Cardiovascular System

1. Cardiovascular System Nursing 1120 By: Diana Blum RN MSN Metropolitan Community College 1

2. Objectives Describe the normal anatomy and function of the heart Describe the blood flow through heart to lungs and body List the data to be obtained in the client with a cardiac disorder Define Age Related Changes Explain the nursing consideration for clients having selected diagnostic procedures to detect or evaluate cardiac disorders 2

3. Objectives Continued Discuss CAD etiology and risk factors commonly collected, treatments prescribed, and related nursing interventions. Discuss the following common cardiac therapeutic measures: medications, diet, 02, exercise program, pacemaker, automatic implantable cardiac defibrillator (AICD), cardiac surgery, EP study with Ablation, CPR 3

4. Objectives continued Discuss the disease condition MI by describing etiology, risk factors, data commonly collected, treatments prescribed and related nursing interventions Describe the complications which may occur following a MI Discuss CHF including the definition, etiology, assessments, treatments, and common nursing interventions. Define types of cardiac arrhythmias and name 5 common HTN as related to blood pressure by identifying the types, S/S, and discussing treatment and related nursing observations and interventions. Describe the following valvular disorders: Mitral stenosis, insufficiency, and prolapse, Aortic stenosis and Aortic insufficiency 4

5. Objectives continued Compare and contrast the following inflammatory conditions of the heart including, definition, data collection, medical treatment and interventions: Endocarditis Myocarditis Pericarditis Discuss the nursing process as it relates to the cardiovascular system 5

6. Cardiac Function Primary function : to pump blood through the pulmonary and systemic circulations This is accomplished by a continual repeating pattern of contractions and relaxation (lub dub) 6

7. 3 Layers of Cardiac tissue Endocardium : innermost layer of the heart-(lines the heart) Myocardium: middle layer made up of muscle fibers and is responsible for the pumping action of the heart Epicardium: the outermost layer and is the visceral pericardium. The coronary arteries are embedded in this layer 7

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9. Blood Flow Right Atrium: receives blood from vena cava and from coronary arteries Tricuspid Valve: passes blood from right atrium to right ventricle Right Ventricle: bottom chamber of the heart that contracts (systole) and pushes blood through pulmonic valve and into pulmonary artery 9

10. Blood Flow Continued Pulmonary artery: carries blood to the lungs Pulmonary veins: carry the newly oxygenated blood back to the heart Left Atrium: accepts blood from pulmonary veins Mitral Valve: moves blood from left atrium to left ventricle Left Ventricle: thickest and strongest muscle Cone shaped and contains apex of heart When the LV contracts (Systole) blood is ejected into aorta and out to Body 10

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12. Coronary Arteries Two major coronary arteries arise from the aorta beyond the aortic valve. Blood flows to the coronary arteries during diastole Left main, LAD, Circumflex feeds most of Left side of the heart Right feeds SA node, AV node, RA, RL 12

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14. Conduction System SA node: (pacemaker) initiates the impulse travels thru atria to the AV node, located on the floor of the RA Impulse is delayed at AV node, then transmitted to bundle of His Then moves down R and L ventricles to Purkinje fibers 14

15. Conduction Continued 15

16. Cardiac Cycle Contraction and relaxation of the heart: lub dub or 1 heart beat Diastole: ventricles at rest and filling up with blood coming from the atria (Dub) Systole: Once the Ventricle is filled with blood and the electrical impulse has reached the terminal fibers of the conduction system, the Ventricle contract and eject blood into the pulmonary artery from the RV and into the aorta from the LV (Lub) 16

17. Video Mysterious Heart Volume 2 chapter 3 17

18. Cardiac Output the volume of blood ejected by the heart each minute and is determined by stroke volume and the heart rate. Normal stroke volume is 60-100 ml Normal cardiac output is 4 to 8 L / min (CO = HR X SV) 18

