CHAPTER 6 ✚ Cardiovascular System 167 ț Medications not helpful. ț Removal of blood at regular intervals: reduces amount of stored iron in clients with iron overload. ț Heart transplant. What can harm my client? ț Infection. ț Malnutrition. ț Fall/injury. ț Depression. If I were your teacher, I would test you on . . . ț Causes and why. ț Signs and symptoms and why. ț Cardiac physical assessment. ț Diagnostic tests. ț Nursing actions to increase oxygenation. ț End-of-life care. Hypertrophic cardiomyopathy: what causes it and why See Figure 6-2 and Tables 6-10 and 6-11. Table 6-10 Causes Why Uncontrolled hypertension Uncontrolled hypertension causes the ventricles and septum muscle to become hypertrophic. This causes the actual chambers of the heart to become very small and little volume ejects out of the heart, decreasing cardiac output. Less forward flow leads to backward flow Inherited gene The inherited gene affects the cells of the myocardium (sarcomeres) so that there is hypertrophy and asymmetry of the left ventricle Acromegaly Excessive growth of the heart muscle due to overproduction of growth hormone Source: Created by author from References #3, #4, #5, #6, #9, and #10. Enlarged heart muscle Right ventricle AB Left ventricle ǡ Figure 6-2. A. Normal heart. B. Hypertrophic cardiomyopathy. 168 MARLENE HURST ✚ Hurst Reviews: Pathophysiology Review Hypertrophic cardiomyopathy: signs and symptoms and why Table 6-11 Signs and symptoms Why ț Fatigue; weakness ț Late signs include signs and symptoms of left-sided heart failure such as nocturnal dyspnea, S3, pink frothy sputum, cough, crackles, orthopnea, tachycardia, restlessness, shortness of breath Arrhythmias; chest pain Especially seen with inherited HCM. As the heart hypertrophies, there is increased oxy- gen demand. When demand exceeds supply, myocardial ischemia occurs, leading to arrhythmias A second contributing factor is that the size of the ventricle itself impedes coronary perfusion. The stiff large muscle mass creates resistance to coronary perfusion during diastole Palpitations The client can sense the arrhythmias as palpitations Faintness; dizziness Decrease in cardiac output; decreased perfusion to the brain Sudden cardiac death (SCD) Lethal arrhythmias leading to death Source: Created by author from References #4, #5, #6, #9, and #10. The left ventricle becomes a large stiff muscle mass. This leaves very little room to fill the left ventricle with volume. As a result, cardiac output drops. Less ventricular filling and less forward flow results in fluid backing up into lungs. As cardiac output drops, oxygen delivery is decreased Quickie tests and treatments Tests: ț Chest x-ray: shows mild to moderate increase in heart size. ț Thallium scan: reveals myocardial perfusion defects. ț ECHO: shows left ventricular hypertrophy and thick intraventricular septum. ț Cardiac catheterization: measures pressures in the heart chambers if surgery is being considered. ț EKG: shows left ventricular hypertrophy; ventricular and atrial arrhythmias. Treatments: ț Beta-adrenergic blockers: slow heart rate, reduce myocardial oxygen demands, increase ventricular filling by relaxing obstructing muscle. ț Calcium-channel blockers: increase ventricular filling by relaxing obstructing muscle. ț Antiarrhythmic drugs: reduce arrhythmias. Coronary artery circulation occurs during diastole when the ventricles relax. This slows heart rate and increases diastolic time, giving the heart muscle more time for oxygen delivery. CHAPTER 6 ✚ Cardiovascular System 169 ț Cardioversion: treats atrial fibrillation. ț Anticoagulants: reduce risk of systemic embolism with atrial fibrillation. ț Implantable cardioverter-defibrillator (ICD): treats ventricular arrhythmias. ț Ventricular myotomy or myectomy (resection of hypertrophied septum): eases outflow obstruction and relieves symptoms. ț Heart transplant: replaces malfunctioning heart. What will harm my client? ț Not taking antibiotics prior to dental or surgical procedures to reduce risk of infective endocarditis. ț Pulmonary edema. ț Lethal arrhythmias: ventricular tachycardia and ventricular fibrillation. If I were your teacher, I would test you on . . . ț Factors that cause hypertension to lead to heart failure. ț Medications that decrease workload on heart. ț Signs and symptoms of fluid volume excess. ț Effective client coping strategies. ț Medications that are contraindicated. ț Pre- and postop care. ț Causes and why. ț Signs and symptoms and why. ț Safety precautions. Dilated cardiomyopathy: what causes it and why See Figure 6-3, Tables 6-12 and 6-13. Enlarged left and right ventricles AB ǡ Figure 6-3. A. Normal heart. B. Dilated cardiomyopathy. If you are on a beta-blocker, you will stay cool as a cucumber (or your vegetable of choice) if you come home one night and there is a man in a mask waiting for you in your bedroom. Why? Because beta-blockers won’t let you release epinephrine and norepinephrine, so you will just kindly say, “Do I know you?” Many medications commonly used to treat heart failure may not help because they may decrease cardiac output even further. 