Instruction: Answer the following questions briefly.

1. Explain the process of pulmonary and systemic circulation. Pathway of blood flow through the heart.

1. Blood enters the right atrium from the superior and inferior venae calvae, and the coronary sinus. 2. From right atrium, it goes through the tricuspid valve to the right ventricle. 3. From the right ventricle, it goes through the pulmonary semilunar valves to the pulmonary trunk 4. From the pulmonary trunk it moves into the right and left pulmonary arteries to the lungs. 5. From the lungs, oxygenated blood is returned to the heart through the pulmonary veins. 6. From the pulmonary veins, blood flows into the left atrium. 7. From the left atrium, blood flows through the bicuspid (mitral) valve into the left ventricle. 8. From the left ventricle, it goes through the aortic semilunar valves into the ascending aorta. 9. Blood is distributed to the rest of the body (systemic circulation) from the aorta.

2. Explain and enumerate the different classifications of Cardiovascular Disease.1.Conduction disoders(Dythymias) - Supraventricular Rhythms - Ventricular Dysrhythmias - Atrioventricular Conduction Blocks - Ventricular Conduction Blocks2.Myocardial disorders(Coronary Heart Disease) - Angina pectoris - Acute Myocardial Infarction - Sudden Cardiac Death3.Structural Disorders - Valvular Hearth Diseases - Cardiomyopathy - Infectious Disorder

3. Give the pathophysiology, sign / symptoms and nursing care for the following disorders.

Inflammatory Heart Disease

Pathophysiology Sign and Symptoms

Nursing Care

Rheumatic Fever/ Rheumatic Heart Disease

-Aschoff bodies, localized areas of tissue necrosis surrounded by immune cell, develop in cardiac tissue

-Fever and migratory join pain-initial manifestation.

-Nursing care focus: providing supportive care and preventing complications.-Teaching to prevent recurrence of RF is extremely important

Endocarditis -inflammation of the endocardium -relatively uncommon -greatest risk factor:previous heart damage

FeverNew onset heart murmurs over valves affectedEmbolic complicationsAnemia

-prevention of endocarditis-Education is the key part of prevention

Myocarditis -inflammatory process damage the myocardial cell-local or diffuse swelling and damage-infectious agent infiltrate interstitial tissues-formation of abscesses-autoimmune injury

Flu-like initiallyFatigueDyspnea and signs of HF if increases in severityMay develop sudden cardiac death in severe HF

-directed at decreasing myocardial work and maintaining cardiac output-both physical and emotional rest are indicated,because anxiety increased myocardial oxygen demand-during acute phase:hemodynamic monitoring and the ECG-frequently assess for manifestations of heart failure

Pericarditis Pericardial damage-release of inflammatory mediators-vasodilation,hype

Pain over the heart worsening with movement or breathing deeply(pleuritic

-early identification and treatment of the disorder can reduce the rick of

remia,and edema:increase capillary permeability-escape of plasma proteins and fibrinogens into the pericardial space-influx of WBC to the site of injury to destroy the causative agent-exudate formation-inflammatory resolve without long-term effects or may produce scar tissue and adheions between the pericardial layres-restict cardiac function

pain)Pericardial friction rub heard best over the lower-middle left sternal borderMild feverSigns of dyspnea if heart failure occurs

complications-promptly report a pericardial friction rub or other manifestations of pericarditis in client with recent AMU,cardiac surgery,or systemic disease associated with a risk pericarditis

Valvular Heart Disease

Pathophysiology Sign and symptoms

Nusring Care

Mitral Stenosis Physiological changes - Consideration In PregnancyThe most important changes in cardiac function occurs in the first 8 weeks of pregnancy with maximum changes at 28 weeks↓ Vascular resistance↓ Blood pressure↑ Heart rate ↑ Stroke volume ↑ CO↑ Blood volume 30% - 50% The fall in the peripheral resistance is about 20-30% at 21-24 weeks & returns to normal at term. This fall is due to1. The trophoblastic erosion

* May be asymptomatic; or severe impairment depending on cardiac output and pulmonary pressures

* Typical earliest manifestation: dyspnea on exertion (DOE)

HEALTH PROMOTION

Prevent RHD – key element in preventing heart valve disorders

Timely and effective treatment of strep throats to prevent

of endometrial vessels, the placental bed serves as a large arteriovenous shunt causing lowered systemic vascular resistance2. There is physiological vasodilatation which is believed to be secondary to endothelial prostacyclin and circulating progesterone.3 .Anemia decreases blood viscosity with resultant decrease in systemic vascular resistance.

