By: Donnahae Rhoden Salmon

1. Describe the pathophysiology of four

common diseases of the cardiovascular
system
2. Discuss the nursing and collaborative
management of patients with selected
cardiovascular disorder
 In 1999, cardiovascular disease was the
second leading cause of death in Jamaica
with a rate of 84.6 per 100,000 population.

 It was the leading cause of death among

hospital inpatients, accounting for 33% of
deaths.
◦ Source:
http://www.paho.org/english/dd/ais/cp_388.htm
 Jamaica:1:4 in the population has
hypertension (GOJ National Report)
 Clinical syndrome characterized by episodes
or paroxysms of pain or pressure secondary
to insufficient coronary blood flow; decreased
oxygen supply
 Caused by atherosclerosis
 Obstructions of coronaries
 Stable angina—occurs on exertion
 Unstable angina—crescendo, threshold lower,

sometimes pain at rest

 Refractory angina
 Variant angina-vasospasm, reversible ST

elevation
 Silent ischemia—ECG changes but w/o

symptoms
 Pain poorly localized
 Viselike, substernal
 More diffuse in women as affects long

segments of artery rather than discrete

segments
 Diabetic may have blunted response due to

damaged nociceptors
 Feeling of weaknes, SOB, diaphoresis
 May subside with nitro
 Presentation in elderly may be less specific
 ECG
 Echo
 Stress test
 Cardiac cath or angiography
 Decrease oxygen demand and increase
oxygen supply
 Pharmacologic therapy
 Reperfusion therapies (percutaneous

coronary interventions such as atherectomy,

intracoronary stents and PTCA)
 Nitrates mainstay: GTN is given 1tab Q5mins,
max 3 tablets.
 Beta blockers—reduce myocardial oxygen

consumption
 Calcium channel blockers—decrease SA node

conduction, decrease workload, decrease BP,

decrease vasospasm. Norvasc (amlodipine) ,
Cardizem (diltiazem)
 Antiplatelet and anticoagulant medications
1. ASA
2. Plavix (clopidogrel) and Ticlid (ticlopidine)
3. Heparin (HIT), Fragmin or Lovenox
4. Glycoprotein IIb/IIIa agents (ReoPro
(abciximab) and Integrilin (eptifibatide))—
prevent adhesion of platelets with fibrinogen
5. oxygen
 Assessment—presentation, description of
pain
 Treat anginal symptoms - GTN, O2, vitals
 Reduce anxiety
 Prevent pain
 Teaching
 F/U
 Myocardial infarction (MI) results when
myocardial tissue becomes necrotic because
of absent or diminished blood supply.
 Coronary thrombosis of a coronary artery
narrowed with plaque (most common)
 Other causes

◦ spasms of the coronary arteries;

◦ blockage of the coronary arteries by embolism of
thrombi, fatty plaques, air, or calcium;
◦ disparity between myocardial oxygen demand and
coronary arterial supply.
 Ageing
 Family History
 Gender
 Post Menopausal Women
 Diet high in saturated fats, cholesterol, sugar,
salt, and total calories
 Elevated serum cholesterol and low-density

lipoprotein levels
 Hypertension
 Obesity
 Diabetes mellitus
 Cigarette smoking
 Hostility and stress
 A sedentary lifestyle
 Oral contraceptive use
 Cocaine
 Anabolic Steroid
 Chest pain (crushing and radiate to jaw, back
and arms)
 SOB
 Racing heart rate
 Diaphoresis
 Clammy skin
 Dizziness
 Nausea and Vomiting
 Psychosocial – Ask about:
 Stressors and how they deal with stressors
 Assess:
 Ability to cope with sudden illness
 Changing life roles
 Respiration (rate, depth and rhythm)
 Observe skin colour and diaphoresis
 Mental status (confusion, dizziness and

anxiety)
 Auscultate
 Irregular heart sounds (S3 and S4)
 Murmur
 Electrocardiogram: ST segment elevation, T
wave inversion, abnormal Q wave
 Elevated Creatinine kinase isoenzyme - MB-

CK) above 0-6% of total CK)

 Elevated Cardiac Troponin I (cTnI) >3.1µg/L)
 Elevated Cardiac Troponin T (cTnT) > 0.2

