Care of Patient with Cardiovascular or Peripheral Vascular Disease

an enlarged, dilated portion of an artery that is more than one and a half times the artery's circumference.

paroxysmal thoracic pain and choking feeling caused by decreased oxygen or anoxia of the myocardium

a common arterial disorder characterized by thickening, loss of elasticity, and calcification of arterial walls, resulting in a decreased blood supply

common arterial disorder characterized by yellowish plaques of cholesterol, lipids, and cellular debris in the inner layers of the walls of large and medium-size arteries

slow rhythm characterized by a pulse rate of fewer than 60 beats per minute

neurohormone secreted by the heart in response to ventricular expansion

the restoration of the heart's normal sinus rhythm by delivery of a synchronized electric shock through two metal paddles placed on the patient's chest

term used to describe a variety of conditions that obstruct blood flow in the coronary arteries

the termination of ventricular fibrillation by delivering a direct electrical countershock to the patient's precordium

any cardiac rhythm that deviates from normal sinus rhythm

a foreign object, a quantity of air or gas, a bit of tissue, or a piece of a thrombus that circulates in the bloodstream until it becomes lodged in a vessel

the surgical removal of the intimal lining of an artery

a syndrome traditionally defined as circulatory congestion as a result of the heart's inability to act as an effective pump

an abnormal deficiency of oxygen in the arterial blood

a weakness of the legs accompanied by cramplike pains in the calves caused by poor circulation of the arterial blood to the leg muscles

decreased blood supply to a body organ or part, often marked by pain and organ dysfunction

an occlusion of a major coronary artery or one of its branches with subsequent necrosis of myocardium caused by atherosclerosis or an embolus

an obstruction or closing off in a canal, vessel, or passage of the body

an abnormal condition in which a person must sit or stand to breathe deeply or comfortably

pertaining to the outside, surface, or surrounding area

an abnormal accumulation of fluid in the thoracic cavity between the visceral and parietal pleurae

abnormal increase in the number of red blood cells in the blood

the accumulation of extravascular fluid in lung tissues and alveoli, most often caused by HF

a rapid, regular rhythm origination in the SA node characterized by a HR of 100-150 bpm or more

• pericardium
• myocardium
• endocardium

• right atrium
• right ventricle
• left atrium
• left ventricle

• atrioventricular (AV) valves (2)
• tricuspid valve
• mitral valve
• semilunar valves
• pulmonary semilunar valves
• aortic semilunar valve

SA node-AV node-bundle of His-right and left bundle branches of AV bundle-Purkinje fibers

• two layered, serous membrane that covers the enter heart
• contains serous fluid that allows friction free movement of the heart as it contracts and relaxes
• outer most layer of the heart

• bulk of heart wall
• thickest and strongest layer of heart
• composed of cardiac muscle tissue
• contraction is responsible for pumping blood

• innermost layer of heart
• composed of thin layer of connective tissue
• lines interior of heart, the valves, and the large vessels of heart

muscular partition dividing left and right side of heart

• upper right chamber
• receives deoxygenated blood from the body
• superior vena cava returns blood from head, neck arms
• inferior vena cava returns blood from lower body
• coronary vein returns blood from the heart muscle to the coronary sinus

• lower right chamber
• receives deoxygenated blood from the right atrium
• pumps blood to the lungs via the pulmonary artery to release carbon dioxide and receive oxygen

• upper left chamber
• receives oxygenated blood from the lungs via the pulmonary veins

• lower left chamber
• receives oxygenated blood from the left atrium
• pumps oxygenated blood out through the aorta to all parts of the body

• located between the atrium and the ventricles
• the right AV valve located between the right atrium and the right ventricle called the tricuspid valve
• the left AV is called the mitral valve located between the left ventricle and left atrium

• contains 3 flaps
• located between the right atrium and right ventricle

• contains two cusps
• located between the left atrium and left ventricle

connect the AV valves to the walls of the heart and work with the papillary muscles to make tight seal and prevent backflow

• located between the right ventricle and the pulmonary artery
• blood is pushed out of the right ventricle and travel to the lung via the pulmonary artery

located between the left ventricle and the aorta

• initiates heartbeat
• located in the upper part of the right atrium, just beneath the opening of the superior vena cava
• known as the pacemaker

slows the impulses to allow the atrium to complete contraction and to allow the ventricles to fill

