Cardiovascular 5
Aortic insufficiency (regurgitation) Definition
blood flows back into the left ventricle during diastole overloading the ventricle and causing it to hypertrophy . extra blood also overloads the left atrium and, eventually, the pulmonary system.
Epidemiology
by itself, most common among males with mitral valve disease, more common among females may accompany Marfan's syndrome , ankylosing spondylitis, syphilis, essential hypertension or a defect of the ventricular septum
Findings
uncomfortable awareness of heartbeat palpitations along with a pounding head dyspnea with exertion paroxysmal nocturnal dyspnea , with diaphoresis , orthopnea and cough fatigue and syncope with exertion or emotion anginal chest pain unrelieved by sublingual nitroglycerin heartbeat that seems to jar the client's entire body client's nailbeds appear to be pulsating if nail tip is pressed, the root will flush and then pale (Quincke's sign) if left ventricle fails, client may show ankle edema and ascites pulsus biferiens
Management
digitalis - increases the heart's contractility (inotropic action) diuretics - to mobilize edematous fluids and to reduce pulmonary venous pressure sodium-restricted diet - to prevent fluid retention anticoagulant agents - to prevent blood clots surgical - valve replacement. however, aortic insufficiency often damages the ventricle before it is detected.
Nursing interventions
same as all other valve disorders - the cardio-care six except don't need to elevate head unless pulmonary problems have begun. monitor the cardio seven monitor for signs of heart failure , pulmonary edema , and drug reactions. post-op: monitor client for hypotension , arrhythmias and clots . client and family teaching
same as all other valve disorders - the cardio five emphasize the need for prophylactic antibiotics during dental care instruct client to raise legs when sitting IV. Failures of the Heart Muscle
Myocardial infarction (MI) Definition - insufficient oxygen supply kills (causes necrosis of) myocardial tissue. MI may be sudden or gradual. total event takes 3 to 6 hours. Epidemiology
almost equal for men and women client history of smoking, obesity, high cholesterol/low density lipoprotein diet, physical/emotional stress a common killer in North America and Western Europe mortality about 25%. Of the sudden deaths from MI, more than half happen within an hour of those who survive the initial MI and recover, up to 10% die within the first year
Findings
persistent, crushing substernal chest pain pain that may radiate to the left arm, jaw, neck and shoulder blades, with a feeling of impending doom pain may persist for 12 hours or more some clients report no pain, or call it mild indigestion fatigue, nausea, vomiting and shortness of breath sudden death within the first hour after an anterior MI, about 25% of clients experience tachycardia or hypertension . up to 50% of clients with an inferior MI experience the opposite: bradycardia or hypotension . women may experience fatigue, achiness, flu-like symptoms
Management
cardiac monitoring for arrythmias oxygen - to prevent tissue hypoxia bed rest - to decrease the workload of the heart pharmacologic agents - to stabilize client stool softeners - to decrease the workload of the heart caused by straining, which can cause vagal stimulation producing bradycardia and arrythmias narcotic analgesics - to reduce pain, anxiety and fear and decrease the workload of the heart beta-blocking agents - to slow heart rate sedatives - to decrease anxiety and fear and to decrease the workload of the heart antiarrhythmic - to prevent arrythmias which are the most common complications after an MI thrombolytic agents - to dissolve the thrombus in the coronary artery and reperfuse the myocardium nitrates - to decrease pain and decrease preload and afterload while increasing the myocardial oxygen supply anticoagulants - to prevent blood clots Swan-Ganz catheter to monitor pressure in pulmonary artery (measure functioning of left ventricle) intra-aortic balloon counterpulsation may be used for cardiogenic shock cardiac catheterization may be performed for PTCA surgery - coronary atherectomy or graft of a coronary artery bypass
Diagnostic studies
history and physical EKG - monitor for changes, arrythmias serum cardiac markers (CK - MB) - rises 4-6 degrees after acute MI; Returns to normal in three to four days. Troponin - rises quickly but remains elevated for two weeks.
Nursing interventions
the cardio-care six plus monitor the following to prevent heart failure, infections and complications
temperature daily weight intake and output respiratory rate breath sounds blood pressure serum enzyme levels EKG readings heart sounds, especially S3 and S4
assess pain and give analgesics as ordered. Record the severity, location, type, and duration of pain. do not give IM injections, or CK will be falsely elevated. watch for crackles, cough, tachypnea, and edema which may predict left ventricle is failing. use antiembolism stockings to prevent venostasis and thrombophlebitis . assistance with range-of-motion exercises client and family teaching
the cardio five explain the ICU or Coronary Care Unit, routine and machinery ask dietitian to speak with the client and family to reinforce teaching encourage client to join the cardiac rehab exercise program counsel gradual resumption of sexual activity; taking nitroglycerin before sex may prevent chest pain advise the client to report typical or atypical chest pain describe postmyocardial infarction syndrome ; have client report it to physician stress that client must modify high-risk behaviors
Congestive heart failure Definition/etiology
heart fails to pump enough blood to support the body's functions types of CHF depend on which part of the heart fails: the left half that pumps to the body, or the right half that pumps to the lungs. etiology
coronary artery disease ( illustration ) myocarditis cardiomyopathy infiltrative disorders: amyloidosis , tumors, sarcoidosis collagen-Vascular disease: systemic lupus erythematosus , scleroderma dysrhythmias that reduce cardiac filling time disorders that increase cardiac workload: hypertension , valve disease, anemia , hyperthyroidism cardiac tamponade
Findings of Left CHF and Right CHF
Management
objective: to restore balance between myocardial oxygen supply and demand treatments include oxygen, digitalis, vasodilators, nitrates antihypertensives, cardiac glycosides, diuretics, intra-aortic balloon counterpulsation , ventricular assist pumping , etc.
Nursing interventions
the cardio care six administer medications as ordered administer oxygen as ordered - to prevent tissue hypoxia monitor hemodynamic indicators monitor for findings of hyponatremia , hypokalemia restrict fluids and assess for findings of fluid retention client and family teaching
medications and side effects how to conserve energy and thus oxygen teach client to report
weight gain of more than two pounds in 24 hours (equals 1 liter ) dyspnea decreased exercise tolerance
importance of sodium-restricted diet
Diagnostic findings - the primary goal is to determine the underlying cause of the heart failure
history and physical exam CXR - to determine heart size and pleural effusions EKG for changes, arrythmias echocardiogram to measure valvular abnormalities nuclear imaging - to determine myocardial contractility, myocardial perfusion, and acute cell injury hemodynamic monitoring of arterial blood pressure, pulmonary artery pressure, pulmonary artery wedge pressure and cardiac output
