CARDIOVASCULAR DISEASES

Overview of function & structure of the heart

HEART - Muscular, pumping organ of the body - Left mediastinum - Weigh 300 400 grams - Resembles a closed fist - Co ered by serous membrane pericardium !ericardium !arietal layer !ericardial #luid pre ent #riction rub "isceral layer

Layer $% &picardium outermost '% Myocardium inner responsible for pumping action( most dangerous layer - cardiogenic shoc) 3% &ndocardium innermost layer Chambers $% *pper collecting( recei ing chamber - +tria '% Lo,er pumping( contracting chamber - "entricles "al es $% +trio entricular al es - -ricuspid . mitral al e Closure of +" al es gi es rise to $st heart sound or /$ or 0lub1 '% /emi lunar al e a%2 !ulmonic b%2 +ortic Closure of semilunar al e gi es rise to 'nd heart sound or /' or 0dub1 &3tra heart /ound /3 entricular 4allop C5# /4 atrial gallop M6, 5!7

5eart conduction system $% /ino atrial node 8/+ node2 8or 9eith-#loc) node2 Loc :unction of /"C . Rt atrium #3- primary pace ma)er of heart -6nitiates electric impulse of ;0 $00 bpm '% +trio enticular node 8+" node or -a,ara node2 Loc inter atrial septum <elay of electric impulse to allo, entricular filling 3% =undle of 5is location inter entricular septum Rt main =undle =ranch Lt main =undle =ranch 4% !ur)en:ie #iber Loc- ,alls of entricles-- "entricular contractions /+ node

+"

!ur)en:ie #ibers =undle of 5is Complete heart bloc) insertion of pacema)er at =undle =ranch Metal !ace Ma)er change >3 ? yo !rolonged !R atrial fib /- segment depression angina /- ele M6 - ,a e in ersion M6 ,idening @R/ arrhythmia

C+< coronary artery dse or 6schemic 5eart <se 865<2 +therosclerosis Myocrdial in:ury +ngina !ectoris Myocardial ischemia M6- myocardial necrosis +-5&RA/CL&RA/6/ - 5ardening or artery due to fat( lipid deposits at tunica intima% +rtery tunica ad entitia outer - -unica intima innermost - -unica media middle +-5&RA/CL&RA/6/ !redisposing #actor $% /e3 male '% =lac) race 3% 5yperlipidemia 4% /mo)ing ?% 5!7 ;% <M B% Aral contracepti e- prolonged use C% /edentary lifestyle D% Abesity $0% 5ypothyroidism /igns . /ymptoms $% Chest pain '% <yspnea 3% -achycardia 4% !alpitations ?% <iaphoresis -reatment ! percutaneous - tansluminar C coronary + angioplasty Ab:E $% '% 3% -o re asculariFe the myocardium -o pre ent angina 6ncrease sur i al rate +R-&R6A/CL&RA/6/ - 7arro,ing or artery due to calcium . C5A7 deposits at tunica media%

!-C+ done to pt ,ith single occluded essel % Multiple occluded essels C coronary + arterial = bypass + and 4 graft surgery 7sg Mgt =efore C+=+4 $% <eep breathing cough e3ercises '% *se of incenti e spirometer 3% Leg e3ercises

ANGINA ECTORIS! + clinical syndrome characteriFed by paro3ysmal chest pain usually relie ed by R&/or 74- nitroglycerin, resulting fr temp myocardial ischemia% !redisposing #actorE $% se3 male '% blac) raise 3% hyperlipidemia 4% smo)ing ?% 5!7 ;% <M B% oral contracepti e prolonged C% sedentary lifestyle D% obesity $0%hypothyroidism !recipitating factors 4 &Gs $% &3cessi e physical e3ertion '% &3posure to cold en ironment - "asoconstriction 3% &3treme emotional response 4% &3cessi e inta)e of food saturated fats% /igns . /ymptoms $% 6nitial symptoms Le ineGs sign hand clutching of chest '% Chest pain sharp, stabbing e3cruciating pain% Location substernal -radiates bac), shoulders, a3illa, arms . :a, muscles -relie e by rest or 743% <yspnea 4% -achycardia ?% !alpitation ;%diaphoresis <iagnosis $%5istory ta)ing . !& '% &C4 /- segment depression 3% /tress test treadmill H abnormal &C4 4% /erum cholesterol . uric acid - increase% 7ursing Management $%2 &nforce C=R '%2 +dminister meds 7-4 small doses enodilator Large dose asodilator $st dose 7-4 gi e 3 ? min 'nd dose 7-4 3 ? min