19. Factors affecting Stroke Volume Preload: the amount of blood remaining in the ventricles at the end of diastole or the pressure generated at the end of diastole Contractility: is the ability of the cardiac muscle fibers to shorten and produce a muscle contraction. (Inotropic, + or -) Afterload: amount of pressure the Ventricle must overcome to eject blood volume out 19

20. Heart Rate SA node : pacemaker of heart 60-100 bpm AV node : 40 -60 bpm, if SA node fails Heart is innervated by sympathetic and parasympathetic nervous system Sympathetic: speeds HR, and increases force of contraction Parasympathetic: slows HR and force 20

21. Heart Tones Murmur: Produced by turbulent sounds across valves Rub: inflamed pericardium-best heart along left sternal border S3 murmur: sounds like �Kentucky� S4 murmur: sounds like �Mississippi� http://www.blaufuss.org/ http://www.med.ucla.edu/wilkes/Rubintro.htm 21

22. Health History 22

23. Present Illness Fatigue Edema Palpitations Pain Aggravating and relieving factors 23

24. Past Medical History HTN renal disease pulmonary disease DM CVA rheumatic fever streptococcal sore throat scarlet fever previous cardiac disease or conditions currents meds and allergy 24

25. Family History: CAD HTN DM 25

26. Review of systems weight gain fatigue dyspnea cough orthopnea palpitations chest pain fainting concentrated urine edema 26

27. Functional assessment effects of illness on ADLs and rest patterns smoker diet stress coping 27

28. Physical Assessment General: Apparent distress Height and weight VS: orthostatic bp in both arms, apical rate and rhythm peripheral pulses: rate, rhythm, quality, equality respiratory rate and effort Skin: color hair distribution, cap refill, temp Thorax: heart sounds, lung sounds, sputum Extremities: pulses, color, temp, edema 28

29. Age Related Changes Heart less able to adapt to changing needs related to activity Valves thicken and stiffen # of pacemaker cells decrease Nerve fibers decrease Frequent dysrhythmias 29

30. Diagnostic Tests EKG: rate, rhythm, ischemia (T-inverted), injury (ST segment elevation), arrhythmias, strain, infarction (q wave) Echocardiogram: (TEE) sound wave test detects size of chambers, valve integrity, flow, wall motion, Cardiac Output 30

31. Diagnostic Tests Continued Biomarkers: Troponin will show elevation 1hr after MI <0.10 is negative 0.10-0.60 is intermediate and may indicate injury >0.60 is positive evidence of MI Myoglobin doubles in 2 hr after MI CPK-MB will show increase 4 hrs after MI BNP can be elevated 48 hrs after MI which indicates heart failure 31

32. Diagnostic Tests Continued CBC: anemia CMP: screening K+, etc PT, INR PTT Lipid profile: see next 2 slides 32

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35. Diagnostic Tests Continued ABG: assess acid/base levels Pulse Oximetry: generally >92% Holter monitoring: 24+ hr of EKG + events Stress test: treadmill or pharmacological Cardiac Catheterization: invasive, NPO 6-8h, consent. Visualizes chambers, valves, arteries, pressures, CO Heart-CT scan: assesses CAD, MRI Nuclear scans: assess heart muscle viability EPS: NPO, consent, IV, assess electrical activity 35

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37. http://preop.medselfed.com/asp/center.asp?centerId=heart&partnerId=preop&id=&cachedate=&emailId=&affId=&campId=&hideNav= 37

38. CAD Video-mysterious heart volume 3 chapter 2 38

39. Etiology of CAD CAD occurs when the intimal lining of the coronaries begin to plaque resulting in jagged edges and narrowed passageway for blood flow Atherosclerosis results in impaired blood flow to the heart muscle 39

40. Risk Factors for CAD Non-controllable- Age Gender Family/personal history of DM and heart disease Controllable- smoking, elevated cholesterol, HTN, sedentary, increased weight, stress 40

41. s/s of CAD Angina which results from a lack of 0xygen to the heart muscle 4Es=exercise, eating, emotion, exposure to cold Weakness, diaphoresis, SOB N/V 41

