CARDIOVASCULAR DISEASES (CVD)

CARDIOVASCULAR DISEASES (CVD)
REVIEW OF ANATOMY AND PHYSIOLOGY

• The heart itself is made up of 4 chambers, 2 atria and 2
ventricles.
• De-oxygenated blood returns to the right side of the
heart via the venous circulation.
• It is pumped into the right ventricle and then to the lungs
where carbon dioxide is released and oxygen is absorbed.
• The oxygenated blood then travels back to the left side
of the heart into the left atria, then into the left ventricle
from where it is pumped into the aorta and arterial
circulation.
• The pressure created in the arteries by the contraction of the left
ventricle is the systolic blood pressure.
• Once the left ventricle has fully contracted it begins to relax and
refill with blood from the left atria. The pressure in the arteries
falls whilst the ventricle refills. This is the diastolic blood pressure.
• The atrio-ventricular septum completely separates the 2 sides of
the heart.
• Unless there is a septal defect, the 2 sides of the heart never
directly communicate. Blood travels from right side to left side via
the lungs only. However the chambers themselves work
together . The 2 atria contract simultaneously, and the 2 ventricles
contract simultaneously.
FUCTIONS OF THE HEART
• Managing blood supply. Variations in the rate and force of heart

contraction match blood flow to the changing metabolic needs
of the tissues during rest, exercise, and changes in body position.
• Producing blood pressure. Contractions of the heart produce
blood pressure, which is needed for blood flow through the
blood vessels.
• Securing one-way blood flow. The valves of the heart secure a
one-way blood flow through the heart and blood vessels.
• Transmitting blood. The heart separates the pulmonary and
systemic circulations, which ensures the flow of oxygenated
blood to tissues.
Cardiac Conduction System
• This pathway is made up of 5 elements
1. The sino-atrial (SA) node
2. The atrio-ventricular (AV) node
3. The bundle of His
4. The left and right bundle branches
5. The Purkinje fibres
• Read and make notes on the cardiac
conducting system
CARDIOVASCULAR DISEASES (CVD)
• These are diseases affecting heart muscles, valves and blood
vessels.
• They can be congenital or acquired.
Risk factors for CVD

The risk factors can be classified as:-
• Modifiable –One can change
• Non-modifiable-one cannot change
Modifiable:- They include
• Cigarette smoking
• Hypertension
• High density lipo-proteins. ( HDL-C)
• Low high density lipoproteins (LHDL-C)
• Diabetes mellitus
The Risk Factors Ctd.
• Psychological factors
– Stress
– Type A Personality (Hurrying + stressed people)
– Low social economic status.
Non-modifiable
They are:
• Age
• Congenital conditions (hereditary)
• Gender – more common in men than women.
• Race- More common in Africans than Caucasian
COMMON SIGNS & SYMPTOMS OF CVD
Chest pain
• Is common in Angina Pectoris and Myocardial Infarction (MI)
• Mnemonic PQRST is used to describe or assess chest pains related to Heart
condition
• P- Provokes. Palliates, Precipitates meaning
• - what starts the pain.
– What relieves, makes less severe or worsens the pain?
– What the patient was doing when the pain started.
• Q – Quality of pain i.e. is it; sharp(

• producing a sudden,piercing physical sensation or effect) , burning (very keenly or
deeply felt) tearing( breaking apart a material by force), crushing (force inwards
compressing forcefully) type of pain.
• R – Region of pain i.e. is it radiating, where is it localized, where is it radiating to?
• S – Severity i.e. How severe is the pain. What are the other symptoms associated
with it, is it coming and going, what else does the patient feel?
• T – Time. When the pain started i.e. in duration and in relation to what the patient
was doing.
COMMON SIGNS & SYMPTOMS OF CVD ctd
oedema
– Is the collection of fluid in interstitial spaces due to poor venous
return.
– Is common in lower limbs and sacral region.
– This is common in Patients with Right sided Heart failure.
Palpitations
• Are rapid forceful irregular heartbeats felt by the patient.
Fatigue
• Is usually as a result of poor cardiac output due to an
advanced Heart failure. Due to poor cardiac output, there is
reduced Oxygen2 supply to the tissues.
COMMON SIGNS & SYMPTOMS OF CVD ctd
Syncope
• Is a feeling of dizziness and fainting due to reduced blood supply to the brain.
Dyspnoea
• Is difficulty in breathing and its common during exertion.
Arrhythmia and dysrhythmia

• Is the irregularity of heart beat which could either be too fast or too slow.
Cyanosis
• Bluish skin colouration and mucus membrane. There can be two types of
cyanosis:-
• Peripheral cyanosis
– Is due to Oxygen reduction in the capillaries as a result of slow circulation.
Central cyanosis
– Is due to reduced Oxygen saturation e.g in lung diseases.
Haemoptysis
– This is coughing out of blood and is also seen in cardiac conditions.
HEART SOUNDS
• Normal heart sounds are labeled as S1 or “Lub”
and S2 or “Dup”
• S1 is fairly loud and is due to closure of
Atrioventricular valves.\
• S2 is softer and is due to closure of aortic and
pulmonary valves (semilunar valves).
• S1 is best heard over the epical (apex area)
• S2 is best heard over the aortic area.
ABNORMAL HEART SOUND
i.Splitting of S1
• - This means that Bicuspid and Tricuspid valves are closing at
different times.
• - It’s common in right bundle block and mitral stenosis
(narrowing of bicuspid valves)
•
ii. Splitting of S2
– It occurs on inspiration from pressure changes within the chest that
delay closure of the pulmonary valve.
– When there’s splitting of S2 during expiration, it’s considered more
serious and is referred to as fixed split and it can be caused by:-
– Right Bundled Block
– Pulmonary HTN
– Right Bundled Failure
ABNORMAL HEART SOUND ctd
• iii. S3 (Ventricular Diastolic Gallop)
– It’s caused by failure of ventricles to initiate contractions
adequate to eject the blood resulting in partially filled
chamber during a diastole. This leads to a low pitched sound
or a “thud”.
• iv. S4 (Atrial Diastolic Gallop)
• It’s produced by a rush of blood flow during a trial
contraction as blood enters a ventricle that hasn’t fully
opened or relaxes to open/receive blood.
• v. Quadruplet Rhythm
• This is a term referring to presence of all 4 heart
sounds.
vi. Summation Gallop

– Is a sound heard when heart rate is abnormally fast and heart sounds are
fused together to form 1 sound.
vii)Opening snap
– Its caused by opening of stiff stenotic mitral valve.
– It doesn’t vary with inspiration or expiration and occurs early in diastole.
viii)Ejection click
– Is caused by rapid blood ejection through a normal valve or by opening of
an abnormal semi-lunar valve and is heard just after S2
viii)Murmurs
• Is an abnormal blowing sound which occurs either in diatole or systole.
– It’s a vibration caused by a turbulent blood flow.
– The following are capable of causing mumurs.
• The abnormal rate of blood flow through a normal structure.
• Normal blood flow through a narrowed structure.
• Backward flow through an incompetent valve.

• Septal defects or patent dactus arteriosus.
• Normal blood flow in a dilated structure.
• Pericardial Friction Rub

– Is a scratching grating sound heard quite close to the chest surface.
– It occurs when parietal and visceral layers of the pericardium rub against each
other during inflammation.
– It may be temporary but is always accompanied by pain.
• Heaves
• Is forceful pulsation that pounds against the examiner’s hands.
Thrills
• Those are palpable vibrations felt over an examiners hand over a
particular site e.g in Aneurism.
DIAGNOSTIC EVALUATION OF CARDIOVASCULAR
HEART DISEASES
Heart conditions are diagnosed in the following ways:-
• History of patient
• Physical examination
• Laboratory tests
• Radiological examinations
• Diagnostic procedures
• History of patient
• Ask guiding questions to determine pre-disposing factors. These should have the
mnemonic PQRST and include family history and present illness.
• Physical Examination
• To assess the patient, inspect and palpate the anatomical regions which include:-
• Aortic area located Rt. 2nd intercostal space.
• Erb’s point-left of the sternal border in the 3 rd intercostal space
• Tricuspid area:- located at sternum and 5 th intercostal space.
• Apical area:- Located at the left 5th intercostal space.
Diagnosis of CVDs ctd
• Epigastric area:- below the tip of the sternum.
•
– Inspect the general appearance to include – skin colour
• Varicosity
• Distended blood vessels
• Clubbing of fingers
– Palpate pulse for rhythm, volume and tension. Bounding pulse (may indicate hypervolemia while
weak pulse may indicate hypovolemia.
– Auscultation to detect abnormal heart sounds.
– Also check for vital signs e.g T, P, R and BP.
•
• Laboratory Tests
• There are several tests that can be done to detect cardiovascular conditions in the Lab.
• The two specific tests for CV conditions especially MI are:-
• Creatinine Kinase Myocardial Biomarker (CK-MB)
– Is a specific cardiac enzyme released from cardiac muscles when they get injured. An
elevation in this enzyme indicates. Myocardial damage and occurs within 4 – 6 hours
following the start of pain.
– It peaks between 18 and 24 hours after an acute ischaemic attack and remains elevated
for 2-3 days after which the levels start to drop.
•
Diagnosis of CVDs ctd
• Troponin
– Consists of 2 specific enzymes i.e – Troponin I and Troponin T
– Of significance to cardiac injury is Troponin 1 which is elevated 3 hours
post cardiac injury and persists for up to several days.
• Other tests that are done for CV conditions include:
• Complete Blood count.
• Blood coagulation factors. How thick or thin the blood is.
• Serum lipids.
• Electrolytes. e.g K, Na, Ca, P & Mg.
• Blood urea Nitrogen (BUN)
• Radiological Examinations
• Chest x- ray
• This can show the position, size, structure of the heart.
• Heart monitor
• Is a non-invasive test which a client wears and produces an ECG tracing continuously
for 24 hours.
• It is able to show the heart’s electrical activity during the period indicated.
Nursing intervention ctd
• Advice the patient to remain still.
• Advice the patient to breathe normally.
• Reassure patient.
• Document any cardiac medication that patient is taking.
• Electrocardiogram pattern:
– The electrical activity of the heart recorded by ECG is
characterized by 6 wave deflections designated by the letter
PQRSTU
– Each of these letters represent 1 phase of a cardiac cycle.
– P wave – Represents electric conduction through atrium. It’s
produced by the impulse originating from the SA node and
subsequently spreads through atrium.
– It’s normally round and smooth at the top and shows a wave of a
trial contraction.
Electrocardiogram pattern ctd
• When on ECG tracing has no P wave, then
impulses are not originating from SAN.
• An ECG tracing with P waves denotes a Sinus
Rhythm
• P-R Interval – This represents time it takes for
original impulse to transverse the atrium and
delay in the AV Node.
• This should be between 0.12– 0.20 seconds
• QRS complex – Represents contraction or
depolarization of the ventricle.
Electrocardiogram pattern ctd
• ST Segment – Represents resting period between the ventricular
depolarization (contraction) and repolarization (relaxation)
• It is also called Refractory period and during this time heart muscles
cannot respond to stimuli.
• T Wave – Represents ventricular repolarization when the ventricles
relax.
• The T-wave can be elevated, inverted, peaked in abnormalities of the
heart.
• Inverted T wave is common in Hypokalemia and Myocardial infarction.
• U wave – May follow a T-wave and when prominent may indicate
electrolyte abnormality such as Hypokalemia.
• Studies done for patient on Anti-coagulation therapy. PTT. INR
• Diagnostic procedures
• Cardiac Catheterization – see handout
• Central Venous Pressure- see handout
Therapeutic procedures
• Percutaneous Transluminal coronary Angioplasty (PTCA)