170 MARLENE HURST ✚ Hurst Reviews: Pathophysiology Review Dilated cardiomyopathy: signs and symptoms and why Table 6-12 Causes Why Chemotherapy Toxic effects of the drugs on the myocardial cells dilate the ventricles and they cannot contract properly. Cardiac output decreases. Signs and symptoms of heart failure are observed Alcohol and drugs Direct toxic effects of alcohol on the myocytes (heart cells) Coronary heart disease Decreased oxygen delivery to the heart muscle leads to pump failure. The heart muscle dies and is replaced by scar tissue. The uninjured heart muscle stretches and thickens to compensate for the lost pumping action Valvular heart disease Increased volume or increased resistance to outflow in the chamber of the heart over time distends the chambers and the muscle becomes stretched, thinned, and weakened Viral or bacterial infections Inflammation of the heart muscle; heart muscle weakens; the heart stretches to compensate, resulting in heart failure Hypertension Ventricles and septum muscle hypertrophy, causing the actual chambers of the heart to become very small and little volume ejects out of the heart, decreasing cardiac output. Less forward flow leads to backward flow Source: Created by author from References #3, #4, #5, #6, #9, and #10. Table 6-13 Signs and symptoms Why Shortness of breath, orthopnea, Left-sided heart failure: ineffective left dyspnea on exertion, paroxysmal ventricular contractility; reduced pumping nocturnal dyspnea, fatigue, ability; decreased cardiac output to body; generalized weakness, dry blood backs up into the left atrium cough at night and lungs Peripheral edema, hepatomegaly, Right-sided heart failure: ineffective right jugular vein distension, ventricular contractility; reduced pumping weight gain ability; decreased cardiac output to lungs; blood backs up into right atrium and peripheral circulation (Continued) CHAPTER 6 ✚ Cardiovascular System 171 Quickie tests and treatments Tests: ț Angiography: rules out ischemic heart disease. ț Chest X-ray: shows moderate to marked cardiomegaly and pulmonary edema. ț Echocardiography: may reveal ventricular thrombi; degree of left ventricular dilation and dysfunction. ț Gallium scan: identifies clients with dilated cardiomyopathy and myocarditis. ț Cardiac catheterization: shows left ventricular dilation and dysfunction, ventricular filling pressures, and diminished cardiac output. ț Endomyocardial biopsy: determines underlying disorder. ț Electrocardiography: rules out ischemic heart disease. Treatments: ț Oxygen therapy. ț ACE inhibitors: reduce afterload through vasodilation. ț Diuretics: reduce fluid retention. ț Beta-adrenergic blockers: treat heart failure. ț Antiarrhythmics: control arrhythmias. ț Pacemaker: corrects arrhythmias. ț Coronary artery bypass graft (CABG) surgery: manages dilated cardiomyopathy from ischemia. ț Valvular repair or replacement: manages dilated cardiomyopathy from valve dysfunction. ț Heart transplant: replaces damaged heart. ț Lifestyle modifications (smoking cessation; low-fat, low-sodium diet; physical activity; abstinence from alcohol/illicit drugs): reduces symptoms and improves quality of life. Table 6-13. (Continued ) Signs and symptoms Why Peripheral cyanosis, tachycardia Low cardiac output Murmur Leaking heart valves Arrhythmia Stretching of the heart muscle leads to abnormal heart rhythms Chest pain; palpitations Arrhythmias may be felt as pain or palpitations Syncope Decreased cardiac output Source: Created by author from References #4, #5, #6, #9, and #10. 172 MARLENE HURST ✚ Hurst Reviews: Pathophysiology Review What can harm my client? ț Pulmonary edema. ț Lethal arrhythmias. ț Malnutrition. ț Infection. If I were your teacher, I would test you on . . . ț Causes and why. ț Signs and symptoms and why. ț Diagnostic tests. ț Medications, proper administration, and possible side effects. ț Client teaching of lifestyle modifications. ț Client care of a pacemaker. ț Complete cardiorespiratory assessment. ț Oxygen safety. ✚ Valvular heart disease Valvular heart disease can affect any of the valves in the heart. Diseased valves may have an altered structure, which changes the blood flow. Disorders of the endo- cardium, the innermost lining of the heart and valves, damage heart valves. Valvular heart diseases include: ț Mitral stenosis. ț Mitral regurgitation. ț Mitral valve prolapse. ț Aortic stenosis. ț Aortic regurgitation. See Table 6-14 for val- vular heart disease at a glance. 