MANAGEMENT OF PATIENTS WITH CARDIOVASCULAR & HEMATOLOGIC PROBLEMS¦ By: Amethyst Vic C. Mergal, RN
THE CARDIOVASCULAR SYSTEM
THE HEART
Three layers of the heart: Endocardium Myocardium Epicardium
Four chambers Heart valves Coronary arteries Cardiac
conduction system
Cardiac hemodynamics
HEART FACTS
Your system of blood vessels - arteries, veins and capillaries - is over 60,000 miles long. That's long enough to go around the world more than twice!
The adult heart pumps about 5 quarts of blood each minute - approximately 2,000 gallons of blood each day - throughout the body.
When attempting to locate their heart, most people place their hand on their left chest. Actually, your heart is located in the center of your chest between your lungs. The bottom of the heart is tipped to the left, so you feel more of your heart on your left side of your chest.
HEART FACTS
The heart beats about 100,000 times each day.
In a 70-year lifetime, the average human heart beats more than 2.5 billion times
An adult woman's heart weighs about 8 ounces, a man's about 10 ounces
A child's heart is about the size of a clenched fist; an adult's heart is about the size of two fists.
Blood is about 78 percent water.
HEART FACTS
Blood takes about 20 seconds to circulate throughout the entire vascular system.
The structure of the heart was first described in 1706, by Raymond de Viessens, a French anatomy professor.
The electrocardiograph (ECG) was invented in 1902 by Dutch physiologist Willem Einthoven. This test is still used to evaluate the heart's rate and rhythm.
The first heart specialists emerged after World War I.
PULMONARY CIRCULATION the portion of the
cardiovascular system which carries oxygen-depleted blood away from the heart, to the lungs, and returns oxygenated blood back to the heart. The term is contrasted with systemic circulation.
SYSTEMIC CIRCULATION the portion of the
cardiovascular system which carries oxygenated blood away from the heart, to the body, and returns deoxygenated blood back to the heart. The term is contrasted with pulmonary circulation.
CORONARY ARTERIES
The heart’s own supply of blood
CARDIAC CONDUCTING SYSTEM
GENERAL CARDIAC ASSESSMENT Health history
Demographic information Family/genetic history Cultural/social factors
Risk factors Modifiable: High blood cholesterol, obesity,
smoking, stress, hypertension, diabetes mellitus.
Nonmodifiable: Family history, increasing age, gender, race
ASSESSING CHEST PAIN
COMPARISON OF PHYSICAL CAUSES OF CHEST PAINCharacter
isticM.I. Pericard
itisG.I. Prob
Angina Dis. Aneurysm
P. Embolism
Onset Gradual/ Sudden
Sudden Gradual/ Sudden
Gradual/ Sudden
Abrupt Gradual/ Sudden
Precipitating Factors
At rest / after exercise or emotional stress
Breathing deeply, rotating trunk, yawning
Inflammation of GI parts; increased HCL; medications
After exercise, emotional stress, eating, envt’l changes
Hypertension
Immobility, Prolonged bedrest
Location Substernal, anterior chest, rarely back, radiates to jaw/neck
Precordial; rotates to neck/ left shoulder & arm
Xiphoid to umbilicus
Substernal, anterior chest; poorly localized
Site of rupture; anterior chest or back; between scapula
Pleural area, retrosternal
Quality Crushing, burning, stabbing, squeezing, vicelike
Pleuritic, sharp
Aching, burning, cramplike, gnawing
Squeezing, feeling of heavy pressure; burning
Sharp, tearing, ripping
Sharp, stabbing
COMPARISON OF PHYSICAL CAUSES OF CHEST PAINCharacter
isticM.I. Pericard
itisG.I. Prob
Angina Dis. Aneurysm
P. Embolism
Intensity Asymptomatic to severe; increases with time
Mild to severe
Mild to severe
Mild to moderate
Severe, unbearable; maximal from onset
Aggravated by breathing
Duration 30 min to 1-2 hours; may wax and wane
Continuous
Periodic 2-10 min; ave: 3-5 min
Continuous; does not abate once started
Variable
Relief Narcotics Sitting up, leaning forward
Physical/ emotional rest, food, antacid
Nitroglycerin, rest
Large, repeated doses of narcotics
02 , sitting up; morphine
Associated Symptoms
Nausea, fatigue, heartburn, equal peripheral pulses
Fever, dyspnea, nausea, anorexia, anxiety
N/V, dysphagia, anorexia, weight loss
Belching, indigestion, dizziness
Syncope, loss of sensations / pulses, oliguria, BP discrepancies, decrease in pulses
Dyspnea, tachypnea, diaphoresis, hemoptysis, cough, apprehension
CORONARY VASCULAR DISORDERS Also called
occlusive disorders Arteriosclerosis Angina Pectoris Myocardial
Infarction
ARTERIOSCLEROSIS
Narrowing and hardening of the arteries. Three types:
Atherosclerosis (fatty deposits called plaque on inner lining of vessel walls).