* Cough, hemoptysis, frequent pulmonary infections (bronchitis, pneumonia), paroxysmal nocturnal dyspnea, orthopnea, weakness,

fatigue, palpitations

* Worsen stenosis: right heart failure, jugular vein distension, hepatomegaly, ascites, peripheral edema, crackles in the lung bases

* Severe mitral stenosis: cyanosis of the face and extremities, chest pain (rare)

* Loud S1,

rheumatic fever (sequel to β-hemolytic streptococcal infection of the pharynx).

Emphasize the importance of complete the full prescription of antibiotics to prevent development of resistant bacteria.

Prophylactic antibiotic therapy before invasive procedures to prevent infectious endocarditis (important health promotion measure for client with preexisting

split S2, mitral opening snap, diastole murmur: low-pitched, rumbling, crescendo-decrescendo, heard best in the apical region; palpable thrill

* Atrial dysrhythmias (atrial fibrillation) due to chronic atrial distention

* Thrombi formation and subsequently embolize to brain, coronary arteries, kidneys, spleen, and extremities – fatal complications.

* Women

heart disease).

are asymptomatic until pregnancy (as the heart compensate for increased circulating volume (30% more in pregnancy).

Mitral Regurgitation

The mitral valve closes incompletely à ‚ allowing blood to regurgitate during systole form L ventricle to L atrium à ƒrising L atrial pressure à „causes L atrial hyperthrophy and pulmonary congestion à … elevated pulmonary artery pressure à causes slight enlargement of the R ventricle.

* May be asymptomatic

* Fatigue, weakness, DOE, orthopnea

* Severe or acute regurgitation: pulmonary congestion and edema

* Murmur: loud, high-pitched, rumbling, and holosystolic (occurring throughout systole); accompanie

HEALTH PROMOTION

Prevent RHD – key element in preventing heart valve disorders

Timely and effective treatment of strep throats to prevent rheumatic fever (sequel to β-hemolytic streptococcal infection of the pharynx).

d by palpable thrill, heard most clearly at the cardiac apex

Emphasize the importance of complete the full prescription of antibiotics to prevent development of resistant bacteria.

Prophylactic antibiotic therapy before invasive procedures to prevent infectious endocarditis (important health promotion measure for client with preexisting heart disease).

Mitral Valve Prolapse

Excess tissue in the valve leaflets and elongated cordae tindienae à ‚impair valve closure during

* Usually asymptomatic

* Audible

HEALTH PROMOTION

Prevent

systoleà ƒsome ventricular blood regurgitates into the L atrium

midsystolic ejection click or murmur; high pitched last systolic murmur

* Most common symptom – atypical chest pain: left sided or substernal, frequently related to fatigue, not exertion

* Tachydysrhythmias causing palpitations, lightheadedness,

syncope

* Progressive worsening: leads to heart failure, embolization may

cause transient ischemic

RHD – key element in preventing heart valve disorders

Timely and effective treatment of strep throats to prevent rheumatic fever (sequel to β-hemolytic streptococcal infection of the pharynx).

Emphasize the importance of complete the full prescription of antibiotics to prevent development of resistant bacteria.

Prophylactic antibiotic therapy before invasive

attacks (TIAs)

procedures to prevent infectious endocarditis (important health promotion measure for client with preexisting heart disease).

Aortic Stenosis The narrowed aortic valve orifice à ‚decreased the L ventricular ejection fraction during systole à ƒL ventricle hypertrophies à „ incomplete emptying of the L atrium à … causes backward pressure through pulmonary veins and pulmonary HTN à† causes R ventricular strain

* Asymptomatic for many years (50 to 70 years of age)

* Classic manifestations: [L ventricular failure] DOE, angina pectoris (66% of the patients), narrow pulse pressure (30 mmHg or less)

* Increased LAP and PAWP

HEALTH PROMOTION

Prevent RHD – key element in preventing heart valve disorders

Timely and effective treatment of strep throats to prevent rheumatic fever (sequel to β-hemolytic streptococcal infection of the

* Harsh systolic murmur in 2nd ICS to the right of the sternum

* Palpable thrill

* S3 and S4 heart sounds – indicating heart failure

pharynx).

Emphasize the importance of complete the full prescription of antibiotics to prevent development of resistant bacteria.

Prophylactic antibiotic therapy before invasive procedures to prevent infectious endocarditis (important health promotion measure for client with preexisting heart disease).