42. MI: Myocardial Infarction Occlusion of a coronary artery resulting in necrosis of the heart muscle. Risk factors: same as for CAD Pathophysiology: AMI-over 4-6 hrs ischemia injury and infarction develop. Ischemia=lack of 02 to heart muscle, if not relieved=injury. After 20 min of ischemia=infarction Main S/S: chest pain and accompanying S/S 42

43. Within 24 hours after infarction, healing begins, collateral circulation begins. 10-14 days after MI=extension of MI may occur due to myocardial tissue vulnerability to stress Complete scar formation and healing takes about 6 weeks Video- mysterious heart volume 1 chapter 2 43

44. Data Collection Same as for CAD but will assess symptom of chest pain with accompanying s/s May have EKG changes with or with-out ST-T wave changes or Q wave changes Cardiac Bio-markers (Troponin, Myoglobin, CPK, CKMB) May proceed with Echocardiogram to assess if wall motion sluggish May go to cath lab 44

45. Angina or MI Angina without MI} often relieved with rest and NTG Angina with MI } may be relieved with rest, NTG, 02, MS, rescue angioplasty, etc. Think MONA Morphine Oxygen Nitroglycerin Aspirin http://www.youtube.com/watch?v=4GlQmTlP2jE&feature=related 45

46. Treatment continued�video mysterious heart volume 3 chapter 3-7 ASA: to prevent platelet aggregation MS: to treat pain associated with MI, <02 consumption, <BP, Pulse & reduces anxiety Beta-blocker: to < workload of heart muscle and <pulse and preload ACE inhibitor: if CHF present to prevent ventricular remodeling and progression of failure 46

47. Treatment continued May need antiarrhythmic meds Stool softeners to reduce valsalva maneuver and prevent constipation r/t narcotic use and bed rest Treat: HTN, DM other co-morbid illnesses Cardiac Rehab to follow 47

48. Treatments Low fat low cholesterol diet Prescribed exercise program 5-7 days a week Knows correct use of NTG for angina Management of DM, HTN Stop smoking Medications to reduce work load or dilate 48

49. Low salt diet (<2000mg) does not include: Soups: canned, freeze dried, broth Sauces Snacks: processed chips, nuts Smoked meat and fish Sauerkraut Seasonings Sodium-processed cold cuts 49

50. Low fat <30% Low cholesterol <200mg Lean meat: skinless Dairy limited: egg beaters, skim milk Olive oil, canola oil Avoid: fried, fatty or heavily marbled meats, sausage, lunch meat, spareribs, frankfurters, salt pork, canned fish in oil, yolks, duck. Cream sauces, gravy, buttered vegetables, sweet rolls, other processed foods 50

51. Exercise 5-7 X week is goal to include stretches with warm-up, progressive walking program, light weights, stretches with cool down. Strengthens heart muscle, reduces BP, BS, weight, stress, tension, appetite, LDLs. Increases HDLs, energy and self esteem and improves immune system 51

52. Principles of Exercise Practice on regular basis Know how to do own pulse Strive for target heart rate Stop if chest pain occurs Complications: CHF & Dysrhythmias 52

53. Nursing interventions for MI Comfort measures Freq VS, cardiac monitoring, I&O, CMS checks, spacing activities Heart & lung sounds, assess fluid volume status, IV responsibilities, note BP & Pulse prior to heart meds!! Client education r/t diet, meds, pulse taking activity, elimination, reporting chest pain and correct use of nitro products for angina 53

54. Medications for Heart Disease Anti-Anginal: nitrates, beta blocker, ca channel blocker Anti-Hypertensive: ACE inhibitors, beta blocker ca channel blocker, diuretics, other vasodilators Anti-Arrhythmic: Rhythmol Cardiac glycoside: Lanoxin 54

55. Medication continued Thrombolytic: Streptokinase, Betapace Anti-coagulant: Heparin, Coumadin, lovenox Anti-platelet aggregate: ASA, Plavix Lipid-Lowering agents: Statins, zetia Diuretics: Lasix, demadex Electrolyte replacement: K+, magnesium 55

