days
2. Provide passive ROM exercises
3. Progress with dangling of the feet at side of bed
4. Proceed with sitting out of bed, on the chair for 30 minutes TID
5. Proceed with ambulation in the room  toilet  hallway TID
6. Cardiac rehabilitation
- To extend and improve quality of life
- Physical conditioning
- Patients who are able to walk 3-4 mph are usually ready to resume sexual activities

Infective endocarditis
- Infection of the heart valves and the endothelial surface of the heart
Can be acute, sub-acute or chronic
NCM 102 Med-Surg Nsg. Cardiovascular Disorders Prepared by: Lindsay Carmelle
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 Etiologic factors
1. Bacteria- Organism depends on several factors
2. Fungi

Risk factors
1. Prosthetic valves
2. Congenital malformation
3. Cardiomyopathy
4. IV drug users
5. Valvular dysfunctions

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

Prevention
- Antibiotic prophylaxis if patient is undergoing procedures like dental extractions, bronchoscopy,
surgery, etc.
- Any invasive procedure that is associated with transient bacteremia may cause the
microrganism to lodge in the damaged, irregular valves

Laboratory Exam
- Blood Cultures to determine the exact organism
 Usually, 3 culture specimens are obtained and antibiotic sensitivity done

Nursing management
1. Regular monitoring of temperature, heart sounds
2. Manage infection
3. Long-term antibiotic therapy is given to ensure eradication of bacteria

Medical management
1. Pharmacotherapy
- IV antibiotic for 2-6 weeks
- Antifungal agents are given – amphotericin B
2. Surgery
3. Valvular replacement

Congestive Heart Failure (CHF)

- A syndrome of congestion of both pulmonary and systemic circulation caused by inadequate
cardiac function and inadequate cardiac output to meet the metabolic demands of tissues
- Inability of the heart to pump sufficiently
- The heart is unable to maintain adequate circulation to meet the metabolic needs of the body

This can happen acutely or chronically

- Acute in Myocardial infarction
- Chronic  cardiomyopathies

Classified according to the major ventricular dysfunction

1. Left Ventricular failure
2. Right ventricular failure

Etiology of CHF
1. CAD
2. Valvular heart diseases
3. Hypertension
4. MI
5. Cardiomyopathy
6. Lung diseases
7. Post-partum
8. Pericarditis and cardiac tamponade

Class 1
- Ordinary physical activity does NOT cause chest pain and fatigue

NCM 102 Med-Surg Nsg. Cardiovascular Disorders Prepared by: Lindsay Carmelle
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 - No pulmonary congestion
- Asymptomatic
- NO limitation of ADLs

Class 2
- SLIGHT limitation of ADLs
- NO symptom at rest
- Symptoms with INCREASED activity
- Basilar crackles and S3

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

Class 4
- SYMPTOMS are present at rest

PATHOPHYSIOLOGY
LEFT Ventricular pump failure
↓
back up of blood into the pulmonary veins
↓
increased pulmonary capillary pressure
↓
pulmonary congestion (edema)
↓
Pulmonary manifestations

LEFT ventricular failure

↓
Decreased cardiac output
↓
Decreased perfusion to the brain, kidney and other tissues
↓
Cerebral anoxia, fatigue, oliguria, dizziness

RIGHT ventricular failure

↓
blood pooling in the venous circulation
↓
increased hydrostatic pressure
↓
peripheral edema
↓
RIGHT ventricular failure
↓
Venous blood pooling
↓
venous congestion in the kidney, liver and GIT

Left Sided CHF Assessment Findings

1. Dyspnea on exertion, activity intolerance
2. PND
3. Orthopnea
4. Pulmonary crackles/rales
5. Cough with Pinkish, frothy sputum
6. Tachycardia
7. Cool extremities
8. Cyanosis
9. decreased peripheral pulses
10. Fatigue
11. Oliguria
12. signs of cerebral anoxia

Right Sided CHF Assessment Findings

1. Peripheral dependent, pitting edema
2. Weight gain
3. Distended neck vein
4. hepatomegaly
5. Ascites

NCM 102 Med-Surg Nsg. Cardiovascular Disorders Prepared by: Lindsay Carmelle
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 6. Body weakness
7. Anorexia, nausea
8. Pulsus alternans
9. Nocturia= urination at night at frequent intervals as the blood moves from interstitial space to
the intravascular space and is excreted

