Nursing Practice III - V -​ Except pulmonary artery as it carries

CARDIOVASCULAR deoxygenated blood from right ventricle to the

Comprehensive Phase lungs
Pressure: ⬆️ ⬆️
“Resistance pressure”
Bleeding: Spurting d/t pressure → difficult to control
Cardiovascular Function: Perfusion – delivery of blood containing
oxygen and nutrients to the body ​ ​ Largest: Aorta

●​ Blood - carry oxygen ○​ Veins

-​ Carries deoxygenated blood
●​ Heart - pump blood -​ Towards the heart
○​ Diastole - relaxation phase → filling of chambers -​ Except pulmonary vein as it carries oxygenated
○​ Systole - contraction phase → ejection of blood
Pressure:
pressure”
⬇️
pressure but ⬆️
blood towards the systemic circulation
volume “Capacitance
●​ 4 Chambers
○​ Deoxygenated: Right atrium and Right ventricle Bleeding: Oozing
○​ Oxygenated: Left atrium and Left ventricle Largest: Inferior vena cava

●​ Valves - prevent backflow of blood ○​ Capillaries

○​ Atrioventricular - between atrium and ventricle
■​ Tricuspid valve - right atrium -​ ⬆️
-​ Gas exchange occurs
surface area → ⬆️
diffusion
-​ Located in the pulmonary and systemic
■​ - left atrium
circulation
-​ Contains valves to facilitate venous return and
○​ Semilunar - looks like semi moon; ventricle to atrial
prevents backflow
circulation
-​ Perfusion and oxygenation
■​ Pulmonic valve - right ventricle
■​ Aortic valve - left ventricle
RISK FACTORS
●​ Modifiable
●​ Sounds
-​ Can be controlled
○​ S1 (Lub) - closure of AV valve → start of systole
-​ Focus of health teaching
○​ S2 (dub) - closure of SL valve → start of diastole
■​ Physical inactivity
■​ Obesity
Stroke volume - amount of blood ejected per contraction
■​ Diet
Cardiac output - amount of blood ejected per minute
■​ Alcohol
⬇️
●​ Formula: CO = SV x HR
SV → ⬇️
CO → ⬇️
organ perfusion
■​ Hypertension
■​ Hyperlipidemia
■​ Diabetes mellitus
●​ Blood vessels - transporter of blood → blood circulation
○​ Arteries
●​ Non-modifiable
-​ Carries oxygenated blood
-​ Away from the heart
■​ Age - ⬆️
-​ Cannot be controlled
age = ⬆️risk of cardiovascular disease
Airah B. Bolinbough, RN
 ■​ Sex inflammation of
■​ Family history blood vessels →
thrombus formation
■​ Race: African, American
⬇️
→ obstruction →
perfusion in distal
extremities →
●​ #1 Cause of death in the Philippines: Ischemic Heart
amputation
Disease (2024) Priority in buerger's disease:
Stop smoking

ARTERIAL VENOUS Skin is cool

DISORDER DISORDER
Dependent rubor
Pathophysiology
⬇️
Narrowed arteries →

⬇️perfusion →
oxygenation
Narrowed vein →
backflow d/t gravity
→ blood pooling
(DREP)
Classic sign of arterial
disorder: Dangle legs →
Rubor → Elevated legs →
Example ●​ disease ●​ Venous Pale
●​ Arterial insufficiency
insufficiency ●​ Varicose veins Legs Intervention 💡A = A legs (pababa) 💡V = V legs (pataas)
●​ Venous
thrombo Dangle the legs Elevate the legs for
embolism 15-20 minutes

Clinical Pressure ( ⬆️BP) Warm, Brown Treatment 1. Antiplatelet 1. Anticoagulant -

Manifestations
Absence of hair - d/t Itching - d/t ⬆️WBC 3. ⬇️
2. Stop smoking
Fat diet 2. ⬆️
more aggressive
Venous return
●​ Elevate legs
lack of perfusion
Prolonged ●​ Ambulation
Intermittent standing/sitting ●​ Anti embolic/
claudication - compression
exertion related Edema stockings
⬇️⬆️
Narrow arteries →
O2 supply →
exertion → ⬆️
O2 Dull ache Location Toes (distal) Ankle (proximal)

→
pain
⬆️
demand → hypoxia
lactic acid → Gangrene ✔️
d/t no oxygenation
❌
No pulse and and perfusion →
sensation necrosis

