NCM 118 (CARDIOVASCULAR SYSTEM)

BSN 4.1 (Prelims)

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➢ Unstable angina due to a non cardiac
cause
➢ Thrombus formation w/ subsequent
coronary artery occlusion

ACUTE CORONARY SYNDROME (ACS)

➔ cascade of symptoms associated with
acute myocardial infarction with or
without infarction(infarction = cell death)
➢ Inclusion of all the pathologic
processes that impede oxygen
transport to the myocardium:
❖ Angina
❖ NSTEMI (Non-ST elevation
myocardial infarction)
NOTE: ACS is just an initial symptom not the
❖ STEMI (ST elevation
myocardial infarction) diagnosis
-MI is more life threatening than NSTEMI
➔ Applied to patients in whom there is a
ANGINA PECTORIS
suspicion or confirmation of myocardial
infarction ➔ clinical syndrome usually characterized by
➔ 3 types ACS: episodes or paroxysms of pain or
1. STEMI pressure in the anterior chest
2. NSTEMI ➔ CAUSE: Insufficient coronary blood
3. UA (Unstable angina) flow = decreased oxygen supply to meet
● STEMI and NSTEMI are a typical rise an increased myocardial demand for
and/or fall in troopin with at least one oxygen
value ● Usually happens because one or more
● UA is considered to be present in heart’s arteries is narrowed or blocked
patients with ischemic symptoms (Ischemia)
suggestive of an ACS without elevation in ● myocardial oxygen demand is determined
biomarkers with or without ECG changes by heart rate = systolic wall tension and
indicative of ischemia contractility, narrowing of a coronary
● Symptoms occur due to a partial or total artery, occurs during exertion and is
blockage of a coronary artery causing relieved by rest
myocardial ischemia (cell starving oxygen) ● Angina is not a disease, but a symptom of
or infarction (cell death) an underlying heart problem, usually
coronary heart disease (CHD)
Caused by a decrease in the oxygen available to ● Manifestation of CAD = inadequate
the myocardium due to: blood flow to the myocardium
➢ unstable/ruptured atherosclerotic plaque ● Can also occur in other cardiac problems:
➢ Coronary vasospasms arterial spasms, aortic stenosis,
➢ Atherosclerotic obstruction w/o clot or cardiomyopathy, uncontrolled
vasospasms hypertension
➢ inflammation/infection

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RISK FACTORS Pain is lower, and
● Major risk Factors - increase the risk of pain/vasospasms may occur at
heart and blood vessels rest
➢ increasing age - 65 or older; 3. Intractable or refractory angina
women at a greater risk of dying ➢ severe incapacitating chest pain
(within a few weeks) 4. Variant angina (Prinzmetal’s angina)
➢ male gender ➢ pain at rest with reversible
➢ hereditary - african-american, ST-segment elevation; thought to
mexican-americans, be caused by coronary artery
american-indians, some vasospasm
asian-american(due to higher rates 5. Silent Ischemia
of obesity and diabetes) ➢ objective evidence of ischemia
● Modifiable risk factors - lifestyle change (such as electrocardiographic
➢ Tobacco smoke changes with a stress test), but pt
➢ HB cholesterol reports no symptoms
➢ HBP
➢ Physical Inactivity
➢ Obesity and being overweight
➢ Diabetes
● Contributing factors
➢ Stress
➢ Alcohol
➢ Diet and nutrition

● Clinical Manifestation
➢ Pain
➢ weakness or numbness (usually
left arm)
➢ shortness of breath
➢ Anxiety
➢ important characteristics of ASSESSMENT AND FINDINGS
angina= abates or subsides with 1. Chest pain - angina
rest or nitroglycerin ★ Most characteristic symptoms
★ Pain - mild to severe retrosternal
pain, squeezing, tightening/burning
TYPES OF ANGINA PECTORIS
sensation
1. Stable Angina ★ Radiates to the jaw and left arm
➢ predictable and consistent pain
that occurs on exertion and is
relieved by rest or with
nitroglycerin
2. Unstable angina (preinfarction angina or
crescendo angina)
➢ sx occurs more frequently and
lasts longer than stable angina.