Laboratory Findings
1. CXR may reveal cardiomegaly
2. ECG may identify Cardiac hypertrophy
3. Echocardiogram may show hypokinetic heart
4. ABG and Pulse oximetry may show decreased O2 saturation
5. PCWP is increased in LEFT sided CHF and CVP is increased in RIGHT sided CHF

Nursing Interventions
1. Assess patient's cardio-pulmonary status
2. Assess VS, CVP and PCWP. Weigh patient daily to monitor fluid retention
3. Administer medications- usually cardiac glycosides are given- DIGOXIN or DIGITOXIN,
Diuretics, vasodilators and hypolipidemics are prescribed

Cardiotonics To increase cardiac contractility

Positive inotropic agents
Diuretics To decrease the intravascular volume in the
circulation
Low Sodium Diet To minimize water retention
Hypolipidemics To decrease the lipid levels of high risk patients

Digoxin Health teaching

- Oral tablet usually once a day
- Increases force of contraction
- DECREASES heart rate
- Assess: Apical pulse, ECG, hypokalemia
- Withhold the drug if apical pulse is less than 60
- Note for early signs of toxicity: NAVDA
- Provide potassium supplements

4. Provide a LOW sodium diet. Limit fluid intake as necessary

5. Provide adequate rest periods to prevent fatigue

6. Position on semi-fowler’s to fowler’s for adequate chest expansion

7. Prevent complications of immobility

Nursing Intervention after the Acute Stage

1. Provide opportunities for verbalization of feelings
2. Instruct the patient about the medication regimen- digitalis, vasodilators and diuretics
3. Instruct to avoid OTC drugs, Stimulants, smoking and alcohol
4. Provide a LOW fat and LOW sodium diet
5. Provide potassium supplements
6. Instruct about fluid restriction
7. Provide adequate rest periods and schedule activities
8. Monitor daily weight and report signs of fluid retention

CARDIAC TAMPONADE
- A condition where the heart is unable to pump blood due to accumulation of fluid in the pericardial
sac (pericardial effusion)
- This condition restricts ventricular filling resulting to decreased cardiac output
- Acute tamponade may happen when there is a sudden accumulation of more than 50 ml fluid in
the pericardial sac

Causative factors
1. Cardiac trauma
2. Complication of Myocardial infarction
3. Pericarditis
4. Cancer metastasis

Assessment Findings
1. BECK’s Triad- Jugular vein distention, hypotension and distant/muffled heart sound
2. Pulsus paradoxus
3. Increased CVP
4. decreased cardiac output
5. Syncope

NCM 102 Med-Surg Nsg. Cardiovascular Disorders Prepared by: Lindsay Carmelle
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 6. anxiety
7. dyspnea
8. Percussion- Flatness across the anterior chest

Laboratory Findings
1. Echocardiogram= shows accumulate fluid in the pericardial sac
2. Chest X-ray

Nursing Interventions
1. Assist in PERICARDIOCENTESIS
2. Administer IVF
3. Monitor ECG, urine output and BP
4. Monitor for recurrence of tamponade

Pericardiocentesis
- Patient is monitored by ECG
- Maintain emergency equipments
- Elevate head of bed 45-60 degrees
- Monitor for complications- coronary artery rupture, dysrhythmias, pleural laceration and
myocardial trauma

Vascular Diseases

General Measures to Improve Peripheral Circulation

1. Implement Regular Physical Activity – to facilitate movement of venous blood
2. Eliminate cigarette smoking- to prevent vasoconstriction
3. Control hyperlipidemia and cholesterol levels- to prevent the progression of atherosclerosis
4. Avoid cold environmental temperature
5. Teach clients to assess fingers and toes daily for circulatory adequacy: Check the peripheral
pulses, capillary refill and temp
6. Report break in the skin

Hypertension
- A systolic BP greater than 140 mmHg and a diastolic pressure greater than 90 mmHg over a
sustained period, based on two or more BP measurements.