Smoking - nicotine is Thickness Deep Superficial

vasoconstrictor
Smoking → Edges Round and Irregular
widespread

Airah B. Bolinbough, RN
 ●​ Descending - distal to the heart; most common
well-defined
○​ Thoracic
Tissue granulation
/ healing issue
❌ ✔️ ■​ Compression of trachea and bronchi → Dyspnea
■​ Compression of esophagus → Dysphagia
○​ Abdominal - AAA
Color Black Red ■​ Palpate: Thrill, Pulsating mass
Light pink Deep pink ■​ Auscultate: Bruit
If confirmed: Do not palpate → Rupture
Drainage ❌ ✔️ ⭐#1 site of peripheral aneurysm: Popliteal
Layers of Vessel Walls
●​ Tunica Intima - innermost
ABDOMINAL AORTIC ANEURYSM (AAA)
●​ Tunica media - middle muscle #1 site formation: Below the renal artery (distal) - d/t no stable
-​ Contract → vasoconstriction organ
-​ Relax → vasodilation
●​ Tunica externa/adventitia - external layer DIAGNOSTICS
●​ Angiography (Aortogram) - uses contrast
●​ Duplex Ultrasound
ANEURYSM ○​ Ascending: 2D echo
-​ Localized irreversible dilation of arteries and that usually ○​ Descending: Abdominal UTZ
weakens the 3 wall layers
COMPLICATION
Patient population: Older male ●​ Dissection - tearing of tunica media causing separation of
tunica media from tunica externa
Types of aneurysm
●​ Saccular - outpouching; one side; usually in the brain → ⬆️
ICP
●​ Fusiform - circumferential (entire circumference is affected);
○​ Type A - ascending
Mngt: Surgical management (near the heart)
■​ Type I - ascending and descending aneurysm
uniform in all sides; usually in aorta ■​ Type II - ascending aneurysm
○​ Type B (III) - descending aneurysm
Ruptured Mngt: Medication management (away from the heart)
●​ Congenital - fetal defect; cerebral aneurysm
●​ Acquired - forms overtime; aortic aneurysm ●​ Rupture
-​ Tearing of tunica external → hemorrhage → shock
AORTIC ANEURYSM Pain: Severe lower back pain
Cause: Atherosclerosis → weakness wall layers -​ d/t aorta is located at the posterior
Risk factor: Hypertension as it exerts force to the wall layers
Atherosclerosis + Hypertension → irreversible damage RBC: ⬇️
Vital signs: Hypo-TAchy-Tachy

Types of Aortic Aneurysm WBC: ⬆️

-​ d/t blood loss

-​ d/t injury
●​ Ascending - proximal to heart
Airah B. Bolinbough, RN
 Prevention: Antihypertensive drugs ●​ Position: Elevate
Definitive treatment: Surgery via endovascular repair with ●​ Wear: Compression stocking → morning → before going out
insertion of heter (minimally invasive) or open surgery of the bed
●​ Activity: Ambulate to increase venous return
RAYNAUD’S DISEASE
Definition: Cold or stress→ vasospasm → ⬇️
perfusion → pallor →
hypoxia → cyanosis → treatment → reperfusion → rubor
Intervention
●​ Never: Massage → dislodge
●​ Activity: Bed rest
Location: Upper extremities ●​ DOC:
Patient population: Young women ○​ Anticoagulant - 1st line; prevents formation of clot
Reverse: Heat → vasodilation ○​ Thrombolytics - breakdown clot
Avoid:
●​ 2C: Cold; Caffeine HYPERTENSION
●​ 2S: Stress; Smoking -​ Abnormal elevation of BP
DOC: Vasodilator (Nitroglycerine) Strongest risk factor: Aging d/t accumulation of fat deposits and
narrowing of arteries
Raynaud’s Phenomenon: Autoimmune → SLE, RA, Scleroderma –
Raynaud’s s/sx Diagnosis: Blood pressure reading
●​ SBP: 140 mmHg
DEEP VEIN THROMBOSIS ●​ DBP: 90 mmHg
-​ Formation of clots within the deep veins -​ Taken more than or equal to 2x
Assessment: Circumference - usually 1 leg is swelling -​ Taken separate times at least 1 week apart
●​ Sign: Homan’s Signs → dorsiflex the foot → calf pain -​ Position the feet flat on floor
●​ Edema: (+) -​ Arm level should be same level with heart
●​ Warmth: (+) -​ Usual errors in taking BP
Common location: Leg, pelvis ○​ Too tight: False high
Most important risk factor: Immobility ○​ Too loose: False low
Cause: ViRCHow’s Triad -​ Avoid Smoking, Alcohol, Caffeine for at least 30 minutes before
●​ Vessel injury BP taking
-​ Rest for at least 5 minutes
●​ CH 🔃
●​ Reduced blood (venous stasis) - d/t immobility
Hypercoagulability - d/t oral contraceptives
Types of Hypertension
Complication: Pulmonary Embolism ●​ Primary/Essential
Dislodge thrombus → vena cava → RA → RV → PV → Lungs Incidence: 90%
●​ Sign: Sudden SOB Cause: Unknown
●​ Position: Semi-fowler’s to promote lung expansion
●​ Administer: Oxygen ●​ Secondary
Incidence: 10%
Cause: Other conditions
MANAGEMENT
Prevent: ⬆️
venous return ●​ Renal - inability to excrete fluids

