CARDIOVASCULAR SYSTEM

Understanding the Heart.

The Layers of the Heart Wall
Anatomy And Physiology – Essential layer of the heart
Epicardium
Normal Anatomy: Microscopic
(visceral – Coronary arteries are found in this layer
pericardium)
– Consists of Three layers- epicardium, myocardium and
endocardium – Middle and thickest layer of the heart
Myocardium (CBQ)
– Responsible for contraction of the heart
– Innermost layer of the heart
Endocardium – Lines the inside of the myocardium
– Covers the heart valves

Myocardial Cell Types

Kinds of Where Found Primary Primary
Cardiac Cells Function Property
Myocardial Myocardium Contraction Contractility
cells and
Relaxation
Specialized Generation Automaticity
cells of the Electrical and Conductivity
electrical conduction conduction of
conduction system electrical
system impulses

– The epicardium covers the outer surface of the heart

– The myocardium is the middle muscular layer of the heart
– The endocardium lines the chambers and the valves
Normal Anatomy: Gross

– The layer that covers the heart is the PERICARDIUM

– There are two parts- parietal and visceral pericardium
– The space between the two pericardial layers is the pericardial
space
– The heart is located in the LEFT side of the mediastinum

How the heart works.

- The heart and circulation.
- The heart as a pump.
- Blood supply to the heart - the coronary arteries.
- The heart valves.
- The heart is a muscular pump.
- Circulating blood carries oxygen from the lungs and
nutrients from the liver.
CARDIOVASCULAR SYSTEM

The Heart has Four one-way Valves:

- Aortic Valve.
- Mitral Valve.
- Pulmonary Valve.
- Tricuspid Valve.

The heart also has four chambers- two atria and two ventricles
- The Left atrium and the right atrium
- The left ventricle and the right ventricle

The heart chambers are guarded by valves

- The atrio-ventricular valves- Tricuspid and bicuspid
- The semi-lunar valves- Pulmonic and aortic valves

The Valves of the Heart

Valve Type Name Location
Separates right
Tricuspid atrium and right
Atrio-ventricular ventricle
(AV) Separates left
Mitral (Bicuspid) atrium and left
ventricle
Between right
Pulmonic ventricle and
Semilunar pulmonary artery
Between left
Aortic
ventricle and aorta
CARDIOVASCULAR SYSTEM

The Blood supply of the heart comes from the Coronary

arteries
- Right coronary artery
- Left coronary artery

The Coronary Arteries

Portion of Portion of
Coronary Artery and
Myocardium Conduction System
its Branches
Supplied Supplied
Right • Right atrium • AV node (90%
• Posterior • Inferior wall of population)
descending of right
• Right • SA node ( >
ventricle 55%) Bundle
margin (AV
nodal) • ½ anterior of His
surface of left • Posterior
ventricle division of left
bundle branch
Left • Anterior • AV node (10%)
• Anterior surface of left • SA node (45%)
descending ventricle • All bundle Cardio physiology
(LAD) • Left atrium branches - Conduction system
• Circumflex • Lateral wall of
- Cardiac (heart) sounds
(LCX) left ventricle
• Part of right - Heart rate and Blood pressure
ventricle - Cardiac cycle

The main functions of this system are:

- to transport oxygen, hormones and nutrients to the
tissues
- and to transport waste products to the lungs and kidneys
for excretion

The CONDUCTING SYSTEM OF THE HEART

Consists of the
1. SA node- the pacemaker
2. AV node- slowest conduction
3. Bundle of His – branches into the Right and the Left
bundle branch
4. Purkinje fibers- fastest conduction

- The heart itself must receive enough oxygenated blood.

- Blood is supplied to the heart through the coronary

arteries, two main branches which originate just above the The Heart: Physiology
aortic valve. 1. The intrinsic conduction system causes the heart muscle
to depolarize in one direction
The venous drainage of the heart 2. The rate of depolarization is around 75 beats per minute
1. Cardiac veins 3. The SA node sets the pace of the conduction
2. Coronary sinus
CARDIOVASCULAR SYSTEM

4. This electrical activity is recorded by the

Electrocardiogram (ECG)

- Blood pressure
- Hormones- ADH, Adrenergic hormones, Aldosterone and
ANF
The Heart sounds  ADH increases water retention
1. S1- due to closure of the AV valves  Aldosterone increases sodium retention and water
2. S2- due to the closure of the semi-lunar valves retention secondarily
3. S3- due to increased ventricular filling  Epinephrine and NE increase HR and BP
4. S4- due to forceful atrial contraction  ANP= causes sodium excretion

Heart rate The Cardiac Cycle:

- Normal range is 60-100 beats per minute 1. Systole: Contraction
2. Diastole: Relaxation
- Tachycardia is greater than 100 bpm
- Bradycardia is less than 60 bpm
- Sympathetic system INCREASES HR
- Parasympathetic system (Vagus) DECREASES HR (CBQ)

The Heart: Physiology

- The amount of blood the heart pumps out in each beat is
called the STROKE VOLUME
- When this volume is multiplied by the number of heart
beat in a minute (heart rate), it becomes the CARDIAC
OUTPUT
- When the Cardiac Output is multiplied by the Total
Peripheral Resistance, it becomes the BLOOD PRESSURE

Blood pressure = Cardiac output X Peripheral resistance

Blood pressure
- Control is neural (central and peripheral) and hormonal
- Baroreceptors in the carotid and aorta
- Hormones - ADH, Adrenergic hormones, Aldosterone and
ANF
CARDIOVASCULAR SYSTEM

- The arteries are vessels that carry blood away from the
heart to the periphery
- The veins are the vessels that carry blood to the heart
- The capillaries are lined with squamos cells, they connect
the veins and arteries
- The lymphatic system also is part of the vascular system
and the function of this system is to collect the
extravasated fluid from the tissues and returns it to the
blood

The Heart: Physiology

- The PRELOAD is the degree of stretching of the heart
muscle when it is filled-up with blood

- The AFTERLOAD is the resistance to which the heart must

pump to eject the blood

Terminology
CHRONOTROPIC - Refers to a change in heart rate CARDIOVASCULAR ASSESSMENT
EFFECT
- A positive chronotropic effect
refers to an increase in heart rate
- A negative chronotropic effect
refers to a decrease in heart rate
DROMOTROPIC - Refers to a change in the speed of
EFFECT conduction through the AV
junction
- A positive dromotropic effect
results in an increase in AV
conduction velocity
- A negative dromotropic effect
results in a decrease in AV
conduction velocity

INOTROPIC - Refers to a change in myocardial

EFFECT contractility
- A postive inotropic effect results in
an increase in myocardial
contractility Cardiac History
- A negative inotropic effect results - Interview
in a decrease in myocardial - Focused assessment
contractility
Cardiac Assessment

Vascular System 1. Health History

- The vascular system consists of the arteries, veins and - Obtain description of present illness and the chief
capillaries complaint
- Chest pain, SOB, Edema, etc.
CARDIOVASCULAR SYSTEM

