CARDIOVASCULAR

NCLEX REVIEW
PART ONE

1- ANATOMY AND PHYSIOLOGY

 Epidemiology

 worldwide, millions of new cases of rheumatic fever are

reported each year
 rheumatic fever follows a group A streptococcal infection -
prevention is simply to find and treat streptococcal pharyngitis
 with malnutrition and crowded living, rheumatic fever is most
common in children between the ages of five and 15
 rheumatic fever strikes most often during cool, damp weather.
In the U.S., it is most common in the northern states
 no one knows how and why group A streptococcal infections
cause the lesions called Aschoff bodies
 damage depends on site of infection: most often the mitral
valve in females and the aortic valve in males
 malfunction of these valves leads to severe pericarditis, and
sometimes pericardial effusion and fatal heart failure. Of those
who survive this complication, about 20% die within ten years
 Anatomy and Physiology

Anatomy
1-Layers
 Pericardium: fibrous sac that
encloses the heart
 Epicardium: covers exterior
surface of heart muscle
 Myocardium: muscular portion
of the heart
 Endocardium: lines cardiac
chambers and covers surface
of heart valves
Anatomy Continue

2-Chambers of heart (
illustration)
 Right atrium:
collecting chamber
for incoming
systemic venous
system
 Right ventricle:
propels blood into
pulmonary system
 Left atrium: collects
blood from
pulmonary venous
system
 Left ventricle: largest
thick-walled muscle
that acts as a high-
pressure pump which
propels blood into
the systemic arterial
system
 Anatomy Continue

3- Heart valves: membranous

openings that allow one way
blood flow
 Atrioventricular valves:
prevent backflow from
ventricles to atria during
systole
 Tricuspid - valve between
right atrium and right
ventricle
 Mitral - valve between left
atrium and left ventricle
 Semilunar valves prevent
backflow from aorta and
pulmonary arteries into
ventricles during diastole
 Pulmonic - valve
between the right
ventricle and
pulmonary artery
 Aortic - valve between
left ventricle and aorta
 Anatomy Continue

4- Blood supply to heart

 Arteries - coronary
 Right supplies right
ventricle and the
back part of the left
ventricle
 Left supplies mostly
left ventricle and
septum
 Veins
 Coronary sinus - wide
venous channel that
drains five coronary
veins into the right
atrium
 Thebesian - the
smallest coronary
veins drain some
venous blood directly
into the right atrium
and ventricle and the
left ventricle
 Anatomy Continue

 Veins

 Coronary sinus - wide

venous channel that
drains five coronary
veins into the right
atrium

 The besian - the smallest

coronary veins drain
some venous blood
directly into the right
atrium and ventricle and
the left ventricle
Anatomy Continue

5- Conduction system
 SA (Sinoatrial) node
-referred to as the
pacemaker of the heart,
and located in the right
atrium
 Junctional tissue - often
referred to as the
atrioventricular node (AV
node)
 Bundle branch Purkinje
system - the electrical
system located in the
septum and into cardiac
tissues
 Physiology

 Physiology

1-Function of the heart is the

transport of oxygen,
carbon dioxide, nutrients
and waste products
Physiology Continue

2- Cardiac cycle consists of:

 Systole - The phase of
contraction during
which the chambers
eject blood
 Diastole - The phase of
relaxation during which
the chambers fill with
blood
 When the heart pumps,
myocardial layers
contract and relax
 The atria and ventricles
work in an
asynchronous manner
 Physiology Continue

3- Blood flow:
 Deoxygenated blood enters
the right atrium through the
superior and inferior venae
cavae
 This blood enters the right
ventricle through the tricuspid
valve
 Then the blood travels through
the pulmonic valve to the
pulmonary arteries and into
the lungs
 Oxygenated blood returns
from lungs through the
pulmonary veins into the left
atrium
 The blood then enters the left
ventricle through the bicuspid
(mitral) valve
 Finally, the blood, from the left
ventricle, goes through the
aortic valve into the aorta and
Physiology Continue:

4- The heart itself is supplied with

blood by the left and right
coronary arteries, which are
found at the base of the aorta
above the aortic valves
 Physiology Continue

 The vascular system is a

continuous network of blood
vessels
 The arterial system
consists of arteries,
arterioles and capillaries
and delivers oxygenated
blood and nutrients to
tissues
 Oxygen, carbon dioxide,
nutrients, and metabolic
waste are exchanged at
the capillary level
 The venous system, veins
and venules, returns the
blood with carbon dioxide
and metabolic wastes to
the heart
 Epidemiology
 Epidemiology
 May be acute or chronic
 May occur at any age
 Pericarditis may occur in up
to 15% of persons with a
transmural infarction.
 Findings
 Sharp chest pain often
relieved by sitting upright and
leaning forward
 Pericardial friction rub
 Dyspnea
 Fever, sweating, chills
 Dysrhythmias and EKG
changes
 Pulsus paradoxus
 Client cannot lie flat without
severe pain or dyspnea
DATA COLLECTION FOR CLIENTS WITH
CARDIOVASCULAR DISORDERS
 Diagnostics

