Handout 6

Problems Oxygenation-Perfusion
Cardiovascular Disorders

Care of Clients with Problems in Oxygenation, Fluid and Electrolyte Balance, Infectious Inflammation and Immunity Response, Cellular
Aberration NCM 112 Theory

Cardiovascular Disorders

How Does it Happen?

Self-Management Education Guide: Decrease Risk for Coronary Heart Disease

KENPOGI
 Handout 6

Problems Oxygenation-Perfusion
Cardiovascular Disorders

Care of Clients with Problems in Oxygenation, Fluid and Electrolyte Balance, Infectious Inflammation and Immunity Response, Cellular
Aberration NCM 112 Theory
• Daily management of HPN • Follow a healthy heart diet
• Stop smoking • Reduce Stress
• Avoid passive smokers • Allow adequate time for rest and relaxation
• If overweight? • These are life-long life-style changes

AnginaPectoris
• Transient Chest pain caused by insufficient blood flow to the myocardium resulting in myocardial ischemia
• Results when myocardial oxygen demand exceeds myocardial oxygen supply
Pathophysiology:

Manifestations
• Pain • Palpitations
• Pallor • Dizziness
• Diaphoresis • Digestive disturbances
• Dyspnea • Angina: PQRST pain Assessment
• Faintness
Types of Angina
1. Stable Angina 5. Angina Decubitus
2. Unstable Angina 6. Intractable Angina
3. Variant Angina 7. Post Infarction Angina
4. Nocturnal Angina
Precipitating Events of Angina Pectoris
1. Exertion 3. Eating heavy meals
2. Emotions 4. Environment
Management

Pharmacological Management:
Vasodilators:
• Nitroglycerine
• Amyl Nitrate
• Isosorbide
Effects
• Direct relaxing effect on vascular smooth muscle ,resulting in generalized vasodilation
• Decrease peripheral resistance, decrease systolic pressure
• Decrease myocardial oxygen demand by decreasing heart rate,BP,mto cardial contractility and calcium out put

Beta Adrenergic Blockers

Propranolol(Inderal) Effects
Metoprolol (Lopressor) Atenolol(Tenormin)
Nadolol (Nadolol) Pindolol (Visken)

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 Handout 6

Problems Oxygenation-Perfusion
Cardiovascular Disorders

Care of Clients with Problems in Oxygenation, Fluid and Electrolyte Balance, Infectious Inflammation and Immunity Response, Cellular
Aberration NCM 112 Theory
Esmolol (Breviblock)
• Decrease myocardial oxygen demand by decreasing heart rate,BP,mto cardial contractility and calcium out put

Calcium Channel Blockers

• Verapamil (Isoptin,Calan) • Amlodipine (Norvasc)
• Nifedipine (Procardia, Adalat,Calcibloc) • Nicardipine (Cardene)
• Diltiazem (Cardizem)
Effects
Inhibit calcium ion transportation into myocardial cells to depress inotropic and chronotropic activity, decreasing cardiac
force workload
• Has a vasodilation effect
• It reduces coronary vasospasm
Other meds
Platelet Aggregation Inhibitors
• ASA
• Diypiridamole (persantin)
• Clopidrogel (Plavix)
• Ticlopidine
Inhibits platelet aggregation
Anticoagulants
• Heparin Sodium
• In activates thrombin and other clotting factors inhibiting conversion of fibrogen to fibrin,fibrin clot
formation is prevented
• Warfarine Na
• Dicumarol
• Inhibit hepatic synthesis of Vit.K

Nursing Intervention for Drug Therapy

Nitroglycerine
•Assume sitting or supine position when taking the drug
•Take maximum dose of 3 doses at 5 minutes interval
•Practice gradual change of position.
•If taken sublingual, the medication causes burning or stinging sensation under the tongue: potent
•Sublingual route :onset of 1-2 minutes duration of action is 30 minutes
•Offers sips of water before giving nitrates:
•Instruct client to avoid drinking alcohol
•Transdermal patch : 1 a day: morning, rotation at chest wall, remove path at night to prevent tolerance.
•Evaluate effectiveness :relief chest pain
•Store in cool dry place; use dark/amber colored air tight container. Do not refrigerate it may destroy by heat light or moisture.
•Change stock every 3 months
•Observe for side effects: head ache, flushed face, dizziness, faintness, tachycardia.--first few doses do not discontinue.
Beta adrenergic blockers
• Assess pulse rate before administration of the drug:
• Administer food to prevent GI upset
• Do not administer Inderal (Propranolol) to clients with asthma
• Do propranolol not administer with px with DM:
• Give extra caution with client with heart failure
• SE: nausea,vomiting,mental depression,mild diarrhea fatigue and impotence
• antidote for beta blocker poisoning is __________