• In this procedure, 1 or more arteries are dilated with a
balloon catheter to open the vessel lumen in order to
improve arterial blood flow.
• Pre and post-operative management is like cardiac
catheterization depending on the vessels that is used.
Coronary Artery stent
• It can be used instead of PTCA to avoid risk of acute
coronary closure.
• It also improves the long term patency of the vessel.
• A balloon catheter with a stent (mesh) is inserted into a
coronary artery and positioned at the site of occlusion.
Artherectomy
• This is removal of an occlusion from an artery by
use of a cutting chamber inserted in with a
catheter or a rotating blade that excises the
occlusion.
• Pre- post operative care is the same as cardiac
catheterization
• Coronary Artery Bypass Graft (CABG)
• The occluded coronary artery is bypassed using
the client’s vein or artery.
Heart Transplant
• A donor heart from an individual with compatible
body weight and blood group is transplanted in a
recipient within 6 hours of removal from donor.
• The surgeon removes the diseased heart leaving
the posterior portion of the atrium to stay and
serve as an anchor of the new heart.
• Because of the remaining client’s atrium, 2
unrelated P-waves are noted on the ECG.
• The patient requires lifetime immunosuppressive
therapy to prevent rejection of the new tissues
VASCULAR DIAGNOSTIC STUDIES
a. Doppler ultrasound
• This aids in detecting artery and venous diseases.
• Arterial wave forms should be pronounced with peak
and valleys reflecting systolic and diastolic pressure.
• Lack of wave form may indicate obstruction in a vein or
an artery.
b. Venogram/Venography
• This is a radiological examination of the vein using a
contrast media.
• Contrast media in dye form is injected into the vein
and watched in the screen for areas of obstruction/
blockage.
VASCULAR DIAGNOSTIC STUDIES ctd
• Magnetic Resonance Imaging
• - This evaluates vascular network, measures blood
flow velocity and stages of vascular diseases.
d. Angiography
• This procedure can assist in the diagnosis of
arterial emboli“, aneurysm, trauma
e. Digital subtraction Angiography/Digital vascular
imaging
• Is a computerized procedure that visualizes the
vascular system.It uses a contrast media while x-
rays are taken under local anesthesia.
VASCULAR DIAGNOSTIC STUDIES ctd
Preparation for the patient
• Ascertain the patient has no pacemaker. Remove
metallic ornaments.
Nursing Responsibilities (Specific)
• Starve patient for 4 hours
• Give light breakfast if examination is mid-morning.
• Transport patient on a stretcher.
• Keep the leg elevated if it’s oedematized to
encourage venous return.
• Check allergy to contrast dye.
• Obtain a signed consent.
CARDIAC ARRHYTHMIAS/DYSRYTHMIAS
• These are clinical disorders of heart beat characterized

by disturbance of the heart rate, rhythm or both.
• -It is normally the dysfunction of heart and function not
its structure.
Pathophysiology
• In dysrhythmias, there’s alteration in impulse formation
as a result of one of the following pathophysiological
processes affecting one or more properties of the heart
muscles.
• i)Altered Automaticity when the heart fails to contract
spontaneously:-
• a) Without External stimulation:this can occur when
the SA node does not initiate impulses.
Pathophysiology ctd and Etiology
b)Altered conduction
• When impulses are initiated but not conducted to the rest of the
parts of the heart.
Etiology
• Inflammatory diseases e.g. Pericarditis
• Degenerative Heart diseases e.g. Arteriosclerosis
• Central Nervous system diseases e.g. Sympathetic and Vagal nerve
disease.
• Congenital Heart diseases.
• Pulmonary diseases i.e. In case of coronary occlusion
• Drugs e.g. Digoxin
• Infections
• Anaemia - severe
• Cardiac surgeries
Types of Dysrhythmias.
• These are 4 main types of Dysrhythmias classified according to

the origin of impulses
• These are:-
• Sinus Arrhythmias
• Atrial “ / Dysrhythmia
• Junctional “ “
• Ventricular “ “
i)Sinus Dysrhythmias
• these are impulse that originate from the SA node with
abnormal pacing
• The normal pacing of the SA node is 60 – 100.
• The most common types of sinus dysrhythmia’s are:-
i)Sinus Dysrhythmias ctd
a)Sinus Bradycardia
• Normal finding in highly trained athletes
• -It’s a heart rate of below 60.
• -It can also be found during sleep
b)Sinus Tachycardia
• It’s a heart rate of more than 100
• It’s a normal finding/response to:-sympathetic nervous
stimuli, high metabolic rate.
• It occurs in normal persons as a result of anxiety, fear
and physical exercise.
• It may also occur as a temporary compensatory
mechanism to maintain oxygen saturation and blood to
ii)Atrial Dysrhythmias
• Are impulses which originate outside the SA node but within the atrial
tissues
• An ectopic focus/foci acts as a pacemaker and it initiates an impulse at
certain levels
• Types include:-
a) Premature atrial Contractions (PAC)
• These are beats that come earlier than normal time for the expected
beats
• They may originate from one or several sites within the atrium
• They may occur in normal persons due to consumption of caffeine or
alcohol
b)Atrial Tachycardia
• Is a heart rate of more than 150 b/min
• Is commonly irregular beat
• Its rapidity causes inadequate filling resulting in reduced cardiac
Dysrhythmias ctd
c)Atrial Flutter
It’s an trial ectopic site discharging impulses at 250-450b/min.
• It’s a less common dysrhythmias and may lead to shock due to decreased
cardiac output.
d)Atrial Fibrillation
• These are chaotic with several ectopic sites in the atrium causing the atrium to
quiver rather than contract. The heart rate is more than 400b/min. The Blood
pools in the atrium and putting the patient at risk of clot formation
iii) Junctional dysrhythmias
• These are impulses that originate in the AV junction and atrioventricular bundle
• They occur when SA node is suppressed or conduction is blocked, impulse cause
retrograde depolarization, causing inverted P- waves
The types of these dysrhythmias are:-
• Wolff Parkinson’s white syndrome-Supra ventricular tachycardia,an accessory
pathway
• Premature junctional contraction (PJC) -Junctional escape rhythm
• Accelerated junctional rhythm -Junctional Tachycardia
• Wondering pacemaker
Management
• Correct the underlying cause

• Place a temporary or permanent pacemaker if the patient is
symptomatic
• Treatment is not necessary if patient is asymptomatic.
• Treatment of choice is pacemaker.
(iv) Ventricular Arrhythmias
• These occur when impulses originate from ventricles below the
bundle of His.
• Ventricular dysrhythmias are potentially fatal if not treated or if
resuscitative measures are not taken.
Characteristics of ventricular Arrhythmias
a. QRS complexes are wider than normal.
b. T-waves and QRS complexes deflect in opposite directions.
c. There is no P- wave since the impulses are originating from the
ventricles and not the SA
Types of ventricular Arrhythmias
i. Premature ventricular contraction:- A contraction that comes
earlier than expected
ii.Adeo –ventricular rhythm
• It’s a safety mechanism to prevent ventricular standstill
rhythm
• It occurs as an escape beat.
• The cells of the purkinje fibres act as a pacemaker firing
impulses at below 40b/min.
• The Rx for this mechanism is to give Atropine to increase the
heart rate.
• Temporary pacemaker can also be applied.
• Avoid all forms that suppress A.V rhythm
iii. Ventricular Tachycardia
iv. Ventricular Fibrillation
• when the ventricles are quivering and contracting
too fast cardiac output is reduced and embolism
could arise
• Electrical impulses arise from many foci in the
ventricles
• It produces no effective muscle contractions and
cardiac output is decreased
• If untreated, it’s the cause of most cardiac death
• Its described as a chaotic rhythm with no
determinable characteristics on an ECG.
Management
• Follow ACLS(Advanced cardiovascular life
Support) protocols:
• Defibrillation (1st line management of ACLS)
• Initiate Cardio Pulmonary Resuscitation (CPR)
• Endotracheal intubation
• Administration of necessary drugs and Oxygen
-Long term treatment is implantation of
cardioverter defibrillators (ICDs)
• If part is at risk of ventricular fibrillation
Dysrhythmias ctd
• Torsades de pointes - no medical significance
(vii) Asystole
• Is characterised by ventricular stand still with cardiac
arrest and its fatal if prompt CPR is not initiated.
• Is characterised on ECG as a nearly flat line
• Pulseless Electrical Activity (PEA)-Is an electrical
activity that is present on an ECG but the heart is not
contracting.
• It results in no Palpable pulse or BP and cardiac
arrest
HEART BLOCKS
Heart blocks result from an interruption in
impulse condition between atria and
ventricles
• It possibly occurs at the level of AV Node,
Bundle of His and Bundle branches .
• The Atrial rate may be normal between 60-
100/min with a slow ventricle rate.
• Its classified according to the severity and
not the location
Classification
1st degree AV Block
• -Occurs when impulses from the SA Node are consistently delayed during
conduction through the AV Node
2) 2nd degree AV Block
• -2nd degree AV Block is divided into 2 types:-
(i) Type 1 (Mobita 1/Wenkebach)