 Diagnostics
 History and physical exam
 Serum
 increased
 white blood cells
 sedimentation rate
 positive
 blood cultures if infection
 Antinuclar antibody (ANA) if due to connctive tissue
disease
 EKG changes on 12-lead
 Echocardiography: to determine pericardial effusion or cardiac
tamponade
 Medical Management

 Medical Management
 Antibiotics: to treat underlying infection
 Corticosteroids: if no response to NSAID or if effusion
 Anti inflammatory/analgesics: NSAID, ASA
 Avoid anticoagulants because they may increase the possibility
of cardiac tamponade from bleeding risk
 Oxygen: to prevent tissue hypoxia
 Surgical
 Emergency pericardiocentesis if cardiac tamponade
develops
 For recurrent constrictive pericarditis, partial
pericardiectomy (pericardial window) or total
pericardiectomy

 Nursing interventions
 Manage pain and anxiety
 Semi-Fowler's or high-Fowler's position
 Mild analgesics to keep pain at 0 to 2; on a scale of 1 to 10
 Medications to treat cause

  

 The Cardio-Care Six

The Cardio-Care Six

THE CARDIO-CARE SIX: A,B,C,D,E,F

 ADL: Help the client with activities of daily living and how to schedule
activities that minimize cardiac stress.
 Bed rest
 Commode at bedside (it is less stressful to the heart than using a bedpan)
 Diversions: offer diversions that don't stress the heart (e.g., no hand-held
electronic games).
 Elevate head of bed or sit client up to a position of comfort.
 Feelings: plan time for the client to express his concerns.
Client and Family Teaching - Teach the
Cardio Five

 Maintain a pericardiocentesis set at the bedside in case of

cardiac tamponade
 Assess respiratory, cardiovascular, and renal status q 1 to 2
hours in acute phase
 Observe for pericarditis complications
 dysrhythmias

 cardiac tamponade

 heart failure

 Observe for signs of infiltration or inflammation at the

venipuncture site, a possible complication of long-term IV
administration. Rotate the IV sites often.
 TEACH THE CARDIO FIVE: TDDDS

 Tests and treatments: discuss them in simple, culturally

sensitive ways.

 Drugs, their side effects, how long client will take them, and
their expected effects.

 Diet: balanced nutrition and restrictions (such as low sodium).

 Disease, its management, when and what signs to report

promptly: the 'watch-for s'.

 Smoker? Stress benefits of stopping smoking, minimization of

other stimulants - caffeine, chocolate, nonprescription drugs,
herb cautions
 
 Myocarditis

 Myocarditis
 Definition - An inflammatory condition of the myocardium
 Epidemiology / Etiology
 May be acute or chronic and may occur at any age.
 Usually an acute virus and self-limited, but it may lead to acute
heart failure.
 Etiologies:
 Viral infection

 Bacterial infection

 Fungal infection

 Serum sickness

 Rheumatic fever

 Chemical agent

 As a complication of a collagen disease, i.e. SLE

Myocarditis

 Findings
 Depends on the type of infection, degree
of myocardial damage, capacity of
myocardium to recover, and host
resistance
 May be minor or unnoticed: fatigue and
dyspnea, palpitations, occasional
precordial discomfort manifested as a
mild chest soreness and persistent fever
 Recent upper-respiratory infection with
fever, viral pharyngitis, or tonsillitis
 Cardiac enlargement
 Abnormal heart sounds

 Possibly signs of heart failure such as

pulsus alternans, dyspnea and crackles
 Tachycardia disproportionate to the
degree of fever
Myocarditis
 Myocarditis

Nursing intervention

 the cardio-care six with modified bedrest

and less help with ADLs
 THE CARDIO-CARE SIX: A,B,C,D,E,F
 ADL: Help the client with activities of daily
living and how to schedule activities that
minimize cardiac stress.
 Bed rest
 Commode at bedside (it is less stressful to
the heart than using a bedpan)
 Diversions: offer diversions that don't stress
the heart (e.g., no hand-held electronic
games).
 Elevate head of bed or sit client up to a
position of comfort.
 Feelings: plan time for the client to express
his concerns. 
 assess for edema ; weigh daily; record
intake and output (figure)
Myocarditis