Types of Hypertension
1. Primary or Essential
- Most common type
2. Secondary
- Due to other conditions like Pheochromocytoma, renovascular hypertension, Cushing’s, Conn’s ,
SIADH

CLASSIFICATION OF BP FOR ADULTS 18 YRS AND OLDER (PHIL. SOCIETY OF HPN)

Optimal
o <120 mmHg / <80 mmHg
Recheck in 2 years.
Normal
o 120-129 mmHg / 80-84 mmHg
Recheck in 2 years.
High normal
o 130-139 mmHg / 85-89 mmHg
Recheck in 1 year.
Stage 1 (mild) HPN

NCM 102 Med-Surg Nsg. Cardiovascular Disorders Prepared by: Lindsay Carmelle
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 o 140-159 mmHg / 90-99 mmHg
Confirm in 2 months.
Stage 2 (moderate) HPN
o 160-179 mmHg / 100-109 mmHg
Evaluate within a month.
Stage 3 (severe) HPN
o 180-209 mmHg / 110-119mmHg
Evaluate within a week.
Stage 4 (very severe) HPN
o 210 mmHg / >/=120 mmHg Evaluate

Pathophysiology
- Multi-factorial etiology
o BP= CO (SV X HR) x TPR
Any increase in the above parameters will increase BP

Risk factors for Cardiovascular Problems in Hypertensive patients

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

Any increase in the above parameters will increase BP

1. Increased sympathetic activity
2. Increased absorption of Sodium, and water in the kidney
3. Increased activity of the RAAS
4. Increased vasoconstriction of the peripheral vessels
5. Insulin resistance

Assessment Findings
1. Headache
2. Visual changes
3. chest pain
4. dizziness
5. N/V

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

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

MEDICAL MANAGEMENT
Drug therapy
- Diuretics
- Beta blockers
- Calcium channel blockers
- ACE inhibitors
- A2 Receptor blockers

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 - Vasodilators
Nursing Interventions
1. Provide health teaching to patient
- Teach about the disease process
- Elaborate on lifestyle changes
- Assist in meal planning to lose weight
- Provide list of LOW fat , LOW sodium diet of less than 2-3 grams of Na/day
- Limit alcohol intake to 30 ml/day
- Regular aerobic exercise
- Advise to completely Stop smoking
2. Provide information about anti-hypertensive drugs
- Instruct proper compliance and not abrupt cessation of drugs even if pt becomes asymptomatic/
improved condition
- Instruct to avoid over-the-counter drugs that may interfere with the current medication
3. Promote Home care management
- Instruct regular monitoring of BP
- Involve family members in care
- Instruct regular follow-up
4. Manage hypertensive emergency and urgency properly

Aneurysm
- Dilation involving an artery formed at a weak point in the vessel wall
- Saccular= when one side of the vessel is affected
- Fusiform= when the entire segment becomes dilated
Risk Factors
1. Atherosclerosis
2. Infection= syphilis
3. Connective tissue disorder
4. Genetic disorder= Marfan’s Syndrome

Pathophysiology
- Damage to the intima and media weakness outpouching of vessel wall
- Dissecting aneurysm tear in the intima and media with dissection of blood through the layers

Assessment
1. Asymptomatic
2. Pulsatile sensation on the abdomen
3. Palpable bruit

Laboratory:
- CT scan
- Ultrasound
- X-ray
- Aortography

Medical Management:
- Anti-hypertensives
- Synthetic graft

Nursing Management:
- Administer medications
- Emphasize the need to avoid increased abdominal pressure
- No deep abdominal palpation
- Remind patient the need for serial ultrasound to detect diameter changes.
Peripheral Arterial Occlusive Disease
- Refers to arterial insufficiency of the extremities usually secondary to peripheral atherosclerosis.
- Usually found in males age 50 and above
- The legs are most often affected

Risk factors for Peripheral Arterial occlusive disease

Non-Modifiable
1. Age
2. gender
3. family predisposition

Modifiable
1. Smoking
2. HPN

NCM 102 Med-Surg Nsg. Cardiovascular Disorders Prepared by: Lindsay Carmelle
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 3. Obesity
4. Sedentary lifestyle
5. DM
6. Stress

Assessment Findings
1. INTERMITTENT CLAUDICATION- the hallmark of PAOD
- This is PAIN described as aching, cramping or fatiguing discomfort consistently reproduced with
the same degree of exercise or activity
- This pain is RELIEVED by REST
- This commonly affects the muscle group below the arterial occlusion
2. Progressive pain on the extremity as the disease advances
3. Sensation of cold and numbness of the extremities
4. Skin is pale when elevated and cyanotic and ruddy when placed on a dependent position
5. Muscle atrophy, leg ulceration and gangrene

Diagnostic Findings
1. Unequal pulses between the extremities
2. Duplex ultrasonography
3. Doppler flow studies