• -In this type, PR intervals gradually get longer with each bit until a P-wave fails
to conduct to the ventricles.
• ii)Type II Mobita II
• Occational impulses from SA node fails to conduct to the ventricles
(3) 3rd degree AV Block
• Is also known as complete heart block
• Impulses from the atrium are completely blocked at the AV node and are not
conducted to the Ventricles.
• The p-waves are normal but there’s no relationship between p-waves and QRS
complexes
Management Options for Dysrhythmias
• Management of dysyrrthmias are:-
a)Pharmacologic
b)Non-pharmacologic
• Non-pharmacologic
i)Interventional procedures
ii)patient family education
Pharmacologic
• Refer to pharmacology notes
• Non-Pharmacologic
i)Interventional Procedures
• Cardioversion
• Is restoration of a normal sinus rhythm by synchronized electrical
shock i.e. A shock delivered when heart is contracting only
Nursing Responsibility
• Clean skin and dry in areas where

electrodes will be placed
• Stop O2 to prevent flames and fires
• Maintain patients airway
• Monitor vital signs
• Administer O2 after
• Clear all before cardioversion
b)Defibrillation
• Is termination of ventricular fibrillations by delivering a

direct counter-shock to a Pericardium
• It’s an emergency measure which requires the nurse to stop
0xygen, “clear all” and post procedure maintain patent
airway and check vital signs, monitor cardiac rhythm.
• Defibrillation can also be done by automated external
defibrillator (AED).
• AED can be used by lay people outside hospital during
cardiac arrest.
• It gives prompt instructions to be followed.
• The patient is required to be on a firm surface.
Radiofrequency catheter ablation
• The procedure destroys the sight of origin for dysrhythmias
or the pathway necessary for it’s progression.
Management ctd
Pacemaker
• Is an electric apparatus used for maintaining a normal sinus
neither by electrically stimulating heart muscles.
• A pacemaker can be permanent, emitting
stimulants/impulses at a constant fixed rate or can be
temporary where it fires only on demand.
Implantable cardioverter Defibrillator
• This consists of a pulse generator or 2 or more lead systems
that continuously monitor the heart activity and
automatically deliver counter –shock to correct dysfunction
Cardio pulmonary Resuscitation
• It uses basic life support (BLS) principles which is an ER
procedure that assists in recognizing a heart arrest.
Management ctd
• The principles of BLS can be summed as:-
S,S,S, ABCD
S – Safety of both the rescuer and victim.
S – Stimulate for responsiveness.
S – Shout for help
A – Establish and maintain a patent Airway by
head tilting.
B - Breathing :- Look Listen
Management ctd
Feel
C – Circulation : Check for central pulses – carotid artery femoral.
D – For a trauma case, D means disability.
For a cardiac problem D means defibrillation.
For a person who has fainted, D means differential diagnosis.
• ii. Patient family education

– Tell them about the predisposing factors.
– Teach them about specific dysrhythmias and their treatment plans.
– Ensure follow-up in order to monitor management.
– Teach patient how to take their own pulse.
– Address patients and family concern.
– Know how to manage patients relatives incase of sudden death
VASCULAR CONDITIONS
ARTERIAL DISORDERS
• This a condition in which fatty materials are deposited along the
arteries.
• The fatly material thickens and hardens and may eventually block
arteries.
• It’s common in inner layers of large and medium sized arteries.
Artheroma
• These are fat deposits at the blood vessels wall that may initiate
inflammatory process
Arteriosclerosis
• Is a disease of the blood vessels characterized by narrowing,
hardening and calcification of arteries.
• The arterial walls become less elastic.
Pathophysiology and Etiology of Arteriosclerosis
• Is a common disorder among the elderly.

• Blood vessels cannot dilate to allow maximum blood
flow when needed such as during exercise.
• Calcium deposition to the walls contribute to the
narrowing and stiffening of the arteries.
• Narrowing of arteries may progress to a total closure of
the vessel.
• Effects of deposits (Calcification) can be seen in an X-ray.
As the intima thickens, vessels become more rigid
resulting in a rise in peripheral resistance and cardiac
workload resulting in rise in Blood Pressure.
• Unlike artherosclerosis which affects large arteries
Risk Factors
• Family History (Hereditary).
• Diabetes Mellitus – Because of the amount of
blood sugar circulating in the body.
• Cigarette smoking – constricts blood vessels.
• Increased BP – with time, the arteries enlarge
and eventually loose their elasticity.
• Age – because with age, arteries loose their
elastic characteristics
• Cholesterol diet – leads to fat deposits –
thickening of inner wall of blood vessels
• Kidney disease – in relation to Hypertension.
Clinical manifestations of Arteriosclerosis Atherosclerosis and Artheroma
• These depend on location and extent of arterial

occlusion.
• Occlusion of the aorta and iliac artery may produce:-
– Male impotence.
– Intermittent calcification in lower limbs.
• It is weakness accompanied with pain associated with
poor circulation.
– Pain on rest resulting from ischemia of distal tissues
and nerves.
• This pain worsens at night when Cardiac Output is less
and due to elevation of the feet.
Clinical manifestations of Arteriosclerosis Atherosclerosis and Artheroma ctd
– Dependent Rubor (reddening of limb in dependent

position)
– Decreased or absent pulses in lower limbs.
– Coolness of affected extremities.
– Loss of hair in lower leg and feet of affected limb.
– Thinning of leg and shinny skin.
– Delayed venous filling when foot is lowered.
– Thickened toe nails.
– Ulceration is common in the affected extremely.
– Edema of the affected extremity.
Diagnosis
• i. History – predisposing factors.

• ii. Clinical investigations e.g venogram-Doppler
• iii. Physical Examination-Do inspection of skin
• iv. Doppler ultra sound.
• v. Laboratory studies of cholesterol levels.
Nursing interventions (Aims)
• i.Restore blood through the narrowed arteries.
• ii. Relieve symptoms and enhance circulation.
Nursing Interventions/Management
• Reduce risk factors through lifestyle changes e.g
modification of diet and stoppage of smoking.
• Pharmacological interventions
• Use of the following groups of drugs:
• Anti-coangulatants
• Thrombolytic agents –dissolve clots
• Antiplatelet s
• Drugs to lower cholesterol
• Anti-hypertensive’s.
Surgical interventions
• Artherectomy
• Balloon angioplasty
• Bypass
• Stenting
Artherectomy: Is a surgical removal of intima
• Amputation if gangrene occurs.
• Pain relief by frequent positioning.
• Patient/ family teaching on lifestyle changes.
• Instruct patient to avoid wound on the leg wear right
shoes + right socks.
• Don’t cut toe nails carelessly.
• Prevention is mainly reduction of risk factors.
Complications
• Angina pectoris – chest pain due to ischemia.
• Myocardial Infarction
• Ischaemic attacks
• Damage to major organs due to insufficient of
blood supply.
• Obstruction of a bypass graft or failure of surgical
procedure.
• Ulceration
ANEURYSM
• Is dilatation or ballooning of blood vessels caused by localized

weakness and stretching in a wall of an artery.
• Usually all the three layers of a blood vessel are involved but
occasionally not all are involved and such aneurysm is called
pseudo aneurysm.
Classification of Aneurism
• By site/location
– Thoracic –aortic aneurysm (TAA)
– Abdominal –aortic aneurysm (AAA)
Types of Aneurism
• Fusiform aneurysm
• Saccular aneurysm
• Dissecting aneurysm
Types of Aneurysim
i)Fusiform Aneurysm
• Is a diffuse dilation involving the entire circular
artery wall.
ii) Saccular Aneurism
• Is distinct, localized, out pouching of an artery
wall commonly on one side.
iii)Dissecting Aneurism
• Is created when blood separates a layer of the
artery wall forming a cavity in between them.
Types aneurysm
Clinical Manifestation
Thoracic – Aortic Aneurysm
• Pain extending to the neck, shoulders, lower back
and abdomen.
• Syncope – due to pooling of blood in the area
that’s delayed and not reaching to the brain.
• Dyspnoea due to pooling of blood reducing the
space for lung expansion.
• Increased heart rate for a slow movement of
blood.
• Cyanosis.
• General weakness and fatigue.
Abdominal Aneurysm
• Prominent pulsating mass in the abdomen at or above the
umbilicus.
• Systolic brut (a murmur/sound heard during auscultation over the
aorta.
• Tenderness on deep palpation of the abdomen.
• Abdominal lower back pain.
Clinical manifestation of Ruptured aneurysm.
• Severe abdominal/back pain due to the rupture followed by some
degree of comfort/relief.
• Hypotension due to rupture and reduced Cardiac Output.
• Increased pulse rate initially which reduces later.
• Severe signs of shock.
– Cold clammy skin
– Fast pulse
Diagnosis
• History
• Physical examination
• Diagnostic tests to locate the aneurysm e.g
ultrasound, CT Scan and arteriography.
Risks and predisposing factors to of Aneurysm

• Age i.e over 60 years due to arteriosclerosis.
• Family history of aneurysm.
• High BP – overstretches the arteries.
Nursing Interventions
• Interventions depend on the location and stage which

the aneurysm is seen.
• Monitor vital signs.
• Check peripheral circulation.
• Observe for signs of rupture.
• In early stages, encourage patient to keep
appointments.
• Administer medication as per the prescription.
– Analgesics
– Anti-hypertensives } to make sure the
aneurysm does not rupture.
– Laxatives
Nursing Interventions ctd
• Advice patient to avoid strenuous activities.
• Advice patient to eat high roughage diet to avoid
constipation.
• Prepare patient for resection of dilated area (pre-
operative care)
• In resection the dilated area is replaced with a graft done
end to end (like bypass).
Pre-op care include:-
• Assessment of a peripheral pulse
• Instruct patient on deep breathing exercises
• Bowel preparation
• Starve patient 6 hrs before surgery
Post-op care
• Monitor vital signs
• Monitor peripheral pulses distal to the graft to detect
signs of occlusion and leakage
• Position in low fowlers to prevent bending or flexion of a
graft
• Monitor for signs of hypovolumea
• 1st is weak pulse then fast rate and then clammy skin
• Later is Hypotension and reduced urine output monitor
for Renal Function and maintain strict input output
• Monitor for respiratory status by auscultating breath
sounds to identify respiratory complications.
• Remind patient to continue with deep breathing exercises
to encourage lung expansion
Post-op care
• Encourage ambulation as soon as patient is able
to
• Maintain nil per oral until bowel sounds are
heard
• Aspirate stomach contents every 3-4 hrs
• Administer medication as prescribed.
• Assess incision site for bleeding and signs of
infection.
• In thoracic aneurism, repair is carried out
through:-
Thoracotomy
• A total cardiopulmonary bypass is necessary for
excises of aneurism of ascending aorta while
partial cardiopulmonary bypass is used in
descending aorta
• Pre-op care is the same as for abdominal
aneurism and also post-op care is the same.
• The following additions are specific to thoracic
aneurism;
• Monitor chest tubes for drainage type, amount
• Monitor cardiac status for dysrhythmias as
patient can lose a lot of blood
Health Messages to share on Discharge
• Encourage patient to take a high roughage diet
e.g. Vegetables, greens like kales to avoid
constipation so as to avoid straining
• Should not lift heavy objects more than 6kg
• Avoid activities requiring heavy pushing/pulling
or strenuous exercises
• Avoid driving because it is its strenuous, as it
uses abdominal muscles
PERIPHERAL ARTERIAL OCCLUSION
DISEASE
This is an occlusive disease also known as arterial insufficiency