 assess for edema ; weigh

daily; record intake and
output
 monitor cardiovascular
status
 watch for signs of left-
sided heart failure
(dyspnea, hypotension
and tachycardia)
 check often for changes in
cardiac rhythm or
conduction

 monitor arterial blood gas

levels as needed to
ensure adequate
oxygenation
Myocarditis
 Endocarditis

 Definition and related terms

 an infection of the endocardium, heart valves, or cardiac
prosthesis resulting from bacterial or fungal invasion.
 endocarditis can be classified as
 native valve endocarditis
 endocarditis in I.V. drug users
 prosthetic valve endocarditis
 Epidemiology
 with proper treatment about 70% of clients recover.
 the prognosis is worse when endocarditis damages
valves severely or involves a prosthetic valve
 infective endocarditis occurs in 50 to 60% of clients with
previous valvular disorders.
 systemic lupus erythematosus (SLE) often leads to
nonbacterial endocarditis.
 in 12% to 35% of clients with subacute endocarditis,
lesions produce clots that show the findings of splenic,
renal, cerebral or pulmonary infarction, or peripheral
vascular occlusion.
 Endocarditis

 especially, a murmur that

changes suddenly, or a new
murmur that develops in the
presence of a fever
 fever
 pericardial friction rub
 anorexia
 malaise
 clubbing of fingers
 petechiae of the skin,
especially on the chest;
conjunctiva, oral mucosa,
abdomen
 splinter hemorrhage under
the nails
 Endocarditis

 neurologic sequelae of embolus  

 infarction of spleen: pain in the upper left quadrant of
abdomen, radiating to the left shoulder, and abdominal
rigidity
 infarction in kidney: hematuria, pyuria, flank pain, and
decreased urine output
 infarction in brain: hemiparesis, aphasia, and other
neurologic deficits
 infarction in lung: cough, pleuritic pain, pleural friction
rub, dyspnea and hemoptysis
 peripheral vascular occlusion: numbness and tingling in
an arm, leg, finger, or toe, or signs of impending
peripheral gangrene
 SIGNS OF VENOUS INSUFFICIENCY
IN THE LOWER EXTREMITIES
 Skin color reddish brown or cyanotic if extremity lowered
 Normal temperature
 Normal pulse
 Often marked edema, usually foot to calf
 Brown pigmentation around ankles
 Diagnostics
 health history
 lab data
 CBC - elevated WBC
 blood cultures - positive for microbe
 ESR - elevated
 CXR - to detect heart failure or cardiomegaly
 transesophageal echocardiogram to detect vegetation and abscesses on
valves
 EKG to detect dysrhythmias
  
 Management - Clients at risk for prosthetic valves
 prophylaxis - to prevent endocarditis; i.e. MVP, cardiac lesions
 antibiotics - to treat underlying infection
 antipyretics - to control fever
 anticoagulants - to prevent embolization
 oxygen - to prevent tissue hypoxia
 surgical - possible valve replacement
 Endocarditis

Nursing interventions
 the Cardio-Care Six
 THE CARDIO-CARE SIX: A,B,C,D,E,F

 ADL: Help the client with activities of daily living and

how to schedule activities that minimize cardiac

stress.
 Bed rest

 Commode at bedside (it is less stressful to the heart

than using a bedpan)

 Diversions: offer diversions that don't stress the

heart (e.g., no hand-held electronic games).

 Elevate head of bed or sit client up to a position of

comfort.
 Feelings: plan time for the client to express his
 Endocarditis

 watch for signs of infiltration or inflammation at venipuncture

site; rotate sites according to agency policy

 reinforce client and family teaching regarding:

 explanation of all procedures in a simple and culturally

sensitive manner
 involvement of the client and family in scheduling the

daily routine activities and allowing client and family to

participate in care
 relaxation techniques (meditation, visualization, or guided

imagery) to cope with stress, pain, or insomnia

 endocarditis and the need for long-term therapy

 the need for prophylactic antibiotics before dental work

and other invasive procedures

 to report fever, tachycardia, dyspnea and sudden

shortness of breath.
 Rheumatic heart disease (rheumatic
endocarditis)

 Definition and related terms

 rheumatic heart disease - damage
to the heart by one or more
episodes of rheumatic fever.
Pathogen is a group A streptococci.
 rheumatic endocarditis - damage to
the heart, particularly the valves,
resulting in valve leakage
(regurgitation) and/or stenosis. To
compensate, the heart's chambers
enlarge and walls thicken.
 Rheumatic heart disease (rheumatic
endocarditis)
 Epidemiology

 worldwide, millions of new cases of rheumatic fever are reported each

year
 rheumatic fever follows a group A streptococcal infection - prevention is
simply to find and treat streptococcal pharyngitis
 with malnutrition and crowded living, rheumatic fever is most common in
children between the ages of five and 15
 rheumatic fever strikes most often during cool, damp weather. In the U.S.,
it is most common in the northern states
 no one knows how and why group A streptococcal infections cause the
lesions called Aschoff bodies
 damage depends on site of infection: most often the mitral valve in
females and the aortic valve in males
 malfunction of these valves leads to severe pericarditis, and sometimes
pericardial effusion and fatal heart failure. Of those who survive this
complication, about 20% die within ten years