• group of conduction fibers
• divides into right and left branches of AV bundle to travel to smaller branches called Purkinje fibers

stage of contraction

• phase of relaxation
• the period between contraction of the atria or the ventricles during which blood enters the relaxed chambers from the systemic circulation and the lungs

heard when the AV valves close

heard when the semilunar valves close

• tiny blood vessels joining arterioles and venules
• allows exchange of products and byproducts between the tissues and blood

• large vessels carrying blood away from the heart
• branch into tiny vessels called arterioles

vessels that convey blood from the capillaries and return it to the heart

• branches of arteries
• blood vessels of the smallest branch of the arterial circulation
• delivers blood to the tissues

tiny veins that link with the larger veins and return to the heart

artery-arteriole-capillary-venule-vein

the delivery of oxygen and nutrient rich arterial blood to cardiac muscle tissue and the return of oxygen poor blood from this active tissue to the venous system

• largest artery of the body
• composed of four parts: ascending aorta, the arch, the thoracic portion of the descending aorta, the abdominal portion of the descending aorta

one of the two large veins returning blood from the peripheral circulation to the right atrium of the heart

air sacks

superior or inferior vena cava-right atrium-tricuspid valve-right ventricle-pulmonary semilunar valve-pulmonary artery-capillaries in the lungs-pulmonary veins-left atrium-bicuspid valve-left ventricle-aortic semilunar valve-aorta

• Cholesterol <200
• HDL >40
• LDL<100

• family history
• age
• gender
• cultural/ethnic considerations

• smoking
• hyperlipidemia
• hypertension
• diabetes
• obesity
• sedentary lifestyle
• stress
• psychosocial factors

• exercise
• anxiety
• fever
• shock
• medications
• HF
• excessive caffeine
• recreational drugs
• tobacco use

• occasional palpitations
• hypotension
• angina

• sleep
• vomitting
• intracranial tumors
• MI
• drugs
• carotid sinus massage
• vagal stimulation
• endocrine disturbances
• increased intracranial pressure
• hypothermia

• fatigue
• lightheadedness
• syncope

• sudden onset of a rapid heartbeat
• originates in atria
• pulse rate of 150-250

• drugs
• alcohol
• mitral valve prolapse
• emotional stress
• smoking
• hormone imbalance
• usually not associated with heart disease

• palpitations
• lightheadedness
• dyspnea
• angina pain

• electrical activity in the atria is disorganized causing the atria to fibrillate or quiver
• very rapid production of atrial impulses

• cardiac surgery
• longstanding hypertension
• pulmonary embolism
• atherosclerosis
• mitral valve disease
• HF
• cardiomyopathy
• congenital abnormalities
• chronic obstructive pulmonary disease
• thyrotoxicosis

• atrial rate of 350-600
• pulse deficit
• palpitations
• dyspnea
• angina
• lightheadedness
• syncope
• fatigue
• change in LOC
• pulmonary edema

• occurs when a defect in the AV junction slows or impairs conduction of impulses from the SA node to the ventricles
• 3 types-first, second, third

• atherosclerotic heart disease (ASHD)
• MI
• heart failure (HF)
• digitalis toxicity
• congenital abnormality
• drugs
• hypokalemia

• no symptoms for 1st degree
• vertigo, weakness and irregular pulse for 2nd degree
• hypotension, angina, bradycardia and HF for 3rd degree

• PVC's
• abnormal heartbeats that arise from the right or left ventricle
• early ventricular beats that occur in conjunction with the underlying rhythm

• irritability of the ventricular musculature
• exercise
• stress
• electrolyte imbalance
• digitalis toxicity
• hypoxia
• MI

• depends on frequency and effect on hearts ability to pump blood effectively
• some pts may experience:
• palpitations
• weakness
• lightheadedness

• occurs when three or more successive PVC's occur
• ventricular rate is >100bpm

• ventricular musculature of the heart is quivering
• rapid and disorganized ventricle pulsation

• myocardial ischemia
• infarction
• untreated VT
• electrolyte imbalances
• digitalis or quinidine toxicity
• hypothermia

• no cardiac output
• loss of LOC
• lack of pulse
• decrease in blood pressure
• decrease in respirations
• seizures
• sudden death
• defibrillation required within 15-20 seconds

• Subjective: symptoms associated with particular dysrhythmia may include palpitations, skipped beats, nausea, lightheadedness, vertigo, anxiety, dyspnea, fatigue and chest discomfort
• Objective: visual observation, syncope, irregular pulse, tachycardia, tachypnea