173 Table 6-14. Valvular Heart Disease at a Glance Signs and symptoms Quickie tests What can harm If I were your teacher, Type What is it? Causes and why and why and treatments my client? I would test you on . . . Mitral Stenosis Mitral stenosis is narrowing of the mitral valve. The left atrium meets resist- ance as it attempts to move blood for- ward into left ven- tricle. Eventually the left atrium dilates and contractility decreases. Forward flow is decreased and fluid backs up into lungs. Increased volume in the lungs increases pressure in lungs. Remember: more volume, more pres- sure. Pulmonary hypertension in turn can lead to right- sided heart failure ț Acute rheumatic fever or infective endocarditis causes inflamed tissues. When they heal, there is scarring and thickening. This narrows the valves ț Congenital abnor- mality causes the valve to thicken by fibrosis and calcification, obstructing blood flow ț Myxoma (non- cancerous tumor in left atrium) obstructs the blood flow through the mitral valve ț Blood clot reduces blood flow through the mitral valve ț Adverse effect of fenfluramine and phentermine diet drug combination causes the valve to thicken by fibrosis and calcification ț Exertional dyspnea: the narrowed mitral valve decreases filling into the ven- tricles. Decreased volume in ventricle decreases SV and CO. Supply does not meet demand, causing exertional dyspnea. The mitral valve is narrowed, causing backward flow of volume from the left atrium into the lungs, resulting in exer- tional dyspnea ț Orthopnea: fluid accumulates in the lungs and the client sits up to breathe better ț Nocturnal dyspnea: when lying down, all the blood that pools in the extremities during the day returns to the heart. This causes more fluid in the lungs ț Atrial fibrillation: the enlarged left atrium interferes Tests ț Echocardiography: shows blood passing through narrowed valve opening ț Electrocardiography (EKG): reveals left atrial enlargement, right ventricular hypertrophy, atrial fibrillation ț Chest x-ray: shows left atrial and ven- trical enlargement, mitral valve calcification ț Cardiac catheteriza- tion: to determine location and extent of blockage Treatments ț Prevention of rheumatic fever ț Digoxin, low- sodium diet, diuretics, vasodila- tors, ACE inhibitors: treat left-sided heart failure ț Oxygen: increases oxygenation ț Embolitic stroke ț Heart failure ț Infection, espe- cially with valve replacement surgery ț Pulmonary embolism ț Causes and why ț Signs and symptoms and why ț Medication administra- tion, monitoring, and possible side effects ț Diagnostic tests ț Proper cardiorespiratory assessment ț Patient comfort techniques ț Pre- and postop nursing care ț Patient teaching regarding infection, prophylactic antibiotics, and lifestyle modifications (Continued) 174 Table 6-14. Valvular Heart Disease at a Glance (Continued ) Signs and symptoms Quickie tests What can harm If I were your teacher, Type What is it? Causes and why and why and treatments my client? I would test you on . . . with normal con- duction pathways. The atrium no longer contracts or contributes to left ventricular volume as before. Loss of atrial contraction decreases CO even more ț Diastolic murmur: turbulent flow occurs at the nar- rowed valve. Murmur is heard after S2. You will hear lub (S1) dub (S2), whoosh . . . lub dub, whoosh ț JVD, hepatomegaly, peripheral edema, weight gain, ascites, epigastric discomfort, tachy- cardia, crackles, pul- monary edema: fluid in the lungs causes increased pressures in the lungs—pulmonary hypertension. Pulmonary hyper- tension leads to right sided heart failure. These signs ț Anticoagulants: prevent thrombus formation around diseased or replaced valves ț Prophylactic antibi- otics before and after surgery and dental care: pre- vent endocarditis ț Nitrates: relieve angina ț Beta-adrenergic blockers or digoxin: slow ventricular rate in atrial fibrillation/flutter ț Cardioversion: con- verts atrial fibrilla- tion to sinus rhythm ț Balloon valvulo- plasty: enlarges orifice of stenotic mitral valve ț Prosthetic valve: replaces damaged