Calcific sclerosis (calcium deposits on the middle layer of the wall of the arteries).
Arteriolar sclerosis (a thickening of the arterioles caused by hypertension).
RISK FACTORS
Increased serum cholesterol (LDL ≥ 160 mg/dl)
Hypertension Cigarette smoking Diabetes Mellitus Family history of
premature CHD
CORONARY ARTERIES
PATHOPHYSIOLOGY
Symptoms are due to myocardial ischemia.
Symptoms and complications are related to the location and degree of vessel obstruction. Angina pectoris Myocardial infarction Heart failure Sudden cardiac death
ANGINA PECTORIS
A syndrome characterized by episodes of paroxysmal pain or pressure in the anterior chest caused by insufficient coronary blood flow
Physical exertion or emotional stress increases myocardial oxygen demand, and the coronary vessels are unable to supply sufficient blood flow to meet the oxygen demand.
TYPES OF ANGINA PECTORIS
ASSESSMENT
Subjective data: PAIN!!!!
Type: squeezing, pressing, burning Location: retrosternal, substernal, left of
sternum, radiates to left arm Duration: short; usually 3-5 mins, <30 mins Cause: emotional stress, overeating, physical
exertion, exposure to cold, may occur at rest Relief: rest, nitroglycerin
Women also complain jaw, upper back pain, & gastric upset
ASSESSMENT
Subjective data: Dyspnea Palpitations Dizziness; faintness Epigastric distress,
indigestion Objective data:
Tachycardia Pallor Diaphoresis ECG changes during attack
ANALYSIS / NURSING DIAGNOSES Altered
cardiopulmonary tissue perfusion related to insufficient blood flow
Pain related to myocardial ischemia
Activity intolerance related to onset of pain
NURSING CARE PLAN
GOAL # 1: provide relief from pain Rest until pain subsides Nitroglycerin (nitrites) Identify precipitating factors:
heavy meals, heavy exercise, stimulants, cold air
Vital signs: hypotension Assist with ambulation:
dizziness, flushing occurs with nitroglycerin
NURSING CARE PLAN
GOAL # 2: provide emotional support Encourage
verbalization of feelings
Reassurance; positive self-concept
Acceptance of limitations
NURSING CARE PLAN
GOAL # 3: health teaching Pain: alleviation, differentiation from M.I.,
precipitating factors Medications: frequency, side effects, dosage,
route.. Diet: restricted calories if weight loss indicated;
restricted fat, cholesterol, gas-forming food; small, frequent meals
Exercise: regular, graded, to promote coronary circulation
Behavior modification Coronary bypass surgery if indicated
EVALUATION/OUTCOME CRITERIA Relief from pain Fewer attacks No myocardial infarction Alters lifestyle; complies with limitations No smoking
MYOCARDIAL INFARCTION irreversible cardiac
damage from occlusion of 1 or more coronary arteries
The term “acute coronary syndrome” includes unstable angina and myocardial infarction
CLINICAL MANIFESTATIONS AND DIAGNOSIS Chest pain, other
symptoms Laboratory tests—
biomarkers WBC: 12000-
15000/µL CK-MB Myoglobin Troponin T or I
ECG changes
EFFECTS OF M.I. ON E.C.G Recent M.I.