56. Medication continued 02 to maintain 02 sat > 92% to reduce chance of angina/ischemia If Angina the nurse needs to have the client lie down, take VS then report to charge nurse unless nitro ordered. Instruct client: If develops chest pain, sit down take 1 nitro every 3- 5 min x 3. If chest pain not relieved call 911 56

57. POST MI Complications 57

58. 90% will develop complication and 80% will demonstrate arrhythmia which is the most common cause of death in clients in the pre-hospital period. (VT>>>VF) CHF and severe Left ventricular failure Papillary muscle dysfunction Pericarditis Thromboembolism Ventricle rupture 58

59. Nursing Diagnosis Decreased cardiac output r/t Dysrhythmias Pain r/t lack of 02 to myocardium Anxiety r/t to feeling of doom, lack of understanding of medical diagnosis 59

60. Surgical Procedures 60

61. New in 1958 having purpose to restore the regular rhythm and to improve tissue perfusion and cardiac output. Temporary / permanent Single chamber or double chamber Teach client how to take 1 min pulse, s/s to report to MD-dizzy, angina, dyspnea Carry card and know precautions 61

62. Video- mysterious heart volume 2 chapter 4 62

63. AICD Implantable defibrillator to correct a life threatening rhythm disturbance. Has pacemaker back-up. Client can feel shock, check battery q2months Instruct on how to take pulse for 1 min s/s to report to MD: firing, s/s of dizziness, dyspnea, weakness, carry card and wear bracelet, CPR for family. Know precautions 63

64. Nursing care for client with newly implanted pacemaker or AICD. Assess cardiac monitor for capture/pacing (pacer) VS post-op then q 4 hours, IV, bed rest till am Dressing dry and intact until AM then often may remove. Increase activity progressively Instruct client not to raise arm above shoulder for 5days. May shower in 5 days 64

65. Angioplasty with Stent Procedure done at the time of cardiac cath. Balloon angioplasty is accomplished to widen or open specific coronary vessel-stent is inserted to maintain patency of the vessel. pre-procedure Plavix given with follow up Plavix 65

66. EP with Ablation Mapping of myocardial tissue to determine irritable focus. Low voltage current delivered to ablate tissue causing SVT or VT 90% effective http://video.google.com/videoplay?docid=5590000557631435292 66

67. Nursing Care NPO prior Coumadin stopped 4 days prior, Heparin 4 hours prior Post � procedure same as heart cath Cardiac monitoring CMS and groin checks VS Ambulate prior to discharge 67

68. Cardiac Surgery Coronary artery bypass graft- done after confirmation with cardiac catheterization. Re-route blood vessels using mammary or saphenous v from aorta around block in coronary artery. Valve replacement or repair Septal repair and other congenital repairs CCU post op, chest tubes Pre-op teaching with post op expectations See client teaching for CABG, Valve repair/replacement, care of PTCA, MI 68

69. http://preop.medselfed.com/asp/center.asp?centerId=heart&partnerId=preop&id=&cachedate=&emailId=&affId=&campId=&hideNav= 69

70. Congestive Heart Failure Video..the mysterious heart volume1 chapter 3 70

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72. DEFINITION:EF < 35% or when the myocardium is no longer able to pump efficiently and fluid accumulates in the lungs and or selected areas of the body as a result 72

73. Systolic failure= most common Left ventricle loses its ability to generate enough pressure to eject blood forward through the aorta resulting in a decrease in the CO which is measured by the EF (ejection fraction)=total Ventricle filling volume that is ejected during Ventricular contraction. 50%=normal 73

74. Causes of CHF CAD, advancing age HTN is a major factor > CHF x 3 DM, Smoking, Obesity Valvular incompetency, alcohol or other chemicals, idiopathic,(unknown) 74