Medical Management
1. Drug therapy
- Pentoxyfylline (Trental) reduces blood viscosity and improves supply of O2 blood to muscles
- Cilostazol (Pletaal) inhibits platelet aggregation and increases vasodilatation
2. Surgery- Bypass graft and anastomoses

Nursing Interventions
1. Maintain Circulation to the extremity
- Evaluate regularly peripheral pulses, temperature, sensation, motor function and capillary refill
time
- Administer post-operative care to patient who underwent surgery
- Administer heat modalities to the leg cautiously to promote vasodilatation
2. Monitor and manage complications
- Note for bleeding, hematoma, and decreased urine output
- Elevate the legs to diminish edema
- Encourage exercise of the extremity while on bed
- Teach patient to avoid leg-crossing
3. Promote Home management
- Encourage lifestyle changes
- Instruct to AVOID smoking
- Instruct to avoid leg crossing

BUERGER’S DISEASE
Thromboangiitis obliterans
- A disease characterized by recurring inflammation of the medium and small arteries and veins of
the lower extremities
- Occurs in MEN ages 20-35
- RISK FACTOR: SMOKING!

Pathophysiology
- Cause is UNKNOWN
- Probably an Autoimmune disease
- Inflammation of the arteries and veins thrombus formation  occlusion of the vessel
Assessment Findings
1. Leg PAIN
- Foot cramps in the arch
- (INSTEP CLAUDICATION) after exercise
- Relieved by rest
- Aggravated by smoking, emotional disturbance and cold chilling
2. Digital rest pain not changed by activity or rest
3. Intense RUBOR (reddish-blue discoloration), progresses to CYANOSIS as disease advances
4. Paresthesias

Diagnostic Studies
1. Duplex ultrasonography
2. Contrast angiography

Nursing Interventions
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 1. Assist in the medical and surgical management
- Bypass graft
- amputation
2. Strongly advise to AVOID smoking
3. Manage complications appropriately

Post-operative care: after amputation

- Elevate stump for the FIRST 24 HOURS to minimize edema and promote venous return
- Place patient on PRONE position after 24 hours several times a day
- Assess skin for bleeding and hematoma
- Wrap the extremity with elastic bandage

Raynaud’s Disease
- A form of intermittent arteriolar VASOCONSTRICTION that results in coldness, pain and pallor of
the fingertips or toes
- Cause : UNKNOWN
- Most commonly affects WOMEN, 16- 40 years old

Assessment Findings
1. Raynaud’s phenomenon
- A localized episode of vasoconstriction of the small arteries of the hands and feet that causes color
and temperature changes
W-B-R is the acronym for the color change
- Pallor- due to vasoconstriction, then 
- Blue- due to pooling of Deoxygenated blood
- Red- due to exaggerated reflow or hyperemia
2. Tingling sensation
3. Burning pain on the hands and feet

Medical management
- Drug therapy with the use of CALCIUM channel blockers
 To prevent vasospasms

Nursing Interventions
1. Instruct patient to avoid situations that may be stressful
2. Instruct to avoid exposure to cold and remain indoors when the climate is cold
3. Instruct to avoid all kinds of nicotine
4. Instruct about safety. Careful handling of sharp objects

Venous diseases

Varicose Veins
- THESE are dilated veins usually in the lower extremities

Predisposing Factors
 Pregnancy
 Prolonged standing or sitting
 Incompetent venous valves

Pathophysiology
Factors  venous stasis increased hydrostatic pressure edema

Assessment findings
- Tortuous superficial veins on the legs
- Leg pain and Heaviness
- Dependent edema

Laboratory findings
- Venography
- Duplex scan pletysmography

Medical management
- Pharmacological therapy
- Leg vein stripping and ligation
- Anti-embolic stockings

Nursing management
1. Advise patient to elevate the legs with pillow to increase venous return
2. Caution patient to avoid prolonged standing or sitting

NCM 102 Med-Surg Nsg. Cardiovascular Disorders Prepared by: Lindsay Carmelle
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3. Provide high-fiber foods to prevent constipation
4. Teach simple exercise to promote venous return
5. Caution patient to avoid constrictive clothing
6. Apply anti-embolic stockings as directed
7. Avoid massage on the affected area

DVT- Deep Vein Thrombosis

- Inflammation of the deep veins of the lower extremities and the pelvic veins
- The inflammation results to formation of blood clots in the area
Predisposing factors
- Prolonged immobility
- Varicosities
- Traumatic procedures
- Increased age
- Malignancy
- Estrogen therapy
- Smoking
Complication
- PULMONARY thromboembolism

