MANAGEMENT OF PATIENTS WITH CARDIOVASCULAR & HEMATOLOGIC PROBLEMS¦ By: Amethyst Vic C. Mergal, RN

THE CARDIOVASCULAR SYSTEM

THE HEART

Three layers of the heart: Endocardium Myocardium Epicardium

Four chambers Heart valves Coronary arteries Cardiac

conduction system

Cardiac hemodynamics

HEART FACTS

Your system of blood vessels - arteries, veins and capillaries - is over 60,000 miles long. That's long enough to go around the world more than twice!

The adult heart pumps about 5 quarts of blood each minute - approximately 2,000 gallons of blood each day - throughout the body.

When attempting to locate their heart, most people place their hand on their left chest. Actually, your heart is located in the center of your chest between your lungs. The bottom of the heart is tipped to the left, so you feel more of your heart on your left side of your chest.

HEART FACTS

The heart beats about 100,000 times each day.

In a 70-year lifetime, the average human heart beats more than 2.5 billion times

An adult woman's heart weighs about 8 ounces, a man's about 10 ounces

A child's heart is about the size of a clenched fist; an adult's heart is about the size of two fists.

Blood is about 78 percent water.

HEART FACTS

Blood takes about 20 seconds to circulate throughout the entire vascular system.

The structure of the heart was first described in 1706, by Raymond de Viessens, a French anatomy professor.

The electrocardiograph (ECG) was invented in 1902 by Dutch physiologist Willem Einthoven. This test is still used to evaluate the heart's rate and rhythm.

The first heart specialists emerged after World War I.

PULMONARY CIRCULATION the portion of the

cardiovascular system which carries oxygen-depleted blood away from the heart, to the lungs, and returns oxygenated blood back to the heart. The term is contrasted with systemic circulation.

SYSTEMIC CIRCULATION the portion of the

cardiovascular system which carries oxygenated blood away from the heart, to the body, and returns deoxygenated blood back to the heart. The term is contrasted with pulmonary circulation.

CORONARY ARTERIES

The heart’s own supply of blood

CARDIAC CONDUCTING SYSTEM

GENERAL CARDIAC ASSESSMENT Health history

Demographic information Family/genetic history Cultural/social factors

Risk factors Modifiable: High blood cholesterol, obesity,

smoking, stress, hypertension, diabetes mellitus.

Nonmodifiable: Family history, increasing age, gender, race

ASSESSING CHEST PAIN

COMPARISON OF PHYSICAL CAUSES OF CHEST PAINCharacter

isticM.I. Pericard

itisG.I. Prob

Angina Dis. Aneurysm

P. Embolism

Onset Gradual/ Sudden

Sudden Gradual/ Sudden

Gradual/ Sudden

Abrupt Gradual/ Sudden

Precipitating Factors

At rest / after exercise or emotional stress

Breathing deeply, rotating trunk, yawning

Inflammation of GI parts; increased HCL; medications

After exercise, emotional stress, eating, envt’l changes

Hypertension

Immobility, Prolonged bedrest

Location Substernal, anterior chest, rarely back, radiates to jaw/neck

Precordial; rotates to neck/ left shoulder & arm

Xiphoid to umbilicus

Substernal, anterior chest; poorly localized

Site of rupture; anterior chest or back; between scapula

Pleural area, retrosternal

Quality Crushing, burning, stabbing, squeezing, vicelike

Pleuritic, sharp

Aching, burning, cramplike, gnawing

Squeezing, feeling of heavy pressure; burning

Sharp, tearing, ripping

Sharp, stabbing

COMPARISON OF PHYSICAL CAUSES OF CHEST PAINCharacter

isticM.I. Pericard

itisG.I. Prob

Angina Dis. Aneurysm

P. Embolism

Intensity Asymptomatic to severe; increases with time

Mild to severe

Mild to severe

Mild to moderate

Severe, unbearable; maximal from onset

Aggravated by breathing

Duration 30 min to 1-2 hours; may wax and wane

Continuous

Periodic 2-10 min; ave: 3-5 min

Continuous; does not abate once started

Variable

Relief Narcotics Sitting up, leaning forward

Physical/ emotional rest, food, antacid

Nitroglycerin, rest

Large, repeated doses of narcotics

02 , sitting up; morphine

Associated Symptoms

Nausea, fatigue, heartburn, equal peripheral pulses

Fever, dyspnea, nausea, anorexia, anxiety

N/V, dysphagia, anorexia, weight loss

Belching, indigestion, dizziness

Syncope, loss of sensations / pulses, oliguria, BP discrepancies, decrease in pulses