3rd . last dose 3 ? min /till painful after 3rd dose notify doc% M6I ?? yrs old ,ith chest painE $st >uestion to as) ptE ,hat did you do before you had chest pain% 'nd >uestionE does pain radiateJ 6f radiate heart in nature% 6f not radiate pulmonary origin "enodilator eins of lo,er e3t increase enous pooling lead to decrease enous return% MedsE +% 7-4- 7sg MgtE $% 9eep in a dry place% + oid moisture . heat, may inacti ate the drug% '% Monitor /(&E orthostatic hypotension dec bp transient headache diFFiness 3% Rise slo,ly from sitting position 4% +ssist in ambulation% ?% 6f gi ing 7-4 ia patchE i% a oid placing it near hairy areas-,ill dec drug absorption ii% a oid rotating transdermal patches- ,ill dec drug absorption iii% a oid placing near micro,a e o en or during defibrillation-,ill burn pt due aluminum foil in patch =% =eta bloc)ers propanolol C% +C& inhibitors captopril <% Ca antagonist - nefedipine +dminister A' inhalation /emi-fo,ler <iet- <ecrease 7a and saturated fats Monitor "/, 6.A, &C4 5-E <ischarge planningE a% + oid precipitating factors 4 &Gs b% !re ent complications M6 c% -a)e meds before physical e3ertion-to achie e ma3imum therapeutic effect of drug d% 6mportance of follo,-up care%

3%2 4%2 ?%2 ;%2 B%2

"I # "$OCARDIAL IN%ARCTION hear attac) terminal stage of C+<

-ypesE $% '% -rasmural M6 most dangerous M6 Mal-occlusion of both R.L coronary artery /ub-endocardial M6 mal-occlusion of either R . L coronary artery CharacteriFed by necrosis . scarring due to permanent mal-occlusion

Most critical period upon d3 of M6 4C to B'h - Ma:ority of pt suffers from !"C premature entricular contraction%

!redisposing factors $% se3 male

/igns . symptoms $% chest pain e3cruciating, ice li)e, isceral

<iagnostic &3am $% cardiac enFymes

'% blac) raise 3% hyperlipidemia 4% smo)ing ?% 5!7 ;% <M B% oral contracepti e prolong ed C% sedentary lifestyle D% obesity $0% hypothyroidism

pain located substernal or precodial area 8rare2 - radiates bac), arm, shoulders, a3illa, :a, . abd muscles% - not usually reli ed by rest r 7-4 '% dyspnea 3% erthermia 4% initial increase in =! ?% mild restlessness . apprehensions ;% occasional findings a%2 split /$ . /' b%2 pericardial friction rub c%2 rales (crac)les d%2 /4 8atrial gallop2

a%2 C!9 M= Creatinine !hospho)inase b%2 L<5 lactic acid dehydrogenase c%2 /4!- 8+L-2 /erum 4lutanic !yru ate -ransaminase- increased d%2 /4A- 8+/-2 /erum 4lutamic A3alo-acetic - increased '% -roponin test increase 3% &C4 tracing /- segment increase, ,idening or @R/ comple3es means arrhythmia in M6 indicating !"C 4% serum cholesterol . uric acid increase ?% C=C increase W=C

7ursing Management $% 7arcotic analgesics Morphine /A4 to induce asodilation . decrease le els of an3iety% '% +dminister A' inhalation lo, inflo, 8C5#-increase inflo,2 3% &nforce C=R ,ithout =! a%2 =edside commode 4% + oid alsal a maneu er ?% /emi fo,ler ;% 4eneral li>uid to soft diet decrease 7a, saturated fat, caffeine B% Monitor "/, 6.A . &C4 tracings C% -a)e '0 30 ml(,ee) ,ine, brandy(,his)y to induce asodilation% D% +ssist in surgicalK C+=+4 $0% !ro ide pt 5a%2 + oid modifiable ris) factors b%2 !re ent complicationsE $% +rrhythmias !"C '% /hoc) cardiogenic shoc)% Late signs of cardiogenic shoc) in M6 oliguria 3% thrombophlebitis - deep ein 4% C5# left sided ?% <resslerGs syndrome post M6 syndrome -Resistant to medications -+dminister $?0,000 4?0,000 units of strepto)inase c%2 /trict compliance to meds - "asodilators $% 7-4 '% 6sordil - +ntiarrythmic $% Lydocaine bloc)s release of norepenephrine '% =rithylium - =eta-bloc)ers 0lol1 $% !ropanolol 8inderal2 - +C& inhibitors - pril $% Captopril 8enalapril2 - Ca antagonist $% 7ifedipine - -hrombolitics or fibrinolytics to dissol e clots( thrombus /(& allergic reactions( uticaria $% /trepto)inase