ST elevation (injury)
T wave inversion (ischemia)
Previous M.I. Q wave
(necrosis / old infarct)
ASSESSMENT
Subjective data: PAIN!!! Nausea SOB Apprehension
Objective data: VS Diaphoresis Emotional restlessness
ANALYSIS / NURSING DIAGNOSES Decreased cardiac output related to
myocardial damage Impaired gas exchange related to poor
perfusion, shock Pain related to myocardial ischemia Activity intolerance related to pain or
inadequate oxygenation Fear related to possibility of death
NURSING CARE PLAN
Goal # 1: reduce pain / discomfort Narcotics – morphine; note response; Avoid
IM Humidified oxygen 2-4 L/min; mouth care –
O2 is drying Position: semi-Fowler’s to improve
ventilation
NURSING CARE PLAN
Goal # 2: maintain adequate circulation; stabilize heart rhythm Monitor VS/UO; observe for cardiogenic shock Monitor ECG for arrhythmias Medications: antiarrhythmics; anticoagulants;
thrombolytics Diagnostics: cardiac catheterizations, CAB surgery Recognize heart failure: edema, cyanosis, dyspnea,
crackles Check labs: troponin, blood gases, electrolytes, clotting
time CVP: (5-15 cm H2O) increases with heart failure ROM of lower extremities; antiembolic stockings
NURSING CARE PLAN
Goal # 3: decrease oxygen demand/promote oxygenation, reduce cardiac workload O2 as ordered Activity: bedrest (24-48 H) with bedside commode;
planned rest periods; control visitors Position: semi-Fowler’s to facilitate lung expansion
and decrease venous return Anticipate needs of client: call light, water /
Reassurance Assist with feeding, turning Environment: quiet and comfortable Medications: CCBs, vasodilators, cardiotonics
NURSING CARE PLAN
Goal # 4: maintain fluid electrolyte, nutritional status IV (KVO); CVP; vital signs UO: 30 cc/hr Labs: electrolytes (Na, K,
Mg) Monitor ECG Diet: progressive low
calorie, low sodium, low cholesterol, low fat, without caffeine
NURSING CARE PLAN
Goal # 5: facilitate fecal elimination Medications: stool
softeners to prevent Valsalva maneuver; mouth breathing during bowel movement
Bedside commode
NURSING CARE PLAN
Goal # 6: provide emotional support Recognize fear of dying:
denial, anger, withdrawal Encourage expression of
feelings, fears, concerns Discuss rehabilitation,
lifestyle changes: prevent cardiac-invalid syndrome by promoting self-care activities, independence
NURSING CARE PLAN
Goal # 7: promote sexual functioning Encourage verbalization of concerns
regarding activity, inadequacy, limitations, expectations – include partner (usually resume activity 5-8 wks after uncomplicated MI or when client can climb 2 flights of stairs
Identify need for referral for sexual counselling
NURSING CARE PLAN
Goal # 8: health teaching Diagnosis and treatment regimen Caution when to avoid sexual activity: after heavy
meal, alcohol ingestion; when fatigued, stressed; with unfamiliar partners; in extreme temperatures
Information about sexual activity: less fatiguing positions
Support groups / Follow-up care Medications: administration, importance, untoward
effects; pulse taking Control risk factors: rest, diet, exercise, no smoking,
weight control, stress reduction
EVALUATION
No complications: stable vital signs; relief of pain
Adheres to medication regimen Activity tolerance is increased Reduction or modification of risk factors
CONGESTIVE HEART FAILURE inability of the
heart to pump sufficient blood to meet the needs of the tissue for oxygen and nutrient.