  
 Rheumatic heart disease (rheumatic
endocarditis)
 Findings
 streptococcal pharyngitis
 sudden sore throat
 throat reddened with exudate
 swollen, tender lymph nodes at angle of jaw
 headache
 fever to 104 degrees Fahrenheit
 polyarthritis manifested by warm and swollen joints
 carditis
 chorea
 erythema marginatum (wavy, thin red-line rash on trunk and
extremities)
 subcutaneous nodules
 fever to 104 degrees Fahrenheit
 heart murmurs  pericardial friction rub and pericardial rub
 no lab test confirms rheumatic fever, but some support the diagnosis
Rheumatic heart disease (rheumatic
endocarditis)
 Diagnostics
 antistreptolysin 0 titer (ASO titer) - increased
 ESR - increased
 throat culture - positive for streptococci
 WBC count - increased
 RBC parameters - normocytic, normochromic anemia
 C-reactive protein - positive for streptococci

 Management
 give antibiotics on schedule to maintain blood levels
 provide analgesics - for pain/inflammation PRN
 oxygen to prevent tissue hypoxia
 surgical - commissurotomy, valvuloplasty, prosthetic heart valve
 Rheumatic heart disease (rheumatic
endocarditis)
 Nursing Interventions
 the cardio-care six
 assist the client with chorea in
grasping objects; prevent falls
 encourage family and friends to
spend time with client and fight
boredom during the long,
tedious convalescence
 reinforce client and family
teaching regarding:
 explanation of all tests and
treatments
 nutritional needs
 hygienic practices
 resumption of ADLs slowly
and scheduling rest periods
 to report penicillin reactions:
rash, fever, chills
 to report findings of streptococcal
infection
 sudden sore throat
 diffuse throat redness and
oropharyngeal exudate
 swollen and tender cervical
lymph glands
 pain on swallowing
 temperature of 101 to 104
degree Fahrenheit
 headache
 nausea
 the avoidance of crowds and
people with respiratory infections
 explanation of the necessity of
long-term antibiotics
 actions to cope with the
temporary chorea
 Valve Disorders

 Mitral stenosis  complications

 Definition - Mitral valve  peripheral and facial cyanosis
thickens, with result of in severe cases
narrowing passageway and  jugular vein distention
blocking blood flow from the
left atrium to the left ventricle  with severe pulmonary
during atrial systole hypertension or tricuspid
 Epidemiology stenosis - ascites
 of clients with mitral  edema
stenosis, two-thirds are  hepatomegaly
female
 diastolic thrill at the cardiac
 most cases of mitral
stenosis are caused by apex
rheumatic fever
 Findings
 mild - no symptoms
 moderate to severe
 dyspnea on exertion

 paroxysmal nocturnal
dyspnea (PND)
 orthopnea

 weakness, fatigue,
 Valve Disorders

 Diagnostics
 history and physical exam
 EKG - for changes of left atrial enlargement and right ventricle
enlargement
 echocardiogram - for restricted movement of the mitral valves and
diastolic turbulance

 Management
 antidysrhythmics as indicated
 if medication fails, atrial fibrillation is treated with cardioversion.
 low-sodium diet - to control underlying heart disease
 oxygen if needed - to prevent hypoxia
 surgery - mitral commissurotomy or valvotomy
 Valve Disorders
 Nursing interventions
 the Cardio-Care Six
 watch closely for findings of heart failure, pulmonary edema and reactions
to drug therapy
 if client has had surgery, watch for hypotension, dysrhythmias, and
thrombus formation
 monitor The Cardio Seven
 reinforce client and family teaching regarding:
 TEACH THE CARDIO FIVE: TDDDS
 Tests and treatments: discuss them in simple, culturally sensitive ways.
 Drugs, their side effects, how long client will take them, and their expected
effects.
 Diet: balanced nutrition and restrictions (such as low sodium).
 Disease, its management, when and what signs to report promptly: the 'watch-
for s '.
 Smoker? Stress benefits of stopping smoking, minimization of other stimulants
- caffeine, chocolate, nonprescription drugs, herb cautions
 explaination of the need for long-term antibiotic therapy and the need for
additional antibiotics before dental care or any invasive procedure
 the need to report early findings of heart failure such as dyspnea or a hacking,
nonproductive cough