Airah B. Bolinbough, RN
 ●​ Endo ⭐150 mins/week
●​ Avoid: Smoking, Alcohol, Caffeine
BP = PVR x CO
●​ Low fluid volume → ⬆️CO → ⬆️BP ⬇️⬇️
●​ Diet: DASH (Dietary Approach to Stop Hypertension)
○​ Na:

Peripheral Vascular resistance (resistance of arteries to blood flow)

○​ Fat:
○​ Fruits & veggies: ⬆️
⬇️ ⬆️ ⬇️ ⬆️
that is determined by vessel diameter
●​ Vasoconstricted blood vessel → small diameter → PVR → BP MANAGEMENT
●​ Vasodilated blood vessel → bigger diameter → PVR → BP BP (>140/90) after 1-3 months: Pharmacologic

Unknown, Related disorder: ⬆️ ⬇️ ⬆️ ⬆️ ⬇️

PVR, CO, BP → chronic arterial
●​ ACE inhibitors
●​ ARBS

●​ Brain: ⬆️
wall injury → narrowed arteries → perfusion → O2 → Organ failure:
pressure in the brain → compression → s/sx
○​ Headache upon waking
Both blocks the RAAS

Normal RAAS: Renin activates the angiotensinogen (precursor) →

-​ Most common characteristic of hypertension Angiotensin I (inactive) → lungs release angiotensin converting enzyme
○​ Neck pain → Angiotensin II → Angiotensin receptors →
○​ ALOC ●​ Vasoconstriction to increase BP in response to hypotension

⬆️ ⬇️ ⬆️ ⬆️⬆️ ⬆️
-​ Dizzy, syncope (effect of hypoxia to brain and is ●​ Increases aldosterone →
the most characteristic sign of cardiac problem) ○​ Vasoconstriction → PVR → BP
○​ Stroke ○​ Na, K→ CO, FV

ACE and ARBS → Blocks RAAS → vasodilation → ⬇️aldosterone →

-​ Brain attack
●​ Heart: ⬆️pressure → chest pain → MI ⬇️PVR, ⬇️BP, ⬇️Na, ⬆️K → ⬇️CO and ⬇️FV
●​ Eyes: ⬆️pressure → blurry vision d/t damage of retina →

1. ACE inhibitors: “-pril” → blocks RAAS → ⬇️BP

retinopathy d/t lack of oxygen to the retina MANAGEMENT
●​ Kidneys: ⬆️pressure → nocturia → oliguria → renal failure
●​ Nose: ⬆️Pressure → epistaxis
●​ Prototype: Captopril
●​ Adverse Reaction: A-C-E-D
●​ Ears: ⬆️pressure → ⬇️oxygen to cochlea → tinnitus
○​ Airway: Angioedema - can cause airway obstruction
NI: Epinephrine → bronchodilation

❌No effect to liver

●​ Peripheral blood vessels: Gangrene, aneurysm
⬇️
○​ Electrolyte: Elevated K - risk for arrhythmia
Diet: K
NI: ECG monitoring

Goal: ⬇️BP
MANAGEMENT ○​ Common: Dry cough
NI: Switch ARBS
WOF: Orthostatic hypotension ○​ Rare: Neutropenia - Risk for Infection
NI: Gradual position changes d/t R/F fall Monitor: Decreased WBC
Health Teaching: Dangle the legs before standing
Initial: Lifestyle

⭐
BMI: Normal thru moderate exercise
30 mins/day
→ ⬇️
2. Angiotensin Receptor Blockers (ARB): “-sartans” → blocks RAAS
BP
-​ Lesser side effects
Airah B. Bolinbough, RN
 ●​ Prototype: Losartan
CI: Teratogenic ❌ ⬇️Heart contractility → HF
●​ Avoid: Grapefruit → toxicity
Not given with Beta blocker →

DIURETICS → ⬆️UO → ⬇️FV → ⬇️CO → ⬇️BP

NI: Contraceptive to lower the adverse effect

SYMPATHETIC RECEPTORS Thiazides - 1st line (K wasting)

SNS - involves 4 receptors ●​ Prototype: Hydrochlorothiazide
Alpha 1: vasoconstriction
-​ Blocking alpha 1 → ⬇️FV → ⬇️ BP
-​ a-1 blocker (-zosin) → vasodilate → ⬇️ PVR → ⬇️
BP
​ Diet: ⬆️
●​ Electrolyte: Hypokalemia
K
●​ Blood sugar: Hyperglycemia
●​ Prototype: Prazosin ​ NI: Monitor CBG
Not 1st line due to risk for postural hypotension ●​ Eyes, skin: Photosensitivity
​ NI: Sunscreen; Sunglasses
Alpha 2: Negative feedback mechanism