'% *ro)inase 3% -issue plasminogen ad:usting factor

Monitor for bleedingE - +nticoagulants $% 5eparin !-6f prolonged bleeding

'% Caumadin delayed reaction ' 3 days !prolonged bleeding

+ntidote antidote "it 9 !rotamine sulfate - +nti platelet !+/+ 8aspirin2 d%2 Resume +<L se3( acti ity 4 to ; ,ee)s !ost-cardiac rehab $%2/e3 as an appetiFer rather then dessert =efore meals not after, due after meals increase metabolism heart is pumping hard after meals% '%2 !osition non-,eight bearing position% When to resume se3( actE When pt can already use staircase, then he can resume se3% e%2 <iet decrease 7a, /aturated fats, and caffeine f%2 #ollo, up care%

CH% # CONGESTIVE HEART %AILURE ! 6nability of heart to pump blood to,ards systemic
circulation% - =ac)flo, $%2 Left si&e& heart fai'ure( !redisposing factorsE $%2 D0L mitral al e stenosis due R5<, aging R5< affects mitral al e streptococcal infection <3E - +so titer anti streptolysine A M 300 total units - /teroids - !enicillin - +spirin ComplicationE R/-C5# +ging degeneration ( calcification of mitral al e 6schemic heart disease 5!7, M6, +ortic stenosis /(/3 !ulmonary congestion( &dema $% <yspnea '% Arthopnea 8<iff of breathing sitting pos platypnea2 3% !aro3ysmal nocturnal dysnea !7A- nalulunod 4% !roducti e cough ,ith blood tinged sputum ?% #rothy sali ation 8from lungs2 ;% Cyanosis B% Rales( crac)les due to fluid C% =ronchial ,heeFing D% !M6 displaced lateral due cardiomegaly $0% !ulsus alternons ,ea)-strong pulse

$$% +nore3ia . general body malaise $'% /3 entricular gallop <3 $% '% CNR cardiomegaly !+! !ulmonary +rterial !ressure !CW! !ulmonary CapillaryWedge !ressure !+! measures pressure of R entricle% 6ndicates cardiac status% !CW! measures end systolic( diastolic pressure !+! . !CW!E /,an ganF catheteriFation cardiac catheteriFation is done at bedside at 6C* 8-rachesostomy bedside2 - <one ? '0 mins scalpel . trachesostomy set C"! indicates fluid or hydration status 6ncrease C"! decrease flo, rate of 6" <ecrease C"! increase flo, rate of 6" &chocardiography re eals enlarged heart chamber or cardiomayopathy +=4 !CA' increase, !A' decrease H H hypo3emia H resp acidosis

3% 4%

'%2 Ri)ht si&e& H% !redisposing factor $% D0L - tricuspid stenosis '% CA!< 3% !ulmonary embolism 4% !ulmonic stenosis ?% Left sided heart failure /(/3 "enous congestion - 7ec) or :ugular ein distension - !itting edema - +scites - Wt gain - 5epatomegalo( splenomegaly - Oaundice - !ruritus - &sophageal aries - +nore3ia, gen body malaise <iagnosisE $% '% CNR cardiomegaly C"! measures the pressure at R atrium 7ormalE 4 to $0 cm of ,ater 6ncrease C"! M $0 hyper olemia <ecrease C"! P 4 hypo olemia #lat on bed post of pt ,hen gi ing C"! !osition during C"! insertion -rendelenburg to pre ent pulmonary embolism . promote entricular filling%

3% &chocardiography enlarged heart chamber ( cardiomyopathy *%Li er enFyme

/4!- 8 +L-2 /4A- +/7sg mgtE 6ncrease force of myocardial contraction H increase CA 3 ;L of CA $% +dminister medsE -3 for L/5#E M morphine /A4 to induce asodilatation + aminophylline . decrease an3iety < digitalis 8digo3in2 < - diuretics A - o3ygen 4 - gases a%2 Cardiac glycosides 6ncrease myocardial H increase CA <igo3in 8Lano3in2% +ntidoteE digi ine <igito3inE metaboliFes in li er not in )idneys not gi en if ,ith )idney failure% b%2 Loop diureticsE Lasi3 effect ,ith in $0-$? min% Ma3 H ; hrs c%2 =ronchodilatorsE +minophillin 8-heophyllin2% + oid gi ing caffeine d%2 7arcotic analgesicE Morphine /A4 - induce asodilaton . decrease an3iety e%2 "asodilators 7-4 f%2 +nti-arrythmics Lidocaine '% +dminister A' inhalation highI Q 3 -4L(min ia nasal cannula 3% 5igh fo,lers 4% Restrict 7aI ?% !ro ide meticulous s)in care ;% Weigh pt daily% +ssess for pitting edema% Measure abdominal girth daily . notify M< B% Monitor "(/, 6.A, breath sounds C% 6nstitute bloodless phlebotomy% Rotating tourni>uet or =! cuff rotated cloc),ise > $? mins H to promote decrease enous return D% <iet decrease salt, fats . caffeine $0% 5-E a2 Complications Eshoc) +rrhythmia -hrombophlebitis M6 Cor !ulmonale R- entricular hypertrophy b%2 <ietary modifications c%2 +dherence to meds