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 MEDICAL MANAGEMENT
★ GOAL: to decrease the oxygen demand of
the myocardium & to increase the oxygen
supply
1. Percutaneous coronary interventional
(PCI) procedures
➢ Percutaneous transluminal
coronary angioplasty (PTCA)
➢ Intracoronary stents and
➢ Precipitated by exercise, eating atherectomy
heavy meals, emotions ➢ CABG (Coronary artery bypass
(excitement and anxiety), extremes graft)
of temperature
➢ Percutaneous transluminal
➢ Relieved by rest and Nitroglycerin
myocardial revascularization
NOTE: Nitroglycerin is administered sublingual (PTMR)
(under the tongue), you can give at least 3 doses PHARMACOLOGIC THERAPY
of nitroglycerin (every 5 mins). After 3 doses, and
1. Nitroglycerin
it is still unrelieved, call the cardiac surgeon to
➢ Vasoactive agent
subject the pt to invasive/non-invasive procedures
2. Beta-adrenergic blocking agents
2. Diaphoresis ➢ Reduce myocardial oxygen
3. Nausea and vomiting consumption by blocking the
4. Cold clammy skin beta-adrenergic sympathetic
5. Sense of apprehension and doom stimulation to the heart
6. Dizziness and syncope(fainting) ➢ Example: Propranolol, Metoprolol,
DIAGNOSTICS AND LABORATORY FINDINGS Atenolol
1. ECG
3. Calcium channel blockers &
➢ May show normal tracing if the
patient is pain-free. Ischemic Antiplatelet agents
changes may show ST ➢ Relaxes the blood vessels =
depression and T wave decrease in blood pressure and an
inversion increase in coronary artery
perfusion
➢ CCB: increase myocardial oxygen
supply by dilating the smooth
muscle wall of the coronary
arterioles
➢ Example: Amlodipine, Verapamil,
diltiazem
NURSING MANAGEMENT
1. Administer prescribed medications
➢ Nitrates = To dilate the coronary
2. Cardiac catheterization
➢ Provides most definitive source arteries
of diagnosis by showing the ➢ Aspirin = to prevent thrombus
presence of atherosclerotic formation
lesions ➢ Beta-Blockers = to reduce BP and
HR
➢ Calcium-Channel Blockers = to
dilate coronary artery and reduce
vasospasm

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 2. Teach pt about management of angina thrombus
attacks ● Conditions that decrease perfusion,
➢ Stop all activities hemorrhage and shock
RISK FACTORS
➢ Put one nitroglycerin tablet
● Hypercholesterolemia
UNDER THE TONGUE ● Smoking
(Sublingual) ● Hypertension
➢ Wait for 5 mins ● obesity
➢ Not relieved -> take another tablet ● Stress
and wait for 5 mins ● sedentary lifestyle
➢ If unrelieved after 3 TABLETS =
seek medical attention!!!
3. Obtain a 12-lead ECG
4. Promote myocardial perfusion
➢ Instruct pt to maintain bedrest
➢ Administer O2 @ 3Lpm (ordered)
➢ Avoid valsalva maneuvers
➢ Provide laxatives/high fiber to
lessen constipation
➢ Avoid increased physical activities
5. Assist in possible treatment modalities
➢ PTCA (to compress plaque ASSESSMENT AND FINDINGS
against the vessel wall) and 1. Chest pain
CABG (improve blood flow to the ➔ severe, persistent, crushing substernal
myocardial tissue) discomfort
6. Provide information to family members to ➔ radiates to the neck, arm, jaw and back
➔ occurs without cause
minimize anxiety and promote family
➔ not relieved or rest or nitroglycerin
cooperation ➔ last 30 mins or longer
7. Assist client to identify risk factors that can 2. Dyspnea
be modified 3. Diaphoresis
8. Refer patient to proper agencies 4. Cold clammy skin
5. Nausea and vomiting
6. Restlessness, sense of doom
7. Tachycardia or bradycardia
8. Hypotension
9. S3 and dysrhythmias