PATHOPHYSIOLOGY
ASSESSMENT
Subjective data: Shortness of breath
Orthopnea (sleeps on two or more pillows)
Paroxysmal nocturnal dyspnea (sudden breathlessness during sleep)
Dyspnea on exertion (climbing stairs)
Apprehension; anxiety; irritability
Fatigue; weakness Reported weight gain; feeling
of puffiness
ASSESSMENT
Objective data: VS:
BP: decreasing systolic; narrowing pulse pressure Pulse: pulsus alternans (alternating strong-weak-
strong cardiac contraction); increased. Respirations: crackles; Cheyne-Stokes
Edema: dependent, pitting (1+ to 4+ mm) Liver: enlarged, tender Distended neck veins Chest X-ray: enlarged heart; dilated pulmonary
vessels; lung edema
Left Ventricular Compared with Right Ventricular Heart Failure
LEFT VENTRICUL
AR FAILURE
RIGHT VENTRICUL
AR FAILURE
Pulmonary crackles
Jugular venous
distention
Tachypnea Peripheral edema
S3 gallop Perioral and peripheral cyanosis
Cardiac murmurs
Congestive hepatomega
ly
Paradoxical splitting of
S2
Ascites
Hepatojugular reflux
ANALYSIS / NURSING DIAGNOSES Decreased cardiac output related to decreased
myocardial contractility Activity intolerance related to generalized body
weakness and inadequate oxygenation Fatigue related to edema and poor oxygenation Fluid volume excess related to compensatory
mechanisms Impaired gas exchange related to pulmonary
congestion Anxiety related to shortness of breath Sleep pattern disturbance related to paroxysmal
nocturnal disturbance
NURSING CARE PLAN
Goal # 1: provide physical rest/ reduce emotional stimuli Position: sitting or semi-Fowler’s until
tachycardia, dyspnea, edema resolved; change position frequently; pillows for support
Rest: planned periods; limit visitors, activity, noise. Chair and commode privileges
Support: stay with client who is anxious; have family member who is supportive present; administer sedatives/tranquilizers as ordered
Warm fluids if appropriate
NURSING CARE PLAN
Goal # 2: provide for relief of respiratory distress; reduce cardiac workload Oxygen: low flow rate; encourage deep
breathing (5-10 min q 2H); auscultate breath sounds for congestion, pulmonary edema.
Position: elevating head of bed 20-25 cm (8-10 in) alleviates pulmonary congestion
Medications – digitalis, ACE inhibitors, inotropic agents, diuretics, tranquilizers, vasodilators
NURSING CARE PLAN
Goal # 3: provide for special safety needs Skin care:
Inspect, massage, lubricate bony prominences
Use foot cradle, heel protectors; sheepskin
Side rails up if hypoxic (disoriented) Vital signs: monitor for signs of
fatigue, pulmonary emboli ROM: active, passive; elastic
stockings
NURSING CARE PLAN
Goal # 4: maintain fluid and electrolyte balance, nutritional status Urine output: 30 cc/hr minimum; estimate
insensible loss in client who s diaphoretic. Monitor BUN, serum creatinine, and electrolytes.
Daily weight; same time, clothes, scale IV: IV infusion pump to avoid circulatory overload;
strict I/O Diet
Low sodium Small, frequent feedings Discuss food preferences with client.
NURSING CARE PLAN
Goal # 5: health teaching Diet restrictions; meal preparation Activity restrictions; planned rest periods Medications: schedule (e.g. diuretics in
early morning); purpose; dosage; side effects (pulse taking, daily weights, intake of potassium-containing foods)
Refer to available community resources for dietary assistance, weight reduction, exercise program.