- Assess risk factors sternum

AORTIC VALVE Behind left half Medial end of the
2. Physical examination of sternum; 2nd right ICS
- Vital signs- BP, PP, MAP opposite 3rd ICS
- Inspection of the skin
- Inspection of the thorax
- Palpation of the PMI, pulses
- Auscultation of the heart sounds

3. Laboratory and diagnostic studies

- CBC
- Cardiac catheterization
- Lipid profile
- arteriography
- Cardiac enzymes and proteins
- CXR
- CVP
- ECG
- Holter monitoring
- Exercise ECG

Laboratory Test Rationale

- To assist in diagnosing MI
- To identify abnormalities
- To assess inflammation
- To determine baseline value
Surface Auscultation - To monitor serum level of medications
Anatomy - To assess the effects of medications
TRICUSPID VALVE lies behind right right half of the
half of the lower end of the CK- MB (creatine kinase)
sternum; body of the sternum - Indicates myocardial damage
opposite the 4th
ICS - Elevates in MI within 4-6 hours
MITRAL VALVE lies behind the apex beat (5th ICS - peaks in 18 hours and then declines till 3 days
left half of the LMCL) - 0-5% of total CK (26-174U/L)
sternum; - Normal value is 0-7 U/L
opposite the 4th
costal cartilage Lactate Dehydrogenase (LDH)
PULMONARY Lies behind the Medial end of the
VALVE medial end of 2nd left ICS
- Elevates in MI in 24 hours
the 3rd left - peaks in 48-72 hours
costal cartilage & - Normally LDH1 is greater than LDH2
the adjoining - MI- LDH2 greater than LDH1 (flipped LDH pattern)
part of the
CARDIOVASCULAR SYSTEM

- Normal value is 70-200 IU/L

Myoglobin
- Oxygen binding protein
- Found in both skeletal and cardiac
- Level rises 1 hour after cell death
- Peaks in 4-6 hours
- Returns to normal w/in 24-36 hours
- Not used alone
- Muscular and RENAL disease can have elevated myoglobin

Troponin I and T
- Troponin I has a high affinity for myocardial injury
- Elevates within 3-4 hours, peaks in 4-24 hours and
persists for 7 days to 3 weeks!
- Troponin I - <0.6 ng/mL
- Troponin T – 0-0.2ng/mL
- REMEMBER to AVOID IM injections before obtaining blood
sample!
Holter Monitoring
- Early and late diagnosis can be made!
- A non-invasive test in which the client wears a Holter
monitor and an ECG tracing recorded continuously over a
SERUM LIPIDS
period of 24 hours
- Lipid profile measures the serum cholesterol, triglycerides - Instruct the client to resume normal activities and
and lipoprotein levels
maintain a diary of activities and any symptoms that may
- Cholesterol= 200 mg/dL develop
- Triglycerides- 40- 150 mg/dL
- LDL- 130 mg/dL
- HDL- 30-70- mg/dL
- NPO post midnight (usually 12 hours)

ELECTROCARDIOGRAM (ECG)
- A non-invasive procedure that evaluates the electrical
activity of the heart
- Electrodes and wires are attached to the patient
- Tell the patient that there is no risk of electrocution
- Avoid muscular contraction/movement

Echocardiogram
– Non-invasive test that studies the structural and functional
changes of the heart with the use of ultrasound
– No special preparation is needed
CARDIOVASCULAR SYSTEM

Stress Test  Keep the leg straight to prevent occlusion

– A non-invasive test that studies the heart during activity  Monitor for bleeding and hematoma formation
and detects and evaluates CAD
 Encourage fluid intake to flush out the dye
– Exercise test, pharmacologic test and emotional test
– Treadmill testing is the most commonly used stress test  Immobilize the arm if the antecubital vein is used
– Used to determine CAD, Chest pain causes, drug effects  Monitor for dye allergy
and dysrhythmias in exercise  Encourage fluid intake to promote renal excretion of dye
– Pre-test: consent may be required, adequate rest , eat a  Monitor nausea, vomiting, rash and other sign of HPS
light meal or fast for 4 hours and avoid smoking, alcohol rxn
and caffeine
– Post-test: instruct client to notify the physician if any CVP
chest pain, dizziness or shortness of breath – The CVP is the pressure within the SVC
– Instruct client to avoid taking a hot shower for 10-12 – Reflects the pressure under which blood is returned to the
hours after the test SVC and right atrium
– Pharmacological stress test – is measured with a central venous line in the SVC and
 Use of dipyridamole balloon flotation catheter in the pulmonary artery
 Maximally dilates coronary artery – Normal CVP is 3 to 8 mmHg/ 4-10 cm H2O

 Side-effect: flushing of face Increased CVP

 Pre-test: 4 hours fasting, avoid alcohol, caffeine 1. increase in blood volume as a result of Na and water
 Post test: report symptoms of chest pain retention, excessive IVF or heart/renal failure

Cardiac Catheterization Decreased CVP

– Insertion of a catheter into the heart and surrounding 2. May indicate decrease in circulating blood volume and
vessels may be to hypovolemia, hemorrhage and severe
– Obtains information about the structure and performance vasodilatation
of the heart valves and surrounding vessels
– Used to diagnose CAD, assess coronary artery patency Measuring CVP
and determine extent of atherosclerosis 1. Position the client supine with bed elevated at 45
degrees (CBQ)
PRE PROCEDURE 2. Position the zero point of the CVP line at the level of
 Ensure Consent the right atrium. Usually this is at the MAL, 4th ICS
 assess for allergy to seafood and iodine 3. Instruct the client to be relaxed and avoid coughing
 Withhold solid food 6-8 hours and liquids for 4 hours and straining.
 note disease that activity that increases intra-thoracic
 document weight and height, baseline VS, blood tests pressure such as coughing and straining
and document the peripheral pulses  If the client is on the ventilator reading should be
 inform client that a local anesthetic will be administered taken at the point of end expiration
before insertion
 Client may feel fatigued because of the need to lie for 2
hours
 Prepare IV line if prescribed
 Prepare insertion site by shaving and cleaning with an
antiseptic solution if prescribed
 Administer pre medication
INTRATEST
 inform patient of a fluttery feeling as the catheter
passes through the heart
 inform the patient that a feeling of warmth and metallic
taste may occur when dye is administered.