MYOCARDIAL INFARCTION
● death of myocardial tissue in regions of
the heart with abrupt interruption or
coronary blood supply
ETIOLOGY
● CAD LABORATORY FINDINGS
● Coronary vasospasm
● Coronary artery occlusion by embolus and

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 ➢ Relaxes bronchioles to enhance
oxygenation
2. ACE Inhibitors
➢ Prevents the formation of
Angiotensin II
➢ Limits the area of infarction
3. Thrombolytics
➢ Streptokinase, alteplase
➢ Dissolve clots in the coronary
artery allowing blood to flow
4. Oxygen Therapy
NURSING INTERVENTION
1. ECG
➢ The ST segment is ELEVATED. T 1. Provide oxygen at 2 Lpm(ordered),
Semi-fowler’s position
wave inversion, presence of Q
2. Administer Medications
wave ➢ Morphine to relieve pain
2. Myocardial enzymes ➢ Nitrates, thrombolytics, aspirin and
➢ Elevated CK-MB, LDH and anticoagulants
Troponin T levels ➢ Stool softener and hypolipidemics
3. CBC 3. Minimize patient anxiety
4. Provide adequate rest periods
➢ Elevated WBC count
5. Minimize metabolic demands
4. Test after the acute stage ➢ Soft diet, low sodium, low
➢ Exercise tolerance test, thallium cholesterol, low fat
scans, cardiac catheterization 6. Assist in treatment modalities (PTCA and
CABG)
ST ELEVATION MYOCARDIAL INFARCTION
7. Monitor for complications of MI, especially
(STEMI)
dysrhythmias (since ventricular
➔ Complete blockage of a coronary artery = tachycardia can happen in the first few
suffered a “STEMI” heart attack or STEMI hours after MI)
8. Provide client teaching

NURSING INTERVENTION AFTER ACUTE

EPISODE
1. Maintain bedrest for the first 3 days
2. Provide passive ROm exercise
NON ST ELEVATION MYOCARDIAL
INFARCTION (NON STEMI) 3. Progress with dangling of the feet at the
side of the bed
➔ Partial blockage is an “NSTEMI” heart
4. Proceed with sitting out of bed, on the
attack
chair for 30 mins TID
5. Proceed with ambulation in the room,
toilet, hallway
6. Check patient’s condition before, during
and after the activity

MEDICAL MANAGEMENT
1. Analgesic
➢ Choice is MORPHINE
➢ Reduces pain and anxiety

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 ● Viruses
CARDIAC REHABILITATION
PATHOPHYSIOLOGY
★ To extend and improve quality of life
➢ Physical conditioning
➢ Patients who are able to walk 3-4
mpH are usually ready to resume
sexual activity

CONGESTIVE HEART FAILURE

➔ A syndrome of congestion of both
pulmonary and systemic circulation
➔ CAUSE: inadequate cardiac function
and inadequate cardiac output to meet
metabolic demands of tissue
➔ Characterized by s/sx of fluid overload
or of inadequate tissue perfusion = heart
is unable to generate a CO sufficient to
meet the body’s demands
➔ Syndrome of ventricular dysfunction
➔ blood often backs up from the lungs
➔ Classifications: left and right heart
failure
ETIOLOGY
● CAD - most common
● HTN
● previous heart attack
● Valvular heart disease
● MI STAGES OF HEART FAILURE
● Cardiomyopathy STAGE A
● Lung disease ❖ At high risk for heart failure but w/o
● Postpartum cardiomyopathy structural heart disease or symptoms of
● pericarditis and cardiac tamponing heart failure
RISK FACTORS STAGE B
● CAD ❖ Structural heart disease but w/o signs or
● HBP symptoms of heart failure
● Previous heart attack STAGE C
● more likely to happen as you age, but ❖ Structural heart disease with prior or
anyone can develop heart failure current symptoms of heart failure
● smoking STAGE D
● obesity ❖ Refractory heart failure requiring
● DM specialized intervention