Dyspnea, tachypnea, diaphoresis, hemoptysis, cough, apprehension

CORONARY VASCULAR DISORDERS Also called

occlusive disorders Arteriosclerosis Angina Pectoris Myocardial

Infarction

ARTERIOSCLEROSIS

Narrowing and hardening of the arteries. Three types:

Atherosclerosis (fatty deposits called plaque on inner lining of vessel walls).

Calcific sclerosis (calcium deposits on the middle layer of the wall of the arteries).

Arteriolar sclerosis (a thickening of the arterioles caused by hypertension).

RISK FACTORS

Increased serum cholesterol (LDL ≥ 160 mg/dl)

Hypertension Cigarette smoking Diabetes Mellitus Family history of

premature CHD

CORONARY ARTERIES

PATHOPHYSIOLOGY

Symptoms are due to myocardial ischemia.

Symptoms and complications are related to the location and degree of vessel obstruction. Angina pectoris Myocardial infarction Heart failure Sudden cardiac death

ANGINA PECTORIS

A syndrome characterized by episodes of paroxysmal pain or pressure in the anterior chest caused by insufficient coronary blood flow

Physical exertion or emotional stress increases myocardial oxygen demand, and the coronary vessels are unable to supply sufficient blood flow to meet the oxygen demand.

TYPES OF ANGINA PECTORIS

ASSESSMENT

Subjective data: PAIN!!!!

Type: squeezing, pressing, burning Location: retrosternal, substernal, left of

sternum, radiates to left arm Duration: short; usually 3-5 mins, <30 mins Cause: emotional stress, overeating, physical

exertion, exposure to cold, may occur at rest Relief: rest, nitroglycerin

Women also complain jaw, upper back pain, & gastric upset

ASSESSMENT

Subjective data: Dyspnea Palpitations Dizziness; faintness Epigastric distress,

indigestion Objective data:

Tachycardia Pallor Diaphoresis ECG changes during attack

ANALYSIS / NURSING DIAGNOSES Altered

cardiopulmonary tissue perfusion related to insufficient blood flow

Pain related to myocardial ischemia

Activity intolerance related to onset of pain

NURSING CARE PLAN

GOAL # 1: provide relief from pain Rest until pain subsides Nitroglycerin (nitrites) Identify precipitating factors:

heavy meals, heavy exercise, stimulants, cold air

Vital signs: hypotension Assist with ambulation:

dizziness, flushing occurs with nitroglycerin

NURSING CARE PLAN

GOAL # 2: provide emotional support Encourage

verbalization of feelings

Reassurance; positive self-concept

Acceptance of limitations

NURSING CARE PLAN

GOAL # 3: health teaching Pain: alleviation, differentiation from M.I.,

precipitating factors Medications: frequency, side effects, dosage,

route.. Diet: restricted calories if weight loss indicated;

restricted fat, cholesterol, gas-forming food; small, frequent meals

Exercise: regular, graded, to promote coronary circulation

Behavior modification Coronary bypass surgery if indicated

EVALUATION/OUTCOME CRITERIA Relief from pain Fewer attacks No myocardial infarction Alters lifestyle; complies with limitations No smoking

MYOCARDIAL INFARCTION irreversible cardiac

damage from occlusion of 1 or more coronary arteries

The term “acute coronary syndrome” includes unstable angina and myocardial infarction

CLINICAL MANIFESTATIONS AND DIAGNOSIS Chest pain, other

symptoms Laboratory tests—

biomarkers WBC: 12000-

15000/µL CK-MB Myoglobin Troponin T or I

ECG changes

EFFECTS OF M.I. ON E.C.G Recent M.I.