POST TEST
 Monitor VS and cardiac rhythm
 Monitor dysrrhytmia and chest pain
 Monitor peripheral pulses, color and warmth and
sensation of the extremity distal to insertion site
 Apply sandbag or compression device to insertion site if Cardiac Implementation
required to maintain pressure 1. Assess the cardio-pulmonary status
 Maintain strict bed rest for 6-12 hours - VS, BP, Cardiac assessment
 Client may turn from side to side but bed should not be 2. Enhance cardiac output
elevated more than 15 degrees - Establish IV line to administer fluids
 Notify physician if client complains of tingling, cool, pale, 3. Promote gas exchange
cyanosis and loss of peripheral pulses
CARDIOVASCULAR SYSTEM

- Administer O2  Instruct patient to avoid

- Position client in SEMI-Fowler’s cold temperatures and
smoking
- Encourage coughing and deep breathing exercises
4. Increase client activity tolerance  Instruct to report
unrelieved pain
- Balance rest and activity periods
immediately
- Assist in daily activities
- Provide strict bed rest if indicated
- Soft foods Cardiac Diseases
-
Assistance in self-care  Coronary Artery Disease
 Myocardial Infarction
5. Promote client comfort
 Congestive Heart Failure
- Assess the client’s description of pain and chest discomfort
 Infective Endocarditis
- Administer medication as prescribed  Cardiac Tamponade
 Morphine for MI  Cardiogenic Shock
 Nitroglycerine for Angina
 Diuretics to relieve congestion (CHF)
6. Promote adequate sleep Vascular Diseases
7. Prevent infection  Hypertension
- Monitor skin integrity of lower extremities  Buerger’s disease
- Assess skin site for edema, redness and warmth  Aneurysm
 Varicose veins
- Monitor for fever
 Deep vein thrombosis
- Change position frequently

8. Minimize patient anxiety Coronary Artery Disease (CAD)

Encourage verbalization of feelings, fears and
- results from the focal narrowing of the large and medium-
concerns
sized coronary arteries due to deposition of atheromatous
Answer client questions. Provide information about
plaque in the vessel wall
procedures and medications
Risk Factors
1. Age above 45/55 and Sex- Males and post-menopausal
females
2. Family History
3. Hypertension
4. DM
5. Smoking
6. Obesity
7. Sedentary lifestyle
8. Hyperlipedimia

Activity Intolerance  Monitor TPR and BP

 Space activities in the Most important MODIFIABLE factors:
day
- Smoking
 Permit rest periods
before activity - Hypertension
 Limit activity 1 hour - Diabetes
before meals - Cholesterol abnormalities
 Teach energy
conservation measures CAD: Pathophysiology
like bed rest
Edema  Instruct patient to avoid
constricting garments - Fatty streak formation in the vascular intima
 Instruct to elevate - ↓
edematous areas - T-cells and monocytes ingest lipids in the area of
 Instruct patient to avoid deposition
dependent positions - ↓
 Teach patient to prepare
low sodium meals - Atheroma
 Apply anti-embolic - ↓
stockings - narrowing of the arterial lumen
Pain  Instruct patient to stop - ↓
activity when pain occurs
- reduced coronary blood flow
 Administer nitroglycerine
for angina - ↓
 Pace activities within - myocardial ischemia
patient’s limits
CARDIOVASCULAR SYSTEM

Pathophysiology
- There is decreased perfusion of myocardial tissue and
inadequate myocardial oxygen supply
- If 50% of the left coronary arterial lumen is reduced or
75% of the other coronary artery, this becomes significant
- Potential for Thrombosis and embolism
Artery walls have three layers.
1. The inner layer provides a slippery surface.
2. The middle layer is strong, elastic and muscular.
3. The outer, fibrous, layer adds strength and contains
tiny blood vessels that supply blood to the arteries
themselves.

Narrowing or obstruction of the coronary arteries is the

main cause of a group of disorders known as ischaemic
heart disease.

Coronary Artery Disease.

- Acute Coronary Syndrome (ACS) is the phrase used
when referring to any cardiac condition involving the
coronary arteries.
- Angina is a feeling of tightness or pain across the chest
that may spread outwards to the shoulders, upper arms
and back.
May occur with exercise or strong emotion and can be
worse after a meal or in cold weather. Symptoms usually
disappear after 1-2 minutes rest.
- Heart attack (myocardial infarction or MI) is when
part of the heart muscle dies. This is usually caused by a
blood clot (coronary thrombosis), which has blocked one
of the coronary arteries supplying the heart and depriving
the tissues of oxygen.

Coronary Artery Disease treatment

 Angioplasty & Stent
 Coronary Artery Bypass Graft.

- Treatment for C.A.D involves the removal or treatment of

risk factors.
- Sometimes procedures to enlarge or bypass coronary
artery narrowing are required.
- If Coronary Disease is not treated and the coronary artery
becomes blocked the result may be a heart attack.

Angioplasty
- Coronary angioplasty involves inserting a balloon into a
diseased (blocked/narrowed) coronary artery through an
artery in the groin or arm.
- Commonly a metal support (stent) is inserted into the
artery to help keep it open.
CARDIOVASCULAR SYSTEM

A close up of a Stent.

C. A. B. G.
- Veins and sometimes arteries are grafted from the aorta
to a point on the coronary artery beyond the area of
disease. This enables an adequate blood supply to reach
those parts of the heart suffering from ischaemia
CARDIOVASCULAR SYSTEM

Artificial Valves

Tissue Valves

Mitral Valves

Valve Replacements
- Aortic Valve Replacement (AVR)
- Mitral Valve Replacement (MVR)

Tricuspid & Bicuspid

Angina Pectoris
- Chest pain resulting from coronary atherosclerosis or
myocardial ischemia

- An Assortment of Replacement Valves

CARDIOVASCULAR SYSTEM

Angina Pectoris: Clinical Syndromes

Nursing Management
Three Common Types of Angina 1. Administer prescribed medications
1. Stable Angina  Nitrates- to dilate the venous vessels decreasing
- The typical angina that occurs during exertion, venous return and to some extent dilate the coronary
relieved by rest and drugs and the severity does not arteries
change  Aspirin- to prevent thrombus formation
 Beta-blockers- to reduce BP and HR
2. Unstable angina  Calcium-channel blockers- to dilate coronary artery and
- Occurs unpredictably during exertion and emotion, reduce vasospasm
severity increases with time and pain may not be
2. Teach the patient management of anginal attacks
relieved by rest and drug
 Advise patient to stop all activities
3. Variant angina  Put one nitroglycerin tablet under the tongue
 Wait for 5 minutes
- Prinzmetal angina, results from coronary artery
 If not relieved, take another tablet and wait for 5
VASOSPASMS, may occur at rest
minutes
 Another tablet can be taken (third tablet)
ASSESSMENT FINDINGS
1. Chest pain - ANGINA If unrelieved after THREE tablets seek medical
attention
- The most characteristic symptom
- PAIN is described as mild to severe retrosternal pain, 3. Obtain a 12-lead ECG
squeezing, tightness or burning sensation
- Radiates to the jaw and left arm
- Precipitated by Exercise, Eating heavy meals, Emotions
like excitement and anxiety and Extremes of
temperature
- Relieved by REST and Nitroglycerin
2. Diaphoresis
3. Nausea and vomiting
4. Cold clammy skin
5. Sense of apprehension and doom
6. Dizziness and syncope

LABORATORY FINDINGS
1. ECG may show normal tracing if patient is pain-free.
Ischemic changes may show ST depression and T wave
inversion