ERI HERAL "USCULAR DISEASE +rterial ulcers $% -hromboangiitis Abliterans male( feet '% Reynauds female( hands enous ulcer $% "aricose eins '% -hrombophlebitis

$+, Thro-.oan)iitis o.'iterates/ 0UERGER DISEASE- +cute inflammatory disorder affecting small to medium siFed arteries . eins of lo,er e3tremities% Male( feet !redisposing factorsE - Male - /mo)ers

/(/3 $% 6ntermittent claudication leg pain upon ,al)ing - Relie ed by rest '% Cold sensiti ity . s)in color changes White !allor bluish cyanosis red rubor

3% <ecrease or diminished peripheral pulses - !ost tibial, <orsalis pedis 4% -ropic changes ?% *lcerations ;% 4angrene formation <3E $% '% 3% ?% Ascillometry decrease peripheral pulse olume% <oppler *-R decrease blood flo, to affected e3tremities% +ngiography re eals site . e3tent of mal-occulsion%

7sg MgtE $% &ncourage a slo, progression of physical acti ity a%2 Wal) 3 -4 3 ( day b%2 Aut of bed ' 3 3 a ( day '% Meds a%2 +nalgesic b%2 "asodilator c%2 +nticoagulant 3% #oot care mgt li)e <M a%2 + oid ,al)ing barefoot b%2 Cut toe nails straight c%2 +pply lanolin lotion pre ent s)in brea)do,n d%2 + oid ,earing constricti e garments 4% + oid smo)ing . e3posure to cold en ironment ?% /urgeryE =9+ 8=elo, the )nee amputation2 '%2RE$NAUD1S !redisposing factorsE $% '% 3% #emale, 40 yrs /mo)ing Collagen dse a%2 /L& pathognomonic sign butterfly rash on face

HENO"ENON acute episodes of arterial spasm affecting digits of hands . fingers

Chipmun) face bulimia ner osa Cherry red s)in carbon mono3ide poisoning /pider angioma li er cirrhosis Caput medusae leg . trun) umbilicus- Li er cirrhosis Lion face leprosy 4% /(/3E b%2 Rheumatoid arthritis <irect hand trauma piano playing, e3cessi e typing, operating chainsa, $% '% 6ntermittent claudication - leg pain upon ,al)ing - Relie ed by rest Cold sensiti ity

7sg MgtE a% +nalgesics b% "asodilators c% &ncourage to ,ear glo es especially ,hen opening a refrigerator% d% + oid smo)ing . e3posure to cold en ironment

VENOUS ULCERS $% VARICOSITIES / Varicose veins - +bnormal dilation of eins lo,er e3t . trun) - <ue toE a%2 6ncompetent al es leading to b%2 6ncrease enous pooling . stasis leading to c%2 <ecrease enous return !redisposing factorsE a% 5ereditary b% Congenital ,ea)ness of eins c% -hrombophlebitis d% 5eart dse e% !regnancy f% Abesity g% !rolonged immobility - !rolonged standing /(/3E $% !ain especially after prolonged standing '% <ilated tortuous s)in eins 3% Warm to touch 4% 5ea iness in legs <3E $% '% "enography -rendelenbergGs test ein distend >uic)ly P 3? secs

7sg MgtE $% &le ate legs abo e heart le el to promote enous return $ to ' pillo,s '% Measure circumference of leg muscles to determine if s,ollen% 3% Wear anti embolic or )nee high stoc)ings% Women panty hose 4% MedsE +nalgesics ?% /urgeryE ein s,eeping . ligation /clerotherapy spider ,eb aricosities /(& thrombosis

THRO"0O HLE0ITIS 8deep ein thrombosis2 - 6nflammation of eins ,ith thrombus formation
!redisposing factorsE $% /mo)ing '% Abesity '% 5yperlipedemia 4% !rolonged use of oral contracepti es ?% Chronic anemia ;% <M B% M6 C% C5# D% !ostop complications $0% !ost cannulation insertion of arious cardiac catheters /(/3E $% '% 3% <3E !ain at affected e3tremities Cyanosis 8S2 5omanGs sign - !ain at leg muscles upon dorsifle3ion of foot% +ngiography <oppler *-R

$% '% 7sg MgtE $% &le ate legs abo e heart le el% '% +pply ,arm, moist pac)s to decrease lymphatic congestion% 3% Measure circumference of leg muscles to detect if s,ollen% 4% *se anti embolic stoc)ings% ?% MedsE +nalgesics% +nticoagulantE 5eparin ;% ComplicationE

u'-onar2 E-.o'is-(
- /udden sharp chest pain - <yspnea - -achycardia - !alpitation - <iaphoresis - Mild restlessness