µg/L
 CBC – ↑ wbc
 Cholesterol - ↑LDL
 CXR – cardiomegaly
 Nuclear scan – areas of infarction
 Cardiac catheteization – affected artery,

compromised ventricular function

56 y/o male patient received as an emergency
department admission for chest pain, rule out
MI. Patient was awakened at 4 AM with sudden
onset of chest pain. He took two Tylenol, 1 ASA
and two doses of Maalox over the period of
two hours without relief. The patient drove
himself to the ED at 7 AM after the pain began
to get worse.
Pt states he had smoked 2 PPD over the past
14 years but quit 6 months ago. Pt is obese
and sedentary. He does not routinely see a
physician and denies any History of heart
problems. He is allergic to PCN and Sulfa.
Weight: 220# (100 kg)
 Oxygen Need
 Ineffective tissue perfusion: Cardiopulmonary
R/T narrowing of the coronary arteries
secondary to atherosclerosis, spasm
manifested by chest pain and diaphoresis
 Patient will experience improve tissue
perfusion after half hour of nursing and
collaborative interventions as evidenced by
no chest pain and a O2 sat of 95-100%
 Monitor and record V/S include pulse
oxymetry and pay close attention to R
 Monitor ECG
 Administer humidified 2-5L O2 via face mask

as ordered
 Administer thrombolytic agents e.g.

streptokinase (should be given within 6 hours

of MI)
 Administer antiplatelet aggregation agents as

ordered e.g. aspirin and clopidogrel (Plavix)

 Administer nitroglycerin as ordered
 Maintain strict bed rest for at least 24 hours

and encourage rest and decrease physical

activity during hospitalization
 Place bed side commode and other

necessities within easy reach for patient

 Create a quiet and restful environment
 Encourage family to participate in care
 Prepare patients for procedure to correct or
alleviate the problem causing the MI
 Percutaneous Transluminal Coronary

Angioplasty (PTCA)
 Coronary Artery Bypass Grafting (CABG)
 Cardiac catheterization
 Pacemaker insertion
 Patient tissue perfusion has improve after 30
minutes of nursing and collaborate
intervention as evidence by O2Sat 98% and no
c/o chest pain
 A heart muscle disease associated with
cardiac dysfunction
 Classified according to the structural and

functional abnormalities of the heart muscle

WHO Classification
anatomy & physiology of the LV
1. Dilated
• Enlarged
• Systolic dysfunction
2. Hypertrophic
• Thickened
• Diastolic dysfunction
3. Restrictive
• Diastolic dysfunction
4. Arrhythmogenic RV dysplasia
• Fibrofatty replacement
5. Unclassified
• Fibroelastosis
• LV noncompaction

Circ 93:841, 1996

 Most common type
 Involves significant dilation of the ventricles

without simultaneous hypertrophy

 Causes include: heavy alcohol intake, viral

infection, chemotherapeutic meds, pregnancy

Left ventricular hypertrophy not due to pressure overload
Hypertrpohy is variable in both severity and location:
-asymmetric septal hypertrophy
-symmetric (non-obstructive)
-apical hypertrophy

Vigorous systolic function, but impaired diastolic function

impaired relaxation of ventricles
elevated diastolic pressures

prevalence as high as 1/500 in general population

mortality in selected populations 4-6% (institutional)
probably more favorable (1%)
Left ventricular hypertrophy not due to pressure overload
Hypertrpohy is variable in both severity and location:
-asymmetric septal hypertrophy
-symmetric (non-obstructive)
-apical hypertrophy

Vigorous systolic function, but impaired diastolic function

impaired relaxation of ventricles
elevated diastolic pressures

prevalence as high as 1/500 in general population

mortality in selected populations 4-6% (institutional)
probably more favorable (1%)
Familial in ~ 55% of cases with autosomal dominant transmission
Mutations in one of 4 genes encoding proteins of cardiac
sarcomere
account for majority of familial cases
Characterized by:
• impaired ventricular filling due to an abnormally stiff (rigid) ventricle
•normal systolic function (early on in disease)
•intraventricular pressure rises precipitously with small increases in volume

restriction

Pressure
normal

Volume

Causes : infiltration of myocardium by abnormal substance

fibrosis or scarring of endocardium
Amyloid infiltrative CM
Primary Amyloidosis
immunoglobulin light chains -- multiple myeloma
Secondary Amyloidosis
deposition of protein other than immunoglobulin
senile
familial
chronic inflammatory process

restriction caused by replacement of normal myocardial contractile

elements by infiltrative interstitial deposits
Elevated systemic and pulmonary venous pressures
right and left sided congestion
reduced ventricular cavity size with SV and CO
Right > Left heart failure
Dyspnea
Orthopnea/PND
Peripheral edema
Ascites/Hepatomegaly