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 STAGE B- ARB (Angiotensin Receptor Blocker
Stage C - aldactone(spironolactone) (diuretics,
MOST COMMON TREATMENT PLAN FOR
EACH STAGE reduce water and sodium but retain potassium)
Stage C - limit fluid intake 1L/day
STAGE A (at high risk for Heart Failure)
ICD - Internal Cardiac Defibrillator
● Quit smoking
● Exercise regularly
● Treat high blood pressure LEFT SIDED HEART FAILURE
● Treat lipid disorders ➔ The left ventricle/left chamber of the
● Discontinue alcohol or illegal drug use heart provides most of the heart’s
● If you have CAD, DM, HBP = taking pumping power
medications as prescribed ➔ The heart can’t pump enough blood =
left-sided heart failure
STAGE B (heart disease, w/o signs of Heart
● Shortness of breath and fatigue = left
Failure) ventricular failure
● All patients should take an ACE inhibitor ● Fluid may back up in the lungs = SOB
or ARB (shortness of breath)
● Beta-blockers should be prescribed for
patients after a heart attack A. Systolic Heart failure
● Surgery options should be discussed for ➢ HF with reduced ejection fraction
(HFrEF)
coronary artery or valve disease
➢ LVEF (left ventricular ejection
STAGE C (Heart disease, with signs of heart fraction) < 40%
failure) ➢ Left ventricle can’t pump
● african-american patients may be vigorously = pumping problem
prescribed a hydralazine/nitrate B. Diastolic Heart failure
combination if symptoms persists ➢ HF with preserved ejection fraction
● Diuretics (water pills) and digoxin may be (HFpEF)
➢ LVEF (left ventricular ejection
prescribed if symptoms persists
fraction) > 50%
● An aldosterone inhibitor may be ➢ left ventricle can’t relax or fill
prescribed when symptoms remain severe fully = filling problem
with other therapies ➢ Less blood can enter your heart,
● Restrict dietary sodium (salt) and the blood pressure. The lungs
● Monitor weight goes up = fluid build up in the
lungs, legs, belly
● Restrict fluids (as appropriate)
● Pacemaker or ICD may be recommended
STAGE D ASSESSMENT AND FINDINGS
● Patient should be evaluated to determine
in the ff treatments are available options: 1. Dyspnea on exertion
- Heart transplant 2. PND - paroxysmal nocturnal dyspnea
- Ventricular assist devices (DOB during night)
- Surgery options 3. Orthopnea -cardinal sign of LSHF
- Research therapies 4. Pulmonary crackles/rales
5. coughing with pinkish, frothy sputum
- Continuous infusion of intravenous
6. tachycardia
inotropic drugs 7. cool extremities
- End of life (palliative therapies) 8. cyanosis
care 9. decreased peripheral pulses
NOTE: 10. fatigue
Warning signs of CHF: Jugular distention, 11. oliguria
12. signs of cerebral anoxia (agitated pt)
edema, and dyspnea
Caused by: left ventricle
Drug of choice: ACE Inhibitors (-pril)