valve that can’t be repaired 175 Mitral Insufficiency/ Regurgitation The mitral valve does not close properly during ven- tricular systole, causing backward flow of blood during systole. This back- ward flow can cause heart failure ț Infective endo- carditis or rheumatic heart disease causes inflammation and damages the valve ț Coronary artery disease: ischemia and/or necrosis of the heart muscle can cause damage to the supporting struc- tures of the mitral valve, impeding proper closure of the valve ț Aging: over time, degenerative changes can weaken the valve and symptoms are related to right- sided heart failure ț Peripheral and facial cyanosis: hypoxemia ț Hemoptysis: high pressure causes a vein or capillaries in the lungs to burst ț Fatigue; weakness: during ventricular systole, blood backs up into left atrium. The left side of the heart, both the atrium and ventri- cles, hypertrophy and dilate. Cardiac output decreases. There is an imbal- ance between sup- ply and demand, causing fatigue in the client ț Pansystolic murmur: murmur heard through all of sys- tole as blood backs up into left atrium. If S1 and S2 are audible, the murmur will be heard between these two sounds: lub, “whoosh,” dub ț Angina: decreased coronary artery circulation Tests ț Auscultation: presence of heart murmur ț Electrocardiography (EKG): shows left ventricle enlargement ț Chest x-ray: shows left ventricle enlargement; fluid accumulation in the lungs ț Echocardiography: shows the faulty valve and amount of blood leaking Treatment ț Anticoagulants: prevent clots ț ACE inhibitors: treat mild heart failure ț Valvuloplasty: repairs the faulty valve ț Valve replacement: with a prosthetic valve ț Severe pulmonary edema ț Embolitic stroke ț Heart failure ț Infection, espe- cially with valve replacement surgery ț Pulmonary embolism ț Causes and why ț Signs and symptoms and why ț Pre- and postop care ț Proper cardiorespira- tory assessment ț Diagnostic tests ț Patient teaching regarding infection and valve replacement surgery ț Medication administra- tion, monitoring, and side effects ț Signs, symptoms, and management of thrombosis and pul- monary embolism (Continued) 176 Table 6-14. Valvular Heart Disease at a Glance (Continued ) Signs and symptoms Quickie tests What can harm If I were your teacher, Type What is it? Causes and why and why and treatments my client? I would test you on . . . The valve cusps bulge into the left atrium when the left ventricle con- tracts, allowing leakage of small amount of blood into the atrium ț Connective tissue disorders (systemic lupus erythe- matosus, Marfan’s syndrome): the chordae tendineae can become elon- gated, which allows the mitral valve leaflets to open backward into the atrium during systole. Remember: backflow equals heart failure ț Congenital heart disease: auto- somal dominant ț Palpitations: heart- beats are more forceful because the left ventricle has to pump more blood to compensate for the leakage back into the left atrium ț Late signs include signs and symp- toms of left-sided heart failure: noc- turnal dyspnea; S3; pink, frothy sputum; cough; crackles; orthopnea; tachy- cardia; restlessness ț Fatigue; weakness: during ventricular systole, blood backs up into left atrium. The left side of heart, both the atrium and ventri- cles, hypertrophy and dilate. Cardiac output decreases. There is an imbal- ance between sup- ply and demand, causing fatigue in the client ț Angina: decreased coronary artery circulation ț Prophylactic anti- biotics before and after surgery and dental care: prevent endocarditis ț Nitrates: relieve angina Tests ț Auscultation: reveals clicking sound; murmur when left ventricle contracts ț Echocardiography: shows the prolapse and determines the severity of regurgitation if present ț Electrocardiography (EKG): may reveal atrial or ventricular arrhythmia ț Holter monitor for 24 hours: may show arrhythmia ț Arrhythmias ț Infective endocarditis ț Mitral insuffi- ciency from chordal rupture Mitral Valve Prolapse ț Causes and why ț Signs and symptoms and why ț Medication administra- tion, monitoring, and side effects ț Proper cardiorespira- tory assessment ț Assessment and treat- ment of infection ț Patient education regarding rest periods, signs of possible depression, safety measures ț Antibiotics before sur- gical, dental, medical procedures and why? To prevent infection of the heart valve [...]