♦

CARDIOVASCULAR
ISCHEMIC CARDIAC DISEASE
ANGINA = caused by obstruction of choronary artery
MI = caused by obstruction of choronary artery
Angina
chest pain resulting from myocardial
ischemia caused by inadequate myocardial blood and O2 supply
TYPES OF ANGINA
UNSTABLE
also called pre - infarction angina
occur with unpredictable degree of exertion or emotion (during rest)
increase in occurrence, duration and severity over time
PRINSMETAL
pain during night, pts wake up with pain
attack may be associated with EKG change
ST segment elevation, negative T
STABLE \CHRONIC OR EXERTIONAL
occur with activities that involves exertion or emotional stress
relieve with rest and nitro
stable pattern = onset , duration , severity, relieving factors
ASSESSMENT OF ANGINA
pain mild to moderate , substernal , crushing, squeezing, may radiating to
the lefts = arm , jaw, neck , back
unaffected by inspiration or expiration
SOB, pallor , sweating, palpitation, tachycardia, dizziness, fainting
digestive disturbance
DIAGNOSES STUDIES
EKG=
ST segment elevation, negative T = means ischemia
stress test -chest pain or EKG changes
cardiac enzymes = CKMB, TROPONIN = NEGATIVES
cardiac catheterization = diagnose and treatment
INTERVENTION
Institute pain relief measures
safety position = seat
place 1 nitro sublingual
if pain not relieve = call 911
apply 2 tablet 5 min after the first one
5 min after put the other
TREATMENT OF PRINSMETAL OF VASOSPASTIC ANGINA
calcium channel blocker ; also used for Reynau-isease
Diltiazem
verapamil
 nifedipine
FOLLOWING ACUTE EPISODES
risk factor modification
exercise, diet low Na , low fat No alcohol. Swallowing
aspirins or Clopidogrel
anticoagulantes
statin

MYOCARDIAL INFARCTION
occur when myocardial tissues is abruptly or severe deprived of oxygen
ASSESSMENT
same to angina
pain not relieve with nitroglycerin
ATYPICAL
woman = fatigue , epigastric pain , SOB
NonSTEMI = non ST segment elevation
elderly = confusion,LOC alteration,SOB
diabetes = without pain
LOCATION of MI
if the obstruction is in the left descending artery =
pts has anterior wall or septal MI
obstruction of the circumflex = posterior lateral
right coronary artery = inferior wall MI
DIAGNOSE OF INFARCTION
CK-MB =.begin to rise 3-4 hours after MI
lasting (dura , normaliza ) elevated 72 hours
TROPONIN = more specific, rise 3-4 hours after MI
lasting elevated 7-10days
MYOGLOBIN = rise 1-2 hours after , lasting elevated 6 hours
LDH level increase
WBC = 20.000- 25.000
EKG=
st elevated, = mean ischemia
negative T , = mean ischemia
patologic Q = necrosis
INTERVENTION of MI
in acute settings
M= morphine
O = oxigen
N= nitroglicerina
A= aspirine chewable
bed rest pts =Semi Fowler
iv line
 EKG monitor
administration of Trombolitic therapy = within 6 hours
ALTEPLASE
recombinant strepto kinase
Complication of Trombolitic therapy
hemorrhagic stroke = slurred speech, paralysis = stop thrombolitic, call
the doctor

FOLLOWING ACUTE EPISODES

bed rest for 24-36 hours
allow the pts to stand to void or use bed side commode
progress to dangling legs at bed side of the bed to the chair for 30 min
progress to ambulation
sexual intercourse is allow when pts is able to climb 2 flight of stairs
without SOB

COMPLICATION OF MI
Heart failure
cardiac dysrrhytmia
cardiogenic shock
pericarditis
cardiac tamponate
post infarction angina
Dressler’s syndrome = pericarditis , pericardial effusion, pleural effusion

CARDIAC DYSRRHYTMIA = priority

PVC= 1-2 pvc after MI = priority = call the doctor
PVC lad to =V-tag lead to =V-fibrillation lead= to ASYSTOLE

HEART FAILURE
inability of the heart to maintain adequate cardiac output to meet the
metabolic need of the body
Right Side Congestive HF
dependent edema (legs or sacral)
JVD = explore at 45ºdegree
abdominal dystention
hepatomegaly
splenomegaly
weight gain
nocturnal enuresis
swelling of the fingers and hand