4. Promote myocardial perfusion

 Instruct patient to maintain bed rest
 Administer O2 @ 3 lpm
Advise to avoid valsalva maneuvers
 Provide laxatives or high fiber diet to lessen
constipation
 Encourage to avoid increased physical activities

5. Assist in possible treatment modalities

 PTCA- percutaneous transluminal coronary angioplasty
 To compress the plaque against the vessel wall,
2. Cardiac catheterization increasing the arterial lumen
3. Provides the MOST DEFINITIVE source of diagnosis by  CABG- coronary artery bypass graft
showing the presence of the atherosclerotic lesions  To improve the blood flow to the myocardial tissue
- Decreased cardiac output
6. Provide information to family members to minimize
- Impaired gas exchange anxiety and promote family cooperation
- Activity intolerance 7. Assist client to identify risk factors that can be modified
- Anxiety 8. Refer patient to proper agencies
CARDIOVASCULAR SYSTEM

Assessment Findings
1. Chest Pain
- Chest pain is described as severe, persistent, crushing
substernal discomfort
- Radiates to the neck, arm, jaw and back
- Occurs without cause, primarily early morning
- NOT relieved by rest or nitroglycerin
- Lasts 30 minutes or longer
2. Dyspnea
3. Diaphoresis
4. cold clammy skin
5. N/V
6. restlessness, sense of doom
7. tachycardia or bradycardia
8. hypotension
9. S3 and dysrhythmias

Laboratory Findings
1. ECG- the ST segment is ELEVATED, T wave inversion,
Myocardial infarction presence of Q wave
- Death of myocardial tissue in regions of the heart with 2. Myocardial enzymes- elevated CK-MB, LDH and
abrupt interruption of coronary blood supply Troponin levels

3. CBC- may show elevated WBC count

4. Test after the acute stage - Exercise tolerance test,
thallium scans, cardiac catheterization
Pain
- Decreased cardiac output
ETIOLOGY and Risk factors - Impaired gas exchange
1. CAD - Activity intolerance
2. Coronary vasospasm - Altered tissue perfusion
3. Coronary artery occlusion by embolus and thrombus - Constipation
4. Conditions that decrease perfusion- hemorrhage, shock
Nursing Intevention
Risk factors 1. Provide Oxygen at 2 lpm, Semi-fowler’s
1. Hypercholesterolemia 2. Administer medications
2. Smoking
3. Hypertension - Morphine to relieve pain
4. Obesity - Nitrates, thrombolytics, aspirin and anticoagulants
5. Stress - Stool softener and hypolipidemics
6. Sedentary lifestyle 3. Minimize patient anxiety
- Provide information as to procedures and drug therapy
Pathophysiology
- Allow verbalization of feelings
- Interrupted coronary blood flow myocardial ischemia
 anaerobic myocardial metabolism for several hours
- Morphine can be administered
4. Provide adequate rest periods
 myocardial death  depressed cardiac function 
triggers autonomic nervous system response  further - Bed rest during acute stage
imbalance of myocardial O2 demand and supply 5. Minimize metabolic demands
- Provide soft diet
- Provide a low-sodium, low cholesterol and low fat diet
CARDIOVASCULAR SYSTEM

6. Assist in treatment modalities such as PTCA and CABG

7. Monitor for complications of MI- especially
dysrhythmias, since ventricular tachycardia can happen Pathophysiology
in the first few hours after MI Diminished contractile proteins poor contraction 
8. Provide client teaching decreased blood ejection  increased blood remaining
in the ventricle  ventricular stretching and dilatation.
 Systolic Dysfunction

Hypertrophic Cardiomyopathy
Associated factors:
1. Genetic
2. Idiopathic

Pathophysiology
Increased size of myocardium  reduced ventricular
volume  increased resistance to ventricular filling 
diastolic dysfunction

Restrictive Cardiomyopathy
Associated factors
1. Infiltrative diseases like AMYLOIDOSIS
2. Idiopathic

Pathophysiology
Rigid ventricular wall impaired stretch and diastolic
filling  decreased output
Medical Management
Diastolic dysfunction
1. Analgesic
- The choice is MORPHINE
- It reduces pain and anxiety Assessment findings
- Relaxes bronchioles to enhance oxygenation 1. PND
2. ACE inhibitors 2. Orthopnea
3. Edema
- Prevents formation of angiotensin II
4. Chest pain
- Limits the area of infarction 5. Palpitations
3. Thrombolytic therapy
6. Dizziness
- Streptokinase, Alteplase 7. Syncope with exertion
- Dissolve clots in the coronary artery allowing blood to
flow
Laboratory Findings
Nursing Interventions After Acute Episode  CXR- may reveal cardiomegaly
1. Maintain bed rest for the first 3 days  Echocardiogram
2. Provide passive ROM exercises  ECG
3. Progress with dangling of the feet at side of bed
4. Proceed with sitting out of bed, on the chair for 30
Myocardial Biopsy
minutes TID
Medical Management
5. Proceed with ambulation in the room  toilet  1. Surgery - heart transplant
hallway TID 2. Pacemaker insertion
6. Cardiac rehabilitation 3. Pharmacological drugs for symptom relief
- To extend and improve quality of life
- Physical conditioning Nursing Management
1. Improve cardiac output
- Patients who are able to walk 3-4 mph are usually
ready to resume sexual activities - Adequate rest
- Oxygen therapy
Cardiomyopathies - Low sodium diet
- Heart muscle disease associated with cardiac dysfunction 2. Increase patient tolerance
1. Dilated Cardiomyopathy - Schedule activities with rest periods in between
2. Hypertrophic Cardiomyopathy 3. Reduce patient anxiety
3. Restrictive cardiomyopathy
- Support patient
Dilated Cardiomyopathy - Offer information about transplantations
Associated Factors - Support family in anticipatory grieving
1. Heavy alcohol intake
Infective endocarditis
2. Pregnancy
- Infection of the heart valves and the endothelial surface
3. Viral infection
of the heart
4. Idiopathic Can be acute, sub-acute or chronic
CARDIOVASCULAR SYSTEM

- Acute in Myocardial infarction

Etiologic factors
- Chronic  cardiomyopathies
1. Bacteria- Organism depends on several factors
2. Fungi

Risk factors
Classified according to the major ventricular
1. Prosthetic valves dysfunction
2. Congenital malformation 1. Left Ventricular failure
3. Cardiomyopathy 2. Right ventricular failure
4. IV drug users
5. Valvular dysfunctions