Calcium channel blockers:

• Assess HR and BP
• Monitor hepatic and renal function
• Administer 1 hour or 2 hours after meals.
• Antidote is glucagon
Platelet Aggregation Inhibitors
• Assess bleeding
• Avoid straining at stool
• ASA with food
• ASA toxicity:
• ASA may cause bronchoconstriction observe for wheezing

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 Handout 6

Problems Oxygenation-Perfusion
Cardiovascular Disorders

Care of Clients with Problems in Oxygenation, Fluid and Electrolyte Balance, Infectious Inflammation and Immunity Response, Cellular
Aberration NCM 112 Theory
Treatment and Surgical Interventions
• Percutaneous Trans Luminal Angioplasty
• Mechanical Dilatation of the coronary vessel wall by compressing the atheromatous plaque.

• Intravascular stenting
• Biologic stent is produces through coagulation of collagen and elastin and other tissues in the vessel wall
by laser, photo coagulation or radio frequency-induced heat

Laser therapy of the heart

• It produces necrosis hemostasis coagulation and evaporation of tissue
Coronary Artery Bypass Graft
• Reduces angina
• Recommended for severe narrowing of one or more branches of the coronary arteries exist
• Myocardial revascularization.

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 Handout 6

Problems Oxygenation-Perfusion
Cardiovascular Disorders

Care of Clients with Problems in Oxygenation, Fluid and Electrolyte Balance, Infectious Inflammation and Immunity Response, Cellular
Aberration NCM 112 Theory

Nursing Intervention for Client with Angina

• Promote comfort
• Relieving pain
• Nitroglycerine
• Promote Tissue Perfusion
• Avoid over fatigue
• Stop activity if chest pain is present
• Facilitate learning
• Promote a positive attitude and active participation of the client and the family -Compliance
• Promote activity and rest
• Slower activity with more rest.
• Plan regular activity program
• Nitroglycerine before exercise
• Increase intent of exercise gradually
• Activity
• Encouraged with in patients’ limitations

• Promote relief of anxiety and feeling of well being

• Facilitate reduction in the clients present level of activity
• Advise client to minimize emo out burst
• Encourage to maintain an optimistic outlook to help relieve the work of the heart
• Diet
• Low Na low fat low cholesterol and high fiber diet
• Avoid saturated fats
• White meat without skin, fish
• Read labels

Myocardial Infarction
• Formation of necrotic areas within the myocardium.
• Prolonged ischemia: lasting 35 to 45 mins produces an irreversible cellular damage and necrosis of the myocardium
Pathophysiology

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 Handout 6

Problems Oxygenation-Perfusion
Cardiovascular Disorders

Care of Clients with Problems in Oxygenation, Fluid and Electrolyte Balance, Infectious Inflammation and Immunity Response, Cellular
Aberration NCM 112 Theory

Manifestations
Pain Acute Pulmonary Edema
Anxiety and Apprehension Elevated CK-MB,
Shock Elevated LDH AST
Fever Elevated Troponin Levels

Collaborative Management
Medications
• Analgesics:
• Relieve Pain(priority)
• Morphine Sulfate
• Nitroglycerine
• Lidocaine
• Thrombolytic therapy
• Disintegrate blood clots
• Streptokinase, urokinase,TPA
• Most crucial 3-6 hours after MI

• Anticoagulant and anti-platelet.

