Cardiac Cycle DIASTOLE the relaxation phase SYSTOLE the contraction phase Cardiac Output Volume of blood ejected

ed by each ventricle in 1 minute CO = SV (stroke volume) x HR (heart rate) Factors influence CO indirectly by affecting SV, including Preload Afterload Systemic vascular resistance Pulmonary vascular resistance Neurologic factors regulate heart function, including: - Sympathetic nervous system stimulation - Parasympathetic nervous system stimulation ANATOMY AND PHYSIOLOGY HYPERTENSION Cardiac SNS Heart rate alpha adrenergic receptors Inotroopic state (vasoconstiction) Neural beta adrenergic receptors Humoral (vasodilation) BP = CO X SVR Renal Humoral Vasodilator (Prostaglandins, kinins) Vasoconstrictor (angiotensin, catecholamines) HYPERTENSION HYPERTENSION Category Systolic Diastolic Normal 210 >120 HYPERTENSION Risk Factors age sex race family history obesity cigarette smoking excess dietary sodium elevated serum lipids

alcohol sedentary lifestyle diabetes socioeconomic status stress HYPERTENSION Clinical Manifestations: headache fatigability dizziness palpitations angina dyspnea epistaxis Complications: Coronary Artery Disease Congestive Heart Failure Cerebrovascular Disease Peripheral Vascular Disease Nephrosclerosis Retinal Damage HYPERTENSION Laboratory Diagnostics: Routine urinalysis Serum electrolytes and uric acid levels Blood glucose levels Lipid profile Chest X-ray ECG HYPERTENSION Diuretics Thiazide Diuretics: Chlorothiazide, Hydrochlorothizide, Indapamide Loop Diuretics: Bumetanide, Ethacrynic acid, Furosemide SE: electrolyte imbalances, metabolic alkalosis, reversible hearing loss Potassium-Sparing Diuretics: Spirinolactone, triamterene, amiloride SE: electrolyte imbalance, gynecomastia, menstrual irregularities HYPERTENSION Beta-adrenergic blockers propranolol, metoprolol, nadolol, atenolol SE: bronchospasm, heart faiulre, AV block, insomnia, hyoglycemia Alpha adrenergic blockers Centrally-acting: clonidine, methyldopa SE: dry mouth, sedation, impotence, constipation, severe rebound hypertension Peripherally-acting: Guanethidine, Reserpine SE: marked orthostatic hypotension, diarrhea, bradycardia

HYPERTENSION Vasodilators hydralazine SE: tachycardia, nasal congestion, flushing, headache, lupuslike syndrome Sodium Nitroprusside SE: hypotension, nausea and vomiting, headcahe, thiocyanate toxicity Nitroglycerin SE: hypotension, headache, dizziness HYPERTENSION Angiotensin-Converting Enzyme Captopril, Enalapril, Lisinopril SE: loss of taste, cough, hyperkalemia, nephrotic syndrome, tachycardia Calcium Antagonists Amlodipine, Diltiazem, Felodipine, Verapamil SE: nausea, headache, change in HR, AV block HYPERTENSION Nursing Management: D Diet I I and O monitoring U Urine output monitoring R Response of BP E Electrolytes/Exercise T Take pulse I Ischemic episodes C Complications: 4Cs (CAD,CRF,CHF,CVA) S Smoking cessation CORONARY ARTERY DISEASE Atherosclerosis is the major causative factor. May manifest as angina pectoris or MI Risk Factors: Non-modifiable:age, gender, race, family history Modifiable: Major risk factors (hyperlipoprotinemia, hypertension, obesity,physical inactivity, smoking) Minor risk factors (personality type, glucose intolerance, psychologic stress, oral contraceptive use) CORONARY ARTERY DISEASE CORONARY ARTERY DISEASE TYPES OF ANGINA STABLE caused by exertion or emotion and cold , maybe relieved by rest. ECG: ST segment depression Treatment: SL Nitroglycerin UNSTABLE

Unpredictable and may progress from stable angina ECG: ST segment changes and/or T wave inversions Treatment: oral nitrates, beta blockers, anticoagulation CORONARY ARTERY DISEASE VARIANT OR PRINZMETAL characterized by recurrent, prolonged attacks of severe ischemia, caused by episodic focal spasm of an epicardial coronary artery. ECG: ST segment elevation Treatment: SL Nitroglycerin & short acting nifedipine (10-30 mg) Categories of MI Transmural (AKA Q-wave MI) - because the majority of MIs affect the left ventricle, this type of infarct can compromise the efficacy of the pump Nontransmural (aka non-Q wave, Subendocardial) - S-T segment elevation and or depression are characteristic findings - T-Wave inversion may be seen Angina Myocardial Infarction Precipitating Factors: stress exertion or at rest digestion of heavy meal stress valsalva maneuver extremes of weather hot baths or showers sexual excitation Location midanterior chest midanterior chest substernal substernal diffuse, not easily located radiation to neck jaw or left arm Description sever pressure, squeezing deep sensation of tightness heaviness with crushing or squeezing feeling oppressive quality similar attacks each time residual soreness for several days after MI Onset and Duration gradual/sudden onset sudden onset 30 min-2 hrs relief from nitroglycerin no relief from rest or nitroglycerin Associated symptoms apprehension apprehension dyspnea nausea and vomiting diaphoresis dyspnea desire to void diaphoresis, dizziness CORONARY ARTERY DISEASE