75. S/S of Left Sided CHF Fatigue Angina Tachycardia Cool extremities Hacking cough Crackles Frothy sputum Gallop 75

76. S/S of Right Sided CHF Jugular distention Anorexia/nausea Dependent edema Distended abdomen Weight gain BP problems 76

77. Assessment Findings C/O SOB, weakness, dry cough, fatigue, can not lie down must sit up to breath, has gained weight Auscultation of the heart} rapid HR, extra heart sounds Auscultation of the lungs} rales, wheezing Examination of the extremities for peripheral edema 77

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79. System Compensation Mediated thru Sympathetic Nervous System: as CO drops, baroreceptors alert brain>>>signals adrenal glands to release catecholamines{norepinephrine and epinephrine} This causes stimulation Beta 1=>>HR Stimulation Beta 2= bronchodilation Activate Alpha receptors peripherally=constriction=>>bp 79

80. Compensation Causing S/S of CHF because: Contractility decreases Stroke volume and CO continue to decrease Afterload (pressure on the other side of the aorta) increases Preload ( pressure caused by increase volume to heart creating an exaggerated stretch in the muscle) increases 80

81. Renal Compensation CO drops initiating renin-angiotensin mechanism Results in powerful vasoconstrictor angiotensin II,>> aldosterone (hormone) which causes kidneys to retain Na and H20 which increases blood volume 81

82. Ventricular Hypertrophy The heart enlarges which results in strain The increase in volume causes the ventricles to dilate Eventually remodeling will occur 82

83. Diagnostic Tests H&P Chest x-ray: see size of heart and fluid in lungs EKG: strain, MI Echocardiogram: size of heart and CO CBC: anemia CMP: screening Thyroid function ABGs BNP=B type natriuretic peptide= hormone released in response to Ventricular stretch ( CHF peptide) Nuclear studies to determine heart function, EF, tissue viability Cardiac Cath to determine exact nature of heart function 83

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85. CHF Management Directed at: Improving LV function (Contractility) by decreasing intravascular volume and decreasing vascular resistance Decreasing venous return (Preload) Decreasing BP (Afterload) Improving gas exchange and 02 Increasing the CO and reducing anxiety 85

86. continued ACE inhibitors to < afterload by dilating vessels and < BP (ARBs) Beta blockers to < 02 demand by reducing the contractility of the heart and HR (not given in acute period) Diuretics <preload by reducing volume returning to the heart-Lasix & (Aldosterone Antagonists) K+ supplement 86

87. continued ASA in low doses or Plavix to help prevent blood clot formation Anticoagulants for those with poor EFs to prevent CVA Antiarrhythmics to control ectopy Biventricular pacing (CRT=cardiac resynchronization therapy) to improve CO Digoxin to increase contractility of myocardial fibers and improving cardiac output. +inotropic agent 87

88. Treatment of CHF Treat underlying cause Rest and hi Fowlers to reduce work load and improve ventilation 02 at 2-6 L/min with 02 sats >92% to increase available 02 and prevent hypoxemia Freq VS and cardiac monitoring 88

89. Treatment continued I & O q shift Daily am weights before breakfast and after voiding. 2-3# weight gain in 1-4 days call MD Sodium restricted diet Medications: to decrease intravascular volume thus reducing venous return, dilate and reduce BP and improve contractility http://chfsolutions.com/zip_how_aquapheresis_works.html# 89

90. Educating the CHF Client Education re: heart failure Explanation of heart failure Expected S/S and when to call MD Self monitoring of daily weights Know medications and need to take them 2000mg sodium restricted diet Importance of low level daily exercise program (energy conservation) Prognosis / advanced directives 90

91. Lead Placement 91

92. A dysrhythmia is a disturbance of the rhythm of the heart caused by a problem in the conduction system. Categorized by site of origin: atrial , AV nodal, ventricular Blocks are interruptions in impulse conduction: 1st, 2nd type 1&2, 3rd or complete heart block 92