... lifestyle modification ✚ Thoracic aortic aneurysm What is it? Thoracic aortic aneurysm occurs in the part of the aorta that passes through the chest (thorax) It is an abnormal widening of the ascending, transverse, or descending part of the aorta (Tables 6 -3 3 and 6 -3 4) What causes it and why Table 6 -3 3 Causes Why High blood pressure Every ventricular contraction causes a shearing or pulsatile force... #6 A recommendation of attending Happy Hour at least 3 to 4 times a week is not good for treating atherosclerosis or arteriosclerosis Sorry 192 MARLENE HURST ✚ Hurst Reviews: Pathophysiology Review CLASSIFICATION OF BLOOD PRESSURE FOR ADULTS See Tables 6-2 6 and 6-2 7 Table 6-2 6 Systolic (mm Hg) Diastolic (mm Hg) Normal Ͻ120 Ͻ80 Prehypertension 120– 139 80–89 Stage I hypertension 140–159 90–99 Stage II... surges through, separating (dissecting) the middle layer of the wall from the still-intact outer layer This forms a new false channel in the wall of the aorta (Tables 6 -3 5 and 6 -3 6) What causes it and why Table 6 -3 5 Causes Why High blood pressure Pressure of the blood flow deteriorates the artery’s wall Hereditary connective-tissue disorders: Marfan’s syndrome, Ehlers–Danlos syndrome Artery wall becomes... author from References #4 to #6 1 83 184 MARLENE HURST ✚ Hurst Reviews: Pathophysiology Review Chronic pericarditis: what is it? Chronic pericarditis (Tables 6-1 9 and 6-2 0) is the result of continued irritation to the pericardial lining The lining becomes thickened and stiff and the client may develop restrictive pericarditis Chronic pericarditis: what causes it and why Table 6-1 9 Causes Why Uremia Chronic... aneurysm Note: Cerebral aneurysms are not discussed in this section See Tables 6 -3 1 and 6 -3 2 (Refer to Chapter 9 for more information on cerebral aneurysms.) What is it? An aortic abdominal aneurysm (bulge in the wall of the aorta) is located in the part of the aorta that passes through the abdomen What causes it and why Table 6 -3 1 Causes Why Atherosclerosis Atherosclerotic changes lead to weakening of... determines if angiography or coronary artery bypass surgery (CABS) is needed ț Holter monitor: detects silent ischemia and angina 189 190 MARLENE HURST ✚ Hurst Reviews: Pathophysiology Review Treatements: ț Lifestyle modifications: low-fat, low-sodium, high-fiber diet; decreased alcohol intake; smoking cessation; weight loss program; exercise program ț Nitrates: decrease cardiac pain caused by angina by vasodilating... techniques ț Signs and symptoms of end-organ damage Rule: No fat ϭ No fun I guess I will have to give up my fried chicken, rice and gravy, and macaroni and cheese 1 93 194 MARLENE HURST ✚ Hurst Reviews: Pathophysiology Review ✚ Coronary artery disease What is it? Coronary artery disease is a condition in which the blood supply to the heart muscles is completely or partially blocked CAD is due to atherosclerosis... (becoming an embolus) and block another artery farther downstream As the coronary artery becomes blocked, the supply of oxygen-rich blood to the heart muscle decreases, causing ischemia This can lead to angina and MI (see Tables 6-2 8, 6-2 9 and 6 -3 0) What causes it and why Table 6-2 8 Causes Why Atherosclerosis Fatty plaques deposit and narrow the arteries over time Congenital defects Irregular vessel shapes... prone to tearing Source: Created by author from References #4 to #6 202 MARLENE HURST ✚ Hurst Reviews: Pathophysiology Review Signs and symptoms and why Table 6 -3 6 Signs and symptoms Why Severe pulsating chest and back pain As the aneurysm increases in size with each shearing force, the layers of the aorta rip apart Cyanosis to lower extremities With every ventricular contraction, blood is being pumped... system, however, remains intact This is known as pulseless electrical activity 188 MARLENE HURST ✚ Hurst Reviews: Pathophysiology Review Ǡ Figure 6-6 Atherosclerosis Buildup of fatty substances in the wall of the artery decreases the size of the lumen What causes it and why Table 6-2 3 Causes Why Repeated injury to the artery wall Immune system involvement or direct toxicity allows materials to deposit . actions to increase oxygenation. ț End-of-life care. Hypertrophic cardiomyopathy: what causes it and why See Figure 6-2 and Tables 6-1 0 and 6-1 1. Table 6-1 0 Causes Why Uncontrolled hypertension. contraindicated. ț Pre- and postop care. ț Causes and why. ț Signs and symptoms and why. ț Safety precautions. Dilated cardiomyopathy: what causes it and why See Figure 6 -3 , Tables 6-1 2 and 6-1 3. Enlarged. atrium ț Late signs include signs and symp- toms of left-sided heart failure: noc- turnal dyspnea; S3; pink, frothy sputum; cough; crackles; orthopnea; tachy- cardia; restlessness ț Fatigue; weakness: during