Common Cardiovascular Disorders

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chapter 19:

Common Cardiovascular Disorders


Tissue Changes in Pericarditis


Underlying Causes of PericarditisUnderlying Cause PathophysiologyInfection Hematogenous spread of bacteria,

virus, or fungus to pericardium. Can be seen with immunocompromised patient.

Dressler’s syndrome Autoimmune reaction after MIRenal failure Build-up of nitrogenous wastes in

bloodstream leads to irritation in pericardial sac.

Defect in pericardium, space-occupying tumor

Repeated episodes of pericarditis lead to scarring and constriction of heart to fill during diastole.

Cardiac surgery or injury Direct tear or compromise to pericardium causes irritation.


Differences Between Chest Pain Related to Ischemia and Pericarditis

Type of Chest Pain

Underlying Causes

Quality of Pain How to Relieve Pain

Ischemic Angina, acute MI Crushing, extreme pressure, choking

Rest, oxygen, nitrates, morphine

Pericarditis Prior respiratory infection, renal failure, surgery, trauma to chest, etc.

Sharp, stabbing, worsens with inspiration

Sitting up and leaning forward, NSAIDs, treat underlying cause if possible


ST-Segment Changes in Pericarditis and MI


12-Lead ECG in Acute Pericarditis


Question

A patient is admitted with chest pain. Which of the following assessment findings suggest that the pain is related to pericarditis and not ischemic chest pain?

A. Patient states pain improves when he leans forward.B. Patient complains of shortness of breath.C. Patient complains of nausea.D. Patient states the pain has not stopped.


Answer

A. Patient states pain improves when he leans forward.Rationale: The best way to distinguish chest pain related to

pericarditis from ischemic chest pain is that it is relieved when the patient leans forward or takes shallow breaths. The patient may or may not have a pericardial rub. Many of the reported symptoms are the same as for the patient with ischemic chest pain. The ECG will reveal diffuse ST-segment elevation that has an upward concavity, and the PR segment is depressed.


Risk Factors for Endocarditis


Signs and Symptoms of Endocarditis• Symptoms occur 2 weeks after bacteremia• Nonspecific complaints make it difficult to diagnose• Examine patients at risk for endocarditis for

signs/symptoms, including:– Petechiae (splinter hemorrhages, Osler’s nodes,

Janeway lesions) – Splenomegaly – Fever + heart murmur (new onset or change)


Pathophysiology of Infective EndocarditisBacteremia (strep, staph)

Endothelial damage exposes basement membrane of valve to turbulent blood flow

Clot on valve leaf (vegetation) exposed to bacteria in blood

Proliferation of vegetations and damage to valve structure

Severe heart failure

Embolization Brain attack

Pulmonary embolusOsler node (peripheral emboli)


Discharge Planning Guide: Endocarditis


Cardiomyopathies and Their Classification

See Box 19-8.


Functional CardiomyopathyType of Cardiomyopathy

Signs/Symptoms Treatment

Dilated: globular dilated ventricles and impaired systolic function

•CHF symptoms•Ventricular dysrhythmias and conduction defects•Mitral and possibly tricuspid insufficiency

•Supportive care•Prevention of acute episodes•Biventricular pacing•Implantable cardioverter-defibrillator (ICD)•Heart transplant

Hypertrophic: hypertrophied nondilated left ventricle that is stiff during diastole

•Angina, syncope, CHF•Atrial fibrillation, ventricular dysrhythmias, and sudden death

•Supportive care•ICD•Percutaneous ablation (if septal defect present)


Question

A 30-year-old client is diagnosed with early-stage dilated cardiomyopathy. The nurse screens the patient for potentially reversible causes and should report which of the following?

A. Client’s father is an alcoholic and has cardiomyopathy.B. Client had the flu last week.C. HIV test is negative.D. The client drinks a six-pack of beer every day.


Answer

D. The client drinks a six-pack of beer every day.Rationale: A potentially reversible cause of dilated

cardiomyopathy is alcohol intake. The familial tendency is present - the client’s father is an alcoholic and also has dilated cardiomyopathy - but this is not a reversible cause. It takes time before the client presents with symptoms of dilated cardiomyopathy, so it is unlikely that the flu from last week caused it. If the client tested positive for HIV, then treatment of HIV would help to reverse the cardiomyopathy.


Vascular ObstructionAcute Arterial Obstruction• Skin is pale• Pain increases with

walking and decreases with rest (intermittent claudication)

• No pulses• Paresthesia • Paralysis

Deep Vein Thrombosis (DVT)• Skin is red• Pain (tender, sore) with

standing or dorsiflexion of foot

• Pulses present• Sensation intact• Able to move limb


Assessing the Client With Peripheral Arterial Disease (PAD)

See Figure 19-5.


PAD: Implications for the Older Patient• PAD is a major reason for decline in ability to walk.• Advanced cases of PAD can lead to ulcers, gangrene, or

amputation.• Consider comorbidities, which increase risk for

complications related to PAD.• Conservative management


Home Care of the Patient With PADInstruct patient to:• Eat a heart-healthy diet.• Control homocysteine levels.• Control cholesterol.• Control diabetes.• Stop smoking.• Exercise regularly.• Participate in stress management activities.


Types of Aortic Aneurysms

See Figure 19-6.


Two Major Patterns of Aortic Dissection

See Figure 19-7.


Assessment Findings of Aortic Aneurysm• Most cases are asymptomatic.• Abdominal pain• Back pain• Syncope• Palpable aortic mass with tenderness• Positive bruit - abdominal aorta• Peripheral pulses


Treatment Options for Chronic Aortic Aneurysm• Control hypertension• Eliminate risk factors• Surgical repair for abdominal aortic aneurysm >5.5 cm• Surgical repair of ascending thoracic aneurysm 5.5 cm or

greater• Surgical repair of descending thoracic aneurysm 6 cm or

greater• Minimally invasive endovascular graft through the

femoral artery: choice for high-risk patients


Classification of Blood Pressure for Adults


Hypertensive Crisis• Acute elevation of BP >180/120 mm Hg associated with

sudden onset or imminent threat of target organ damage• Management goal: decrease MAP, but no more than a

25% reduction in the first hour; if patient remains stable, decrease BP to 160/100 to 160/110 within 2 to 6 hours (AHA Guidelines, 2003)– Use arterial line to monitor BP continuously


QuestionA client presents with BP 200/140 mm Hg, HR 50, RR 20.

The serum creatinine is 3.0. The patient is neurologically intact. The nurse should question which of the following orders?

A. Prepare for arterial line insertion.B. Perform neuro checks every hour.C. Give labetalol 20 mg IVP, and if MAP has not decreased

in 5 minutes by 20%, give 40 mg IVP.D. Start nicardipine drip at 5 mg/h IV if labetalol is

unsuccessful.


AnswerC. Give labetalol 20 mg IVP, and if BP has not decreased in

5 minutes by 20%, give 40 mg IVP.Rationale: The client’s HR is 50 and the beta-blocker

labetalol could lower the heart rate further, so the nurse needs to question this order. The other orders are appropriate. The doctor should consider another short-acting IVP medication to lower the BP, with the goal of reducing the MAP by no more than 25% in the first hour; if the patient remains stable, BP is lowered to 160/100 to 160/110 within 2 to 6 hours (AHA Guidelines, 2003).

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Common Cardiovascular Disorders