-​ Decreases SNS → ⬇️
-​ alpha 2 agonist (stops alpha 1, beta 1 and beta 2)
BP
●​ Prototype: Clonidine, Methyldopa (for pregnant)
Loop diuretics - K wasting
●​ Prototype: Furosemide
CI: Sulfa allergy → “sulf”-mide

❌-​ Central acting on the brain

DO NOT abruptly stop as it may cause rebound
hypertension
Diet: ⬆️
○​ Electrolyte: Hypokalemia
K
○​ Hearing: Ototoxic

❌ NI: Taper
Not given with Beta blocker →
and heart rate → Heart failure
⬇️
heart contractility
NI: Push slowly

❗
UO not increasing within 5-20 minutes → renal problem →
REPORT

⬇️ ⬆️ ⬇️
Beta 1 (heart): tachycardia → contractility
⬇️CO → ⬇️BP → K sparing → ⬆️K

Vasodilate → ⬇️ ⬇️
-​ Blocking beta 1 →
PVR →
HR →
BP
contractility → ●​ Prototype: Spironolactone

Diet: ⬇️K
●​ Adverse effect: Hyperkalemia

B1-blockers: “-olol” CI: “sartan” “-pril” → severe hyperkalemia

●​ Prototype: Metroprolol Administration: Morning to decrease nocturia and incidence of fall
-​ Administer with meals → GI upset for px with orthostatic hypotension
-​ Hold if patient is:
○​ Bradycardia (<60 bpm), Hypotensive (<90/60 mmHg) HYPERTENSIVE CRISIS
○​ Breathing problem: Asthma Blood pressure
○​ Bad for decompensated HF (SOB, Edema) ●​ SBP: 180
○​ Blood sugar masking → hides s/sx hypoglycemia ●​ DBP: 120
●​ Antidote: Glucagon Cause: Non-compliance
“BB Gun”
Types of hypertensive crisis
CALCIUM CHANNEL BLOCKERS: “dipine” ●​ Hypertensive Urgency: No organ damage
●​ Prototype: Amlodipine, verapamil, diltiazem ●​ Hypertension Emergency: With organ damage
○​ Vera and diltiazem causes constipation
Airah B. Bolinbough, RN
Clinical Manifestation ●​ Infarction - damage
●​ Severe headache
●​ Epistaxis DISEASES
●​ Blurry vision 1. Plaque + exertion = Stable angina
●​ ALOC: Dizzy and syncope 2. Plaque + obstruction (partial) = Unstable angina
Plaque + complete obstruction → damaged endocardium = NSTEMI
Treatment: IV antihypertensives via infusion that is continuous Plaque + Complete obstruction → damaged all layers → STEMI
●​ Potent vasodilator: Nitroprusside → 1st line = ACUTE CORONARY SYNDROME
●​ Calcium channel blocker: Nicardipine 3. Vasospasms → prinzmetal/variant angina
●​ Beta blocker: Labetalol

⬇️ ⬇️
ANGINA PECTORIS MYOCARDIAL INFARCTION
❌
Goal: Gradual
Sudden
BP
BP → Hypoperfusion → stroke
●​ Lower the BP by 20-25%
Substernal pain Substernal
Anterior Anterior
●​ Stop at 140/90 Vague, radiates → left arm, jaw, Vague, radiates → left arm,
Position of hypertensive crisis: High Fowler’s → ⬇️BP shoulder
Exertion related
shoulder, & jaw
Occurs even at rest
Relieving factor: Rest, NTG Unrelived by rest and NTG
CORONARY CIRCULATION Short duration <30 minutes Great duration: >30 minutes
Coronary arteries in the superficial area perfuse the heart
Aorta → Phase: Diastole TRIGGERS
●​ Right coronary artery ●​ Exertion
○​ Posterior Descending Artery → Posterior LV, Inferior LV ●​ Emotion strong
●​ Left Coronary Artery ●​ Eating, heavy
○​ Left anterior descending artery → Anterior LV → worst MI ●​ Exposure to heat
○​ Circumflex artery → Lateral wall of left ventricle
TYPES
CORONARY ARTERY DISEASE
Narrowed/blocked coronary artery → ⬇️
Perfusion → ⬇️
O2 → myocardial
tissues → anaerobic respiration → lactic acid → nerve ending irritation
Stable Angina - exertion/stress
●​ Rest, NTG: Relieved
●​ Pattern: Predictable
→ chest pain (hallmark) ●​ Duration: <15 minutes