resulting in inadequate blood flow in the arteries
Causes
i) Atherosclerosis
ii) Arteriosclerosis
Iii) Emboli
iv)Damaged weak vessels
v) Arterial venous fistula
vi)Aneurysm
Vii)Cigarette smoking
Clinical Manifestation/Diagnosis
NB: The clinical manifestations of PAOD can be
severe, acute or chronic depending on the degree
and area affected
Diagnosis
i) History given by patient.
ii) Comparission between affected limb and the other
iii) Angioplasty and angiography
iv) Doppler ultrasound
v) Compare temperature of the 2 extremities: The
affected-cool
Signs and Symptoms
i) Pale mottled skin (spotted)
ii) Cyanosis over the area affected
iii) Absent or low sensations
iv) Tingling sensations
v) Intermittent claudication (cramping pain)
vi)Absent peripheral pulses
vii)Atrophy-shrinking of the involved extremity
Management
• Advice patient to take low cholesterol diet
• Moderate Exercise
• Use of orthopaedics mattress
• Administer vasodilators
• Surgical repair e.g. Bypass graft
• Tell patient to stop smoking
• Avoidance of prolonged standing or sitting
• Avoid crossing legs when sitting because
circulation is interfered with.
Management
• When arterial insufficiency is confined to lower
extremities, its characterized by hardening and loss
of elasticity by walls of arteries.
• The following signs and symptoms are seen in these
patients:
– Sharp cramping pain, during exercise, due to
reduced oxygen supply
– Skin disease ranging from pallor to ulcerations
– Numbness
– Loss of hair on the leg
– Loss of peripheral pulses depending on the area
of occlusion
PULMONARY EMBOLISM
Emboli
This is a foreign substance that travels through the
systemic circulation e.g.
• Air emboli
• Fat “
• Pus “
• Clot “
• Pulmonary Embolism is a condition characterized
by complete or partial obstruction of pulmonary
artery or its branches
Pathophysiology
• An embolus travelling in blood vessels may

lodge at a point in pulmonary vessels
blocking blood flow to areas beyond the
embolus.
• This leads to poor or no perfusion beyond
these areas.
• The airways distal to embolus constrict and
alveoli shrink and collapse, a condition
referred to as Atelectasis.
Risk and Predisposing Factors
a)Venous stasis
• Heart diseases
• Dehydration
• Immobility
• Incompetent venous valves
• Obesity
• Pregnancy
Risk and Predisposing Factors ctd
b)Vessel Wall Injury
• Trauma
• Fracture
• Extensive burns
• Infections
• Intravenous Infusion
• History of previous major surgery
Risk and Predisposing Factors ctd
c)Hypercoagulability
• Blood diseases/disorders
• Abnormal blood and bone marrow formation
• Polycythaemia
• Estrogen therapy
• Systemic infections
• Smoking
-Nicotine reduces Oxygen carrying capacity in the
blood as it combines with Haemoglobin, reducing the
surface of Oxygen attachment
• Sudden sharp pains

• Tachycardia
• Difficulty in breathing
• Apprehension and anxiety
• Crackles on auscultation
• Haemoptysis
• Cyanosis
• Signs of shock
Diagnosis studies
• Chest x-ray
• ECG
• Ventilation perfusion mismatch-Oxygen amount
in the lungs is sufficient and adequate but
perfusion is not adequate
• Pulmonary angiography and Arterial Blood Gases
(ABGs)
Specific Nursing Interventions
• Administer Oxygen
• Do Resuscitation using ABC principles
• Place patient in semi-fowlers position
• Evaluate respirations for rate, rhythm, depth
and sounds
• Encourage patient to breath normally
Specific Nursing Interventions ctd
• Administer IV fluids to maintain Cardiac Output
but avoid fluid overload K.V.O (keep vein open) so
as to give IV drugs
• Administer analgesics as prescribed
• Monitor for cardiac arrhythmias Carbon Dioxide
it may affect the heart
• Be with the patient to explain procedures calmly
to allay anxiety (Reassure patient).
• Maintain a quite environment
Preventive Measures
• Pulmonary Embolism is a common complication of
D.V.T
•
• Identify risk factors which patients are likely to
have.
• Implement appropriate prophylactic regimen e.g.
anti-coagulants
• Assess predisposed patients for DVT/shift.
• Encourage patients to ambulate early.
• Perform passive Range of Motion (ROM) for
patients who cannot move
Preventive Measures
• Avoid placing pillows directly under the knees-

blockage of a popliteal artery
• Encourage fluid intake and avoid dehydration
• Monitor laboratory values for any abnormalities
• Educate patient on risk factors;-
– Diet
– Moving (ambulation)
– smoking
VENOUS DISORDERS
a)DEEP VENOUS THROMBOSIS AND THROMBOPHLEBITIS
• Venous system is divided into 2;-
– Superficial veins
– Deep veins
• Thrombosis is formation of a clot which can form
superficially (thrombophlebitis) or in the deep vein
(thrombosis).
Thrombophlebitis
• Thrombophlebitis is an acute inflammatory condition where
a clot forms in a superficial vein.
• -Most common causes are;-
• (a).Intravenous Infusion
(b) Varicosities
Thrombosis
Is when a clot forms in a deep vein, common in lower

limb but occasionally in upper limb.
Pathophysiology
• A clot may be formed from a platelet, fibrin or both
red and white blood cells.
• The clot comes into contact with intima of blood
vessels.
• A clot in blood vessel forms commonly in an area
where blood flow is slow or turbulent
• The attached clot in the intima of the vein starts an
inflammatory process characterized by pain,
swelling,redness and warmth
Predisposing Factors
i) Reduced blood flow rate which may be caused
by;-
a)Immobility.
b) Pressure on popliteal vein e.g. pillow under
knee, sitting for long hours.
c) Pressure on veins by an adjacent tumor-pressing
on veins.
d) Prolonged low Blood Pressure e.g. In shock
e) Varicosities
Predisposing Factors ctd
ii)Changes in blood composition which trigger blood
clotting:
• A) Increased Viscosity e.g. In dehydration and
polycythaemia
• b) Aggregation of platelets associated with some
drugs.
• c) Damage to blood vessel wall caused by
accidental injury, surgery and cannula insertion
Clinical Manifestations
• Fever
• Chills
• Tachycardia
• Pallor over the affected limb
• Oedema
• Throbbing pain
• Guarding of the affected limb
• Weakness of the limb
• Diminished peripheral pulses
Diagnostic studies
• High haematocrit levels ;Normal range :37-48-
women,45-52-Men
• Coagulation studies e.g.PTT,INR
• Doppler ultrasound
• Trendelenburg test, which may demonstrate
vessel valve incompetence
• Venography
• MRI-Assesses blood flow, turbulent movement
and venous valvular competence
Management
• Bed rest during acute phase
• Provide bed cradle
• Elevate the limb but avoid putting pillows
under the knee because it may dislodge
the thrombi.
• Measure cuff area circumference
• Do limb Observation and vital signs
observation, noting temperature
Management ctd
• Apply tight stockings or anti-embolic stockings

• Assess the degree of discomfort or pain which
is directly related to extent of circulatory deficit
• Look out for sudden chest pains accompanied
by dyspnea, which may suggest pulmonary
Embolism
• Encourage patient to change position
frequently to avoid spasm
Management ctd
• Administer medication as prescribed e.g;

– Analgesics
– Anti-pyretics
– Anti-coagulants
– Thrombolytics
• Monitor Laboratory studies i.e;-
– INR
– PTT
– APT-Then alert Doctor or nurse incharge
• Prepare patient for surgical intervention e.g.
Thrombectomy-excission of a product if circulation is
severely occluded
Health Messages
• Teach a patient about anti-coagulants e.g. avoids

OTC (over The Counter)
• Take Drugs same time everyday
• Never discontinue drugs that you are on
• Monitor signs of bleeding in the gum, stool, nose
• Use soft toothbrush
Health Messages ctd
• Use electrical razor for shaving
• Avoid dark green leafy vegetables-Vit K
• Avoid excessive use of alcohol
• Wear medical alert that identifies use of anti-
coagulants
• Observe for malaena stool
Prevention
• Early ambulation
• Early fluid intake to avoid dehydration
• Avoid prolonged sittings
• Use elastic stockings while taking long
journeys
Complications
• Pulmonary Embolism
• Recurrence of DVT
iii)THROMBO EMBOLISM
Is a condition in which blood vessel is blocked by
an embolus carried in blood system from site of
formation.
Causes are same as those of DVT
Signs and Symptoms
• -Tingling sensation
• -Coolness
• -Cyanosis over affected area
Management is the same as DVT depending on the
site
iv)PHLEBOTHROMBOSIS
• In this condition,a clot forms within a

vein usually caused by
haemostasis,hypercoagulability or
occlusion
• Management is mainly by preventive
measures as given in DVT
CARRDIOVASCULAR CONDITIONS AND THEIR MANAGEMENT
CORONARY ARTERY DISEASE (CAD)

1)
• Is narrowing or obstruction of one or more of the coronary

arteries i.e Right or left coronary artery commonly as a result
of Atherosclerosis, which is accumulation of fatty tissues in
the arteries
Pathophysiology
• Narrowing causes reduced perfusion of Myocardial tissue
and inadequate myocardial Oxygen supply. Narrowing and
blockage leads to:
• Increased Blood Pressure due to peripheral resistance.
• Angina/chest pain due to mismatch of Oxygen supply and
demand
• Dysrhythmia due to weakening of muscle layer of the heart
Pathophysiology ctd
• Myocardial infarction (MI)

• Heart failure
• Development of collateral circulation may occur
in chronic CAD
• Symptoms occur when occlusion causes
inadequate blood supply to muscles, causing
ischaemia,which is usually an occlusion of (50-
75%) of the lumen
• The term acute coronary syndrome is used to
describe clinical manifestations of CAD that
range from stable angina to acute MI.
Risk factors
Modifiable Non-modifiable
• Smoking Age
• Obesity Gender
• Hypertension Family
• Diabetes Mellitus Race
• Stress
• Diet
Clinical Manifestations
• Angina pectoris also known as stable
angina.
• Is the same as exertional chest pain.
• Chest pain is caused by blockage or
spasms of the coronary artery and may
not be a diseases on its own but a
symptom.
Classification of causes of CAD
• Obstruction of blood flow in coronary Artery.