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 6. body weakness
NURSING DIAGNOSIS
7. anorexia, nausea
8. Pulsus alternans - an arterial pulse with
● Activity intolerance (or risk for activity alternating strong and weak beats
intolerance) related to imbalance COMPLICATIONS
between oxygen supply and demand
because of decrease CO 1. Kidney damage or failure
● Excess fluid volume related to excess 2. heart valve problems
fluid or sodium intake and retention of fluid 3. Heart rhythm problems - bradycardias
because of HF and its medical therapy 4. Liver damage
● Anxiety related to breathlessness and ASSESSMENT AND FINDINGS
restlessness from inadequate oxygenation
● Powerlessness related to inability to 1. CXR may reveal cardiomegaly
perform role responsibilities because of 2. ECG may identify cardiac hypertrophy
chronic illness and hospitalization 3. Echocardiogram may show hypokinetic
● Noncompliance related to lack of heart
knowledge 4. cardiac radionuclide scan, and/or MRI
NOTE: 5. BNP. Or N-temrinala-pro-BNP
Anasarca - generalized edema (NT-pro-BNP) level - indicates myocardial
stress
RIGHT SIDED HEART FAILURE 6. ABG and pulse oximetry may show
decreased O2 saturation
➔ The right ventricle/right chamber, moves
7. PCWP is increased in left-sided HF, CP is
“used” blood from the heart back to
increase in right-sided HF
your lungs to be resupplied with
oxygen MEDICAL MANAGEMENT
➔ CAUSE: Right chamber has lost its
1. Early identification and documentation of
ability to pump
the type of HF
● The heart can’t fill with enough blood,
2. Pharmacologic therapy (varies with the
and the blood backs up into the veins =
type of HF)
Edema (ankles, legs, and belly)
3. Basic objectives in treating pt with HF:
● Right ventricle fails = congestion of the
● Eliminate/reduce any etiologic
viscera and the peripheral tissues
contributing factors
predominates
● Reduce workload of the heart by
● Occurs because the right side of the heart
reducing afterload and preload
cannot eject blood and cannot
4. Counseling and education about sodium
accommodate all the blood that normally
restriction, monitoring daily weights and
returns
other signs of fluid retention, encouraging
● Usually it is the left-sided heart failure
exercise, and recommending avoidance of
that causes the right-side heart failure
excessive fluid intake, alcohol, and
Other causes include
smoking
❖ CAD
5. Oxygen therapy (based on the degree of
❖ HBP
the pulmonary congestion and resulting
❖ Congenital heart defects
hypoxia)
❖ Arrhythmia
6. Others may require hospitalization and
❖ Lung Disease
endotracheal intubation (ET intubation)
❖ Other long-term health conditions: DM,
HIV, and thyroid problems PHARMACOLOGIC THERAPY
ASSESSMENT AND FINDINGS Angiotensin-Converting Enzyme Inhibitor
❖ Promotes vasodilation and diuresis by
1. Peripheral dependent, pitting edema(pinch decreasing afterload and preload
and should return at 2 secs according to Angiotensin II Receptor Blockers (ARBs)
bruner’s) ❖ Lowered blood pressure and lowered
2. Weight gain systemic vascular resistance
3. Distended neck vein ❖ Similar side effects: Hyperkalemia,
4. hepatomegaly hypotension and renal dysfunction
5. Ascites

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Hydralazine and Isosorbide Dinitrate
❖ Combination of both may be another
alternative for patients who cannot take
ACE-Is. Nitrates cause venous
❖ Venous dilation, which reduces the
amount of blood return to the heart and
lowers preload
DIGITALIS
❖ Digoxin increases the force of myocardial
contraction and slows conduction through
the AV node.
❖ It improves contractility, increase left
ventricular output
NURSING INTERVENTIONS
1. Assess patient’s cardio-pulmonary status
2. Asses VS, CVP, and PCWP. Weigh patient
daily to monitor fluid retention
3. Administer medications - usually cardiac
glycosides are given (Digoxin, or Digitoxin,
Diuretics, vasodilators, and
hypolipidemics)
4. Provide a Low sodium diet. Limit fluid
intake as necessary
5. Provide adequate rest periods to prevent
fatigue
6. Position on Semi-Fowler’s position for
adequate chest expansion
7. Prevent complications of immobility
8.
NURSING INTERVENTIONS AFTER THE
ACUTE STAGE
1. Provide opportunities for verbalization of
feelings
2. Instruct patient about the medication
regimen- digitalis, vasodilators and
diuretics
3. Instruct to avoid OTC drugs,
stimulants, smoking and alcohol
4. Provide a Low fat and Low sodium diet
5. Provide potassium supplements
6. Instruct about fluid restriction
7. Provide adequate rest periods & schedule
activities
8. Monitor daily weight and report signs of
fluid retention
Example:
NOTE:
Cardinal Sign = Jugular vein Distention and
Edema

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