Assessment findings
- Leg tenderness
- Leg pain and edema
- Positive HOMAN’s SIGN
HOMAN’s SIGN
The foot is FLEXED upward (dorsiflexed) , there is a sharp pain felt in the calf of the leg
indicative of venous inflammation

Laboratory findings
- Venography
- Duplex scan

Medical management
- Antiplatelets- aspirin
- Anticoagulants
- Vein stripping and grafting
- Anti-embolic stockings

Nursing management
1. Provide measures to avoid prolonged immobility
- Repositioning Q2
- Provide passive ROM
- Early ambulation
2. Provide skin care to prevent the complication of leg ulcers
3. Provide anti-embolic stockings
4. Administer anticoagulants as prescribed
5. Monitor for signs of pulmonary embolism sudden respiratory distress

Blood disorders
Anemia
Nutritional anemia
Hemolytic anemia
Aplastic anemia
Sickle cell anemia

Anemia
- A condition in which the hemoglobin concentration is lower than normal
NCM 102 Med-Surg Nsg. Cardiovascular Disorders Prepared by: Lindsay Carmelle
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 Three broad categories
1. Loss of RBC- occurs with bleeding
2. Decreased RBC production
3. Increased RBC destruction

Hypoproliferative Anemia
Iron Deficiency Anemia
- Results when the dietary intake of iron is inadequate to produce hemoglobin
Etiologic Factors
1. Bleeding- the most common cause
2. Mal-absorption
3. Malnutrition
4. Alcoholism

Pathophysiology
- The body stores of iron decrease, leading to depletion of hemoglobin synthesis
- The oxygen carrying capacity of hemoglobin is reduced tissue hypoxia

Assessment Findings
1. Pallor of the skin and mucous membrane
2. Weakness and fatigue
3. General malaise
4. Pica
5. Brittle nails
6. Smooth and sore tongue
7. Angular cheilosis

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

Medical management
1. Hematinics
2. Blood transfusion

Nursing Management
1. Provide iron rich-foods
- Organ meats (liver)
- Beans
- Leafy green vegetables
- Raisins and molasses

2. Administer iron
- Oral preparations tablets- Fe fumarate, sulfate and gluconate
- Advise to take iron ONE hour before meals
- Take it with vitamin C
- Continue taking it for several months
- Oral preparations- liquid
- It stains teeth
- Drink it with a straw
- Stool may turn blackish- dark in color
- Advise to eat high-fiber diet to counteract constipation
- IM preparation
- Administer DEEP IM using the Z-track method
- Avoid vigorous rubbing
- Can cause local pain and staining

Aplastic Anemia
- A condition characterized by decreased number of RBC as well as WBC and platelets

Causative Factors
1. Environmental toxins- pesticides, benzene
2. Certain drugs- Chemotherapeutic agents, chloramphenicol, phenothiazines, Sulfonamides
3. Heavy metals
4. Radiation

Pathophysiology
Toxins cause a direct bone marrow depression
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 ↓
Acellular bone marrow
↓
decreased production of blood elements
PANCYTOPENIA

Assessment Findings
- fatigue
- pallor
- dyspnea
- bruising
- splenomegaly
- retinal hemorrhages

Laboratory Findings
1. CBC- decreased blood cell numbers
2. Bone marrow aspiration confirms the anemia- hypoplastic or acellular marrow replaced by fats

Medical Management
1. Bone marrow transplantation
2. Immunosupressant drugs
3. Rarely, steroids
4. Blood transfusion

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

Megaloblastic Anemias
- Anemias characterized by abnormally large RBC secondary to impaired DNA synthesis due to
deficiency of Folic acid and/or vitamin B12
Folic Acid deficiency
Causative factors
1. Alcoholism
2. Mal-absorption
3. Diet deficient in uncooked vegetables

Pathophysiology of Folic acid deficiency

Decreased folic acid
↓
impaired DNA synthesis in the bone marrow
↓
Impaired RBC development, impaired nuclear maturation but CYTOplasmic maturation continues
↓
large size

Vitamin B12 deficiency

Causative factors
1. Strict vegetarian diet
2. Gastrointestinal mal-absorption
3. Crohn's disease
4. Gastrectomy
Vitamin B12 deficiency: Pernicious Anemia
- Due to the absence of intrinsic factor secreted by the parietal cells
- Intrinsic factor binds with Vit. B12 to promote absorption