93. To map= to determine if regular or irregular 93

94. P-wave = atrial electrical activity QRS= ventricular electrical activity T wave= resting phase of ventricle 94

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96. P wave 96

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98. QT Wave 98

99. Heart rates NSR: heart rate is 60-100bpm ST: heart rate 101-180 bpm SB: heart rate <60 bpm 99

100. NSR 100

101. Sinus rhythm PR interval- 0.12-0.20sec QRS-0.06-0.10sec QT segment 0.36-0.44 sec Heart rate 60-100 101

102. Sinus arrythmia Hr= 60-100 bpm On strip it looks regular but does not map out PR interval= 0.12-0.20 102

103. Junctional escape rhythm 103

104. SB 104

105. Sinus Bradycardia All criteria same except rate < 60bpm S/S: dizziness, syncope, angina, hypotension, sweating, nausea, dyspnea Sometimes no S/S Treat underlying cause IV atropine, pacemaker 105

106. ST 106

107. Sinus Tachycardia All criteria same as with NSR except rate >100 Causes: fever, dehydration, hypovolemia, increased sympathetic nervous system stimulation, stress, exercise, AMI S/S: Palpations #1, angina and < CO from < V filling time Treatment: correct cause, eliminate caffeine, nicotine, alcohol. Beta blockers may be ordered 107

108. First degree heart block 108

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110. Second degree heart block type 1 110

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112. Second degree heart block type 2 112

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114. 3rd degree heart block of complete heart block 114

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116. Atrial Fibrillation 116

117. A fib continued Atrial rate > 400 bpm with a varying Ventricular rate Overall rhythm irregular No P waves, unable to measure PR interval QRS=normal: Twave undeterminable Causes: Rheumatic fever, mitral valve stenosis, cad. HTN, MI, hyperthyroidism, COPD, CHF see pp. 604 117

118. A fib continued Concern with A fib is the development of atrial thrombus and loss of atrial kick from ineffective atrial function. Treatment: Ca channel blockers and anti- arrhythmics to convert, beta blockers to < HR, anticoagulants to prevent embolization. Synchronized cardioversion 118

119. Atrial flutter 119

120. Paced beat 120

121. Premature ventricular conduction (PVC) 121

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123. Ventricular tachycardia 123

124. Torsades de pointe 124

125. Ventricular Fibrillation 125

126. Vtach/Vfib Both can be life threatening VT= V HR 100-250 bpm Causes: AMI, CAD, hypokalemia, dig toxic S/S: palpitations, dizzy, angina, <LOC Treatment: assess for pulse, if none, defib VF=Rate undeterminable Cause: same Treatment: CPR 126

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128. Hypertension 128

129. HTN is described as persistent elevation of arterial blood pressure greater than 140/90 on at least 2 or more readings on different dates. The Joint National Committee, Detection, Evaluation, and Treatment of High Blood Pressure defines normal: BP as S < 120 mm Hg and D < 80 mm Hg PreHTN: SBP 120-139 DBP 80-89 Stage 1: SBP 140-159 DBP 90-99 Stage 2: SBP >160 DBP >100 129

130. Types of Hypertension Essential HTN: (Primary) which is the most common 90-95% of population Secondary HTN: is a result of another disease, kidney, pregnancy. 130

131. Factors that determine arterial pressure Cardiac output which is the volume of blood pumped by the heart in 1 minute Peripheral vascular resistance which is the force in the peripheral blood vessels that the left ventricular must overcome to eject blood out of the heart 131

132. Possible Causes of PVR Narrowing of blood vessels, PVD, CAD, kidney disease: > renin/angiotensin =vasoconstriction Release of catecholamine (epinephrine and adrenalin) = vasoconstriction > blood volume= more work to pump > Blood viscosity=harder to pump Ability of blood vessel to stretch 132

133. Causative Factors of HTN Hyperlipidemia Obesity Atherosclerosis Sedentary DM Family Hx Cigarette smoking Age > 60 Men Post menapausal women 133