• Coronary Artery surgery spasms caused by
procedures e.g cardiac catheterization.
• Conditions decreasing myocardial oxygen supply.
Precipitating factors.
• Exercise after heavy meal.
• Cold weather
• Walking against the wind
• Anger/fright/emotional upset
Precipitating factors.
• Coitus – sexual intercourse.

• Stable angina occurs commonly with activities
or with the above precipitating factors.
• Stable angina is as a result of fixed lesion.
• The pain in stable angina is usually relieved with
sublingual Nitroglycerine within 5 minutes.
Diagnostic studies
• Based on the history which will highlight
predisposing factors.
• Provide pain relief.
• Prevent progression of further attacks by:-
• Instruct the patient about the tests and
diagnostic procedures e.g stress test, cardiac
catheterization.
• Assist client to identify risk factors and to avoid
them.
• Assist client to set goals that will promote life.
As that will reduce disease progression.
• Advice client to be complaint to therapy by
instruct them to lower cholesterol and lower
sodium diet.
• Instruct client on community resources
regarding exercises and stress.
• The client is put on Nitroglycerine to be taken
before and during activities
Management ctd
Surgical Management
• 1. PTCA (percutaneous transluminal coronary angioplasty):
minimally invasive procedure to open stenosed coronary arteries)
• 2. Vascular stent: a tiny tube placed inside a blocked blood vessel
to keep it open.
• 3. Coronary Artery Bypass graft
Medications
• -Give Nitroglycerine which dilate coronary artery and preload and
afterload
• -Give Calcium channel blockers to dilate coronary artery
medications, which reduce development of
Atheroma/Atherosclerosis
• -Give lipolytics which are cholesterol lowering medications which
reduce development of Atheroma/Atherosclerosis
• Give Beta blockers to reduce BP
Unstable angina
• Is a progression from a stable that presents with
more intense pain than previously i.e In stable and
lasts longer than the previous time.
• -This occurs without precipitating factors and also
increases in occurrence.
• - It is an indication of atherosclerotic instability
which can rupture and dislodge and form a thrombus
• -Any patient with unstable angina needs to be
admitted in ICU to rule out Myocardial infarction (MI)
• -Unstable angina is not relieved with only
Nitroglycerine alone and also not relieved in 5 mins
like stable angina
Varient (Vasospastic) Angina.
• Its also called Brinzmetal angina.
• Its chest pain resulting from coronary artery spasms
without atherosclerotic formation.
• It lasts longer than 5-20 minutes
• its associated with ST segment elevation on an ECG
• Its cyclic in nature occurring at the same time.
• Its diagnosis can be made by use of Ergonorine to induce
coronary spasms that are realized by ECG during cardiac
catheterization.
• The main treatment is by Nitroglycerine and Calcium
channel blockers to dilate coronary artery.
• Prognosis following accurate is……….
C/Manifestation of unstable and variant angina
• -Chest pain that the pt. describes as moderate

• -the pain is substernal and radiates to right
shoulder and neck and lasts between 5-20 min.
• -Dyspnoea
• -pallor.
• -palpitations
• -Tachycardia
• -dizziness
• -Sweating
Diagnosis
• Is by stress test
• Cardiac catheterization
• Cardiac Enzymes
1.Immediate management
• Resuscitation;-principles SSS ABC
• S-Safety A-Airway
• S-Stimulation B-Breathing
• S-Shout for help C-Circulation
2.-MONA
• M-Morphine
• O-Oxygen
• N-Nitroglycerine
• A-Asprin
3-Assess the pain P,Q,R,S,T as in previous notes

4. provide bed rest
5. Obtain a 12 lid ECG
6. provide continuous cardiac monitoring
7. Instruct client on purpose of medical and
surgical procedures
8. Instruct client to seek medical interventions
immediately.
9. Instruct client to take drugs as prescribed
10.Provide permanent diet
11.Assist client to manage modifiable factors
immediately
12. Include all advice that is in stable angina.
13. Surgical procedures are the same as those of
PTCA,Stent,Bypass,graft
14. Medications given are;-
• i).Lipolytics
ii).Antiplatelets e.g.Asprin
iii).Nitrates
Silent Angina
• -Is detected during a routine ECG where ST elevation
or inversion may be seen without any symptoms
expressed by patient
Predisposing factors
• -Major predisposing factor is DM and its common with
patients with DM type II since these patients develop
neuropathy, which decreases their ability to express
chest pain.
• -They may also mis-interpret angina pain with other
symptoms like nausea.
• -Their management is the same as for these patients
with stabled and unstable angina.
TERMINOLOGIES ASSOCIATED WITH MYOCARDIAL INFARCTION
1)Zone of Ischaemia:Is the outermost area of

infarcted cardiac muscles
• It consists of variable cells.
• Repolarization in this zone is temporarily
impaired but can be eventually restored to
normal with good management.
• These cells can manifest as a T wave
inversion in an ECG
TERMINOLOGIES ASSOCIATED WITH
MYOCARDIAL INFARCTION ctd
Zone of Injury
• -Area immediately surrounding infarcted zone.
• -Cells in these area don’t fully repolarize and manifest in
ECG as ST elevation
• Zone of Infarction
• -Area of dead necrotic muscle both depolarization and
repolarization are not possible.
• -The lack of electrical activity in this area manifest as
pathological Q-wave.
• -As healing takes place cells in this area are replaced by scar
tissue.
•
Transmural MI
• Is also called Q-wave MI or full thickness MI.
• This infarction involves all muscles of the heart
i.e.all the 3 layers
Acute Coronary Syndrome

Is a term used to define the life-threatening
consequences as CAD notably;-
i)Unstable angina
ii)Non ST elevation MI (NON-STEMI)
iii),ST-Elevation MI (STEMI).
• Non-ST Elevation MI is an acute MI without ST-
Elevation on the 12 lid ECG.Its common in non-
transmural MI, does not involve all muscles of
heart.
• STEMI Is an acute MI with –Elevation on ECG
tracing.
MYOCARDIAL INFARCTION
• This is necrosis of part of the cardiac muscle (myocardium)
due to occlusion of coronary artery which occurs when
there’s severe deprivation of Oxygen to that part.
• Is also known as Cardiac Arrest or Heart Attack.
Pathophysiology
• Lack of Oxygen and nutrients leads to ischaemia and
necrosis of myocardial tissue if blood flow is not restored.
• Infarction (obstruction of blood supply to an organ) does
not occur instantly but evolves in several hours.
• Obvious physical disease occur after 6hrs from the onset of
pain when the infarcted areas appear blue and swollen.
Pathophysiology ctd
• After 48 hrs , the infarct turns grey and yellow
as neutrophils invade the tissues
• By 8-10 days , infarction granulation tissue
forms which is followed by a scar tissue after 3
months.
• The scar tissue permanently changes the size ,
shape and function of the affected area.
Predisposing Factors
• Cigarrete smoking -Diet

• HTN -Sedentary lifestyle
• DM .
• Race
• Sex
• Family
Diagnosis
i)ECG
ii)Cardiac enzymes also known as cardiac
biomarkers or cardiac markers .There are 2 main
cardiac enzymes that confirm the diagnosis of MI.
a)Troponin 1
b)Creatinine -kinase myocardial biomarker (CK-MB)
- These are the specific and confirmatory for the
diagnosis of MI
- They are produced when there’s damage of the
cardiac muscle and released into the blood stream
4-6 hrs
Diagnosis ctd
Other investigations include;-

III) WBC count is elevated
IV) Cardiac catheterization
V) Take History of the acute pain.
Clinical manifestation
• Pain which is crushing,substernal and radiating
to the jaw, back and left arm.
• The pain occurs without precipitating factor
commonly during rest or sleep.
• The pain is not relieved by rest or
• The pain lasts more than 20mins.
• The pain is accompanied by nausea and
vomiting.
• The pain is accompanied by sweating,Dyspnoea.
• Dysrhythmias – as the ischaemia in the heart

reduces oxygen supply to myocardial tissue
interfering with SAN and AVN.
• Feeling of anxiety and fear.
• Pallor
• Cyanosis
• Coolness of the extremities
• Eventually shock due to reduced Cardiac Output
Nursing interventions
• Establish and maintain ABCD and MONA
• Open Airway by doing head tilting.
• Check that tongue does not fall back.
• B-Breathing D-Defibrillation
• C-Check central pulses
• Ensure that you have a working defibrillator.