Assessment findings
1. weakness
2. fatigue
3. listless
4. neurologic manifestations are present only in Vit. B12 deficiency

Assessment findings
Pernicious Anemia
- Beefy, red, swollen tongue
- Mild diarrhea
- Extreme pallor
- Paresthesias in the extremities

NCM 102 Med-Surg Nsg. Cardiovascular Disorders Prepared by: Lindsay Carmelle
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 Laboratory findings
1. Peripheral blood smear- shows giant RBCs, WBCs with giant hyper-segmented nuclei
2. Very high MCV
3. Schilling’s test
4. Intrinsic factor antibody test

Medical Management
1. Vitamin supplementation
2. Folic acid 1 mg daily
3. Diet supplementation
4. Vegetarians should have vitamin intake
5. Lifetime monthly injection of IM Vit B12

Nursing Management
1. Monitor patient
2. Provide assistance in ambulation
3. Oral care for tongue sore
4. Explain the need for lifetime IM injection of vit B12

Hemolytic Anemia: Sickle Cell

- A severe chronic incurable hemolytic anemia that results from heritance of the sickle
hemoglobin gene.
Causative factor
- Genetic inheritance of the sickle gene- HbS gene
Pathophysiology
Decreased O2, Cold, Vasoconstriction can precipitate sickling process
Factors  cause defective hemoglobin to acquire a rigid, crystal-like C-shaped configuration 
Sickled RBCs will adhere to endothelium  pile up and plug the vessels  ischemia results
pain, swelling and fever

Assessment Findings
1. jaundice (hemolytic jaundice)
2. enlarged skull and facial bones
3. tachycardia, murmurs and cardiomegaly
- Primary sites of thrombotic occlusion: spleen, lungs and CNS
- Chest pain, dyspnea

Assessment Findings
1. Sickle cell crises
- Results from tissue hypoxia and necrosis
2. Acute chest syndrome
- Manifested by a rapidly falling hemoglobin level, tachycardia, fever and chest infiltrates in
the CXR

Medical Management
1. Bone marrow transplant
2. Hydroxyurea
3. Increases the HbF
4. Long term RBC transfusion

Nursing Management
1. manage the pain
Support and elevate acutely inflamed joint
Relaxation techniques
analgesics
2. Prevent and manage infection
Monitor status of patient
Initiate prompt antibiotic therapy
3. Promote coping skills
- Provide accurate information
- Allow patient to verbalize her concerns about medication, prognosis and future pregnancy
4. Monitor and prevent potential complications
- Provide always adequate hydration
- Avoid cold, temperature that may cause vasoconstriction
- Leg ulcer
 Aseptic technique
- Priapism
 Sudden painful erection
Instruct patient to empty bladder, then take a warm bath

NCM 102 Med-Surg Nsg. Cardiovascular Disorders Prepared by: Lindsay Carmelle
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 Polycythemia
 Refers to an INCREASE volume of RBCs
 The hematocrit is ELEVATED to more than 55%
 Classified as Primary or Secondary

Primary Polycythemia
- A proliferative disorder in which the myeloid stem cells become uncontrolled

Causative factor
- unknown

Pathophysiology
- The stem cells grow uncontrollably
- The bone marrow becomes HYPERcellular and all the blood cells are increased in number
- The spleen resumes its function of hematopoiesis and enlarges
- Blood becomes thick and viscous causing sluggish circulation
- Overtime, the bone marrow becomes fibrotic

Assessment findings
- Skin is ruddy
- Splenomegaly
- headache
- dizziness, blurred vision
- Angina, dyspnea and thrombophlebitis

Laboratory findings
1. CBC- shows elevated RBC mass
2. Normal oxygen saturation
3. Elevated WBC and Platelets

Complications
1. Increased risk for thrombophlebitis, CVA and MI
2. Bleeding due to dysfunctional blood cells

Medical Management
1. To reduce the high blood cell mass- PHLEBOTOMY
2. Allopurinol
3. Dipyridamole
4. Chemotherapy to suppress bone marrow

Nursing Management
1. Primary role of the nurse is EDUCATOR
2. Regularly asses for the development of complications
3. Assist in weekly phlebotomy
4. Advise to avoid alcohol and aspirin
5. Advise tepid sponge bath or cool water to manage pruritus

NCM 102 Med-Surg Nsg. Cardiovascular Disorders Prepared by: Lindsay Carmelle
I. Nate, R.N.