• Other meds
• BABA
• Diazepam (valium)

Treatment:
• Goal
• Prevention of further tissue injury and infarct size
• Maximize perfusion and minimize tissue demands.
• Cardiac monitoring-dysrhythmias
• PTCA
• Diet: low Cholesterol and Low Na
• Bedrest: 24-28 hours to decrease o2 demand
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 Handout 6

Problems Oxygenation-Perfusion
Cardiovascular Disorders

Care of Clients with Problems in Oxygenation, Fluid and Electrolyte Balance, Infectious Inflammation and Immunity Response, Cellular
Aberration NCM 112 Theory
• Progressive ambulation unless complication occurred
Nursing Interventions
• Promote oxygenation and Tissue perfusion
• Avoid fatigue
• O2 therapy
• Semi-fowlers
• Monitor:
• ECG
• VS
• Effects of daily activities
• Rate and rhythm of pulse
• Promote rest and minimize unnecessary disturbance
• Promote comfort
• Relieve pain
• Morphine sulfate as prescribe
• Diazepam
• CCU
• Provide psychosocial support to client and family
• Promote Activity
• Gradual
• Monitor signs of dysrhythmias during activity
• Promote Nutrition and Elimination
• Small frequent feedings
• Low calorie, cholesterol and Na diet
• Avoid stimulants
• Avoid very hot and cold foods
• Vagal stimulation that can lead to bradycardia and cardiac arrest
• Use bedside commode
• Administers stool softeners
• Promoting relief of anxiety and feeling of well being
• Provide an opportunity for the client and the family to explore their concerns and identify alternative
methods if necessary.
• Facilitate learning
• Teaching is started once the client is free of pain and excessive anxiety.
• Promote positive attitude and active participation of client and family

Teaching and Counseling

Self-Management and Education Guide
• Discontinue smoking
• Control HPN
• Low calorie, saturated fats and cholesterol and low Na intake
• Progressive exercise
• Take prescribe meds
• Sex: after 4-6 weeks from discharge.
• Stress management techniques
• Return to usual home activities,relationships and work at earliest is beneficial
Teaching guide on resumption of Sexual activity
• Assume less fatigue position
• The non –Mi Partner takes the active role
• Perform the activity in a cool, familiar environment
• Take nitrates before
• Refrain from sexual activity during fatiguing day, after eating a large meal, or drinking alcohol.
• If dyspnea is, chest pain, dizziness, palpitations occur moderation should be observed, if symptoms persist __________?
• Develop other means of sexual expression

Complication of MI
• Dysrhythmias • Ruptured myocardium
• Cardiogenic Shock • Ventricular aneurysm
• Thromboembolism • CHF
• Pericarditis

1. CARDIOGENIC SHOCK
• Results from profound left ventricular failure usually from massive MI
• It result in low cardiac output>>>>>systemic Hypoperfusion
• High mortality rate
KENPOGI
 Handout 6

Problems Oxygenation-Perfusion
Cardiovascular Disorders

Care of Clients with Problems in Oxygenation, Fluid and Electrolyte Balance, Infectious Inflammation and Immunity Response, Cellular
Aberration NCM 112 Theory
• Pathophysiology

Collaborative Management

• Monitor hourly output. LOC arrhythmias

• Provide psychosocial support
• Decrease pulmonary Edema
• Crackles and wheezing
• Note: Dyspnea, cough hemoptysis, orthopnea
• Monitor ABG and MAC
• Fowlers Position: reduce venous return
• Administer drug therapy as ordered
• Utilize counter pulsation device
• Mechanical cardiac assistance/ diastolic augmentation)
• Intra-aortic balloon catheter via femoral artery into the aorta
Nursing intervention
• Perform hemodynamic monitoring
• PAP, PCWP Intra arterial BP.
• Oxygen therapy
• Correct Hypovolemia: IV fluid s as ordered
Pharmaco Therapy
• Vasodilators:
• Nitroglycerine, Nitroprusside, Phentolamine
• Inotropic agents:
• Digitalis, Dopamine, Dubotamine
• Diuretics: Furosemide
• Nabicarbonate:
2. Thromboembolism
• When platelets aggregate at the area of necrosis, an attempt of the body to repair the tissue injury.
• Can lead to pulmonary embolism
• Nursing Interventions
• Pharmocotherapy
• Anticoagulants
• Thrombolytics
• Observe signs and symptoms of PE
• Dysnea
• Chest pain
• Coughing
• Hemoptysis
• Rapid weak pulse
• Pallor
• Early ambulation:

3. PERICARDITIS
• An inflammation of the pericardium which occurs approximately 1-6 weeks after acute MI
• Antigen –antibody response
• Pericardial effusion/Cardiac tamponade
• Constrictive pericarditis:
KENPOGI
 Handout 6

Problems Oxygenation-Perfusion
Cardiovascular Disorders

Care of Clients with Problems in Oxygenation, Fluid and Electrolyte Balance, Infectious Inflammation and Immunity Response, Cellular
Aberration NCM 112 Theory
Manifestations:
• Pain
• Anterior chest
• Relieve by upright and leaning position
• Pericardial friction rub:
• Scratching, grating, creaking sound
• Dyspnea
• Fever, sweating, chills
• Joints pain
• Arrhythmias
Nursing Intervention
• Elevate HOB
• Promote Rest
• Administer prescribes pharmacotherapy
• ASA
• Corticosteroids
• Cardiac tamponade: Becks Triad
• Jugular vein distention
• Muffles heart sounds
• Diminished or absent pulse
Mgmt.:
Pericardiocentesis
(aspiration of blood in the pericardial sac)

4. Rupture of Myocardium
• It is common in transmural MI
o There is necrosis is necrosis of the entire heart wall-from the peri cardium to the endocardium
• It causes immediate cardiac tamponade and death

5. Ventricular Aneurysm
• Involves thinning, ballooning and hypokinesis of the left ventricular wall after a transmural MI.
• The dysfunctional area often becomes filled with necrotic debris and clot sometimes is rimmed by the calcium ring.
• The debris or clot may fragment and travel into the systemic arterial circulation, thereby immobilization.
• The aneurysm may rupture causing cardiac tamponade and death
6. CHF
HEART FAILURE
AKA
• Congestive heart failure
• Congestive Cardiac Failure
• Pump Failure
In ability of the heart to provide sufficient pumping action to maintain blood flow to meet the demands of the body.

2 main types
1. LSCHF
2. RSCHF
Cause

Cardiac
• HPN Non- Cardiac
• Arrythmias • Alcohol
• Valvular Heart Defects • Smoking
• Amyloidosis • Obesity
• Ischemic Heart Diseases • Diabetes
• Myocarditis
• Endocarditis

KENPOGI
 Handout 6

Problems Oxygenation-Perfusion
Cardiovascular Disorders

Care of Clients with Problems in Oxygenation, Fluid and Electrolyte Balance, Infectious Inflammation and Immunity Response, Cellular
Aberration NCM 112 Theory

PATHOPHYSIOLOGY

TO THE LEFT TO THE LEFT!!!

KENPOGI
 Handout 6

Problems Oxygenation-Perfusion
Cardiovascular Disorders

Care of Clients with Problems in Oxygenation, Fluid and Electrolyte Balance, Infectious Inflammation and Immunity Response, Cellular
Aberration NCM 112 Theory

TO THE RIGHT TO THE RIGHT

KENPOGI
 Handout 6

Problems Oxygenation-Perfusion
Cardiovascular Disorders

Care of Clients with Problems in Oxygenation, Fluid and Electrolyte Balance, Infectious Inflammation and Immunity Response, Cellular
Aberration NCM 112 Theory

• Diagnostics
1. No gold Standard Test

KENPOGI
 Handout 6

Problems Oxygenation-Perfusion
Cardiovascular Disorders

Care of Clients with Problems in Oxygenation, Fluid and Electrolyte Balance, Infectious Inflammation and Immunity Response, Cellular
Aberration NCM 112 Theory
2. Framingham Criteria
3. Boston Criteria
4. Echocardiogram
5. CXR
6. ECG

Functional Classification(NYHA)

Class DESCRIPTION

I NO LIMITATION is experience in any activities: there are no symptoms from ordinary activities
II Slight MILD LIMITATION OF ACTIVITY; the patient is comfortable at rest or with mild exertion
III Marked LIMITATION OF ANY ACTIVITY: The patient is comfortable only at rest
IV Any physical ACTIVITY BRINGS ON DISCOMFORT AND SYMPTOMS OCCUR AT REST