ST elevation (injury)

T wave inversion (ischemia)

Previous M.I. Q wave

(necrosis / old infarct)

ASSESSMENT

Subjective data: PAIN!!! Nausea SOB Apprehension

Objective data: VS Diaphoresis Emotional restlessness

ANALYSIS / NURSING DIAGNOSES Decreased cardiac output related to

myocardial damage Impaired gas exchange related to poor

perfusion, shock Pain related to myocardial ischemia Activity intolerance related to pain or

inadequate oxygenation Fear related to possibility of death

NURSING CARE PLAN

Goal # 1: reduce pain / discomfort Narcotics – morphine; note response; Avoid

IM Humidified oxygen 2-4 L/min; mouth care –

O2 is drying Position: semi-Fowler’s to improve

ventilation

NURSING CARE PLAN

Goal # 2: maintain adequate circulation; stabilize heart rhythm Monitor VS/UO; observe for cardiogenic shock Monitor ECG for arrhythmias Medications: antiarrhythmics; anticoagulants;

thrombolytics Diagnostics: cardiac catheterizations, CAB surgery Recognize heart failure: edema, cyanosis, dyspnea,

crackles Check labs: troponin, blood gases, electrolytes, clotting

time CVP: (5-15 cm H2O) increases with heart failure ROM of lower extremities; antiembolic stockings

NURSING CARE PLAN

Goal # 3: decrease oxygen demand/promote oxygenation, reduce cardiac workload O2 as ordered Activity: bedrest (24-48 H) with bedside commode;

planned rest periods; control visitors Position: semi-Fowler’s to facilitate lung expansion

and decrease venous return Anticipate needs of client: call light, water /

Reassurance Assist with feeding, turning Environment: quiet and comfortable Medications: CCBs, vasodilators, cardiotonics

NURSING CARE PLAN

Goal # 4: maintain fluid electrolyte, nutritional status IV (KVO); CVP; vital signs UO: 30 cc/hr Labs: electrolytes (Na, K,

Mg) Monitor ECG Diet: progressive low

calorie, low sodium, low cholesterol, low fat, without caffeine

NURSING CARE PLAN

Goal # 5: facilitate fecal elimination Medications: stool

softeners to prevent Valsalva maneuver; mouth breathing during bowel movement

Bedside commode

NURSING CARE PLAN

Goal # 6: provide emotional support Recognize fear of dying:

denial, anger, withdrawal Encourage expression of

feelings, fears, concerns Discuss rehabilitation,

lifestyle changes: prevent cardiac-invalid syndrome by promoting self-care activities, independence

NURSING CARE PLAN

Goal # 7: promote sexual functioning Encourage verbalization of concerns

regarding activity, inadequacy, limitations, expectations – include partner (usually resume activity 5-8 wks after uncomplicated MI or when client can climb 2 flights of stairs

Identify need for referral for sexual counselling

NURSING CARE PLAN

Goal # 8: health teaching Diagnosis and treatment regimen Caution when to avoid sexual activity: after heavy

meal, alcohol ingestion; when fatigued, stressed; with unfamiliar partners; in extreme temperatures

Information about sexual activity: less fatiguing positions

Support groups / Follow-up care Medications: administration, importance, untoward

effects; pulse taking Control risk factors: rest, diet, exercise, no smoking,

weight control, stress reduction

EVALUATION

No complications: stable vital signs; relief of pain

Adheres to medication regimen Activity tolerance is increased Reduction or modification of risk factors

CONGESTIVE HEART FAILURE inability of the

heart to pump sufficient blood to meet the needs of the tissue for oxygen and nutrient.