Complications: Arrythmias (most common) Cardiogenic shock Dresslers syndrome Ventricular aneurysm CORONARY ARTERY DISEASE Laboratory Diagnostics ECG Stress Test Nuclear Imaging Cardiac Enzymes Diagnostics Diagnostics Echocardiography Cardiac Perfusion Studies ECG Cardiac Enzyme Analysis CK- MB = Creatine Kinase , elevated within 8 hours after onset of symptoms Normal Values: Men: 38-174 U/l Women: 26- 140 U/l CARDIAC TROPONIN (T, I) Normal Values: Troponin I: 1.5 ng/ml MI Troponin T: >0.1- 0.2 ng/ml MI LDH, LDH1/LDH2 ratio, flipped LDH rises within 48 hours after onset CORONARY ARTERY DISEASE Medical Management: Surgery (Revascularization Procedures): Percutaneous transluminal angioplasty Coronary artery bypass graft (CABG) Medications: Angina: ASA, nitroglycerin MI: thrombolytics, anticoagulants, morphine, nitroglycerine, B-blockers, antidystrythmic drugs, (+) inotropic drugs, stool softeners CORONARY ARTERY DISEASE Nursing Management: Assess the presence and degree of pain and chest discomfort. Promote interventions towards pain relief. Administer nitrates or morphine as ordered. Promote measures to maintain cardiac parameters within normal limits and maintain an effective cardiac rhythm. Place the patient on a cardiac monitor and continuously monitor cardiac rate and rhythm . Monitor electrolytes. Administer Oxygen Place the patient in position of comfort Instruct patient to avoid activities that increase the Valsalva response

CORONARY ARTERY DISEASE 7. Provide health teaching re: Diet (Low sodium diet and low fat) smoking cessation weight reduction program return to work Regular exercise sexual activity Avoid if FUSHIAE Fatigue Unfamiliar partner Stress Heavy meals Intake of alcohol Anal intercourse Extreme temperature CORONARY ARTERY DISEASE Care for a Patient who underwent PTCA/CABG Pre-operative: 1. Explain equipment to be used (monitors, hemodynamic procedures, ventilator, drainage tubes). 2. Demonstrate activity and exrecises. Reassure client that pain medications will be provided. Post-operative: 1. Maintain patent airway. 2. Promote lung re-expansion 3. Monitor cardiac status: Monitor VS and cardiac rhythm. Report significant changes. Perfrom peripheral pulse checks. Administer anticoagulants as ordered CORONARY ARTERY DISEASE 4. Maintain fluid and electrolyte balance. Maintain adequate cerebral perfusion. 6. Provide pain relief. 7. Prevent abdominal distention. 8. Monitor and prevent complication (thrombophlebitis, cardiac tamponade, arrythmias, CHF) 9. Provide client teaching regarding: Limitation with progressive increase in exercise. Sexual intercourse Medical regimen Diet Wound dressing CORONARY ARTERY DISEASE Cardio-pulmonary Resuscitation 1. Assess LOC 2. Position victim on a firm surface.

3. Open airway head-tilt-chin lift maneuver (except if with suspected cervical fracture) Sweep the mouth with the finger Place ear over nose and mouth If no respiration, ventilate 2x. CORONARY ARTERY DISEASE 4. Assess for circulation Check for carotid pulse If none, start chest compressions. For one rescuer: C:V 30:2 For 2 rescuer: C:V 30:2 Depth: 1.5 -2 inches (adult) 1-1.5 inches (children) 0.5-1 inch (infant) Remember!!! Stop CPR only if: victim responds, (+)replacement, exhaustion, victim transported to ER CONGESTIVE HEART FAILURE Inability fo the heart to provide adequate blood supply in relation to the venous return and metabolic needs of the body. Causes: 1. Valvular problems. 2. MI, myocarditis, ventricular aneurysm, cardiomyopathies 3. Metabolic disorders 4. Pulmonary hypertension CONGESTIVE HEART FAILURE Clinical Manifestations: 1. Right-sided heart failure H Hepatomegaly E Edema A Ascites D Distended neck vein 2. Left-sided heart failure C Coughing and Dyspnea H Hemoptysis O Orthopnea P Pulmonary Congestion Paroxysmal Nocturnal Dyspnea CONGESTIVE HEART FAILURE Laboratory Diagnostics: Chest-X-ray Echocardiography Hemodynamic Monitoring

Swan-Ganz catheter CVP (Normal is 0-8 mmHg or 5-10 cmsH2O) CONGESTIVE HEART FAILURE Nursing Care: 1. Inspect sterile dry dressing and change every 24 hours. 2. If catheter is inserted via an extremity, immobilize the extremity. 3. Observe catheter site for leakage. 4. Continuously monitor PA pressures and report significant changes. 5. Irrigate line before reading the PCWP. 6. Maintain pressure bag at 300 mmHg. Goals of medical management: 1. Decrease cardiac workload2. Control of excess fluid retention Medical Management: U Upright position N Nitrates L Lasix O Oxygen A Administer Morphine D Digoxin F Fluids (decrease) A Afterload (decrease) S Sodium restriction T Test (Digoxin level, ABG, potassium level) CONGESTIVE HEART FAILURE Nursing Management: 1. Provide oxygenation Administer oxygen by nasal cannula. Position patient in semi- or high-Fowlers position. 2. Provide rest and activity. Encourage activity with prescribed restrictions. Monitor of intolerance to activity. Assist in ADLs as necessary. 3. Monitor for signs of fluid and electrolyte imbalance. 4. Provide skin care. Use prophylactic measures to prevent skin breakdown. 5. Assist in maintaining adequate nutritional intake. 6. Avoid valsalva maneuver. 7. Give prescribed medications and monitor for side-effects. 8. Provide patient/family opportunities to discuss their concerns. 9. Apply and monitor rotating tourniquets Occlude vessels of each limb for no more than 45 minutes. Rotate in a clockwise direction. Assess continuously for peripheral pulses.

Assess for skin breakdown. 10. Assist in phlebotomy.