ATHEROSCLEROSIS Unstable angina - clot → worsening cardiac ischemia

-​ #1 cause of angina ●​ Rest, NTG: Unrelieved
●​ Pattern: Erratic
●​ Arteriosclerosis - stiffening of arterial wall ●​ Duration: >15 minutes
●​ Atheroma - fatty plaque
Prinzmetal Angina - Variant d/t vasospasm → ECG changes: Transient
●​
●​ Ischemia - ⬇️perfusion → ⬇️
Atherosclerosis - stiffening d/t plaque
CO ST elevation
Intractable/Refractory - unresponsive to interventions
Airah B. Bolinbough, RN
DIAGNOSTIC
●​ Troponin, cardiac enzymes: (-) only increased if there is
●​
●​ Tub bath ❌ ❌ ❌
Heavy lifting - → valsalva

myocardial damage
●​ ECG: ST depression, T wave inversion – zone of ischemia
●​
●​
Bending at the waist
“Bleeding, swelling, fever, new bruising, pain” → REPORT ❗
●​ Lipid profile: ⬆️
●​ Cardiac catheterization (coronary angiography): atherosclerosis

●​ Stress testing: Chest pain, ECG changes

LIPID PROFILE
Lipid values: Hyperlipidemia
Diet: NPO 10-12 hours
CARDIAC CATHETERIZATION ●​ Cholesterol: <200
-​ Radiographic examination of the coronary arteries via a catheter ●​ Triglyceride: <150
by pushing a contrast → shows blockage ●​ LDH (bad): <100
-​ Contrast is nephrotoxic ●​ HDL (good): >60

Anesthesia: Local TREATMENT FOR HYPERLIPIDEMIA: “-statin” medications

Sedation: Mild ●​ Taken: ODHS
Most common site: Femoral artery; Radial artery - less complication
●​ Allen’s test - done if catheter is inserted to the radial pulse
●​ S/E: Myalgia - muscle pain
●​ WOF: Liver failure - statins are hepatotoxic → Assess
enzymes (ALT)
⬆️
liver

Pre-procedure:
●​ Priority assessment: Iodine, shellfish allergy STRESS TESTING
●​ Renal function: S-Creatinine; Void ●​ Exercise stress testing - treadmill
●​ Withhold: Blood thinners, metformin – causes lactic acidosis; ●​ Pharmacological (chemical) stress testing - adenosine
stop metformin 48 hours prior
●​ Diet: NPO (6-8 hours) incase there will be complication and there Night prior: Adequate sleep to prevent palpitation causing false
is need to convert in an open surgery positive result
●​ Teaching: Warmth, flushing of skin, metallic taste, false feeling of
urination – normal Avoid:
●​ False positive: Smoking, Alcohol, Caffeine → Palpitation
Post procedure ●​ False negative: NTG because it is the treatment
Goal:
1. Prevent bleeding “Chest pain, ST changes” Stop → Prevent chance of MI → Report
●​ Activity: Rest
●​ Legs: Immobilize; straight
●​ Puncture site: Use sandbag to apply pressure Goal: ⬆️
MANAGEMENT
O2 supply → VASODILATION →
pain → prevents MI
⬇️O2 demand (rest) → ⬇️chest
2. Perfusion
●​ Assessment: Distally for obstruction Nitroglycerin - mainstay → coronary vasodilation → ⬆️perfusion → ⬆️O2
→ ⬇️chest pain
Discharge ●​ S/E: Headache → cerebral vasodilation
●​ Ambulate light ●​ A/E: Hypotension → NI: SIt or lie down to prevent falls

Airah B. Bolinbough, RN
 ●​ Stop: <90/60 mmHg
●​ CI: Sildenafil (viagra) - both vasodilators → severe hypotension
Assess: Pain → ECG ⭐ quickest test to rule out MI
→ death MYOCARDIAL INFARCTION
Priority teaching: Carry sublingual NTG at all times -​ Complete occlusion to coronary arteries → severe hypoperfusion
Sublingual NTG - acute attack or for prevention
●​ Stop and rest before taking meds
→ damage
#1 Complication: Arrhythmia (Premature ventricular Complex →
→ ventricular tachycardia and ventricular fibrillation → Death)
>6⭐
●​ Sobra: Max 3 doses x 5 minutes

●​ Swallow ❌
5 minutes after 3rd dose call 911
- placed under the tongue
●​ Saket - tingling or burning is normal → effective/absorbs in the
CLINICAL MANIFESTATIONS
●​ Chest pain: Levine's Sign
○​ Substernal, sudden, severe, crushing, radiating,
blood stream under the tongue prolonged
❌
●​ Storage - dark and amber
Light, heat, moisture
●​ Six months replacement
●​ Radiation:
○​ Left arm, jaw, shoulder, back
○​ Vagus nerve: Epigastric pain (atypical sign) → Common:
Women
NTG Patch (transdermal) - long term management GI and Heart have the same cranial nerve (CN X)
●​ 1 patch at a time, 1x daily ○​ Time: Morning
●​ Maximum: 14 hours to decrease tolerance ○​ Duration: >30 minutes
●​ Location: Rotate daily ●​ Feeling: Impending doom
○​ Most common: upper body ●​ SNS is activated during MI