PATHOPHYSIOLOGY

ASSESSMENT

Subjective data: Shortness of breath

Orthopnea (sleeps on two or more pillows)

Paroxysmal nocturnal dyspnea (sudden breathlessness during sleep)

Dyspnea on exertion (climbing stairs)

Apprehension; anxiety; irritability

Fatigue; weakness Reported weight gain; feeling

of puffiness

ASSESSMENT

Objective data: VS:

BP: decreasing systolic; narrowing pulse pressure Pulse: pulsus alternans (alternating strong-weak-

strong cardiac contraction); increased. Respirations: crackles; Cheyne-Stokes

Edema: dependent, pitting (1+ to 4+ mm) Liver: enlarged, tender Distended neck veins Chest X-ray: enlarged heart; dilated pulmonary

vessels; lung edema

Left Ventricular Compared with Right Ventricular Heart Failure

LEFT VENTRICUL

AR FAILURE

RIGHT VENTRICUL

AR FAILURE

Pulmonary crackles

Jugular venous

distention

Tachypnea Peripheral edema

S3 gallop Perioral and peripheral cyanosis

Cardiac murmurs

Congestive hepatomega

ly

Paradoxical splitting of

S2

Ascites

Hepatojugular reflux

ANALYSIS / NURSING DIAGNOSES Decreased cardiac output related to decreased

myocardial contractility Activity intolerance related to generalized body

weakness and inadequate oxygenation Fatigue related to edema and poor oxygenation Fluid volume excess related to compensatory

mechanisms Impaired gas exchange related to pulmonary

congestion Anxiety related to shortness of breath Sleep pattern disturbance related to paroxysmal

nocturnal disturbance

NURSING CARE PLAN

Goal # 1: provide physical rest/ reduce emotional stimuli Position: sitting or semi-Fowler’s until

tachycardia, dyspnea, edema resolved; change position frequently; pillows for support

Rest: planned periods; limit visitors, activity, noise. Chair and commode privileges

Support: stay with client who is anxious; have family member who is supportive present; administer sedatives/tranquilizers as ordered

Warm fluids if appropriate

NURSING CARE PLAN

Goal # 2: provide for relief of respiratory distress; reduce cardiac workload Oxygen: low flow rate; encourage deep

breathing (5-10 min q 2H); auscultate breath sounds for congestion, pulmonary edema.

Position: elevating head of bed 20-25 cm (8-10 in) alleviates pulmonary congestion

Medications – digitalis, ACE inhibitors, inotropic agents, diuretics, tranquilizers, vasodilators

NURSING CARE PLAN

Goal # 3: provide for special safety needs Skin care:

Inspect, massage, lubricate bony prominences

Use foot cradle, heel protectors; sheepskin

Side rails up if hypoxic (disoriented) Vital signs: monitor for signs of

fatigue, pulmonary emboli ROM: active, passive; elastic

stockings

NURSING CARE PLAN

Goal # 4: maintain fluid and electrolyte balance, nutritional status Urine output: 30 cc/hr minimum; estimate

insensible loss in client who s diaphoretic. Monitor BUN, serum creatinine, and electrolytes.

Daily weight; same time, clothes, scale IV: IV infusion pump to avoid circulatory overload;

strict I/O Diet

Low sodium Small, frequent feedings Discuss food preferences with client.

NURSING CARE PLAN

Goal # 5: health teaching Diet restrictions; meal preparation Activity restrictions; planned rest periods Medications: schedule (e.g. diuretics in

early morning); purpose; dosage; side effects (pulse taking, daily weights, intake of potassium-containing foods)

Refer to available community resources for dietary assistance, weight reduction, exercise program.

EVALUATION

Increase in activity level tolerance – fatigue decreased

No complications – pulmonary edema, respiratory distress

Reduction in dependent edema

THE HEMATOLOGIC SYSTEM

THE BLOOD

Composition of the blood RBC, WBC, Platelets, Plasma

RBC normal erythropoeisis requires : pyridoxine, Vit B12,

folic acid, protein, copper, cobalt; HEMOBGLOBIN : Iron; Oxygen transport; Acid-base

buffer WBC

granulocytes –neutrophils, eosinophils, basophils agaranulocytes –lymphocytes (T,B), monocytes

Plasma albumin, water, clotting factors, antibodies

IRON DEFICIENCY ANEMIA Composition of the blood

RBC, WBC, Platelets, Plasma

RBC normal erythropoeisis requires : pyridoxine, Vit B12, folic

acid, protein, copper, cobalt;

HEMOGLOBIN : IRON; Oxygen transport; Acid-base buffer

WBC granulocytes –neutrophils, eosinophils, basophils agranulocytes –lymphocytes (T,B), monocytes

