Session 7Nadeeka Jayasinghe

OBJECTIVESNursing assessment of a patient with

cardiovascular problemsDiagnostic testsMedical and surgical conditions related to

the cardiovascular system:(Coronary Heart Disease, MI, Cardiogenic shock, endocarditis, myocarditis, pericarditis)

HistoryCurrent and past cardiovascular systemsFamily history of cardiovascular problems (high

blood pressure, increased cholesterol levels, stroke)Other diseases - diabetes, respiratory disordersExercise programHistory of cigarette smokingDiet – salt & fat intakeSymptoms – pain, shortness of breath, fatigue,

palpitations, cough and faintingMedicationLifestyle – social support, stress, coping strategies

Physical AssessmentBlood PressurePulse – strength, equality, regularityApical pulse auscultation – rate, quality,

rhythmSkin – colour, temperature, lesions, edema(ex: pitting edema in patients with congestive

heart failure)

Diagnostic StudiesCan help identify the presence of

cardiovascular diseaseCan be used as a screening tool to recognise

increased risk of developing cardiovascular dieasese (ex: serum lipid level)

Diagnostic studiesCardiac monitoring – continuous observation,

during or after surgery, monitor responses to drug therapy

ECG – 12 leadBlood tests: heamglobin, electrolytes, cardiac

enzymes (CK, troponin)Hemodynamic studies – pressures involved in

blood circulation (heart rate, arterial blood pressure, central venous pressure, stroke volume, cardiac output)

Coronory Artery DiseaseAtherosclerosis is an abnormal accumulation of lipids and fibrous tissues in the vessel wall.

The atheromas (plaque) protrude into the lumen of the vessel, narrowing it and obstructing blood flow.

The thrombus may obstruct blood flow leading to myocardial infarction or sudden death.

Risk FactorsModifiable risk factors:

- Cholesterol levels- Cigarette smoking- Hypertension- Diabetes mellitus

2. Nonmodifiable risk factors:- Age- Gender- Family history- Race

Myocardial Infarction (MI)Myocardial cells are permanently destroyedCaused by reduced blood flow in coronary artery due to

embolus or thrombusPharmacologic Therapy:

- Thrombolytic- Analgesics- ACE inhibitors

Emergency percutaneous transluminal coronary angioplasty

Myocardial InfarctionSigns/Symptoms:

1. Chest pain, substernally with radiation to arm, neck, jaw, or back; and unrelieved by rest or nitrates. 2. Diaphoresis and cool, clammy, pale skin. 3. Nausea and vomiting. 4. Dyspnea. 5. Palpitations or syncope. 6. Restlessness and anxiety. 7. Tachycardia or bradycardia. 8. Hypertension or hypotension

Nursing Management1.Administer prescribed medications, morphine, nitrates, thrombolytic, anticoagulants; or stool softeners during rehabilitation.2. Monitor ECG and cardiac enzymes( CPK,LDH)3. Provide liquids or solid diet as tolerated (low sodium, low cholesterol, low fat)4. Monitor and record vital signs.5. Provide restful environment.6. Psychological support.7. Positioning.

Cardiogenic ShockDecreased cardiac output and evidence of tissue

hypoxia in the presence of adequate intravascular volume. Cardiogenic shock is the leading cause of death in acute MI, with mortality rates of up to 70-90% in the absence of aggressive, highly experienced technical care.

Signs and symptoms: HypotensionAbsence of hypovolemiaClinical signs of poor tissue perfusion (ie,

oliguria, cyanosis, cool extremities, altered mentation)

Cardiogenic Shock - diagnosisBiochemical profileCBCCardiac enzymes (eg, creatine kinase and CK-MB, troponins,

myoglobin, LDH)Arterial blood gasesLactateBrain natriuretic peptideEchocardiography should be performed early to establish the

cause of cardiogenic shockChest radiographic findings are useful for excluding other

causes of shock or chest pain (eg, aortic dissection, tension pneumothorax, pneumomediastinum)

Coronary angiography is urgently indicated in patients with myocardial ischemia or MI who also develop cardiogenic shock

Intensive Care management

Cardiogenic Shock - ManagementFluid resuscitation to correct hypovolemia and

hypotension, unless pulmonary edema is presentPrompt initiation of pharmacologic therapy to

maintain blood pressure and cardiac outputAdmission to an intensive care setting (eg, cardiac

catheterization suite or ICU or critical care transport to a tertiary care center)

Early and definitive restoration of coronary blood flow; at present, this represents standard therapy for patients with cardiogenic shock due to myocardial ischemia

Correction of electrolyte and acid-base abnormalities (eg, hypokalemia, hypomagnesemia, acidosis)

ACTIVITY3 groupsEndocarditis, Myocarditis, PericarditisAnatomy, Etiology, Clinical manifestations /

Causes, Complications, Treatment