CARDIOVASCULAR DISORDERS CRITICAL CARE

The number of patients with cardiovascular disease in the world continues to grow.
• Considerable research and clinical progress has clarified the diagnosis and management of many cardiac
conditions.
• Atherosclerosis provides a common link among CAD, atherosclerotic aortic disease, PAD, and carotid
artery disease.
 The risk factors and general management strategies for all of these diseases are the same.
• Acute MI, aortic aneurysm, aortic dissection, and embolic stroke represent the acute manifestations of
chronic disease progression.
• Heart failure is a consequence of damaged heart muscle that results from MI, cardiomyopathy, valve
disease, or
 hypertension.

Pulmonary Hypertension
• Pulmonary hypertension is a progressive sustained increase in pulmonary pressures with resultant right
heart failure and ultimately death.
• Medical management focuses on multidrug therapies and prevention of complications.
• Nursing management includes symptom management, education on multidrug treatments, including IV
site care and developing extended support systems.

Endocarditis
• Endocarditis is an infection on the endocardial surface of the heart, heart valves, or both.
• Medical management requires prolonged intravenous antibiotic treatment. Some patients require
excision of the involved valve for eradication of infection.
• Nursing management includes monitoring for worsening symptoms and patient education on the need for
prolonged medication for treatment, including intravenous site care.

Valvular Heart Disease

• Valvular heart disease is the structural and functional abnormalities of cardiac valves.
• Medical management includes medications to control symptoms and surgical interventions to repair or
replace involved valve.
• Nursing management includes medication titration to improve flow through involved valves, monitoring
patient
• symptoms and responses to treatment and organizing patient care activities to prevent fatigue.

Atherosclerosis of the Aorta

• Aortic disease results from progressive atherosclerosis and hypertension. This includes aneurysmal and
local dilatation of the wall and aortic dissection where blood separates the vascular layers.
• Medical management depends on symptoms and hemodynamics. rrective surgery is aimed at aneurysms
more
• than 5 cm wide. Acute dissection requires immediate control of hypertension and pain, with surgical
correction
• required for dissection of the ascending aorta.
• Nursing management focuses on monitoring for changes in the cardiovascular status, administering
medications for significant blood pressure reduction and pain control.

Peripheral Artery Disease

• PAD includes chronic venous disease and acute arterial changes.
• Medical management aims at controlling or eliminating risk factors, pharmacologic management including
anticoagulants vasodilators and antiplatelets, and surgical interventions of PTCA, stents, or vascular
bypass.
 • Nursing care includes assessment of pulses, maintenance of skin integrity, and pain control.

Carotid Artery Disease

• Carotid artery disease results in obstruction of the major arterial supply to the brain.
• Medical management focuses on limiting risks and when obstruction is greater than 60% performing
surgical
• endarterectomy.
• Nursing management includes monitoring neurologic assessment and educating patients and family of
stroke
• symptoms.

Venous Thromboembolism
• VTE includes both DVT and PE with clot formation and obstruction of large vessels.
• Medical management focuses on prevention and treatments with anticoagulation.
• Nursing management is aimed at prevention with activity started as soon as possible for critically ill
patients and
• monitoring the effects of anticoagulation.

Hypertensive Emergency
• Hypertensive emergency is defined as acute blood pressure elevation greater than 180/120 mm Hg and
may include symptoms of CNS or cardiovascular compromise, acute kidney failure, or catecholamine
excess.
• Medical management is aimed at use of appropriate medications to initially decrease by no more than
20% to 25% over several hours.
• Nursing management is focused on close symptom monitoring with judicious use of blood pressure
lowering medications.

Case Study, CARDIOVASCULAR DISORDERS CRITICAL CARE

1. Katherine Young, 21 years of age, is a female patient who received a permanent atrioventricular
pacemaker for the diagnosis of sick sinus rhythm, a disorder that leads to periods of tachycardia
and periods of extreme bradycardia or sinus arrest. The nurse received the end-of-shift report
and arrives at Ms. Young’s room where she assesses the patient’s incision dressing on the upper
left chest, and it is dry. The patient’s left arm is edematous and ecchymotic and twice the size of
the other arm. The patient states that her left arm feels numb and tingling. The distal pulses are
present and at baseline. None of the findings were noted in the end-of-shift report.
a. What nursing management should the nurse provide immediately?
b. Explain the general care of the patient after receiving an implanted pacemaker.