❌ ✔️
○​ Area: CLean, dry, hair less Anxiety, Diaphoresis
●​ Shower: because it is waterproof RR: SOB
●​ MRI: due to magnets and it will cause burns
●​ Nurses must wear gloves to decrease headache Kidneys: ⬇️
GI: Nausea and vomiting → CN X
blood perfusion → oliguria
Skin: Pale, cool
MANAGEMENT
1. Beta blocker → ⬇️ BP →⬇️ ⬇️⬆️
heart contractility → O2 demand
2. Calcium channel blocker - prevent vasospasm →
3. Anti platelet - prevents platelet clumping
O2 supply stream → ⬆️
Myocardial enzymes exits the myocardial muscles → leak to blood
cardiac enzymes
​
​
Prototype: Aspirin (ASA)
A/E: Bleeding, tinnitus
●​ Cardiac biomarkers:
○​ Troponin I/T: ⬆️
most reliable, sensitive, and specific
biomarker (protein)
​ CI: Asthma

⬆️⬆️
○​ CK-MB: most sensitive enzyme
4. Anticoagulant - blocks clotting factors (Vitamin K) ○​ Myoglobin: earliest marker but not specific
●​ Heparin ○​ LDG, AST: non commonly used because it is
●​ Warfarin

NURSING INTERVENTION
unspecific
●​ WBC, ESR, CRP:
●​ Heterization: Clot
⬆️
Priority: Oxygen ●​ ECG: Quickest test for MI
Position: Semi-fowler’s for proper lung expansion ○​ Zone of ischemia: T wave inversion
Activity: Rest
Airah B. Bolinbough, RN
 ○​ Zone of injury: ST elevation ●​ Coronary Artery Bypass Grafting (CABG) - detour the
○​ Zone of necrosis: Q-wave indicates past history of MI blockage using graft
Priority: ST elevation - indicated ongoing MI Common graft: Greater saphenous vein of the leg → creating
Abnormal ECG waves: Assess the patient before the ECG new path (like flyover)
●​ Atherectomy - removal of plaque
MANAGEMENT
1.​ Morphine - opioid analgesic AUSCULTATION LANDMARKS
-​ Not the first DOC d/t respiratory effect ●​ All - Aortic valve → Right 2nd ICS Sternal border → S2
-​ Given if unresponsive to NTG ●​ People - Pulmonic → Left 2nd ICS Sternal border → S2
WOF: Respiratory depression ●​ Enjoy - Erbs point → Left 3rd ICS Sternal border → S2
Antidote: Naloxone (Narcan) ●​ Time - Tricuspid → Left 4th ICS Sternal border → S1
2.​ Oxygen - first nursing intervention because no need for MD ●​ Magazine - Mitral → Left 5th ICS Sternal border → S1 → Apex →
order PMI (loudest sound)
Independent: 2L/min
3.​ Nitroglycerin - first DOC for pain VALVULAR PROBLEMS
Route: Sublingual
4.​ Aspirin (antiplatelet)
STENOSIS
Alternative: Clopidogrel
5.​ Thrombolytics - breakdown clots
-​
(contraction) →
→ CO
⬇️
Improper opening of the valves especially during systole phase

⬇️ blood flow → hypertrophy d/t forceful exertion

●​ Prototype: Urokinase, Streptokinase, Alteplase
●​ Given within 6 hours
●​ WOF: Bleeding INSUFFICIENCY/REGURGITATION
●​ Antidote: Aminocaproic Acid (Amicar)
6.​ Position: Semi fowler’s
-​
diastolic phase (relaxation) → ⬇️
Improper closing → backflow → dilated heart chamber during
CO
7.​ Diet:
●​ Na: ⬇️
●​ Cholesterol: ⬇️
Regurgitation heart sound: Murmur - turbulent blood flow; whooshing
sound
●​ Portion: SFF
●​ Avoid: ​Extreme temperature → valsalva PROLAPSE
8.​ Activity: Bed rest without bathroom privilege -​ Bulging of in the left atrium
NI: Bedside commode -​ Hear best a left 5th ICS midclavicular line → systolic, mitral click

10.​ Avoid valsalva maneuver → ⬆️

9.​ Resume sex: 2 flights of stairs without chest pain and SOB

●​ Elimination: Stool softener

oxygen demand Risk factor
●​ Non-modifiable: Women, family hx
●​ Drug: Lactulose ●​ Modifiable: Stress