Framingham CRITERIA
• Requires the simultaneous presence of at least 2 of the following major criteria or 1 major criterion in conjunction with 2
of the following minor criteria:
• STAGES
• Major
• Paroxysmal nocturnal dyspnea • Minor
• Neck vein distension • Bilateral ankle edema
• Rales • Nocturnal cough
• Cardiomegaly • Dyspnea on ordinary exertion
• Acute pulmonary edema • Hepatomegaly
• S3 gallop • Pleural effusion
• Increase intravenous pressure • Decrease in vital capacity by 1/3 from
• Hepatojugular reflux maximum recorded
• Wt loss: 4.5 Kg in 5 days • Tachycardia (> 120bpm)

Boston criteria
• No more than 4 points are allowed from each categories; hence the composite score (the sum of the subtotal from each
category) maximum 12
• Definite Heart Failure: 8-12 points
• Possible Heart Failure: 5-7 points
• Unlikely:4 points or less
Criterion Point Criterion Point
Value Value

Category I: History Wheezing 3

Rest dyspnea 4 Third Heart sound 3
Orthopnea 4 Category III: Chest Radiography

PND 4 Alveolar Pulmonary Edema 4

Dyspnea while walking on level area 2 Interstitial Pulmonary Edema 3

Dyspnea while climbing 1 Bilateral Pleural Effusion 3

Category II: Physical Examination Cardio Thoracic Ratio greater than .0.50 3
HR abnormality (1 pt if 91-110bpm: 2 1 or 2 Upper Zone Flow redistribution 2
points if > 110 bpm)
Jugular venous Elevation(2 pts if > 6 2 or 3
cm H2O;3 pts if > than 6cm H20 plus
hepatomegaly or edema

KENPOGI
 Handout 6

Problems Oxygenation-Perfusion
Cardiovascular Disorders

Care of Clients with Problems in Oxygenation, Fluid and Electrolyte Balance, Infectious Inflammation and Immunity Response, Cellular
Aberration NCM 112 Theory
Lung Crackles (1 pt basilar 2 pts if more 1 or 2
than basilar

Diagnostic tests
• Imaging
• CXR
• ECG/EKG
• Echocardiography
• Blood Test
• CBC
• Na and K
• Measuring Liver function, Renal function
• Body weight monitoring

Management Drugs
• 3 D’s
• Dilators
• ACE inhibitors
• Beta blockers
• Calcium Chanel Blockers
• Diuretics
• Furosemide
• Digitalis
• Digoxin

These are symptoms of digitalis toxicity:

• Confusion.
• Irregular pulse.
• Loss of appetite.
• Nausea, vomiting, diarrhea.
• Fast heartbeat.
• Vision changes (unusual), including blind spots, blurred vision, changes in how colors look, or seeing spots.

Management of Digitalis toxicity

• Breathing Assistance
• If you are having trouble breathing, breathing machines may help. If your heart is beating too slowly or irregularly, you
may be given medication or electric shock therapy (cardioversion).

• Stomach and Blood Cleaning

• To treat toxicity, your doctor might pump your stomach by inserting a tube down your throat. You might also be asked to
take charcoal tablets to lower the level of digitalis in your blood.

• If your condition is extreme, your doctor may use a method called hemodialysis (blood filtering). This will remove
digitalis from your blood. Specific antibodies may also be prescribed to target and lower digitalis levels in your body.

Management CHF L/R

• Moderate physical activity, when symptoms are mild or moderate; bed rest when severe symptoms
• Weight reduction: physical activity and diet modification
• Monitor weight: parameter that can easily be measure at home. Rapid increase is generally due to fluid retention
• Sodium restriction: precipitate or exacerbate heart failure
• Fluid restriction: Px with CHF has diminished ability to excrete free water load
• Behavior modification:
• Low Na diet
• Treatment of anemia
• Surgery:
• Heart Transplant
• Palliative and hospice care:
• Make sure the patient has a medical “POWER OF ATTORNEY” and discussed his or her wishes with
this individual

KENPOGI
 Handout 6

Problems Oxygenation-Perfusion
Cardiovascular Disorders

Care of Clients with Problems in Oxygenation, Fluid and Electrolyte Balance, Infectious Inflammation and Immunity Response, Cellular
Aberration NCM 112 Theory

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