134. S/S Often none Occipital headache more severe on rising Lightheadedness Epistaxis Known as the �Silent Killer� 134

135. Complications Damage to blood vessels of the eyes, heart, kidney, brain resulting in: Stroke CHF AMI Renal failure Blindness 135

136. Lifestyle Change Education Exercise, dash diet, stop smoking, weight management and control, stress reduction, medications and recording BP frequently Avoid OTC meds Instruct on how to do postural BPs 136

137. Valvular Disorders 137

138. STENOSIS: narrowing of the opening of the valves INSUFFICIENCY: inability of the valves to close 138

139. Stenosis Narrowing of the opening of the valves. Limits the amount of blood which is ejected from one chamber to the next. i.e., the L A would not empty completely into the L V when it contracts. Result in an increased amount of blood remaining in the L A after contraction has occurred 139

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141. Mitral Stenosis Mitral valve leaflets become thickened and fibrotic. Affect women age 20-40 CHF may develop TX if failure develops: Digoxin, Lasix, beta blockers, and anti arrhythmics, lo Na diet, etc Will monitor with yearly echocardiogram Surgery if worsens Prophylactic antibiotics prior to invasive procedure or dental work 141

142. Insufficiency (Also referred to as regurgitation) The inability of the valves to close completely. Allows the blood to backflow. i.e., After the L A has contracted some of the blood will flow back into the L A Mitral valve is the most commonly affected 142

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144. Mitral Insufficiency Often accompanies mitral stenosis as a result of rheumatic fever. Valve leaflet become rigid and shorten, prevents closure of valve. Hypertrophy of Left Atrium and Ventricle = L sided heart failure occurs Murmur heard. F/U with echocardiogram TX: vasodilators, same as for stenosis 144

145. Mitral Valve Prolapse When the Left ventricle leaflets become enlarged, and protrude into the left atrium during systole. Benign but may progress to Mitral insufficiency More common in women age 20-55 145

146. S/S of mitral prolapse Often none Others experience chest pain, palpitations, dizziness, syncope, dysrhythmias Monitor with echocardiogram May do heart catherization Manage stress, beta blockers if tachycardia 146

147. Aortic Stenosis Occurs when valve cusps become fibrotic and calcify. Most commonly caused by aging and atherosclerosis. Occurs most predominantly in men Untreated will lead to Left sided CHF 147

148. Aortic Insufficiency Caused primarily by rheumatic fever May also be caused by chronic HTN Predominantly in men Hypertrophy of the Left ventricle and eventually to left sided CHF Blood may eventually back up into the pulmonary system and lead to Right Ventricle failure 148

149. S/S and Treatment Aortic murmur, tachycardia, palpitations, CHF with fatigue, SOB, ascites Monitored with echocardiogram assessing L ventricular dilatation Chest X-ray-enlargement of heart May do cardiac cath May need valve repair or replacement 149

150. Inflammatory Diseases of the Heart 150

151. Inflammation of the heart most often results from systemic infections and may include any layer of the heart: Endocardium Myocardium Pericardium 151

152. Endocarditis Inner layer: tends to affect the valves (Mitral=L). Organisms (Bacterial or fungal) present in blood stream and collect (colonize) on the valves: Rheumatic heart disease, congenital defects or mitral valve prolapse IV drug users or invasive procedures 152

153. Clients with known valvular disease need to be treated with prophylactic antibiotics prior to any invasive procedure including dental. Immunosuppression and any source of contamination places clients at risk 153

154. Pathophysiology Bacteria may enter blood stream: staph, strep, E coli. Bacteria collect on valves and vegetate Vegetation may break off with blood flow and cause emboli Complications: Ventricular septal defect, CHF(#1 cause of death) and embolization 154

155. S/S Fever- (99-105) Chills and night sweats may accompany Malaise, fatigue and weight loss Appearance of petechiae in the mouth, conjunctiva and legs Chest and abdominal pain indicating embolization 155