Fatigue/ exercise tolerance

Clinically mimics constrictive Pericarditis

 Occurs when the myocardium of the right
ventricle is progressively infiltrated and
replaced by fibrous scar and adipose tissue.
 Different from or have characteristics of more
than one of the previously described types
e.g. left ventricular and stress induced
cardiomyopathy
 Heart failure
 Dysrhythmia leading to sudden cardiac death
 Cardiac conduction defects
 Pulmonary of cerebral embolism
 Valvular dysfunction
 Directed toward identifying and managing
underlying or precipitating causes
 Correcting heart failure
 Beta blockers
 Fluid restriction
 Exercise-rest regimen
 Antiarrhythmic meds e.g. amiodarone to

correct dysrhythmias
 Surgery e.g. mitral valvuloplasty, heart

transplant
 Assist patient into a resting position (usually
sitting with legs down) during a symptomatic
episode
 Administer prescribed medications on time
 Ensure low sodium diet and adequate fluid
intake
 Administer O2 if needed
 Plan activities to occur in cycles to maximise rest
 Provide patient with appropriate information to
relieve anxiety
 A condition resulting from the heart’s
inability to pump sufficient blood to meet the
body’s need
• MI
• Arrhythmias
• Heart valve lesions
• Congenital malformations
• Renal Failure
• Fluid overload
• Severe anaemia
• Hypertension
• Pulmonary diseases e.g. COPD
 Right Sided Heart Failure/diastolic cardiac
dysfunction

 Left sided Heart Failure/systolic cardiac

dysfunction
 Signs and symptoms of right sided heart
failure includes:
◦ Oedema of ankles sometimes pitting
◦ Unexplained weight gain
◦ Upper abdominal pain due to liver congestion
◦ Anorexia and Nausea
◦ Nocturia and Weakness
◦ Distended jugular neck veins
 Signs and symptoms of left sided heart
failure:
◦ SOB
◦ Dyspnoea on exertion
◦ Orthopnoea (Unable to lie flat – may need to sleep
with pillows or sitting up in a chair
◦ Cough (may be dry and non-productive – occurs at
nights
◦ Fatigue
◦ Insomnia
◦ Restlessness
◦ Pulmonary oedema
 ECG shows ventricular hypertrophy
 CXR shows cardiomegaly
 Echocardiogram with which shows

hypertrophy, dilation of chambers, abnormal

contraction
 ABG may detect hypoxemia
 Pharmacologic Interventions
◦ Diuretics e.g. lasix which eliminates excess water
◦ Inotropic agents such as digoxin which improve
myocardial contractility and increase the ability of
the heart to pump effectively
◦ Vasodilators e.g. hydralazine – works by dilating
peripheral blood vessels hence reducing the
workload of the heart
Pharmacologic Cont’d
◦Angiotensin-converting enzyme (ACE) inhibitors
which reduces heart rate and work load

◦Beta-adrenergic blockers such as propranolol which

decrease myocardial work load
 Impaired gas exchange related to fluid
accumulation in the alveoli manifested by SOB
and O2Sat of 90%
 Within 30 minutes of nursing and

collaborative intervention patient will have

adequate gas exchange as evidenced by
normal breath sounds and skin colour, a
respiratory rate of 18-20 bpm and O2Sat of
95-100%
 Auscultate lung fields for breath sounds – the
presence of crackles may signal alveolar fluid
congestion
 Administer humidified O2 5L as prescribed

to increase O2Sat rate

 Administer diuretics as ordered – diuretics

promote normovolemia by reducing the fluid

in the blood. Fluid overload decreases
perfusion in the lungs causing hypoxaemia
 Monitor v/s paying close attention to P and
BP
 Auscultate heart sounds
 Strict monitoring of intake and output
 Weigh daily
 Monitor potassium levels of patients on

diuretic therapy
 Monitor digoxin levels and look out for signs

of digoxin toxicity such as fatigue muscle

weakness
 Place the patient on strict bed rest to reduce
the workload on the heart
 Provide a bedside commode to reduce patient

walking to the bathroom

 Assist the patient with ADL
 Restrict dietary intake of sodium
 Teach the patient about his condition
 Angina Pectoris
 MI
 Cardiomyopathy
 Congested Cardiac Failure
 Evaluation
◦ At the end of 30 minutes after nursing and
collaborative interventions patient experiences
improve gas exchange as evidence by increase O2
of Sat 97%.
 Thank you for participating
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Suddarth’s textbook of medical-surgical nursing. Philadelphia: Lippincott
Williams & Wilkins.
 Nutritional management of hypertension. Cajanus (2005) Vol.38 (3), 135-
139.
 Physical activity & cardiovascular disease. Nyam News (2008). August
Nos. 1 & 2.
 Steps to heart health: Patient education. Mayo Clinic.
 Government of Jamaica National Report Millennium Development Goals
PIOJ (2009).
 Wilks, R., Younger, N., Tulloch-Reid, M., McFarlane, S., Francis, D.
(2008). Jamaica Health and Lifestyle Survey.
 NCLEX – PN review made incredibly easy
 Ignativicius Medical Surgical Nursing
 Somers Diseases and disorders a nursing

therapeutic manual