2. The nurse on the telemetry unit responds to the cardiac monitor alarm on a patient recovering
from a myocardial infarction. Upon entering the room, the nurse notes that the rhythm on the
monitor appears to be ventricular tachycardia.
a. What action should the nurse take first?
b. The nurse notes the patient has no pulse, and tells someone to get the code cart and
another to call the hospital’s code team. Upon arrival of the code cart, the nurse
prepares the defibrillator for use. At what energy level does the nurse set the biphasic
defibrillator for the first shock?
 c. After defibrillation, the nurse assesses the patient, finds him pulseless, and initiates
cardiopulmonary resuscitation. The code team has arrived, and epinephrine is
administered. What is the rationale for this medication in this emergency situation?
d. What is the difference between monophasic and biphasic defibrillators?

3. Edgar Santos, 55 years of age, is a male patient who is admitted to the ED via ambulance with
acute onset of midsternal chest pain radiating down the left arm and radiating up the left side of
the neck. The patient complains of shortness of breath and is cool, pale, and diaphoretic. The
vital signs include: blood pressure, 160/90 mm Hg; heart rate, 110 bpm; respiratory rate, 26
breaths/min; and temperature 99°F. The 12-lead ECG reveals an anterior wall ST-elevation
myocardial infarction (STEMI).
a. What first actions should the nurse take after the patient has arrived in the
emergency department?
b. The emergency physician has contacted a cardiologist and the patient is scheduled
for a percutaneous coronary intervention (PCI) in less than 60 minutes from the
door-to-balloon time. Explain the reasoning for this action based on evidence-based
guidelines and considering the clinical manifestations and the pathophysiology of
the STEMI.

4. Brienne Smith, 21 years of age, is a female patient who is admitted to the hospital with the
diagnosis of infective endocarditis. Ariane had her tongue and nose pierced 6 weeks ago. The
drug screen is negative. She presents with grade II tricuspid insufficiency murmur, and a
temperature of 104°F. The patient complains of extreme fatigue, and anorexia. The
echocardiogram reveals vegetations on the tricuspid valve.
a. What risk factors predisposed Ms. Smith’s to develop infective endocarditis?
b. Explain the pathophysiology of infective endocarditis as it relates to this case.
c. What additional clinical manifestations should the nurse include in the assessment of
the patient?
d. What medical management should the nurse anticipate for the patient?
e. What nursing management should be provided for the patient and family?

5. Mrs. Silverstone, a 58-year-old patient with suspected aortic stenosis, presents to the cardiac
care clinic for evaluation. About 1 month ago she noticed that she was having increasing
difficulty completing the 2-mile walk that she had been doing for the last 5 years. The
cardiologist has ordered a Doppler echocardiogram to diagnose aortic stenosis definitively.
(Learning Objective 1)
a. On this visit, Mrs. Robbins states that she is having difficulty sleeping and has
episodes of chest pain. How does the nurse correlate these clinical manifestations
to aortic stenosis?
b. The nurse assesses Mrs. Silverstone for what types of heart sounds that are
consistent with aortic stenosis?
c. What is the rationale for prophylactic antibiotics prior to invasive procedures for the
patient with aortic stenosis?

Critical Thinking Exercises, Critical Care Vascular Disorders

1. You are in the ICU and caring for a 75-year-old female who underwent coronary artery
bypass grafting 2 days ago. She is pulling at her chest tubes and trying to get out of bed by
herself. You are concerned she may have delirium.
a. What interventions are your priorities to keep this patient safe?
b. Identify what parameters need to be assessed immediately.
c. What diagnostic testing should be done to rule out physiologic problems? Labs: CBC,
ABG, Electrolytes,
d. Which types of medications may be contributing to her delirium?

2. A 47-year-old male presents to the emergency department complaining of malaise, fever,

and painful nodules on the pads of his fingers. He admits to being an active IV drug abuser,
while denying regular medical and dental care. Upon physical examination, the nurse notes
a soft systolic murmur and small painful nodules on the pads of his fingers. Based upon
these physical examination findings, the physician thinks that the patient may have infective
endocarditis and prescribes antibiotics.
a. What should the nurse ensure happens before the antibiotics are given?
b. What are the care priorities for this patient?