Pathophysiology
Direct invasion of microbes
↓
microbes adhere to damaged valve surface and proliferate
↓
damage attracts platelets causing clot formation
↓
erosion of valvular leaflets and the clot and vegetation can
embolize
Assessment findings
1. Intermittent high grade fever
2. anorexia, weight loss
3. cough, back pain and joint pain
4. splinter hemorrhages under nails
5. Osler’s nodes- painful nodules on fingerpads
6. Roth’s spots- pale hemorrhages in the retina
7. Heart murmurs
8. Heart failure= usually acute heart failure
Prevention
Etiology of CHF
- Antibiotic prophylaxis if patient is undergoing 1. CAD
procedures like dental extractions, bronchoscopy,
2. Valvular heart diseases
surgery, etc.
3. Hypertension
- Any invasive procedure that is associated with transient 4. MI
bacteremia may cause the microrganism to lodge in the 5. Cardiomyopathy
damaged, irregular valves 6. Lung diseases
7. Post-partum
Laboratory Exam 8. Pericarditis and cardiac tamponade
- Blood Cultures to determine the exact organism
 Usually, 3 culture specimens are obtained and New York Heart Association
antibiotic sensitivity done Class 1
- Ordinary physical activity does NOT cause chest pain
Nursing management and fatigue
1. Regular monitoring of temperature, heart sounds - No pulmonary congestion
2. Manage infection
3. Long-term antibiotic therapy is given to ensure - Asymptomatic
eradication of bacteria - NO limitation of ADLs

Medical management Class 2

1. Pharmacotherapy - SLIGHT limitation of ADLs
- IV antibiotic for 2-6 weeks - NO symptom at rest
- Antifungal agents are given – amphotericin B - Symptoms with INCREASED activity
2. Surgery - Basilar crackles and S3
3. Valvular replacement
- New York Heart Association
Congestive Heart Failure (CHF)
- A syndrome of congestion of both pulmonary and systemic Class 3
circulation caused by inadequate cardiac function and
inadequate cardiac output to meet the metabolic demands - Markedly limitation on ADLs
of tissues - Comfortable at rest BUT symptoms present in LESS than
- Inability of the heart to pump sufficiently ordinary activity
- The heart is unable to maintain adequate circulation to
Class 4
meet the metabolic needs of the body
- SYMPTOMS are present at rest
This can happen acutely or chronically
CARDIOVASCULAR SYSTEM

3. Echocardiogram may show hypokinetic heart

4. ABG and Pulse oximetry may show decreased O2
saturation
5. PCWP is increased in LEFT sided CHF and CVP is
increased in RIGHT sided CHF

PATHOPHYSIOLOGY Nursing Interventions

LEFT Ventricular pump failure 1. Assess patient's cardio-pulmonary status
↓ 2. Assess VS, CVP and PCWP. Weigh patient daily to
back up of blood into the pulmonary veins monitor fluid retention
↓ 3. Administer medications- usually cardiac glycosides are
increased pulmonary capillary pressure given- DIGOXIN or DIGITOXIN, Diuretics, vasodilators
↓ and hypolipidemics are prescribed

pulmonary congestion (edema) Cardiotonics To increase cardiac

↓ Positive inotropic agents contractility
Diuretics To decrease the intravascular
Pulmonary manifestations volume in the circulation
Low Sodium Diet To minimize water retention
LEFT ventricular failure Hypolipidemics To decrease the lipid levels of
↓
high risk patients
Decreased cardiac output
↓
Digoxin Health teaching
Decreased perfusion to the brain, kidney and other tissues
↓ - Oral tablet usually once a day
Cerebral anoxia, fatigue, oliguria, dizziness - Increases force of contraction
- DECREASES heart rate
RIGHT ventricular failure
↓ - Assess: Apical pulse, ECG, hypokalemia
blood pooling in the venous circulation - Withhold the drug if apical pulse is less than 60
↓ - Note for early signs of toxicity: NAVDA
increased hydrostatic pressure - Provide potassium supplements
↓
peripheral edema
4. Provide a LOW sodium diet. Limit fluid intake as
↓
necessary
RIGHT ventricular failure
5. Provide adequate rest periods to prevent fatigue
↓
Venous blood pooling
6. Position on semi-fowler’s to fowler’s for adequate
↓
chest expansion
venous congestion in the kidney, liver and GIT
7. Prevent complications of immobility
Left Sided CHF Assessment Findings
1. Dyspnea on exertion, activity intolerance
Nursing Intervention after the Acute Stage
2. PND
1. Provide opportunities for verbalization of feelings
3. Orthopnea
2. Instruct the patient about the medication regimen-
4. Pulmonary crackles/rales
digitalis, vasodilators and diuretics
5. Cough with Pinkish, frothy sputum
3. Instruct to avoid OTC drugs, Stimulants, smoking and
6. Tachycardia
alcohol
7. Cool extremities
4. Provide a LOW fat and LOW sodium diet
8. Cyanosis
5. Provide potassium supplements
9. decreased peripheral pulses
6. Instruct about fluid restriction
10.Fatigue
7. Provide adequate rest periods and schedule activities
11.Oliguria
8. Monitor daily weight and report signs of fluid retention
12.signs of cerebral anoxia
Cardiogenic Shock
Right Sided CHF Assessment Findings
1. Peripheral dependent, pitting edema - Heart fails to pump adequately resulting to a decreased
2. Weight gain cardiac output and decreased tissue perfusion
3. Distended neck vein
4. hepatomegaly Etiology
5. Ascites 1. Massive MI
6. Body weakness 2. Severe CHF
7. Anorexia, nausea 3. Cardiomyopathy
8. Pulsus alternans 4. Cardiac trauma
9. Nocturia= urination at night at frequent intervals as 5. Cardiac tamponade
the blood moves from interstitial space to the
Assessment Findings
intravascular space and is excreted
1. HYPOTENSION
2. Oliguria (less than 30 ml/hour)
Laboratory Findings
3. Tachycardia
1. CXR may reveal cardiomegaly
4. Narrow pulse pressure
2. ECG may identify Cardiac hypertrophy
CARDIOVASCULAR SYSTEM

5. weak peripheral pulses - Elevate head of bed 45-60 degrees

6. cold clammy skin
- Monitor for complications- coronary artery rupture,
7. changes in sensorium/LOC
dysrhythmias, pleural laceration and myocardial trauma
8. pulmonary congestion

Laboratory Findings
- Increased CVP due to pooling of blood in the venous Vascular Diseases
system
 Normal is 4-10 cmH2O
- Metabolic acidosis