• Assess CV status and maintain cardiac monitoring.
• Provide rest in a quiet environment in fowlers
position.
Nursing interventions ctd
• Give oxygen to the patient.
• Assess vital signs
• Obtain a 12 – lid ECG
• Administer medication as prescribed e.g
morphine.
• Establish an IV access for the administration of
drugs.
• Check for signs of bleeding.
• Monitor blood values.
• Administer Beta blockers to slow the heart rate
and myocardial perfusion.
• Assess patient for complications e.g Heart
failure/ shock.
• Keep strict input and output.
• Reassure the patient and relatives.
• Keep patient warm.
• Maintain bed rest for 24-36hrs
• Allow minimal movement e.g use of commode

• Provide ROM to prevent thrombus formation and
maintain muscle strain.
• Advice patient to wake up from bed slowly so that
they don’t get hypotensive.
• Encourage patient to talk about his fears and
continue to give reassurance
• Start client on cardiac Rehab which is the process of
actively assisting the client with a cardiac disease to
achieve and maintain a vital and productive life
within the limitations of the heart disease.
Complications of MI
 Arrhythmias
• Pericarditis
 Endocarditis
• ventricular rupture
 cardiogenic shock
• Cardiac failure • Pulmonary Oedema
• Mitral incompetence
• Thrombophlebitis
RHEUMATIC FEVER
• Is an inflammatory disease that develops from
untreated Growth of A Beta Haemolytic
Streptococcal infections in the upper respiratory
tract.
• Is also known as scarlet fever
• Rheumatic fever in the late stages can involve;-
– Heart
– Joints
– Skin
– Brain
• Its more common in children than in adults
Pathophysiology
• Focal inflammatory lesions known as Aschoffs

nodules are characteristic of Rheumatic fever.
• The lesions have a central area of connective tissue
surrounded by inflammatory cells.
• They develop around small blood vessels and
through the heart.
• When the lesions heal, they leave hydrotic (causing
discharge of water) areas in heart.
• These lesions can result in pericarditis, myocarditis
or Endocarditis.
• Rheumatic pericarditis and myocarditis typically
heal without consequences.
Pathophysiology ctd
• Rheumatic endocarditis on the other hand can

damage the valves causing them to be narrowed
(stenotic) or incompetent (Insufficient).
• Incompetent valves cannot close completely
allowing regurgitation, backward flow of blood
within the chambers.
• A narrowed/stenotic valve will not relax enough
to allow flow of blood within the chambers
• Mitral valve is mostly affected, followed by aortic
valve then the tricuspid valve
• Vary with the stage at which the patient is seen.

Stage.1
• Is characterized by acute streptococcal pharyngeal
infection, fever, chills, sore throat and
lymphadenopathy.
• There’s also pus which can be seen on the oral
pharynx
Stage 2.
• Is asymptomatic stage and is also referred to as
latent stage
• This stage may last between 3-6 weeks during which
Clinical manifestation ctd
Stage 3.
• Takes few weeks to more than a year and is
characterized by carditis.
• Severe swelling of large joints and sydenham’s chorea
(involuntary motor movements),Rash, subcutaneous
nodules, over tendons and bony surfaces.
Stage 4.
• Is characterized by valvular deformities and generalized
Endocarditis.
Diagnosis
• History of throat infections

• Positive cultures for streptococcus
• Rest ESR (Erythrocytes Sedimentation Rate)
• Rest anti-streptolysin o,which indicates antibody
production against streptococcus
• Presence of carditis
• Valvular abnormalities which can be detected
through heart murmurs
Management and Rx
• There is no complete cure for rheumatic fever.
The aims of Rx are:-
i).Control and prevent it’s occurance/recurrence.
ii. Prompt treatment of streptococcal pharyngitis.
iii. Position patient comfortable when they have
joint pains and swelling.
iv. Encourage plenty of fluids.
Management and Rx ctd
v. Administer drugs as prescribed , including

corticosteroids and Analgesics to reduce
inflammatory process and scar formation.
Drug of choice for treatment is Aspirin (large does)
treat Fever ,Pain
vi. Give prophylactic anti-biotic e.g Penicillin (taken
for years).
vii)Surgical Rx may be done if the heart valves are
damaged.
viii)Recurrence of RF can be relatively common and
heart complication are long term and severe
Prevention and Complications
Prevention
• Prompt treatment of scarlet fever.
Complications
• Heart damage.
• Heart failure
• Pericarditis
• Chorea
RHEUMATIC HEART DISEASE (RHD)
• Is a progression of Rheumatic Fever (RF), damage
to heart muscles and valves following episodes of
RF after many years.
• Diagnosis of RHD is made much later after RF.
Pathophysiology
• Inflammation may involve the lining of the
endocardium and causes adhesions.
• Development of R.H.D symptoms depends on
circulation and the involvement of the inner
lining of the heart.
Management and Treatment
• Prophylactic penicillin is given for many years.
• Provide bed rest when the heart shows signs of
CF.
• Restrict Na intake
• Administer diuretics to reduce cardiac workload.
• Prepare patient for Valve replacement, repair
prosthesis is used (open heart surgery)
• When the heart fails, the rest of the
management is the same as that of MI
INFLAMMATORY DISEASES OF THE HEART
PERICARDITIS
• Is an acute / chronic inflammation of the
pericardium.
• Chronic pericarditis causes thickening of the
pericardium which constricts the heart, leading
to compression.
• The pericardial sac becomes inflamed resulting
in lack of pericardial elasticity.
• It may also result in accumulation of fluid within
the sac, heart failure or cardiac tamponade.
INFLAMMATORY DISEASES OF THE HEART ctd
MYOCARDITIS
• Is an acute / chronic inflammation of the myocardium
as a result of systemic infection, pericarditis or allergic
response.
ENDOCARDITS
• Is an inflammation of the inner lining of the heart and
the valves.
• It’s common in clients who have suffered rheumatic
fever earlier.
• It’s also common after valve replacement and IV drug
abuses ,because of sharing needles and this goes
directly to the heart.
C/Manifestations
• Fever
• Anorexia
• Weight loss
• Fatigue
• Cardiac murmurs
• Signs of heart failure
• Embolic complications
• Splinter Haemorrhage in nail beds.
• Splenomegaly- because spleen works extra hard to
make more RBCs and it gets enlarged.
• Clubbing of finger nails as a sign of chronic anaemia.
Nursing Interventions of Endocarditis
• Provide adequate rest balanced with activity to

prevent thrombus formation.
• Apply Ted stockings to enhance venous return.
• Monitor cardiac status to detect dysrhythmias.
• Monitor for signs of heart failure.
• Monitor for signs of emboli formation
• Monitor for signs of confusion.
a. Instruct patient on signs of complications e.g
Pulmonary Embolism (acute chest pain /companied
by dyspnea
b. Instruct patient about oral hygiene.So as to avoid
normal flora in the mouth to get into circulation and
cause infections.
c. Instruct patient to brush teeth at least twice in a
day with a soft toothbrush.
d. Instruct patient on drug compliance or
prophylactic antibiotic administration.
• Monitor for signs of Pulmonary
embolism.
• Evaluate blood cultures
• Administer medication as prescribed
• Prepare patient for surgical procedures
e.g valve replacement.
• Client and family Education.The following
health messages should be shared with a
patient on discharge:-
Nursing Interventions of Endocarditis ctd
 Inform any medical personnel about their
condition.
 Must take antibiotic cover before any invasive
procedures e.g Removal of tooth, operations.
General : -Balanced diet
-No Smoking
-Keeping a normal weight (BMI)
CARDIAC TAMPONADE
• Is a pericardial effusion which occurs when space

between parietal and visceral layer of
pericardium fill with fluid or blood
• It places the client at risk of fluid accumulation in
the pericardial cavity which restricts ventricular
filling and reduces the Cardiac Output
• An acute tamponade can occur with a small
volume of blood of between 20-50 m/ls in
pericardial space
• The pericardium is also called as “pericardial
sac.” It is the connective tissue layer that
encompasses the entire heart including the
root of the great vessels.
• It consists of the outer fibrous layer (fibrous
pericardium) and an inner double layer of
serous membrane (serous pericardium).
Causes of cardiac tamponade
• gunshot or stab wounds
• blunt trauma to the chest from a car or industrial accident
• accidental perforation after cardiac catheterization, angiography, or
insertion of a pacemaker
• punctures made during placement of a central line, which is a type of
catheter that administers fluids or medications
• cancer that has spread to the pericardial sac, such as breast or lung cancer
• a ruptured aortic aneurysm
• pericarditis, an inflammation of the pericardium
• lupus, an inflammatory disease in which the immune system mistakenly
attacks healthy tissues
• high levels of radiation to the chest
• hypothyroidism, which increases the risk for heart disease
Layers of the heart
Clinical manifestations
• Pulsus paradoxus – Is a drop of systolic BP of

about 10mmHg
• Raised Jugular Vein Pressure (JVP)
• Distention of jugular veins
• Clear lung fields
• Distant muffled heart sounds – like they are
coming from fluid.
• Reduced Cardiac Output, due to restriction of
constriction of pericardium.
• Establish and maintain ABC – intubate, give

oxygen, iv fluids and manage Cardiac Output
• Strict input and output and maintenance of
chart.
• Attach 12 lead ECG.
• Prepare client for pericardiocentensis, which
is the tapping of pericardial fluid or blood.
• Monitor for recurrence of cardiac
tamponade.
HYPERTENSION (HTN)
• This is persistent elevation of systolic BP to 130
mmHg and diastolic pressure above 80mmHg.
Types
• i. Primary /Essential HTN
• ii. Secondary HTN
PRIMARY/ESSENTIAL HTN
• This has no known cause/etiology and is
referred to as idiopathic
Risk and predisposing factors
• Age
• Family history
• Race
• Sex – males more affected
• Obesity
• Smoking
• Stress
Secondary HTN
Occurs as a result of other disorders

Precipitating disorders include
• Renal condition
• Cardiovascular disorders
• Pregnancy
• Some Medications
• Some endocrine disorders:e.g.
 Diabetes Mellitus
 Phoechromocytoma
• Initially asymptomatic
• Headaches
• Visual disturbances
• Dizziness
• Tinitus
• Epistasis
Nursing Interventions (general)
Treatment depends on cause and organs involved
with 2 major goals;-
a)Reduce BP
b)Prevent/Lessen extent of organ damage
• To achieve these goals, the nurse should;-
– Take BP at regular intervals
– Take History of patient
Nursing Interventions (general)
• Identify medications in use