SURGERY Causes
●​ Angioplasty/PCI/PTCA - repair coronary arteries by inflating ●​ Congenital - fetal defect; Marfan’s syndrome
balloon to place a permanent stent ●​ Acquired - Rheumatic heart disease, Endocarditis, Kawasaki
Nursing intervention: Same with heter disease

Airah B. Bolinbough, RN
Diagnostic: 2D echo Increased preload and afterload = decreased CO

CLINICAL MANIFESTATIONS RIGHT SIDED HEART FAILURE (BACKWARD)

●​ Tachycardia, Palpitations First sign: Venous congestion
NI: Avoid caffeine Second: Systemic s/sx
●​ Chest pain (atypical) ●​ Superior VC: Jugular vein distention
●​ Fatigue, syncope - d/t decreased CO HOB at 30 degrees
●​ Inferior VC: Portal vein hypertension
COMPLICATIONS ○​ Hepatomegaly
Acute: Arrhythmia ○​ Abdomen: Ascites
Long term: Regurgitation ○​ Rectum: Hemorrhoids
○​ Spleen: Splenomegaly
TREATMENT -​ Fx is to breakdown RBC → excessive breakdown of
Asymptomatic: Continue to monitor
Symptomatic: Surgery → ⬆️
blood → excessive hemolysis → hemolytic anemia
bilirubin → jaundice
○​ Legs: Edema; varicosities
SURGERY ○​ Weight: Gain
●​ Valvuloplasty - repair of valve ○​ Cor Pulmonale - backflow of blood to RA → RA is
●​ Valve replacement - overworked
Hemodynamic monitoring: CVP - measurement of CVP determins RSHF

Mechanical valve Bioprosthetic valve LEFT SIDED HEART FAILURE

-​ Made of metal Lungs → LA → Failure of LV → blood backflow to lungs → pulmonary
(titanium) congestion (1st) → cellular hypoxia (2nd) → RAAS activation (3rd;
compensation) → abnormal heart sounds (4th)
Durability 20-30 years 10-15 years

Thromboembolism ⬆️
Increased clot
⬇️ 1st: Pulmonary Congestion
●​ Earliest: SOB
Position:
formation because it ●​ Orthopnea → Flat
is a non-cell type ●​ Paroxysmal nocturnal dyspnea
●​ Lung sounds: Crackles
Anticoagulation Lifelong 3 months ●​ Cough: Moist
●​ Sputum: Pink, frothy

HEART FAILURE
-​ Progressive pump failure of the heart
2nd: Cellular hypoxia →
●​ LOC: Dizzy, Syncope
⬇️
oxygen saturation

Preload ●​ Energy: Weak, fatigue

-​ Stretch of ventricles during diastolic phase ●​ Appetite: Anorexia
Afterload ●​ Nails: Clubbing
-​ Squeeze/peripheral vascular resistance
Airah B. Bolinbough, RN
 ●​ RBC: Polycythemia - kidney releases erythropoietin → Goal: ⬇️
Preload, ⬇️ ⬇️ ⬆️⬇️
Afterload, Cardiac contractility → ⬆️CO
polycythemia → can lead to heart failure
Beta blockers ⬇️ ⬇️
Ace inhibitors & ARBS:
BP →
BP →
Afterload
Afterload

⬇️ Diuretic ⬆️UO → ⬇️FV → ⬇️Preload

3rd: RAAS Activation
●​ K: Hypokalemia

●​ ⬆️
Na → ⬆️
●​ Vasoconstriction: Hypertension
H20 → Retention: oliguria
Digoxin: Digitalis

○​ Stroke volume: ⬆️ → ⬆️CO

●​ (+) Inotropic - Strength

4th: Abnormal Heart sounds ●​ (-) Chronotropic - HR

●​ S3: ventricular Gallop ​ HR <60bpm → Hold
●​ S4: atrial gallop ●​ Digoxin Toxicity: 0.5-2.0 narrow → Administer: same time
Hemodynamic monitoring: Pulmonary arterial pressure (PAP) daily
○​ Nausea
DIAGNOSTIC ○​ Abdominal sign
Human B natriuretic Peptide (BNP) ○​ Visual disturbance - classic sign
●​ hBNP: Confirm HF blood lab test -​ Halo: Yellow or green
○​ Normal value: <100 ○​ Diarrhea
●​ 2D echo: confirm HF - study/procedure ○​ Anorexia
○​ EF: <40% → HF ●​ Antidote: Digibind (Immune fab)
●​ CXR: Cardiomegaly, pulmonary edema