Nursing Interventions
1. Place patient in a modified Trendelenburg (shock )
position
2. Administer IVF, vasopressors and inotropics such as
DOPAMINE and DOBUTAMINE
3. Administer O2
4. Morphine is administered to decreased pulmonary
congestion and to relieve pain, relieve anxiety
5. Assist in intubation, mechanical ventilation, PTCA,
CABG, insertion of Swan-Ganz cath and IABP
6. Monitor urinary output, BP and pulses
7. Cautiously administer diuretics and nitrates
CARDIAC TAMPONADE
General Measures to Improve Peripheral Circulation
- A condition where the heart is unable to pump blood due 1. Implement Regular Physical Activity – to facilitate
to accumulation of fluid in the pericardial sac (pericardial movement of venous blood
effusion) 2. Eliminate cigarette smoking- to prevent vasoconstriction
- This condition restricts ventricular filling resulting to 3. Control hyperlipidemia and cholesterol levels- to prevent
decreased cardiac output the progression of atherosclerosis
- Acute tamponade may happen when there is a sudden 4. Avoid cold environmental temperature
accumulation of more than 50 ml fluid in the pericardial 5. Teach clients to assess fingers and toes daily for
sac circulatory adequacy: Check the peripheral pulses,
capillary refill and temp
Causative factors 6. Report break in the skin
1. Cardiac trauma
2. Complication of Myocardial infarction Hypertension
3. Pericarditis - A systolic BP greater than 140 mmHg and a diastolic
4. Cancer metastasis pressure greater than 90 mmHg over a sustained period,
based on two or more BP measurements.
Assessment Findings
1. BECK’s Triad- Jugular vein distention, hypotension and Types of Hypertension
distant/muffled heart sound 1. Primary or Essential
2. Pulsus paradoxus
- Most common type
3. Increased CVP
2. Secondary
4. decreased cardiac output
5. Syncope - Due to other conditions like Pheochromocytoma,
6. anxiety renovascular hypertension, Cushing’s, Conn’s , SIADH
7. dyspnea
8. Percussion- Flatness across the anterior chest Classification Of Hypertension By Jnc-Vii

Laboratory Findings
1. Echocardiogram= shows accumulate fluid in the
pericardial sac
2. Chest X-ray

Nursing Interventions
1. Assist in PERICARDIOCENTESIS
2. Administer IVF
3. Monitor ECG, urine output and BP
4. Monitor for recurrence of tamponade

Pericardiocentesis
- Patient is monitored by ECG
- Maintain emergency equipments
CARDIOVASCULAR SYSTEM

3. chest pain
4. dizziness
5. N/V

Diagnostic Studies
1. Health history and PE
2. Routine laboratory- urinalysis, ECG, lipid profile, BUN,
serum creatinine , FBS
3. Other lab- CXR, creatinine clearance, 24-huour urine
protein

Medical Management
1. Lifestyle modification
2. Diet therapy
3. Drug therapy

MEDICAL MANAGEMENT
Drug therapy
- Diuretics
- Beta blockers
- Calcium channel blockers
- ACE inhibitors
- A2 Receptor blockers
Pathophysiology -
Vasodilators
- Multi-factorial etiology Nursing Interventions
o BP= CO (SV X HR) x TPR 1. Provide health teaching to patient
Any increase in the above parameters will increase BP - Teach about the disease process
- Elaborate on lifestyle changes
Risk factors for Cardiovascular Problems in - Assist in meal planning to lose weight
Hypertensive patients
Major Risk factors - Provide list of LOW fat , LOW sodium diet of less than 2-
1. Smoking 3 grams of Na/day
2. Hyperlipidemia - Limit alcohol intake to 30 ml/day
3. DM - Regular aerobic exercise
4. Age older than 60 - Advise to completely Stop smoking
5. Gender- Male and post menopausal women
6. Family History 2. Provide information about anti-hypertensive drugs
- Instruct proper compliance and not abrupt cessation of
drugs even if pt becomes asymptomatic/ improved
condition
- Instruct to avoid over-the-counter drugs that may
interfere with the current medication

3. Promote Home care management

- Instruct regular monitoring of BP
- Involve family members in care
- Instruct regular follow-up
4. Manage hypertensive emergency and urgency properly

Aneurysm
- Dilation involving an artery formed at a weak point in the
vessel wall
- Saccular= when one side of the vessel is affected
- Fusiform= when the entire segment becomes dilated
Any increase in the above parameters will increase BP
1. Increased sympathetic activity Risk Factors
2. Increased absorption of Sodium, and water in the 1. Atherosclerosis
kidney 2. Infection= syphilis
3. Increased activity of the RAAS 3. Connective tissue disorder
4. Increased vasoconstriction of the peripheral vessels 4. Genetic disorder= Marfan’s Syndrome
5. Insulin resistance
Pathophysiology
Assessment Findings - Damage to the intima and media weakness
1. Headache outpouching of vessel wall
2. Visual changes
CARDIOVASCULAR SYSTEM

- Dissecting aneurysm tear in the intima and media with Medical Management
dissection of blood through the layers 1. Drug therapy
- Pentoxyfylline (Trental) reduces blood viscosity and improves
Assessment supply of O2 blood to muscles
1. Asymptomatic - Cilostazol (Pletaal) inhibits platelet aggregation and increases
2. Pulsatile sensation on the abdomen vasodilatation
3. Palpable bruit 2. Surgery- Bypass graft and anastomoses

Laboratory: Nursing Interventions

- CT scan 1. Maintain Circulation to the extremity
- Ultrasound - Evaluate regularly peripheral pulses, temperature,
- X-ray sensation, motor function and capillary refill time
- Aortography - Administer post-operative care to patient who
underwent surgery
Medical Management: - Administer heat modalities to the leg cautiously to
- Anti-hypertensives promote vasodilatation
- Synthetic graft
2. Monitor and manage complications
Nursing Management: - Note for bleeding, hematoma, and decreased urine
output
- Administer medications
- Emphasize the need to avoid increased abdominal
- Elevate the legs to diminish edema
pressure - Encourage exercise of the extremity while on bed
- No deep abdominal palpation - Teach patient to avoid leg-crossing
- Remind patient the need for serial ultrasound to detect
diameter changes.
Peripheral Arterial Occlusive Disease
- Refers to arterial insufficiency of the extremities usually 3. Promote Home management
secondary to peripheral atherosclerosis.
- Encourage lifestyle changes
- Usually found in males age 50 and above - Instruct to AVOID smoking
- The legs are most often affected
- Instruct to avoid leg crossing
Risk factors for Peripheral Arterial occlusive disease
BUERGER’S DISEASE
Non-Modifiable
Thromboangiitis obliterans
1. Age
2. gender - A disease characterized by recurring inflammation of the
3. family predisposition medium and small arteries and veins of the lower
extremities
Modifiable - Occurs in MEN ages 20-35
1. Smoking - RISK FACTOR: SMOKING!
2. HPN
3. Obesity Pathophysiology
4. Sedentary lifestyle
- Cause is UNKNOWN
5. DM
6. Stress - Probably an Autoimmune disease
- Inflammation of the arteries and veins thrombus
Assessment Findings formation  occlusion of the vessels
1. INTERMITTENT CLAUDICATION- the hallmark of PAOD
- This is PAIN described as aching, cramping or fatiguing
discomfort consistently reproduced with the same
degree of exercise or activity
- This pain is RELIEVED by REST
- This commonly affects the muscle group below the
arterial occlusion
2. Progressive pain on the extremity as the disease
advances
3. Sensation of cold and numbness of the extremities
4. Skin is pale when elevated and cyanotic and ruddy
when placed on a dependent position
5. Muscle atrophy, leg ulceration and gangrene