EVALUATION
Increase in activity level tolerance – fatigue decreased
No complications – pulmonary edema, respiratory distress
Reduction in dependent edema
THE HEMATOLOGIC SYSTEM
THE BLOOD
Composition of the blood RBC, WBC, Platelets, Plasma
RBC normal erythropoeisis requires : pyridoxine, Vit B12,
folic acid, protein, copper, cobalt; HEMOBGLOBIN : Iron; Oxygen transport; Acid-base
buffer WBC
granulocytes –neutrophils, eosinophils, basophils agaranulocytes –lymphocytes (T,B), monocytes
Plasma albumin, water, clotting factors, antibodies
IRON DEFICIENCY ANEMIA Composition of the blood
RBC, WBC, Platelets, Plasma
RBC normal erythropoeisis requires : pyridoxine, Vit B12, folic
acid, protein, copper, cobalt;
HEMOGLOBIN : IRON; Oxygen transport; Acid-base buffer
WBC granulocytes –neutrophils, eosinophils, basophils agranulocytes –lymphocytes (T,B), monocytes
Plasma albumin, water, clotting factors, antibodies
PATHOPHYSIOLOGY
CAUSES &EFFECTS
1. Poor intake if iron rich foods
2. Poor absorption & utilization of iron from foods
3. Acute / chronic blood loss
ANALYSIS / NURSING DIAGNOSES Altered nutrition, less than body
requirements, related to inadequate iron absorption
Altered tissue perfusion related to reduction in red cells
Risk for activity intolerance related to profound weakness
Impaired gas exchange related to decreased oxygen-carrying capacity
NURSING CARE PLANS
Goal # 1: promote physical and mental equilibrium Position: optimal for respiratory excursion;
deep breathing; turn frequently to prevent skin breakdown
Rest: balance with activity, as tolerated; assist with ambulation
Keep warm: no hot water bottles, heating pads, due to increased sensitivity
Diet: high in protein, iron, vitamins
NURSING CARE PLANS
Goal # 1: promote physical and mental equilibrium Medication (hematinics)
oral iron therapy (FeSO4) – give with meals IM therapy (iron dextran)
use second needle for injection Z-track inject 0.5 mL of air before
withdrawing needle to prevent tissue necrosis
Rotate sites Do not rub site or allow wearing
of constricting garments after injection
NURSING CARE PLANS
Goal # 2: health teaching Dietary regimen Iron therapy: explain purpose, dosage, side
effects (black/green stools, constipation, diarrhea); take with meals
Activity: exercise to tolerance, with planned rest periods
EVALUATION
Hemoglobin and hematocrit level return to normal range
Tolerates activity without fatigue Selects foods appropriate for dietary
regimen
LEUKEMIA
Fatal neoplastic disease that involves the blood forming tissues of the: Bone marrow Spleen Lymph nodes
Uncontrolled & destructive proliferation of one type of WBC & its precursors
LEUKEMIA
Types: Acute nonlymphocytic (ANLL) – also known as
acute myelogenous leukemia (AML); seen generally in older age (>60 yr).
Acute lymphoblastic (ALL) – common in children 2-10y/o
Chronic lymphocytic (CLL) – generally affects the elderly
Chronic myelogenous (CML) – also known as chronic granulocytic leukemia (CGL); more likely to occur between 25-60 years old.
LEUKEMIA
Risk Factors Viruses Genetic abnormalities Exposure to chemicals Radiation Treatment for other types of cancer (e.g.
alkylating agents)
ASSESSMENT
Subjective data: Fatigue, weakness Anorexia, nausea Pain: joints, bone (acute leukemia) Night sweats, weight loss, malaise
ASSESSMENT
Objective data: Skin: pallor due to anemia; jaundice Fever: frequent infections; mouth ulcers Bleeding: petechiae, purpura, ecchymosis,
epistaxis, gingiva Organ enlargement: spleen, liver Enlarged lymph nodes; tenderness Bone marrow aspiration: increased
presence of blasts
ASSESSMENT
Lab data: WBC – abnormally low (<1000/mm3) or
extremely high (>200,000/mm3); differential is important
RBC – normal to severely decreased Hgb – low or normal Platelets – usually low
ANALYSIS / NURSING DIAGNOSES Risk for infection related to immature or abnormal
leukocytes Activity intolerance related to hypoxia and weakness Fatigue related to anemia Altered tissue perfusion related to anemia Anxiety related to diagnosis and treatment Altered oral mucous membrane related to
susceptibility to infection Fear related to diagnosis Ineffective individual or family coping related to
potentially fatal disease
NURSING CARE PLAN