• ECG
• Telemetry
• Holter

• Cardioglycoside-Digoxin
• Antidysrhythmic
• Beta adrenergic blockers
• Calcium channel blockers
• inotropic agent
• anticoagulant

• symptomatic relief
• promotion of comfort
• relief of anxiety
• emergency action
• patient teaching
• assess apical pulse
• explain diagnostic and monitoring devices
• teach importance to stop smoking
• teach about medication therapy
• teach how to take pulse
• teach to avoid exercising beyond the tolerance level
• avoid strenuous or isometric activity
• teach reserving energy
• stress management

sudden cessation of cardiac output and circulatory process

• severe VT
• ventricular fibrillation
• ventricular asystole

• abrupt LOC with no response to stimuli
• gasping respirations followed by apnea
• absence of pulse
• absence of blood pressure
• pupil dilation
• cyanosis

• CPR
• A-airway B- breathing C- circulation

• made of titanium
• controls pacing system
• one or more leads placed into the heart
• initiates or controls HR by delivering electrical impulse via electrode to the myocardium
• electrodes placed in right atrium and/or right ventricle
• used when medications don't work for dysrhythmias such as 2nd and 3rd degree AV block

• monitor HR and rhythm by apical pulse
• VS
• LOC checks
• observe insertion site for erythema, edema, and tenderness
• teach medical alert bracelet
• report s/s of failure: weakness, vertigo, chest pain, pulse changes

a cavity or channel within any organ of the body

• occurs when the cardiac muscle is deprived of oxygen
• atherosclerosis of the coronary arteries creates narrowed lumina of arteries which prevents delivery of oxygen rich blood to the myocardiam causing ischemia of the heart muscle

• Pain-described as heaviness or tightness in chest
• Pain is substernal or retrosternal
• pain radiates to: down thelft inner arm to the little finger, upward to jaw and shoulder
• pain described as pressure or squeezing
• may exhibit dyspnea, anxiety, apprehension, diaphoresis, nausea
• symptoms in woman differ. report heaviness, squeezing or pain in the left side of the chest, or pain in the abdomen, arm, mid-back, or scapular pain.
• woman may also c/o palpitations, chest discomfort

• Subjective: pts statement regarding location, intensity, radiation and duration of pain. Sense of impending death. Assess precipitating factors, relief measures.
• Objective: pts behavior, rubbing the left arm or pressing a fist against the sternum. Monitor V/S

• Patient hx
• ECG
• Holter monitoring
• exercise stress test
• Thallium 201 scanning
• PET
• coronary angiography

• control symptoms by reducing cardiac ischemia
• risk factors are identified and corrected if possible
• precipitating factors are identified and avoided
• Antiplatelet aggregation therapy-aspirin
• vasodilators
• beta adrenergic blocking agents
• calcium channel blockers
• nitroglycerin sublingual- up to 3 times

• Coronary artery bypass graft
• percutaneous transluminal coronary angioplasty
• stent placement

• surgical management of pt with ASHD and CAD
• blood flow to the myocardium is through grafts bypassing occluded coronary arteries

• PTCA
• invasive procedure used to widen the narrowing in a coronary artery without open heart surgery
• need to sign consent for CABG when done
• catheter guided by fluoroscopy through the femoral or brachial artery to the coronary arteries where a balloon is inflated against the narrowing wall

• used to treat abrupt or threatened vessel closure after PTCA
• expandable meshlike structures designed to maintain vessel patency by compressing the arterial walls and resisting vasoconstriction
• placed over the angioplasty site to hold vessel open

• promote comfort
• promote tissue perfusion
• promote activity and rest
• promote relief of anxiety and a feeling of well being
• teach the patient and family

• occlusion of a major coronary artery or one of its branches with subsequent necrosis of myocardium caused by atherosclerosis or an embolus.
• interrupted blood supply leads to ischemia
• ischemia lasting 35-45 minutes causes necrosis causing impairment of the ability of the cardiac muscle to contract and pump blood.
• Collateral circulation allows for circulation of blood through new vessels that develop to compensate for the loss of circulation from the occluded artery

• Subjective:
• heavy pressure or squeezing in center of chest behind sternum
• Pain, retrosternal and in heart region, often radiating down the left arm and to the neck, jaw, and teeth
• anxiety
• dyspnea
• weakness, faintness
• nausea
• Objective:
• Pallor
• erratic behavior
• hypotension, shock
• cardiac rhythm changes
• vomiting
• fever diaphoresis