Diagnostic Findings
1. Unequal pulses between the extremities
2. Duplex ultrasonography Assessment Findings
3. Doppler flow studies 1. Leg PAIN
- Foot cramps in the arch
 CARDIOVASCULAR SYSTEM

- (INSTEP CLAUDICATION) after exercise 1. Instruct patient to avoid situations that may be
- Relieved by rest stressful
- Aggravated by smoking, emotional disturbance and cold 2. Instruct to avoid exposure to cold and remain indoors
chilling when the climate is cold
3. Instruct to avoid all kinds of nicotine
2. Digital rest pain not changed by activity or rest
4. Instruct about safety. Careful handling of sharp objects
3. Intense RUBOR (reddish-blue discoloration),
progresses to CYANOSIS as disease advances Venous diseases
4. Paresthesias

Diagnostic Studies
1. Duplex ultrasonography
2. Contrast angiography

Nursing Interventions
1. Assist in the medical and surgical management
- Bypass graft
- amputation
2. Strongly advise to AVOID smoking
3. Manage complications appropriately

Post-operative care: after amputation

- Elevate stump for the FIRST 24 HOURS to minimize
edema and promote venous return
- Place patient on PRONE position after 24 hours several
times a day
- Assess skin for bleeding and hematoma
- Wrap the extremity with elastic bandage
Raynaud’s Disease
- A form of intermittent arteriolar VASOCONSTRICTION that
results in coldness, pain and pallor of the fingertips or toes Varicose Veins
- Cause : UNKNOWN - THESE are dilated veins usually in the lower extremities
- Most commonly affects WOMEN, 16- 40 years old
Predisposing Factors
 Pregnancy
 Prolonged standing or sitting
 Incompetent venous valves

Pathophysiology
Factors  venous stasis increased hydrostatic
pressure  edema

Assessment findings
- Tortuous superficial veins on the legs
- Leg pain and Heaviness
- Dependent edema
Assessment Findings
1. Raynaud’s phenomenon Laboratory findings
- A localized episode of vasoconstriction of the small arteries of - Venography
the hands and feet that causes color and temperature changes - Duplex scan pletysmography
W-B-R is the acronym for the color change
- Pallor- due to vasoconstriction, then  Medical management
- Blue- due to pooling of Deoxygenated blood - Pharmacological therapy
- Red- due to exaggerated reflow or hyperemia - Leg vein stripping and ligation
2. Tingling sensation - Anti-embolic stockings
3. Burning pain on the hands and feet
Nursing management
Medical management 1. Advise patient to elevate the legs with pillow to increase
- Drug therapy with the use of CALCIUM channel blockers venous return
2. Caution patient to avoid prolonged standing or sitting
 To prevent vasospasms 3. Provide high-fiber foods to prevent constipation
4. Teach simple exercise to promote venous return
Nursing Interventions 5. Caution patient to avoid constrictive clothing
6. Apply anti-embolic stockings as directed
 CARDIOVASCULAR SYSTEM

7. Avoid massage on the affected area  Nutritional anemia

 Hemolytic anemia
DVT- Deep Vein Thrombosis  Aplastic anemia
- Inflammation of the deep veins of the lower extremities  Sickle cell anemia
and the pelvic veins
- The inflammation results to formation of blood clots in the Anemia
area - A condition in which the hemoglobin concentration is lower
Predisposing factors than normal
- Prolonged immobility
Three broad categories
- Varicosities 1. Loss of RBC- occurs with bleeding
- Traumatic procedures 2. Decreased RBC production
- Increased age 3. Increased RBC destruction
- Malignancy
Hypoproliferative Anemia
- Estrogen therapy Iron Deficiency Anemia
- Smoking - Results when the dietary intake of iron is inadequate to
Complication produce hemoglobin
- PULMONARY thromboembolism Etiologic Factors
1. Bleeding- the most common cause
Assessment findings 2. Mal-absorption
- Leg tenderness 3. Malnutrition
- Leg pain and edema 4. Alcoholism
- Positive HOMAN’s SIGN
Pathophysiology
HOMAN’s SIGN
The foot is FLEXED upward (dorsiflexed) , there is a sharp
- The body stores of iron decrease, leading to depletion
pain felt in the calf of the leg indicative of venous of hemoglobin synthesis
inflammation - The oxygen carrying capacity of hemoglobin is
reduced tissue hypoxia
Laboratory findings
- Venography
- Duplex scan

Medical management Assessment Findings

- Antiplatelets- aspirin 1. Pallor of the skin and mucous membrane
- Anticoagulants 2. Weakness and fatigue
- Vein stripping and grafting 3. General malaise
4. Pica
- Anti-embolic stockings
5. Brittle nails
6. Smooth and sore tongue
Nursing management 7. Angular cheilosis
1. Provide measures to avoid prolonged immobility
- Repositioning Q2 Laboratory findings
- Provide passive ROM 1. CBC- Low levels of Hct, Hgb and RBC count
- Early ambulation 2. Low serum iron, low ferritin
2. Provide skin care to prevent the complication of leg 3. Bone marrow aspiration- MOST definitive
ulcers
3. Provide anti-embolic stockings Medical management
4. Administer anticoagulants as prescribed 1. Hematinics
5. Monitor for signs of pulmonary embolism sudden 2. Blood transfusion
respiratory distress
Nursing Management
1. Provide iron rich-foods
- Organ meats (liver)
- Beans
- Leafy green vegetables
- Raisins and molasses

2. Administer iron
- Oral preparations tablets- Fe fumarate, sulfate and
gluconate
- Advise to take iron ONE hour before meals
- Take it with vitamin C
- Continue taking it for several months
Blood disorders
 Anemia
- Oral preparations- liquid
CARDIOVASCULAR SYSTEM