Goal # 1: prevent, control, and treat infection Protective isolation if indicated Observe for early signs of infection:
Inflammation at injection sites Vital signs changes Cough Obtain cultures
Give antibiotics as ordered Mouth care: clean q2h, examine for new
lesions, avoid trauma
NURSING CARE PLAN
Goal # 2: assess and control bleeding, anemia Activity: restrict; to prevent trauma Observe for hemorrhage: vital signs; body
orifices, stool, urine Control localized bleeding: ice, pressure at least
3-4 min after needle sticks, positioning Use soft-bristle or foam-rubber toothbrush to
prevent gingival bleeding Give blood/blood components as ordered;
observe for transfusion reactions
NURSING CARE PLAN
Goal # 3: provide rest comfort, nutrition Activity: 8 hr sleep or rest; daily nap Comfort measures: flotation mattress, bed cradle,
sheepskin Analgesics: without delay
Mild pain (Acetaminophen; without aspirin) Severe pain (codeine, meperidine HCl)
Diet: bland High in protein, minerals, vitamins Low roughage Small, frequent feedings Favorite foods
Fluids: 3000 – 4000 mL/day
NURSING CARE PLAN
Goal # 4: reduce side effects from therapeutic regimen Nausea: antiemetics, usually half-hour
before chemotherapy Increased uric acid level: force fluids Stomatitis: antiseptic anesthetic
mouthwashes Rectal irritation: meticulous toileting, sitz
bath, topical relief
NURSING CARE PLAN
Goal # 5: provide emotional / spiritual support Contact clergy if client desires Allow, encourage client-initiated discussion
of death (developmentally appropriate) Allow family to be involved with care If death occurs, provide privacy for family,
listening, sharing of grief
NURSING CARE PLAN
Goal # 6: health teaching Prevent infection. Limit activity. Control bleeding. Reduce nausea. Mouth care. Chemotherapy: regimen; side effects.
EVALUATION
Alleviate symptoms; obtain remission. Prevent complications (e.g. infection). Ventilates emotion – accepts and deals
with anger. Experiences peaceful death (e.g. pain
free).
IDIOPATHIC THROMBOCYTIC PURPURA
Potentially fatal disorder characterized by spontaneous increase in platelet destruction
Possible autoimmune response Predominant in 2 – 4-year-olds and
girls/women ≥10 years old Secondary thrombocytopenia – viral
infections, drug hypersensitivity (i.e. quinidine, sulfonamides), lupus, or bone marrow failure Treat cause
ASSESSMENT
Subjective data: Spontaneous skin hemorrhages – lower
extremities Menorrhagia Epistaxis
ASSESSMENT
Objective data: Bleeding: GI, urinary, nasal;
following minor trauma, dental extractions.
Petechiae; ecchymosis Tourniquet test – positive,
demonstrating increased capillary fragility
Lab data Decreased platelets
(100,000/µL). Increased bleeding time
ANALYSIS / NURSING DIAGNOSES Risk for injury related to hemorrhage Altered tissue perfusion related to fragile
capillaries Impaired skin integrity related to skin
hemorrhages
NURSING CARE PLAN
Goal # 1: prevent complication from bleeding tendencies Precautions:
Injections – use small-bore needles; rotate sites; apply direct pressure
Avoid bumping, trauma. Use swabs for mouth care
Observe for signs of bleeding, petechiae, following blood pressure reading, ecchymosis, purpura.
Administer steroids to increase platelet count in ITP; give platelets <20,000-30,000/µL with STP; high-dose immunoglobulins.
NURSING CARE PLAN
Goal # 2: health teaching Avoid traumatic activities:
Contact sports Violent sneezing, coughing, nose blowing. Straining at stool Heavy lifting
Signs of decreased platelets – petechiae, ecchymosis, gingival bleeding, hematuria, menorrhagia
Use MedicAlert tag/card Precautions: self-medication; particularly avoid aspirin-
containing drugs Prepare for splenectomy if drug therapy is
unsuccessful
EVALUATION
Returns for follow-up. No complications (e.g. intracranial
hemorrhage). Platelet count > 200,000/µL. Skin remains intact. Resumes self-care activities.
REFERENCES
Donofrio, J. Haworth, K. Schaeffer, L. Thompson, G. (Eds.). (2005). Cardiovascular care made incredibly easy. Philadelphia: Lipincott Williams & Wilkins.
Lagerquist, S.L. (Ed.) (2005). Davis’s nclex-rn success. (2nd ed.). Philadelphia: F.A. Davis Company.
Topol EJ (Ed.). (2000). Cleveland clinic heart book. New York: Hyperion.