• Serum tests: CK-MB, myoglobin, troponin I, WBC elevated of 12000-15000/mm
• 12 lead ECG-ST segment elevation and development of Q waves. In time the ST segment returns and the T wave inverts
• chest x-ray

• prevention of further tissue injury and limiting the size of the infarction
• rapid diagnosis needed
• medications such as morphine and diazepam use to alleviate pain and anxiety
• continuous IV of amiodarone for PVCs
• Beta adrenergic blockers  early in MI
• Angiotensin converting enzyme (ACE) used after MI to prevent or slow progression of HF
• Calcium channel blockers
• Oxygen
• Fibrinolytic agents used to attempt reprefusion
• Reprefusion needs to happen 3-5 hours after onset of MI
• mortality and infarction size can be significantly reduced if thrombolytic therapy starts within 30-60 minutes of symptom onset

• administer O2
• IV morphine sulfate for relief of pain and anxiety and to reproduce vasodilation
• heparin therapy or unfractionated or low molecular weight heparin to inhibit further clotting and prevent re-occlusion of the coronary artery after the thrombolytic therapy opens the vessel
• antiplatelet agents such as aspirin and ticlopidine to decrease platelet release of tromboxane
• IV nitroglycerin may help patients with left ventricular infarctions
• administer lipid lowering agents
• stool softener to reduce valsalva maneuver

• when heart is no longer able to pump enough blood to sustain the body's metabolic needs
• once called congestive heart failure
• neurohormonal problem as a result of chronic release in the body of substances such as catecholamines (epinephrine and norepinephrine).
• circulatory congestion and compensatory mechanisms may occur
• may develop after an MI, in response to prolonged hypertension or diabetes, or in relation to valvular or inflammatory HD
• Left ventricle is most often affected by coronary atherosclerosis and hypertension, HF usually begins there.
• untreated left sided HF leads to right sided HF

• left ventricle is unable to pump enough blood to meet the body's demands
• decreased cardiac output
• pulmonary congestion-increased pressre in the left side of the heart backs up into the pulmonary system and the lungs become congested with fluid and fluid leaks through the engorged capillaries and permeates air spaces in the lungs

• dyspnea
• paroxysmal nocturnal dyspnea
• orthopnea
• pulmonary crackles
• wheezing
• pink frothy sputum
• cough

• right ventricle is unable to pump effectively against increased pressure in the pulmonary circulation
• most often a result of blood backing up from a failing left ventricle or chronic pulmonary disease (cor pulmonale) and pulmonary hypertension
• results in peripheral congestion and inability to accommodate all the venous blood that is normally returned to the right side of the heart causing it to be reflected backward into the systemic circulation forcing fluid out of the vasculature into interstitial tissue (peripheral edema)

• distended jugular veins
• anorexia, nausea, and abdominal distention
• liver enlargement with right upper quadrant pain
• ascites
• edema in feet, ankles, sacrum, may progress up the legs into thighs, external genitalia, and lower trunk

a gain of 1L of fluid

• Subjective:
• c/o dyspnea, orthopnea, paroxysmal nocturnal dyspnea and cough.
• fatigue
• anxiety
• weight gain
• edema
• psychosocial stress
• major depression
• Objective:
• respiratory distress
• edema
• abdominal distention secondary to ascites
• weight gain
• adventitious breath sounds
• abnormal heart sounds (gallops and murmurs)
• activity intolerance
• jugular vein distention
• oliguria
• cyanosis

• dependent on s/s
• chest xray reveals pulmonary vascular congestion, pleural effusion, cardiomegaly (cardiac enlargement)
• ECG reveals dysrhythmias
• echocardiogram to determine valvular heart diseas, presence of pericardial fluid, HF, and ejection fraction
• pulmonary artery catherization to assess right and left ventricular function
• stress test
• cardiac catherization
• MUGA scanning
• electrolytes, sodium, calcium, magnesium and potassium
• blood chemistry
• LFT
• BNP
• arterial blood gas

• increase cardiac efficiency with digoxin and vasodilators
• ACE inhibitors decrease peripheral vascular resistance, improve cardiac output and have proven to extend lives
• beta blockers to prevent cardiac remodeling (occurs when the left ventricle dilates, hypertrophies and develops a more spherical shape causing stress on the ventricle walls, increasing the magnitude of regurgitation through the mitral valve, and depresses mechanical performance.
• angiotensin II receptor blockers selectively and competitively block the vasoconstrictive and aldosterone secreting effects of angiotensin leading to vasodilation
• lower oxygen requirements of the body systems
• treat edema and pulmonary congestion with diuretics, sodium restricted diet and restricted fluid intake with daily weight