Aortic Regurgitation

aortic valve cusps widen and fail to close during diastole

* Asymptomatic for many

HEALTH PROMOTIO

à ‚blood regurgitates from the aorta into the L ventricle à ƒincreasing L ventricular volume and decreasing cardiac output à „L ventricle dilates and hypertrophies in response to the increase in blood volume and workload.

years even when severe.

* Persistent palpitation (esp when in recumbent, visible throbbing pulse in the arteries of the neck

* Musset’s sign: head bobbing and shake the whole body by the force of contraction in time with the pulse

* Dizziness, exercise intolerance

* Common signs: fatigue, DOE, orthopnea, PND

* Anginal pain occur at night and may not respond to

N

Prevent RHD – key element in preventing heart valve disorders

Timely and effective treatment of strep throats to prevent rheumatic fever (sequel to β-hemolytic streptococcal infection of the pharynx).

Emphasize the importance of complete the full prescription of antibiotics to prevent development of resistant bacteria.

Prophylactic antibiotic therapy

conventional therapy

* Murmur: heard during diastole, “blowing”, high-pitched (heard best at 3rd left ICS), palpable thrill, ventricular heave, S3 and S4

* Displaced apical impulse to the left

* ŒWater hammer pulse (arterial pressure waveform has a rapid upstroke and quickly collapsing downstroke), widened pulse pressure, Ž Quinke’s sign (visible pulsation in the nail

before invasive procedures to prevent infectious endocarditis (important health promotion measure for client with preexisting heart disease).

bed), Corrigan’s sign (visible carotid pulsation), Musset’s sign, ‘ Early diastolic murmur

Tricuspid Stenosis

Tricuspid stenosis results from alterations in the structure of the tricuspid valve that precipitate inadequate excursion of the valve leaflets. The most common etiology is rheumatic fever, and tricuspid valve involvement occurs universally with mitral and aortic valve involvement. With rheumatic tricuspid stenosis, the valve leaflets become thickened and sclerotic as the chordae tendineae become shortened. The restricted valve opening hampers blood flow into the right ventricle and, subsequently, to the pulmonary vasculature. Right atrial enlargement is observed as a consequence. The obstructed venous

* Obstructs blood flow from the R atrium to the R ventricle

* Usually results from RHD; mitral stenosis

* Manifestations are related to systemic congestion and right-sided heart failure

* Murmur: low-pitched, rumbling diastolic clearly heard in the 4th ICS at the L sternal

HEALTH PROMOTION

Prevent RHD – key element in preventing heart valve disorders

Timely and effective treatment of strep throats to prevent rheumatic fever (sequel to β-hemolytic streptococcal infection of the pharynx).

Emphasize the importance

return results in hepatic enlargement, decreased pulmonary blood flow, and peripheral edema. Other rare causes of tricuspid stenosis include carcinoid syndrome, endocarditis, endomyocardial fibrosis, systemic lupus erythematosus, and congenital tricuspid atresiaIn the rare instances of congenital tricuspid stenosis, the valve leaflets may manifest various forms of deformity, which can include deformed leaflets, deformed chordae, and displacement of the entire valve apparatus. Other cardiac anomalies are usually present.

border or over the xiphoid process

of complete the full prescription of antibiotics to prevent development of resistant bacteria.

Prophylactic antibiotic therapy before invasive procedures to prevent infectious endocarditis (important health promotion measure for client with preexisting heart disease).

Tricuspid Regurgitation

The pathophysiology of tricuspid regurgitation focuses on the structural incompetence of the valve. The incompetence can result from primary structural abnormalities

* Blood flow back into the right atrium during systole

* Usually occurs

HEALTH PROMOTION

Prevent RHD – key element in preventing

of the leaflets and chordae or, more often, be secondary to myocardial dysfunction and dilatation. [1]

Tricuspid valve insufficiency due to leaflet abnormalities may be secondary to endocarditis or rheumatic heart disease. When due to the latter, it generally occurs in combination with tricuspid stenosis. Ebstein anomaly is the most common congenital form of tricuspid regurgitation.Inspiration increases the severity of tricuspid regurgitation. Inspiration induces widening of the RV, which enlarges the tricuspid valve annulus and thus increases the effective regurgitant orifice areaChronically, tricuspid regurgitation leads to RV volume overload, which results in right-sided congestive heart failure (CHF). This manifests as hepatic congestion, peripheral edema, and ascites.

secondary to R ventricular dilation

* Stretching distorts the valve and its supporting structures

* RHD, infective endocarditis, inferior MI, trauma

* Manifestations are related to right-sided heart failure; common atrial fibrillation (atrial distention)

* Murmur: high-pitched, blowing systolic murmur heard over the tricuspid or xiphoid area.

heart valve disorders

Timely and effective treatment of strep throats to prevent rheumatic fever (sequel to β-hemolytic streptococcal infection of the pharynx).

