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Cardiovascular 5

  1. Aortic insufficiency (regurgitation)
  2. Definition
    1. blood flows back into the left ventricle during diastole overloading the ventricle and causing it to hypertrophy.
    2. extra blood also overloads the left atrium and, eventually, the pulmonary system.
  3. Epidemiology
    1. by itself, most common among males
    2. with mitral valve disease, more common among females
    3. may accompany Marfan's syndrome, ankylosing spondylitis, syphilis, essential hypertension or a defect of the ventricular septum
  4. Findings
    1. uncomfortable awareness of heartbeat
    2. palpitationsalong with a pounding head
    3. dyspneawith exertion
    4. paroxysmal nocturnal dyspnea, with diaphoresis, orthopneaand cough
    5. fatigue and syncopewith exertion or emotion
    6. anginal chest pain unrelieved by sublingual nitroglycerin
    7. heartbeat that seems to jar the client's entire body
    8. client's nailbeds appear to be pulsating
    9. if nail tip is pressed, the root will flush and then pale (Quincke's sign)
    10. if left ventricle fails, client may show ankle edemaand ascites
    11. pulsus biferiens
  5. Management
    1. digitalis - increases the heart's contractility (inotropic action)
    2. diuretics - to mobilize edematous fluids and to reduce pulmonary venous pressure
    3. sodium-restricted diet - to prevent fluid retention
    4. anticoagulant agents - to prevent blood clots
    5. surgical - valve replacement. however, aortic insufficiency often damages the ventricle before it is detected.
  6. Nursing interventions
    1. same as all other valve disorders - the cardio-care six except don't need to elevate head unless pulmonary problems have begun.
    2. monitor the cardio seven 
    3. monitor for signs of heart failure, pulmonary edema, and drug reactions.
    4. post-op: monitor client for hypotension, arrhythmiasand clots.
    5. client and family teaching
      1. same as all other valve disorders - the cardio five 
      2. emphasize the need for prophylactic antibiotics during dental care
      3. instruct client to raise legs when sitting
        IV. Failures of the Heart Muscle
  7. Myocardial infarction (MI)
  8. Definition - insufficient oxygen supply kills (causes necrosisof) myocardial tissue. MI may be sudden or gradual. total event takes 3 to 6 hours.
  9. Epidemiology
    1. almost equal for men and women
    2. client history of smoking, obesity, high cholesterol/low density lipoprotein diet, physical/emotional stress
    3. a common killer in North America and Western Europe
    4. mortality about 25%. Of the sudden deaths from MI, more than half happen within an hour
    5. of those who survive the initial MI and recover, up to 10% die within the first year
  10. Findings
    1. persistent, crushing substernal chest pain
    2. pain that may radiate to the left arm, jaw, neck and shoulder blades, with a feeling of impending doom
    3. pain may persist for 12 hours or more
    4. some clients report no pain, or call it mild indigestion
    5. fatigue, nausea, vomiting and shortness of breath
    6. sudden death
    7. within the first hour after an anterior MI, about 25% of clients experience tachycardiaor hypertension.
    8. up to 50% of clients with an inferior MI experience the opposite: bradycardiaor hypotension.
    9. women may experience fatigue, achiness, flu-like symptoms
  11. Management
    1. cardiac monitoring for arrythmias
    2. oxygen - to prevent tissue hypoxia
    3. bed rest - to decrease the workload of the heart
    4. pharmacologic agents - to stabilize client
    5. stool softeners - to decrease the workload of the heart caused by straining, which can cause vagal stimulation producing bradycardia and arrythmias
    6. narcotic analgesics - to reduce pain, anxiety and fear and decrease the workload of the heart
    7. beta-blocking agents - to slow heart rate
    8. sedatives - to decrease anxiety and fear and to decrease the workload of the heart
    9. antiarrhythmic - to prevent arrythmias which are the most common complications after an MI
    10. thrombolytic agents - to dissolve the thrombus in the coronary artery and reperfuse the myocardium
    11. nitrates- to decrease pain and decrease preload and afterload while increasing the myocardial oxygen supply
    12. anticoagulants - to prevent blood clots
    13. Swan-Ganz catheter to monitor pressure in pulmonary artery (measure functioning of left ventricle)
    14. intra-aortic balloon counterpulsation may be used for cardiogenic shock
    15. cardiac catheterizationmay be performed for PTCA
    16. surgery - coronary atherectomy or graft of a coronary artery bypass
  12. Diagnostic studies
    1. history and physical
    2. EKG - monitor for changes, arrythmias
    3. 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.