Echocardiogram → UTZ of the heart

💡
●​ K: Hypokalemia increases risk for toxicity (<3.5)
Digoooxin = hypoookalemia
●​ Avoid giving with antacid - decrease absorption
●​ Transthoracic echocardiogram - chest
○​ Teaching: Non-invasive
○​ Intraprocedure Position: Left side lying
Dilators: vasodilation → perfusion →
Dopamine, Dobutamine: (+) inotropes →
⬆️ ⬆️⬆️
O2 → contractility
heart contractility
●​ Transesophageal echocardiogram - esophagus
○​ Pre-procedure NURSING INTERVENTION
​ ​ ​ NPO: 6-8 hours to prevent aspiration Priority: Oxygen
​ ​ ​ Sedation: Moderate Monitoring:
Anesthesia: Topical spray to the throat to ●​ Daily weight - best parameter
decrease gag reflex ○​ >2-3 lbs per day or >5 lbs per week → REPORT
●​ Intra-procedure Position: Left side lying, tilt head ●​ I & O
forward to ensure epiglottis is close and esophageal is ○​ UO: <30cc/hour → REPORT
open ●​ Edema, weight gain → decompensation → REPORT
●​ Post-procedure ●​ SOB, Crackles, Pink frothy sputum → pulmonary edema →
​ Priority: Aspiration → NPO until gag reflex returns REPORT
​ Position: High fowler’s Position:
​ Throat soreness: Lozenges ●​ HOB: Semi fowler’s
●​ Legs: Flat/dangle → ⬇️
venous return

MANAGEMENT Diet:
Airah B. Bolinbough, RN
 ●​ Na ⬇️⬇️
●​ Fluid
<2g/day
<2L/day
●​ Lying - diaphragm umaangat → less thoracic space → more
rubbing of parietal and visceral → more pain

●​ Cholesterol ⬇️
Thirsty: Suck something that is hard (candy)

●​ Avoid Smoking, Alcohol, Caffeine

●​ Orthopneic position (tripod) - sitting down with hands over the
table → diaphragm is lowered → more space for thoracic cavity
→ decrease pain

●​ Rest to ⬇️ ⬆️
Activity: Balance with frequent rest periods
CO DIAGNOSTIC
●​ Activity to function
●​ Fatigue, dyspnea, chest pain → stop → report
Avoid: Valsalva
CBC: ⬆️ ⬆️
Confirmation: 2D echo

ESR, CRP:

MANAGEMENT CAUSES AND TREATMENT

1.​ HOB elevated, Legs of bed flat ●​ Causes
2.​ Oxygen ○​ Infection: Antibiotic IV for 4-6 hours
3.​ Push diuretics
4.​ End Na and H2O
○​ SLE: Immunosuppressants
○​ MI: Dressler’s syndrome
○​ Cancer: Chemotherapy
⬆️
oxygen

LAYERS OF THE HEART ●​ Position: Tripod or orthopneic

●​ Endocardium – innermost ●​ Pain relief: NSAIDs - first line → Concurrent: Colchicine
●​ Myocardium - muscle, middle ●​ Anti-inflammatory - Steroids - 2nd line
●​ Epicardium/Visceral pericardium - outermost ●​ Activity: Rest
●​ Pericardium - sac that protects heart from trauma and infection
○​ Visceral - inner, adheres to the heart CARDIAC TAMPONADE
○​ Parietal - outermost -​ Leaky capillaries → rapid fluid accumulation to pericardial space
○​ Pericardial cavity - contains fluids to prevent friction → compress chambers of the heart
■​ Normal: 10-50 mL -​ Medical emergency
■​ Pericardial effusion: >50ml → slow
■​ Cardiac tamponade: >100-200mL → rapid BECK’S TRIAD

PERICARDITIS
●​ Distant/muffled heart sound - fluid dampens the sound

⬇️
●​ Decreased blood pressure - d/t compressed left ventricle →
→ BP
⬇️CO
-​ Inflammation of the pericardium → rubbing of visceral and
parietal
Sound: Friction rub (scratching sound; paper like scratching each
⬆️
compression of the heart (LV) - ⬇️
○​ Pulsus paradoxus - inhale → lung expand →
>10 mmHg
●​ Distended neck veins → RV fail → backflow → Jugular vein
other; sandpaper like) distention
●​ Location: Left lower sternal border
●​ Best heard: Exhalation, lean forward - heart is closer to the TREATMENT
chest wall Pericardiocentesis - aspiration of pericardial fluid
Classic feature: Chest pain worsen with inhalation ●​ Position: Semi-fowler
●​ Movement → inhalation, coughing, swallowing → increase pain ●​ Needle placement: X-ray

Airah B. Bolinbough, RN
 ●​ Amount of fluid: 2D Echo
●​ Needle attached to ECG - touches myocardium → ECG changes
→ withdraw needle

Airah B. Bolinbough, RN