156. Treatment and Diagnostics H&P and Lab tests CBC with diff with leukocytosis, > sed rate, blood cultures May have heart murmur Echocardiogram to visualize valves and vegetation Chest x-ray: CHF Long term antibiotics, rest, limited activity, prophylactic anticoagulants, valve replacement after inflammation treated 156

157. Nursing Assessment Frequent VS and assess for fever Assess for heart murmur Note cough Assess peripheral edema Rest with limited activity, administer meds in a timely manner 157

158. Nursing Diagnosis Decreased CO r/t impaired valve function Pain r/t tissue inflammation Ineffective tissue perfusion r/t embolization Activity intolerance r/t fatigue and bed rest Knowledge deficit r/t lack of information regarding illness and management 158

159. myocarditis 159

160. Muscle layer: Local or diffuse inflammation of the myocardium. May be viral or bacterial, an autoimmune process or drug toxicity. May result in cardiomyopathy=enlarged heart. 160

161. Pathophysiology Characterized by degeneration and necrosis of myocardial tissue that is different of that caused by MI Tissue next to necrosed area hypertrophies, loses elasticity, results in CHF and arrhythmias 161

162. S/S Asymptomatic May have fever, fatigue, sore throat, dyspnea, muscle aches Lymph nodes may be enlarged Chest pain 7-10 days after virus CHF S/S 162

163. Diagnosis Based on Hx, S/S, and testing-enzymes> May hear friction rub, rales Jugular vein distention Chest x-ray, echocardiogram=hypertrophy EKG=arrhythmias Biopsy (RV) shows lymphatic infiltration and cell necrosis 163

164. Treatment Bed rest 02 Meds: cardiac glycoside-Lanoxin, anticoagulants, antiarrhythmic, antibiotics, steroids Cardiac monitoring NI same as for endocarditis ND same as for endocarditis 164

165. Pericarditis 165

166. Outer-surrounds heart Inflammation of the pericardium. Primary or secondary Acute or chronic Acute: virus, bacteria, fungi, chemotherapy, MI Chronic: TB, radiation or metastases 166

167. Pathophysiology Inflammation causes an increase in the amount of pericardial fluid and inflammation of surrounding tissues. Fluid accumulates in the pericardial space Adhesions may occur which causes loss of elasticity which causes constriction and prevents adequate filling of ventricles. May lead to tamponade==pericardiocentesis 167

168. Tamponade 168

169. S/S Chest pain is hallmark Most severe on inspiration, sharp, stabbing, or dull and burning. Pain is relieved by sitting up or leaning forward Dyspnea, chills and fever 169

170. Diagnosis WBC elevated Serial EKG show that ST segment increases and resolves in several weeks. A fib may occur QRS = low voltage Echocardiogram to see pericardial thickening and effusion Enzymes can be increased Blood cultures to ID organism 170

171. Treatment Analgesics Antipyretics Anti-inflammatory agents Antibiotics May need OR to create a pericardial window to allow for drainage of fluid NI and ND same as for endocarditis 171

172. Nursing the Heart Client 172

173. Assessment Heart rate and rhythm, color, temperature, cognition Circulation: peripheral CMS checks Vital signs to include 02 saturations and telemetry interpretation Subjective: c/o chest pain, SOB, fatigue, lightheadedness, dizziness 173

174. Nursing Diagnosis Activity intolerance Ineffective airway clearance Ineffective breathing patterns Cardiac output, decreased Tissue perfusion, altered, coronary Fatigue 174

175. Ekg practice 175

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183. References www.mirule.com retrieved on 4/8/07. Images found at www.aol.com. Retrieved on 4/8/07. Aehlert, B. RN BSPA (2006). EKGs Made Easy. Mosby (3rd ed). St Louis. 183

184. The End 184 Refer to handout: Determining Nutrition Health from NURS 1510 for Low fat, low cholesterol and low sodium diet instructions for clients with heart disease Refer to handout: Determining Nutrition Health from NURS 1510 for Low fat, low cholesterol and low sodium diet instructions for clients with heart disease