• Obtain weight
• Evaluate dietary patterns and reduce Sodium
intake
• Assess visual and CVDs
• Evaluate Renal functions
• Monitor laboratory result
Non-pharmacological
1st line of management of HTN

i)Weight reduction if necessary and the person
should be advised to maintain ideal weight
Dietary control, reduce cholesterol, reduce
carbohydrates
ii)Minimize alcohol
iv)Avoid smoking
v)Avoid stress
vi)Avoid OTC (Over the counter) drugs
Pharmacological interventions
Step 1 is started with a single medication then
monitored for its effectiveness, this is in addition to
the non-pharmacological intervention above.
These medications can be:
-Diuretic:e.g.Furosemide (Lasix),bumetanide,demadex
(torsemide)
-Beta blockere.g.e:Acebutolol(sectral) propranolol
(Inderal)
-Calcium channel blocker:Nifedipine (Adalat),Amlodipine
(Norvasc)
-ACE Inhibitor (ACE-Angiotensin Converting
Enzyme)e.g.:Captopril,Benazepril (Lotensin),Enalapril (Vasotec)
Pharmacological interventions ctd
Step.2:Involves thorough evaluation of 1 st line management
(lifestyle and step.1 and its effectiveness
• -If found not effective medication dose is increased or a 2 nd
drug is added.
Step.3
• -Involves thorough evaluation of 1st line of
management,step1 and step 2 and effectiveness.
• -If found not to be effective compliance of the drug is
evaluated.
• -If found not to be effective a 2 nd or a 3rd medication is
added.
• -evaluate compliance and carefully asses the client
Client –Family Education.
• Lifestyle change.
• Diet i.e.Reduced Na, Fat, cholesterol, Eat a good
balanced diet.
• Regular physical exercise program .
• Stress Reduction to help client identify stressful
situations and avoid them through bio feedback
and other methods.
Client –Family Education ctd
• Drugs;-Advice patient not to increase dosage on

their own.
– Advice patient not to stop drugs without direction
by prescriber
– advice patient to continue taking medication even
when B.P is low
– advice patient to avoid OTC.
• Teach patient how to monitor their own BP
• Instruct patient to keep follow up dates
HYPERTENSIVE CRISIS
• This is any clinical condition requiring immediate

reduction in BP.
• It is an acute life threatening condition that
warrants Emergency Response management.
• It can lead to: – Stroke
- Renal Failure
- Cardiac Failure
C/Manifestations.
• Diastollic BP of more than 120mmHg

• Severe headache
• Drownsiness
• Confussion
• Tachycardia
• Tachypnoea
• Cyanosis
• Establish and maintain the ABCs

• Administer Antihypertensives as prescribed.
• Monitor vital signs assessing, BP every 5
minutes
• Look out for Hypotension.
• Place client in supine position if hypotension is
present.
• Have Emergency Response tray and equipment
ready.
• Maintain bed rest with fowlers position of 30-
45 degrees elevation
• Monitor 1nput and output strictly and avoid
fluid overload.
• Catheterize the patient
Complications
• Heart F
• Blindness
• Cardiovascular Accident (CVA)
• Renal failure
HEART FAILURE (CCF)
• Inability of the heart to maintain adequate

circulation to meet metabolic needs of the body.
• Heart failure can be acute (sudden) or chronic
(develops) over time.
• A client with chronic can develop an acute
episode i.e. acute on chronic heart failure.
• Heart failure can occur on left, right or both
sides.
Main causes of HF
• Systole/Systolic where the heart fails to eject

blood from chambers to the arteries and this may
be caused by repeated MIs or cardiomyopathy.
• Diastolic-failure of the heart to relax resulting in
inadequate filling.
• Dysfunctioning valves which can be stenotic or
incompetent and this can be caused by
endocarditis or RHD
• Structural abnormalities as found in congenital
heart conditions.
LEFT SIDED HEART FAILURE
Pathophysiology
• When the left side doesn’t contract ,fill or relax
effectively, blood is not pumped out and does
not move forward through the aorta.
• This leads to accumulation and retention of
blood within the left ventricle with a backflow
to the left atrium, pulmonary veins and to the
lungs resulting in pulmonary Oedema.
• Signs of left sided heart failure manifest as
dysfunctioning respiratory system and are
evidenced in pulmonary system.
Signs and symptoms
• Dyspnoea.
• Pink frothy sputum/Haemoptysis.
• Rales and crackles on Auscultation.
• Tachycardia.
• Fatigue.
• Pallor and cyanosis.
• Confusion and dis-orientation due to reduced
cerebral perfusion.
• Tachyponoea
• Hypercapnoea.(increased Carbon dioxide content in
blood.)
RIGHT SIDED HEART FAILURE
Pathophysiology
• Blood from the body parts flows into the R.A
through the inferior and superior V-cava.
• There is forward movement of the same blood
into the R.V through Tricuspid valve.
• If the R.V does not contract, fill or relax
adequately there will be an accumulation and
retention of blood in the right ventricle.
• This leads to a backflow in the RA ,superior and
inferior vena cava, resulting in oedema of the
lower extremities.
Signs of Right-sided heart failure
• Are evident in the systemic circulation as

peripheral oedema.
• Pitting oedema in feet, leg.
• Ascitis from portal HTN.
• Tenderness of Right upper quadrant
• Distended jugular veins.
• Abdominal pain
• Anorexia & Nausea
• Fatigue
• Weight gain
Management
• Establish and maintain the ABCs

• Nurse patient in high fowlers position.
• Suction patient as needed.
• Reassure patient and relatives.
• Administer medication as prescribed.
• Monitor lung sounds for crackles and rales.
• Assess for oedema by pressing on tibia
• Insert a catheter and monitor input/output
• Diet
• Hygiene } general
• Activities of daily living (ADL)
Client and family education
• Lifestyle changes stop smoking and Alcohol

• Diet “reduced Na and cholesterol, Fat
• physical Exercise but balance Exercise and
Rest
• Stress Reduction techniques
• Drug compliance.
• Keep Doctors appointments
• Cardiac rehabilitation
VALVULAR HEART DISEASES
• Are conditions that occur when the heart

valves cannot fully open (stenosis) or close
completely (insufficiency) or those that are
incompetent,causing regurgitation.
• This prevents efficient blood flow through the
heart.
Types Of Valvular Heart Diseases
Mitral stenosis.
• Is when the mitral/bicuspid valves are not
opening fully,
• Mitral insufficiency/regurgitation-Is when the
mitral/bicuspid valves are not closing fully.
• Mitral prolapsed-Is when the valve protrudes into
LA during systolic phase.
 Aortic stenosis-Is when aortic valve is not
opening fully.
 Aortic insufficiency-Is when it’s not closing fully
Repair procedures
• The following corrective measures may be

undertaken e.g
• Repair procedures/corrective measures.
• i. Baloon valvoplasty
• - Is where a balloon is inserted through the
femoral vein and passed into a stenotic valve in
an attempt to open the stenosis.
• ii. Valve tightening and suturing can be done on
a malfunctioning valve.
Repair procedures
iii. Valvotomy can also be done during Open Heart

surgery to narrow a widened valve.
iv. Valve replacement
• Mechanical prosthetic valve : Is the placement of
an artificial valve.
• Bio prosthetic valve : Is the replacement from
other animal tissues e.g. from pig.
• NB: Valve Repair may require management in ICU
and when out is like that of Endocarditis or heart
failure.
SHOCK
Is a syndrome characterized by hypoperfusion of

body tissues that results in lack of oxygen to cells
and cellular hypoxia.
General clinical manifestations of shock
• Cold clammy skin.
• Cyanosis
• Rapid thready pulse
• Low BP
• Restlessness
Types of shocks
These are classified according to underlying
conditions:
i. hypovolaemic shock
ii. Cardiogenic shock
iii. Distributive shock
iV.Neurogenic shock
V.Septic shock
VI.Anaphylactic shock
Hypovolaemic shock
• Results from loss of fluid from vascular system through

blood or fluid loss.
• Is the most common type of shock which can be caused
by any condition which reduces the volume in the
vascular compartment by 15%.
• Relative hypovolemic shock is reduction in intravascular
fluid not necessarily through bleeding e,g in Oedema.
• Conditions that can cause hypovolaemic shock are:-
• Excessive blood loss in trauma or surgery.
• Excessive vomiting, diarrhea etc.
• Shifting of fluids e.g. in the abdomen from vascular
circulation.
Clinical manifestations
• Tachycardia i. Hypotension
• Restlessness ii. Oliguria
• Tachypnoea iii. Mental
confusion
• Cold clammy skin
Cardiogenic shock
• Results from inability of the heart to pump
sufficient blood for perfusion of tissues and
body cells.
Causes can be:-
– MI
– Arrhythmias
– Heart failure
– Heart surgery
• Reduced cardiac output.

• Fall in arterial BP
• Impaired coronary perfusion
• Reduced left ventricular ejection
• Pulmonary oedema due to poor emptying of left
ventricle.
Distributive shock
a)Neurogenic shock
Results from interference with sympathetic nervous system
that helps to maintain vasomotor tone
Causes are;-
• Spinal cord injury leading to less of tone at level of injury.
• Spinal anaesthesia
• Brain damage leading to loss of function in the medullar
vasomotor Centre.
• Insulin shock causing inadequate blood glucose which
affects the function of vasomotor Centre producing typical
shock signs.
• Severe pain which inhibits vasomotor centre resulting in
massive vasodilation.
Signs and Symptoms
• -Is characterized by massive vasodilation and
therefore all features are due to vasodilation.
The symptoms that can be observed are;-
a) Hypotension
b) Oedema due to pooling of blood in the dilated
vessels.
b)Septic shock
• -Results from severe infection that can be

caused by gram-ve or gram+ve virus/fungi,
bacteria.
• Pathophysiology
Release of endotoxins from the blood stream
causes a chain in the release of other
substances that lead to widespread
vasodilation
Pathophysiology ctd
• Some of the endotoxins cause selective

vasoconstriction which result in a major
maldistribution within the body.
• The general massive vasodilation results in
hypotension despite the high cardiac output.
Predisposing factors
• Extremes of Age
• Immunosuppression.
• Steroid therapy.
• Surgery especial neurological and GIT
• Malnutrition
• Invasive instrumentation e.g Endoscopy.
c)Anaphylactic Shock.
Results from allergic reaction of antibody
• Etiology and pathophysiology
• -This shock is produced by release of 4 substances i.e
• Histamine-causes arterial dilatation and capillary
permeability leading to Eodema.
• Serotonin-causes venous constriction.
• Slow reacting substances-causes bronchiolar constriction
leads to dyspnoea.
• Bradykinin-causes vasodilation and capillary permeability
leading Eodema.
• -The bodys response to these substances is massive
dilatation. And fluid leakage out of capillaries constricted
bronchioles leading to Eodema and difficulty in breathing.
General Pathophysiology of shock.
Is divided into 2;-Early (Compensatory stage.
-Late- (Decompensatory).
Early/Compensatory Stage.
• The body develops compensatory mechanisms
that include sympathetic nervous system ,renin-
angiotensin and secretion of Aldosterone by
adrenal cortex to retain Na and H2O in the body.
• -Altered K+ intravenous levels to cause reduced
Cardiac Output.
General Pathophysiology of shock ctd
• The overall effect of sympathetic nervous system
response in hypovolemic and cardiogenic shock is
an increase in systemic vascular resistance.
• The compensatory effect is temporary but allows
time for the underlying cause to be corrected.
Late/Decompensatory progressive stage.
• As shock progresses, blood flow to all body
tissues becomes impaired.
• Cells in constricted organs receive insufficient
O2 and the following take place;-
a)Reduced blood flow to the heart, which leads to
impaired cardiac ability,reduced BP and reduced
Cardiac Output
b)Anaerobic metabolism occurs, leading to
acidosis, decreased adenosine triphosphate
cellular Na+ K+ pump failure.
c) Arterial dilatation leading to fluid shift from IV
to interstitial space. This causes massive oedema.
d)Reduced blood flow to the kidney which causes
GFR,tubular necrosis and anuria and
oliguria
e) Reduced blood flow to pancreas leading to
production of myocardial depressant factor.
The final stage of progressive or decompensatory
stage of shock leads to development of multiple
organ dysfunction syndrome (MODS)
General Management of shock ctd.
• Determine the type of shock through patient’s

signs and symptoms and underlying cause.
• Take history
• Initiative resuscitative measures by use of ABCD.
• Establish an IV line and give at least 2L of fluid in
about 10 min if its hypovolemic shock.
• Administer medications as prescribed e.g.
Vasodilators/vasoconstrictors position in supine
at 30-45 degrees elevation
• Strict vital signs every ½ hour.
General Management of shock.
• Assess level of consciousness.