  13. Nursing interventions
    1. the cardio-care six plus monitor the following to prevent heart failure, infections and complications
      1. temperature
      2. daily weight
      3. intake and output
      4. respiratory rate
      5. breath sounds
      6. blood pressure
      7. serum enzyme levels
      8. EKG readings 
      9. heart sounds, especially S3 and S4 
    2. assess pain and give analgesics as ordered. Record the severity, location, type, and duration of pain.
    3. do not give IMinjections, or CK will be falsely elevated.
    4. watch for crackles, cough, tachypnea, and edema which may predict left ventricle is failing.
    5. use antiembolism stockings to prevent venostasisand thrombophlebitis.
    6. assistance with range-of-motion exercises
    7. client and family teaching
      1. the cardio five 
      2. explain the ICU or Coronary Care Unit, routine and machinery
      3. ask dietitian to speak with the client and family to reinforce teaching
      4. encourage client to join the cardiac rehab exercise program
      5. counsel gradual resumption of sexual activity; taking nitroglycerin before sex may prevent chest pain
      6. advise the client to report typical or atypical chest pain
      7. describe postmyocardial infarction syndrome; have client report it to physician
      8. stress that client must modify high-risk behaviors
  14. Congestive heart failure
  15. Definition/etiology
    1. heart fails to pump enough blood to support the body's functions
    2. 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.
    3. etiology
      1. coronary artery disease(illustration)
      2. myocarditis
      3. cardiomyopathy
      4. infiltrative disorders: amyloidosis, tumors, sarcoidosis
      5. collagen-Vascular disease: systemic lupus erythematosus, scleroderma
      6. dysrhythmiasthat reduce cardiac filling time
      7. disorders that increase cardiac workload: hypertension, valve disease, anemia, hyperthyroidism
      8. cardiac tamponade

      1. Findings of Left CHF and Right CHF
      1. Management
        1. objective: to restore balance between myocardial oxygen supply and demand
        2. treatments include oxygen, digitalis, vasodilators, nitrates antihypertensives, cardiac glycosides, diuretics, intra-aortic balloon counterpulsation, ventricular assist pumping, etc.
      2. Nursing interventions
        1. the cardio care six 
        2. administer medications as ordered
        3. administer oxygen as ordered - to prevent tissue hypoxia
        4. monitor hemodynamic indicators
        5. monitor for findings of hyponatremia, hypokalemia
        6. restrict fluids and assess for findings of fluid retention
        7. client and family teaching
          1. medications and side effects
          2. how to conserve energy and thus oxygen
          3. teach client to report
            • weight gain of more than two pounds in 24 hours (equals 1 liter)
            • dyspnea
            • decreased exercise tolerance
          4. importance of sodium-restricted diet
      3. Diagnostic findings - the primary goal is to determine the underlying cause of the heart failure
        1. history and physical exam
        2. CXR - to determine heart size and pleural effusions
        3. EKG for changes, arrythmias
        4. echocardiogram to measure valvular abnormalities
        5. nuclear imaging - to determine myocardial contractility, myocardial perfusion, and acute cell injury
        6. hemodynamic monitoring of arterial blood pressure, pulmonary artery pressure, pulmonary artery wedge pressure and cardiac output