Common Cardiovascular Disorders

Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Chapter 19:

Common Cardiovascular
Disorders

Tissue Changes in Pericarditis
Underlying Causes of Pericarditis
Underlying Cause Pathophysiology
Infection Hematogenous spread of bacteria,
virus, or fungus to pericardium.
Can be seen with
immunocompromised patient.
Dresslers syndrome Autoimmune reaction after MI
Renal failure Build-up of nitrogenous wastes in
bloodstream leads to irritation in
pericardial sac.
Defect in pericardium, space-
occupying tumor
Repeated episodes of pericarditis
lead to scarring and constriction of
heart to fill during diastole.
Cardiac surgery or injury Direct tear or compromise to
pericardium causes irritation.
Differences Between Chest Pain Related
to Ischemia and Pericarditis
Type of Chest
Pain
Underlying
Causes
Quality of Pain How to Relieve
Pain
Ischemic Angina, acute MI Crushing,
extreme
pressure,
choking
Rest, oxygen,
nitrates,
morphine
Pericarditis Prior respiratory
infection, renal
failure, surgery,
trauma to chest,
etc.
Sharp, stabbing,
worsens with
inspiration
Sitting up and
leaning forward,
NSAIDs, treat
underlying cause
if possible
ST-Segment Changes in Pericarditis and
MI
12-Lead ECG in Acute Pericarditis
Question
A patient is admitted with chest pain. Which of the
following assessment findings suggest that the pain is
related to pericarditis and not ischemic chest pain?
A. Patient states pain improves when he leans forward.
B. Patient complains of shortness of breath.
C. Patient complains of nausea.
D. Patient states the pain has not stopped.
Answer
A. Patient states pain improves when he leans forward.
Rationale: The best way to distinguish chest pain related to
pericarditis from ischemic chest pain is that it is relieved
when the patient leans forward or takes shallow
breaths. The patient may or may not have a pericardial
rub. Many of the reported symptoms are the same as
for the patient with ischemic chest pain. The ECG will
reveal diffuse ST-segment elevation that has an upward
concavity, and the PR segment is depressed.
Risk Factors for Endocarditis
Signs and Symptoms of Endocarditis
Symptoms occur 2 weeks after bacteremia
Nonspecific complaints make it difficult to diagnose
Examine patients at risk for endocarditis for
signs/symptoms, including:
Petechiae (splinter hemorrhages, Oslers nodes,
Janeway lesions)
Splenomegaly
Fever + heart murmur (new onset or change)
Pathophysiology of Infective Endocarditis
Bacteremia (strep, staph)
Endothelial damage exposes basement membrane of valve to turbulent blood flow
Clot on valve leaf (vegetation) exposed to bacteria in blood
Proliferation of vegetations and damage to valve structure
Severe heart failure
Embolization
Brain attack
Pulmonary embolus
Osler node (peripheral emboli)
Discharge Planning Guide: Endocarditis
Cardiomyopathies and Their Classification

See Box 19-8.
Functional Cardiomyopathy
Type of
Cardiomyopathy
Signs/Symptoms Treatment
Dilated: globular
dilated ventricles and
impaired systolic
function
CHF symptoms
Ventricular
dysrhythmias and
conduction defects
Mitral and possibly
tricuspid insufficiency
Supportive care
Prevention of acute
episodes
Biventricular pacing
Implantable
cardioverter-
defibrillator (ICD)
Heart transplant
Hypertrophic:
hypertrophied
nondilated left
ventricle that is stiff
during diastole
Angina, syncope, CHF
Atrial fibrillation,
ventricular
dysrhythmias, and
sudden death

Supportive care
ICD
Percutaneous ablation
(if septal defect
present)
Question
A 30-year-old client is diagnosed with early-stage dilated
cardiomyopathy. The nurse screens the patient for
potentially reversible causes and should report which of
the following?
A. Clients father is an alcoholic and has cardiomyopathy.
B. Client had the flu last week.
C. HIV test is negative.
D. The client drinks a six-pack of beer every day.

Answer
D. The client drinks a six-pack of beer every day.
Rationale: A potentially reversible cause of dilated
cardiomyopathy is alcohol intake. The familial tendency
is present - the clients father is an alcoholic and also
has dilated cardiomyopathy - but this is not a reversible
cause. It takes time before the client presents with
symptoms of dilated cardiomyopathy, so it is unlikely
that the flu from last week caused it. If the client tested
positive for HIV, then treatment of HIV would help to
reverse the cardiomyopathy.
Vascular Obstruction
Acute Arterial
Obstruction
Skin is pale
Pain increases with
walking and decreases
with rest (intermittent
claudication)
No pulses
Paresthesia
Paralysis
Deep Vein Thrombosis
(DVT)
Skin is red
Pain (tender, sore)
with standing or
dorsiflexion of foot
Pulses present
Sensation intact
Able to move limb
Assessing the Client With Peripheral
Arterial Disease (PAD)

See Figure 19-5.
PAD: Implications for the Older Patient
PAD is a major reason for decline in ability to walk.
Advanced cases of PAD can lead to ulcers, gangrene, or
amputation.
Consider comorbidities, which increase risk for
complications related to PAD.
Conservative management
Home Care of the Patient With PAD
Instruct patient to:
Eat a heart-healthy diet.
Control homocysteine levels.
Control cholesterol.
Control diabetes.
Stop smoking.
Exercise regularly.
Participate in stress management activities.

Types of Aortic Aneurysms

See Figure 19-6.
Two Major Patterns of Aortic Dissection

See Figure 19-7.
Assessment Findings of Aortic Aneurysm
Most cases are asymptomatic.
Abdominal pain
Back pain
Syncope
Palpable aortic mass with tenderness
Positive bruit - abdominal aorta
Peripheral pulses
Treatment Options for Chronic Aortic
Aneurysm
Control hypertension
Eliminate risk factors
Surgical repair for abdominal aortic aneurysm >5.5 cm
Surgical repair of ascending thoracic aneurysm 5.5 cm or
greater
Surgical repair of descending thoracic aneurysm 6 cm or
greater
Minimally invasive endovascular graft through the
femoral artery: choice for high-risk patients
Classification of Blood Pressure for Adults
Hypertensive Crisis
Acute elevation of BP >180/120 mm Hg associated with
sudden onset or imminent threat of target organ damage
Management goal: decrease MAP, but no more than a
25% reduction in the first hour; if patient remains stable,
decrease BP to 160/100 to 160/110 within 2 to 6 hours
(AHA Guidelines, 2003)
Use arterial line to monitor BP continuously

Question
A client presents with BP 200/140 mm Hg, HR 50, RR 20.
The serum creatinine is 3.0. The patient is
neurologically intact. The nurse should question which
of the following orders?
A. Prepare for arterial line insertion.
B. Perform neuro checks every hour.
C. Give labetalol 20 mg IVP, and if MAP has not decreased
in 5 minutes by 20%, give 40 mg IVP.
D. Start nicardipine drip at 5 mg/h IV if labetalol is
unsuccessful.

Answer
C. Give labetalol 20 mg IVP, and if BP has not decreased in
5 minutes by 20%, give 40 mg IVP.
Rationale: The clients HR is 50 and the beta-blocker
labetalol could lower the heart rate further, so the nurse
needs to question this order. The other orders are
appropriate. The doctor should consider another short-
acting IVP medication to lower the BP, with the goal of
reducing the MAP by no more than 25% in the first
hour; if the patient remains stable, BP is lowered to
160/100 to 160/110 within 2 to 6 hours (AHA
Guidelines, 2003).

Common Cardiovascular Disorders

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Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

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