• prevent disease progression and complications
• V/S
• respiratory distress
• pulmonary edema
• monitor s/s of left sided vs right sided HF
• elevate legs to decrease edema
• watch abdominal girth
• monitor body weight
• assess lungs for crackles or wheezes
• note coughing
• note dyspnea
• assess for depression

• assess left ventricular systolic function
• upon discharge and left ventricular ejection fraction is <40% administer ACE inhibitor or angiotensin
• at discharge administer anticoagulant if chronic or recurrent atrial fibrillation
• encourage smoking cessation
• instruct patient on activity, diet medication, f/u appointment, weight monitoring and what to do if symptoms worsen
• provide flu and pneumonia shot
• at discharge institute optional beta blocker therapy for stabilized patients with left ventricular systolic dysfunction who have no contraindications

• provide O2
• administer oxygen by nasal cannula for dyspnea
• semi fowlers or high fowlers position
• energy conservation
• encourage activity within prescribed restrictions
• assist with ADL's
• provide diversionary activities
• monitor for signs of fluid and potassium imbalance
• skin care
• adequate nutritional intake
• monitor constipation
• give prescribed medications
• give pt and family opportunities to discuss concerns
• teach about disorder and self care

• accumulation of extravascular fluid in lung tissues and alveoli, most often caused by HF
• is an acute and extensive, life threatening complication of HF caused by severe left ventricular dysfunction
• fluid from the left side of the heart backs up into the pulmonary vasculature and results in extravascular fluid accumulation in the interstitial space and alveoli

• severe respiratory distress
• frothy sputum
• restlessness
• vague uneasiness
• agitation
• disorientation
• diaphoresis
• severe dyspnea
• tachypnea
• tachycardia
• pallor or cyanosis
• cough
• audible wheezing, crackles
• cold extremities

• chest xray
• arterial blood gas
• Pao2 and Paco2

• simultaneous intervention to promote oxygenation, improve cardiac output and reduce pulmonary congestion
• high fowlers or arms over side of bed with arms supported on bedside table
• morphine sulfate
• oxygen at 40-100%, nonrebreather face mask
• administer sublingual nitroglycerin
• diuretics
• foley
• inotropic agents
• nitroprusside

• O2
• place patient upright with legs in a dependent position to decrease venous return to the heart, relieving pulmonary congestion and dyspnea
• monitor arterial blood gas
• administer drugs
• lung sounds
• emotional support
• V/S
• I&O
• serum electrolytes

• stenosis: thickening of the valve tissue, causing the valve to narrow
• insufficiency: occurs when the valve is unable to close completely
• include mitral stenosis, mitral insufficiency, aortic insufficiency, aortic stenosis, tricuspid insufficiency, tricuspid stenosis, pulmonary insufficiency and pulmonary stenosis
• occur primarily from congenital conditions or hx of rheumatic fever (showing 10-40 post fever)

• mitral valve stenosis-dyspnea on exertion, hemoptysis, fatigue, palpitations, loud accentuated s1, low pitched, rumbling diastolic murmur, atrial fibrillation on ECG
• mitral valve regurgitation-Acute: generally poorly tolerated with fulminating pulmonary edema and shock developing rapidly, new systolic murmur. Chronic: weakness, fatigue, exertional dyspnea, palpitations, and s3 gallop
• aortic valve stenosis-angina, syncope, dyspnea on exertion, heart failure, normal or soft S1, diminished or absent S2
• Aortic valve regurgitation-Acute: abrupt onset of profound dyspnea, chest pain, left ventricular failure and shock. Chronic: fatigue, exertional dyspnea, orthopnea, paroxysmal nocturnal dyspnea, waterhammer pulse, heaving precordial impulses, diminished or absent S1, S3 or S4
• Tricuspid and pulmonic stenosis-Tricuspid: peripheral edema, ascites, hepatomegaly, diastolic low pitched murmur. Pulmonic: fatigue, loud mid systolic murmur

• chest xray
• ECG
• echocardiogram
• cardiac catherization

• activity limitations
• sodium restricted diets
• diuretics
• digoxin
• anti-dysrhythmics
• surgical procedures: open mitral commissurotomy, valve replacement (

rhumatetic fever