Emphasize the importance of complete the full prescription of antibiotics to prevent development of resistant bacteria.

Prophylactic antibiotic therapy before invasive procedures to prevent infectious

endocarditis (important health promotion measure for client with preexisting heart disease).

Pulmonic Stenosis

Clinically significant narrowing of a valve or a blood vessel increases pressure proximal to the obstruction. This pressure gradient is necessary to maintain flow across the stenotic site. In pulmonic stenosis, hypertrophy of the right ventricle ensues and maintains this forward flow. The magnitude of right ventricular pressure and the pressure gradient across the pulmonary valve are generally proportional to the degree of obstruction. Under usual circumstances, proportional right ventricular hypertrophy maintains normal pulmonary blood flow. If the normal output is not maintained, right-sided heart failure

* Blood flow from the R ventricle into the pulmonary system

* Congenital; RHD, cancer

* Manifestations are related to right-sided heart failure

* Murmur: harsh, systolic crescendo-decrescendo heard in the pulmonic area, 2nd L ICS

HEALTH PROMOTION

Prevent RHD – key element in preventing heart valve disorders

Timely and effective treatment of strep throats to prevent rheumatic fever (sequel to β-hemolytic streptococcal infection of the pharynx).

Emphasize

ensues. This occurs in neonates with critical pulmonary stenosis and in patients with severe obstruction that occurs in childhood or adulthood.Changes in the geometry of the left ventricle and decreased left ventricular function can also occur. [10, 11]The changes are proportional to the degree of right ventricular hypertrophy; however, they revert to normal after obstruction of the right ventricular outflow tract is relieved.With increasing right ventricular hypertrophy, right ventricular compliance decreases with a resultant increase in end-diastolic pressure and with prominent a waves in the right atrium. As right atrial pressure rises, a right-to-left shunt may occur if the foramen ovale is patent or if an atrial septal defect is present; this change results in systemic arterial desaturation and clinically discernible cyanosis. This shunting may occur even without measurable elevation

the importance of complete the full prescription of antibiotics to prevent development of resistant bacteria.

Prophylactic antibiotic therapy before invasive procedures to prevent infectious endocarditis (important health promotion measure for client with preexisting heart disease).

of right atrial pressure and is attributable to decreased right ventricular compliance Such a right-to-left shunt can also occur in patients with an underdeveloped (hypoplastic) right ventricle

Pulmonic Regurgitation

(pulmonary) regurgitation (PR) is incompetency of the pulmonic valve causing blood flow from the pulmonary artery into the right ventricle during diastole. ... PR is usually asymptomatic.

* Incomplete valve closure allows blood flow back into the right ventricle during diastole, decreasing blood flow to the pulmonary circuit

* Manifestations are related to right-sided heart failure

* Murmur: high-pitched, decrescendo, blowing, heard at left sternal border during

HEALTH PROMOTION

Prevent RHD – key element in preventing heart valve disorders

Timely and effective treatment of strep throats to prevent rheumatic fever (sequel to β-hemolytic streptococcal infection of the pharynx).

Emphasize the importance of complete the full

diastole prescription of antibiotics to prevent development of resistant bacteria.

Prophylactic antibiotic therapy before invasive procedures to prevent infectious endocarditis (important health promotion measure for client with preexisting heart disease).

Cardiomyopathy Disorders that affect the heart muscle itself affecting both systolic and diastolic functions.

Primary

With the exception of treating an underlying cause, little can be done to treat either dilated

dilated and restrictive cadriomyopathies: similar to client with heart failure

hypertrophic cardiomyopat

cardiomyopathy: idiopathic

Secondary cardiomyopathy: result of the other process such as ischemia, infectious disease, exposure to toxins, connective tissue disorders, metabolic disorders, or nutritional deficiencies.

Mortality: higher in older adults, men, and African Americans (AHA, 2001).

or restrictive cardiomyopathies; focus on managing heart failure and treating dysrhythmias.

Hypertrophic cardiomyopathy treatment focuses on reducing contractility and preventing sudden cardiac death.

Restrict strenuous physical exertion, dietary and sodium restrictions

hy: similar to client with myocardial infarction

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