Left Side Congestive HF

 sign of pulmonary congestion
SOB
tachypnea
crackles
dry cough
paroxysmal nocturnal dyspnea
how know that pts is getting better = decrease las almohadas
how know that pts is getting worst = aumentan las almohadas
ACUTE PULMONARY EDEMA
severe SOB ; orthopnea
pallor
tachycardia
ascending crackles
expextoration of large amount of blood -tinged= pink Frotty Sputum
anxiety
apprehension
bubbling respiration
nasal flaring
cyanosis
INTERVENTION of CHF of Acute setting
place the pts in hight Fowler position
O2
iv line
furosemide
digoxin
niseritine = for uncompensated HF
DIAGNOSE of CHF
BNP >100 = CHF
Following acute episode
medication
Digoxin = cardiac protection
ACE = pril = cardiac protection
low doses of lol =Beta Blocker = cardiac protection
avoid caffeine, tea , cocoa, chocolate
low fat , sodium
diet high in K to prevent digoxin toxicity
avoid isometric exercise

PERICARDITIS
acute or chronic inflammation of the pericardium
pericardial sac get inflamed
ASSESSMENT
chest pain
 precordial in the anterior chest that radiate to the left side of the neck-
shoulder or back
grating and aggravated by breathing ( inspiration)
worsening in supine position
may be relive by leaning forward
pericardial friction rub = scratch high pitched sound
fever and chills in case of infection
fatigue malaise
increase WBC
EKG change = STEMI = st elevation , atrial fibrillation
INTERVENTION
position the pts in HIGH FOWLER or Upright
analgesic, NSAID, colchicine (for inflammation), steroid
antibiotics for infection
diuretic , digoxin
in case of chronic = pericardiectomy

CARDIAC TAMPONATE
pericardial effusion occur when the space between the parietal and
visceral layers of the pericardium get fill with fluid
ASSESSMENT
beck’s triad =
venous hypertension = JVD with clear long
hypotension
muffled or distant heart sound
pulse Paradoxes=
decreased BP systolic>10 at the end of inspiration
wide pulse pressure
sign of decrease Cardiac output
INTERVENTION
pts is in ICU admission with hemodinamic monitor
iv Fluid
prepare for prericardiocentesis
in case of recurrence = pericardial window or pricarectomy

CARDIOGENIC SHOCK
is failure to the heart to pump adequate. Reduction of cardiac output
compromised of tissue perfusion
ASSESSMENT
hypotension , BP <90/60
tachicardia
decrease urine output <30 ml/hours
confusion
 restlessness
cold clammy skin
pulmonary congestion
tachipnea
hypotension + tachycardia y cerveza fría sudorosa y pálida
INTERVENTION
morphine
oxigen
prepare for intubation and mechanical ventilation
diuretic
vasopressors = DOPAMINE , EPINEPHRINE
assist with the insertion of sawn - ganz catheter
sawn - ganz catheter check PCWP(4-12) if >12= fluid overload
if <4 fluid volume deficiency pulmonary archery pressure
CVP measurement
right atrium is located at the midaxilary line at the 4 intercostal space
cero point need to be at the level of right atrium (flevostatic axis )
the pts need to be supine with head of bed at 45º
need to be relax , avoid coughing or staining
CVP(3-8 or 5-10)< 3 dehydration , >10 overload

ENDOCARDITIS
pts has antecedentes of infection (streptococcus)
inflammation of the inner lining of the heart and valves that occur
primarily pts who are iv drug abuse = primarily for the board
pts have had value replacement
port of entry (oral) especially pts who has had a dental procedure in to
the previous 3-6 months
ASSESSMENT
fever
anorexia
weight loss
fatigue
cardiac murmur
heart failure
petichea
Osler node = reddish te ser lession in the pad of finger
janeway lession (hemorrhagic lesions on the fingers , toes , nose
clubbing finger
EMBOLIC COMPLICATION
septic embolus
stroke , slurred speech, paralysis, weakness
pulmonary embolism = SOB tachipnea , chest pain, cyanosis
 renal embolism = flak pain + hematuria
splenic embolism = board like abdominal pain + hypovolemic shock sign
INTERVENTION OF ENDOCARDITIS
antibiotic by PICC line in place for >4-6 week
menos de un mes Mid line / más de un mes PICC line
home care instructions
aseptic technique during IV antibiotics administration
record temperature daily for up to 6 week and report fever
oral higiene at least twice daily With soft toothbrush and rise well after
avoid use oral irritation device and flossing
administration of profilactic antibiotics 1-2 week before any invasive
procedure

HEART SOUNDS
S1 = normal sound , close of tricuspid and mitral valve
heard at the 5 intercostal space
S2 = normal sound , closure of aortic and pulmonary valve
vest heart in the second left intercostal space
S3 = ventricular gallop
heart in the apex
may be normal in children , pregnant
in adult = CHF
S4 = always pathologic
ischemic or hyperthrophic
cardio myopathy
HTN
ventricular hypertrophy
AORTIC area
right second intercostal space
PULMONIC
left second intercostal space
TRICUSPIDE
fifth intercostal space at the lower left of sternum border
MITRAL
fifth intercostal space at the apex , 5 intercostal mid clavicular line