• Provide safety measures to prevent injury and
infections.
• Take an ECG
• Insert urinary catheter.
• Monitor Input/0utput strictly.
• Assess pulmonary status by auscultating the
lungs.
• Assess (Arterial Blood Gases )ABGs.
• Monitor levels of Oxygen saturation.
Complications
Effects of shock on organs are;-

• Brain damage due to reduced cerebral perfusion.
• Heart failure due to lack of Oxygen to the layers
of heart.
• Acute Respiratory distress.
• Paralytic ileus.
• Acute renal failure.
• Liver failure
• DIC
CARDIAC SURGERY
Operations of heart are divided into 2:-
i) Open heart surgery.
ii) Closed heart surgery
Open Heart surgery

• In open heart surgery,the patients circulation is
connected to the lung heart machine.
Procedure
• A big cannula is connected to aorta and another to superior

and inferior vena cava
• The 2 are connected to the machine.
• The blood is oxygenated in the lung part of machine and
actively pumped to the aorta, thereby bypassing the heart
and the lungs.
• To stop the heart, cardioplegia is put, aorta is clumped and
cardioplegia is passed through it and coronary arteries
where it passes the heart muscles leading to stoppage of
the heart.
• No blood goes to the heart but the rest of the body receives
blood from the machine.
• The heart is cooled to very low temperature to protect it
from anaerobic bacteria.
Indications for Open Heart Surgery
a)Patent ductus arteriosus.

b)Mitral stenosis
c)Coartation of the aorta.
a)Patent ductus Arteriosus

• Is the failure of foetal ductus arteriosus to close
within the 1st week leading to a connection
between. Pulmonary artery and aorta
Signs and Symptoms
• There’s a characteristic machinery-like murmur
with signs of heart failure.
• Widened pulse pressure (difference between
diastolic and systolic Blood Pressure).
Management
-IV Indomethacin or Ibuprofen enhance closure of
the arteriosus.
-A coil may be placed in the opening to occlude
PDA during cardiac catheterization.
Surgical
• Surgical ligation of the opening via a left
thoracotomy
b) Mitrial Stenosis
c) Coarctation/narrowing of the Aorta.
-The signs of coarctation of the aorta are those of
Heart Failure in an infant.
-Management is by resection of narrowed part
and anastomosis or graft is done.
CONGENITAL HEART DISEASES
Are divided into 3 groups;-
a)Cyanotic Babies) due to deoxygenated blood in their
circulation.
b)A cyanotic Babies :- Have oxygenated blood in circulation but
have a congenital heart disease.
c) Acquired heart diseases.
Cyanotic congenital (Blue Babies)

These are conditions that cause cyanosis early in life.
They are:- (i) Tetrology of Fallots (TOF)
(ii) Transposition of Great Arteries
(iii) Tranus arteriosus
(iv) Tricuspid arteriosus
(V)Total anomalous pulmonary venous connection
Tetralogy of fallots
• Includes 4 defects:- Ventricular septal defect
(VSD): Is an abnormal opening between left and
Right ventricles.
• Pulmonary stenosis:- Is the narrowing at
entrance of pulmonary artery.
• Ventricular hypertrophy:- Is where the
ventricles are abnormally big, both the RT and
left.
• Overriding of Aorta; Part of the Aorta is in the
right ventricle.
Tetralogy of fallots
Transposition of Great Arteries

• The PA leaves the left ventricle and aorta lives
the Right ventricle
Trancus Arteriosus
• This is failure of normal separation and division
of embryonic Pulmonary Artery & Aorta
resulting in a single vessel that overrides both
ventricles causing the blood to mix.
• This leads to severe desaturation and hypoxia
Tricuspid Arteriosus
• Absence of tricuspid valve leading to lack of

communication between Right Atrium and
Right ventricle.
• Its commonly associated with pulmonary
stenosis and transposition of great vessels.
• There is complete mixing of oxygenated and
deoxygenated blood from both sides of the
heart resulting in systemic desaturation,
pulmonary obstruction, reduced Pulmonary.
blood flow.
Total Anomalous Pulmonary Venous Connection
– Is failure of pulmonary veins to join to the Left Atrium.
– Mixed blood is returned to the Right Atrium & shunted
from right to left through an atrial septal defect.
– The Right side of the heart hypertrophies while the left
remains small leading to heart failure.
A cyanotic congenital
• These are congenital heart diseases that do not
produce cyanosis in early life.
• They are:- (i) Atrial septal defect.
(ii) Ventricular septal defect.
(iii) Left ventricular outflow tract obstruction
which is blockage below the aorta.
Acquired Heart conditions
• These are mainly caused by rheumatic heart disease
and other infections and they include:-
• Mitral stenosis
• Rheumatic heart disease
• Aortic stenosis
• Aortic regurgitation/insufficiency/incompetence
• Endocarditis
• Mitral regurgitation
• Coronary heart disease
• Heart traumas are also commonly caused by
accidents.
Diagnosis of heart conditions particularly in children
History as given by the parents since birth. This history may

include:-
• Cyanosis
• Recurrent chest infection
• Difficulty in breathing
• Oedema of Extremities
• Physical Examination – Inspection may reveal cyanosis
• Auscultation will reveal heart murmurs.
• Palpation may reveal pitting eodema
• Flaring of nose/ (nasal flares)
• Intercostal retraction i.e. inward, outward chest movement
during respiration.
• Pedal and scral Oedema.
Investigations
3. Investigations – Chest = Xray may show enlarged heart and
ventricular septal defects.
ECG would show the rhythm
Echocardiogram is accurate and is an ultra sound of the heart
which will show: -
• Position of the heart
• Connection to and from the heart.
• Position of the septum
• Valves
• Holes and heart leakages
4. Cardiac catheterization:- Will show areas of constriction and
flow of blood.
5. Coronary angiography.
Management of child Before operation
• Observe child for signs and symptoms of

defect.
• Monitor strict input/output.
• Monitor vital signs closely.
• Monitor respiratory status.
• Auscultate breath sounds for crackles, rhonchi and
rales.
• Position patient in fowlers to decrease
• respiratory labour.
• Administer humidified oxygen.
• Prepare for intubation if necessary.
• Monitor for hyper cyanotic period. Give 100%
oxygen if hyper cyanosis exists.
• Assess for signs of heart failure e.g peri-orbital
oedema
• Assess peripheral pulses
• Monitor input/output strictly.

• Weigh the diapers if the child has not been
catheterized.
• Obtain daily weight to assess for retention of
fluid in the body.
• Provide caloric diet.
• Plan interventions or activities to allow for
maximum rest.
• Prepare parents and the child for surgery.
• Allow both parents and child and verbalize their
concerns regard their disorder and the surgery.
• Instruct the caretaker about the immediate
post-operative management.
• Post-operative management is done in the ICU
and when stable the child is nursed as any child
with heart failure

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REVIEW OF ANATOMY AND PHYSIOLOGY

• Managing blood supply. Variations in the rate and force of heart

Risk factors for CVD

• Q – Quality of pain i.e. is it; sharp(

Arrhythmia and dysrhythmia

vi. Summation Gallop

• Backward flow through an incompetent valve.

• Pericardial Friction Rub

• Percutaneous Transluminal coronary Angioplasty (PTCA)

• These are clinical disorders of heart beat characterized

• These are 4 main types of Dysrhythmias classified according to

• Correct the underlying cause

• Torsades de pointes - no medical significance

(i) Type 1 (Mobita 1/Wenkebach)

• Clean skin and dry in areas where

• Is termination of ventricular fibrillations by delivering a

• ii. Patient family education

• Is a common disorder among the elderly.

• These depend on location and extent of arterial

– Dependent Rubor (reddening of limb in dependent

• i. History – predisposing factors.

• Is dilatation or ballooning of blood vessels caused by localized

Risks and predisposing factors to of Aneurysm

• Interventions depend on the location and stage which

This is an occlusive disease also known as arterial insufficiency

• An embolus travelling in blood vessels may

• Sudden sharp pains

• Avoid placing pillows directly under the knees-

Is when a clot forms in a deep vein, common in lower

• Apply tight stockings or anti-embolic stockings

• Administer medication as prescribed e.g;

• Teach a patient about anti-coagulants e.g. avoids

• In this condition,a clot forms within a

CORONARY ARTERY DISEASE (CAD)

• Is narrowing or obstruction of one or more of the coronary

• Myocardial infarction (MI)

• Obstruction of blood flow in coronary Artery.

• Coitus – sexual intercourse.

• -Chest pain that the pt. describes as moderate

3-Assess the pain P,Q,R,S,T as in previous notes

1)Zone of Ischaemia:Is the outermost area of

Acute Coronary Syndrome

• Cigarrete smoking -Diet

Other investigations include;-

• Dysrhythmias – as the ischaemia in the heart

• Ensure that you have a working defibrillator.

• Allow minimal movement e.g use of commode

• Focal inflammatory lesions known as Aschoffs

• Rheumatic endocarditis on the other hand can

• Vary with the stage at which the patient is seen.

• History of throat infections

v. Administer drugs as prescribed , including

• Provide adequate rest balanced with activity to

• Is a pericardial effusion which occurs when space

• Pulsus paradoxus – Is a drop of systolic BP of

• Establish and maintain ABC – intubate, give

Occurs as a result of other disorders

• Identify medications in use