Plasma albumin, water, clotting factors, antibodies

PATHOPHYSIOLOGY

CAUSES &EFFECTS

1. Poor intake if iron rich foods

2. Poor absorption & utilization of iron from foods

3. Acute / chronic blood loss

ANALYSIS / NURSING DIAGNOSES Altered nutrition, less than body

requirements, related to inadequate iron absorption

Altered tissue perfusion related to reduction in red cells

Risk for activity intolerance related to profound weakness

Impaired gas exchange related to decreased oxygen-carrying capacity

NURSING CARE PLANS

Goal # 1: promote physical and mental equilibrium Position: optimal for respiratory excursion;

deep breathing; turn frequently to prevent skin breakdown

Rest: balance with activity, as tolerated; assist with ambulation

Keep warm: no hot water bottles, heating pads, due to increased sensitivity

Diet: high in protein, iron, vitamins

NURSING CARE PLANS

Goal # 1: promote physical and mental equilibrium Medication (hematinics)

oral iron therapy (FeSO4) – give with meals IM therapy (iron dextran)

use second needle for injection Z-track inject 0.5 mL of air before

withdrawing needle to prevent tissue necrosis

Rotate sites Do not rub site or allow wearing

of constricting garments after injection

NURSING CARE PLANS

Goal # 2: health teaching Dietary regimen Iron therapy: explain purpose, dosage, side

effects (black/green stools, constipation, diarrhea); take with meals

Activity: exercise to tolerance, with planned rest periods

EVALUATION

Hemoglobin and hematocrit level return to normal range

Tolerates activity without fatigue Selects foods appropriate for dietary

regimen

LEUKEMIA

Fatal neoplastic disease that involves the blood forming tissues of the: Bone marrow Spleen Lymph nodes

Uncontrolled & destructive proliferation of one type of WBC & its precursors

LEUKEMIA

Types: Acute nonlymphocytic (ANLL) – also known as

acute myelogenous leukemia (AML); seen generally in older age (>60 yr).

Acute lymphoblastic (ALL) – common in children 2-10y/o

Chronic lymphocytic (CLL) – generally affects the elderly

Chronic myelogenous (CML) – also known as chronic granulocytic leukemia (CGL); more likely to occur between 25-60 years old.

LEUKEMIA

Risk Factors Viruses Genetic abnormalities Exposure to chemicals Radiation Treatment for other types of cancer (e.g.

alkylating agents)

ASSESSMENT

Subjective data: Fatigue, weakness Anorexia, nausea Pain: joints, bone (acute leukemia) Night sweats, weight loss, malaise

ASSESSMENT

Objective data: Skin: pallor due to anemia; jaundice Fever: frequent infections; mouth ulcers Bleeding: petechiae, purpura, ecchymosis,

epistaxis, gingiva Organ enlargement: spleen, liver Enlarged lymph nodes; tenderness Bone marrow aspiration: increased

presence of blasts

ASSESSMENT

Lab data: WBC – abnormally low (<1000/mm3) or

extremely high (>200,000/mm3); differential is important

RBC – normal to severely decreased Hgb – low or normal Platelets – usually low

ANALYSIS / NURSING DIAGNOSES Risk for infection related to immature or abnormal

leukocytes Activity intolerance related to hypoxia and weakness Fatigue related to anemia Altered tissue perfusion related to anemia Anxiety related to diagnosis and treatment Altered oral mucous membrane related to

susceptibility to infection Fear related to diagnosis Ineffective individual or family coping related to

potentially fatal disease

NURSING CARE PLAN

Goal # 1: prevent, control, and treat infection Protective isolation if indicated Observe for early signs of infection:

Inflammation at injection sites Vital signs changes Cough Obtain cultures

Give antibiotics as ordered Mouth care: clean q2h, examine for new

lesions, avoid trauma

NURSING CARE PLAN

Goal # 2: assess and control bleeding, anemia Activity: restrict; to prevent trauma Observe for hemorrhage: vital signs; body

orifices, stool, urine Control localized bleeding: ice, pressure at least

3-4 min after needle sticks, positioning Use soft-bristle or foam-rubber toothbrush to

prevent gingival bleeding Give blood/blood components as ordered;

observe for transfusion reactions

NURSING CARE PLAN

Goal # 3: provide rest comfort, nutrition Activity: 8 hr sleep or rest; daily nap Comfort measures: flotation mattress, bed cradle,

sheepskin Analgesics: without delay

Mild pain (Acetaminophen; without aspirin) Severe pain (codeine, meperidine HCl)

Diet: bland High in protein, minerals, vitamins Low roughage Small, frequent feedings Favorite foods

Fluids: 3000 – 4000 mL/day

NURSING CARE PLAN

Goal # 4: reduce side effects from therapeutic regimen Nausea: antiemetics, usually half-hour

before chemotherapy Increased uric acid level: force fluids Stomatitis: antiseptic anesthetic

mouthwashes Rectal irritation: meticulous toileting, sitz

bath, topical relief

NURSING CARE PLAN

Goal # 5: provide emotional / spiritual support Contact clergy if client desires Allow, encourage client-initiated discussion

of death (developmentally appropriate) Allow family to be involved with care If death occurs, provide privacy for family,

listening, sharing of grief

NURSING CARE PLAN

Goal # 6: health teaching Prevent infection. Limit activity. Control bleeding. Reduce nausea. Mouth care. Chemotherapy: regimen; side effects.

EVALUATION

Alleviate symptoms; obtain remission. Prevent complications (e.g. infection). Ventilates emotion – accepts and deals

with anger. Experiences peaceful death (e.g. pain

free).

IDIOPATHIC THROMBOCYTIC PURPURA

Potentially fatal disorder characterized by spontaneous increase in platelet destruction

Possible autoimmune response Predominant in 2 – 4-year-olds and

girls/women ≥10 years old Secondary thrombocytopenia – viral

infections, drug hypersensitivity (i.e. quinidine, sulfonamides), lupus, or bone marrow failure Treat cause

ASSESSMENT

Subjective data: Spontaneous skin hemorrhages – lower

extremities Menorrhagia Epistaxis

ASSESSMENT

Objective data: Bleeding: GI, urinary, nasal;

following minor trauma, dental extractions.

Petechiae; ecchymosis Tourniquet test – positive,

demonstrating increased capillary fragility

Lab data Decreased platelets

(100,000/µL). Increased bleeding time

ANALYSIS / NURSING DIAGNOSES Risk for injury related to hemorrhage Altered tissue perfusion related to fragile

capillaries Impaired skin integrity related to skin

hemorrhages

NURSING CARE PLAN

Goal # 1: prevent complication from bleeding tendencies Precautions:

Injections – use small-bore needles; rotate sites; apply direct pressure

Avoid bumping, trauma. Use swabs for mouth care

Observe for signs of bleeding, petechiae, following blood pressure reading, ecchymosis, purpura.

Administer steroids to increase platelet count in ITP; give platelets <20,000-30,000/µL with STP; high-dose immunoglobulins.

NURSING CARE PLAN

Goal # 2: health teaching Avoid traumatic activities:

Contact sports Violent sneezing, coughing, nose blowing. Straining at stool Heavy lifting

Signs of decreased platelets – petechiae, ecchymosis, gingival bleeding, hematuria, menorrhagia

Use MedicAlert tag/card Precautions: self-medication; particularly avoid aspirin-

containing drugs Prepare for splenectomy if drug therapy is

unsuccessful

EVALUATION

Returns for follow-up. No complications (e.g. intracranial

hemorrhage). Platelet count > 200,000/µL. Skin remains intact. Resumes self-care activities.

REFERENCES

Donofrio, J. Haworth, K. Schaeffer, L. Thompson, G. (Eds.). (2005). Cardiovascular care made incredibly easy. Philadelphia: Lipincott Williams & Wilkins.

Lagerquist, S.L. (Ed.) (2005). Davis’s nclex-rn success. (2nd ed.). Philadelphia: F.A. Davis Company.

Topol EJ (Ed.). (2000). Cleveland clinic heart book. New York: Hyperion.