- It stains teeth ↓
Impaired RBC development, impaired nuclear maturation but
- Drink it with a straw
CYTOplasmic maturation continues
- Stool may turn blackish- dark in color ↓
- Advise to eat high-fiber diet to counteract constipation large size
- IM preparation
- Administer DEEP IM using the Z-track method
Vitamin B12 deficiency
- Avoid vigorous rubbing Causative factors
- Can cause local pain and staining 1. Strict vegetarian diet
2. Gastrointestinal mal-absorption
Aplastic Anemia 3. Crohn's disease
- A condition characterized by decreased number of RBC 4. Gastrectomy
as well as WBC and platelets Vitamin B12 deficiency: Pernicious Anemia
- Due to the absence of intrinsic factor secreted by the
Causative Factors parietal cells
1. Environmental toxins- pesticides, benzene - Intrinsic factor binds with Vit. B12 to promote
2. Certain drugs- Chemotherapeutic agents, absorption
chloramphenicol, phenothiazines, Sulfonamides
3. Heavy metals Assessment findings
4. Radiation 1. weakness
2. fatigue
Pathophysiology 3. listless
Toxins cause a direct bone marrow depression 4. neurologic manifestations are present only in Vit.
↓ B12 deficiency
Acellular bone marrow
↓ Assessment findings
decreased production of blood elements Pernicious Anemia
PANCYTOPENIA
- Beefy, red, swollen tongue
Assessment Findings - Mild diarrhea
- fatigue - Extreme pallor
- pallor - Paresthesias in the extremities
- dyspnea
- bruising
- splenomegaly
- retinal hemorrhages Laboratory findings
1. Peripheral blood smear- shows giant RBCs, WBCs with
Laboratory Findings giant hyper-segmented nuclei
1. CBC- decreased blood cell numbers 2. Very high MCV
3. Schilling’s test
2. Bone marrow aspiration confirms the anemia- 4. Intrinsic factor antibody test
hypoplastic or acellular marrow replaced by fats
Medical Management
Medical Management
1. Vitamin supplementation
1. Bone marrow transplantation
2. Folic acid 1 mg daily
2. Immunosupressant drugs
3. Diet supplementation
3. Rarely, steroids
4. Vegetarians should have vitamin intake
4. Blood transfusion
5. Lifetime monthly injection of IM Vit B12
Nursing management
1. Assess for signs of bleeding and infection
2. Instruct to avoid exposure to offending agents
Nursing Management
1. Monitor patient
Megaloblastic Anemias
2. Provide assistance in ambulation
- Anemias characterized by abnormally large RBC 3. Oral care for tongue sore
secondary to impaired DNA synthesis due to deficiency 4. Explain the need for lifetime IM injection of vit B12
of Folic acid and/or vitamin B12
Folic Acid deficiency Hemolytic Anemia: Sickle Cell
Causative factors
- A severe chronic incurable hemolytic anemia that
1. Alcoholism
results from heritance of the sickle hemoglobin gene.
2. Mal-absorption
Causative factor
3. Diet deficient in uncooked vegetables - Genetic inheritance of the sickle gene- HbS gene
Pathophysiology
Pathophysiology of Folic acid deficiency Decreased O2, Cold, Vasoconstriction can precipitate
Decreased folic acid sickling process
↓
Factors  cause defective hemoglobin to acquire a
impaired DNA synthesis in the bone marrow
rigid, crystal-like C-shaped configuration  Sickled
CARDIOVASCULAR SYSTEM

RBCs will adhere to endothelium  pile up and plug - Blood becomes thick and viscous causing sluggish
the vessels  ischemia results pain, swelling and circulation
fever - Overtime, the bone marrow becomes fibrotic
Assessment Findings
Assessment findings
1. jaundice (hemolytic jaundice)
2. enlarged skull and facial bones - Skin is ruddy
3. tachycardia, murmurs and cardiomegaly - Splenomegaly
- Primary sites of thrombotic occlusion: spleen, lungs - headache
and CNS - dizziness, blurred vision
- Chest pain, dyspnea - Angina, dyspnea and thrombophlebitis

Assessment Findings Laboratory findings

1. Sickle cell crises 1. CBC- shows elevated RBC mass
- Results from tissue hypoxia and necrosis 2. Normal oxygen saturation
2. Acute chest syndrome 3. Elevated WBC and Platelets
- Manifested by a rapidly falling hemoglobin level,
tachycardia, fever and chest infiltrates in the CXR Complications
1. Increased risk for thrombophlebitis, CVA and MI
Medical Management 2. Bleeding due to dysfunctional blood cells
1. Bone marrow transplant
2. Hydroxyurea Medical Management
3. Increases the HbF 1. To reduce the high blood cell mass- PHLEBOTOMY
4. Long term RBC transfusion 2. Allopurinol
3. Dipyridamole
Nursing Management
1. manage the pain 4. Chemotherapy to suppress bone marrow
Support and elevate acutely inflamed joint
Relaxation techniques Nursing Management
analgesics 1. Primary role of the nurse is EDUCATOR
2. Prevent and manage infection 2. Regularly asses for the development of
Monitor status of patient complications
Initiate prompt antibiotic therapy 3. Assist in weekly phlebotomy
3. Promote coping skills 4. Advise to avoid alcohol and aspirin
5. Advise tepid sponge bath or cool water to manage
- Provide accurate information pruritus
- Allow patient to verbalize her concerns about
medication, prognosis and future pregnancy Leukemia
4. Monitor and prevent potential complications - Malignant disorders of blood forming cells
- Provide always adequate hydration characterized by UNCONTROLLED proliferation of
- Avoid cold, temperature that may cause WHITE BLOOD CELLS in the bone marrow-
vasoconstriction replacing marrow elements .
- Leg ulcer - The WBC can also proliferate in the liver, spleen
 Aseptic technique and lymph nodes.
- Priapism - The leukemias are named after the specific lines of
 Sudden painful erection blood cells afffected primarily
 Instruct patient to empty bladder, then take a  Myeloid
warm bath  Lymphoid
 Monocytic
Polycythemia
 Refers to an INCREASE volume of RBCs - The leukemias are named also according to the
 The hematocrit is ELEVATED to more than 55% maturation of cells
 Classified as Primary or Secondary - ACUTE
 The cells are primarily immature
Primary Polycythemia
- CHRONIC
- A proliferative disorder in which the myeloid stem  The cells are primarily mature or differentiated
cells become uncontrolled
- ACUTE myelocytic leukemia
Causative factor - ACUTE lymphocytic leukemia
- unknown
- CHRONIC myelocytic leukemia
Pathophysiology - CHRONIC lymphocytic leukemia
- The stem cells grow uncontrollably
- The bone marrow becomes HYPERcellular and all Etiologic Factors
the blood cells are increased in number - UNKNOWN
- The spleen resumes its function of hematopoiesis - Probably exposure to radiation
and enlarges - Chemical agents
CARDIOVASCULAR SYSTEM

- Infectious agents
- Genetic

Pathophysiology of ACUTE Leukemia

- Uncontrolled proliferation of immature cells
suppresses bone marrow function  severe
anemia, thrombocytopenia and granulocytopenia
- Uncontrolled proliferation of DIFFERENTIATED
cells slow suppression of bone marrow function
 milder symptoms

Assessment Findings
Acute Leukemia
- Pallor
- Fatigue
- Dyspnea
- Hemorrhages
- Organomegaly
- Headache
- vomiting
- Leukemia

Chronic Leukemia
- Less severe symptoms
- Organomegaly
- Leukemia

Laboratory Findings
- Peripheral WBC count varies widely
- Bone marrow aspiration biopsy reveals a large
percentage of immature cells- BLASTS
- Erythrocytes and platelets are decreased

Medical Management
1. Chemotherapy
2. Bone marrow transplantation

Nursing Management
1. Manage AND prevent infection
- Monitor temperature
- Assess for signs of infection
-
Be alert if the neutrophil count drops below 1,000
cells/mm3
2. Maintain skin integrity
3. Provide pain relief
4. Provide information as to therapy- chemo and
bone marrow transplantation