Cardiovascular and Circulatory Function

heart failure

a clinical syndrome resulting from structural or functional cardiac disorders that impair the contraction of the heart (systolic failure/pumping failure) or the filling of the heart (diastolic failure/relaxing failure)

left-sided heart failure (pumping/LV failure)

blood backs up into the pulmonary circulation
manifestations: pulmonary congestion, crackles/wheezes, S3 “ventricular gallop”, dyspnea on exertion, orthopnea, low O2 sat, dry nonproductive cough → pink frothy sputum, and oliguria

right-sided heart failure (filling/RV failure)

blood backs up into the systemic venous circulation
manifestations: visceral and peripheral congestion, dependent edema, Jugular Venous Distention, hepatomegaly, ascites, weight gain, and peripheral organ swelling

what are diagnostics, therapy, interventions, gerontologic considerations of heart failure?

diagnostic findings: ANP, BNP, serum troponin
therapy: ACE inhibitors, ARBs, beta-blockers, diuretics, Digoxin, IV inotropes/vasopressors
interventions: pace activities, avoid exertion in extreme heat, cold, or humidity, enforce sodium restrictions, obtain daily weights
gerontologic considerations: often present with atypical signs, age-related renal decline increases sensitivity to volume shifts and diuretic resistance

pulmonary edema

severe breakdown of compensatory mechanisms where IV failure causes blood to back up into pulmonary capillaries, forcing fluid into pulmonary interstitial spaces and alveoli

signs of pulmonary edema

restlessness, extreme anxiety, tachypnea, severe dyspnea, cyanosis, cool/clammy skin, rapid weak pulse, noisy/moist breathing, and pink, frothy sputum production

emergency interventions for pulmonary edema

position patient upright with legs dangling over side of the bed to use gravity to reduce venous return, administer high-flow oxygen, IV loop diuretics, and IV vasodilators

classifications of hypertension

normal: <120 over <80
elevated: 120-129 over <80
stage 1 hypertension: 130-139 over 80-89
stage 2 hypertension: greater than 140 over greater than 90

primary hypertension

accounts for 90-95% of cases, unidentifiable

secondary hypertension

accounts for 5-10% of cases, caused by identifiable conditions such as renal disease, sleep apnea, or pregnancy

hypertension

“the silent killer”, uncontrolled HTN leads to vascular damage in target organs: retina (hemorrhages), kidneys (renal failure), heart (LV hypertrophy, MI), and brain (stroke)

what are the diagnostics of hypertension?

BP measurement: sit quietly, use correct cuff size, support arm at heart level
white coat vs masked HTN: white coat HTN occurs when office readings are elevated but home readings are normal, masked HTN occurs when office readings are normal, but home readings are elevated
physical findings: retinal vascular changes, presence of an S3 gallop, renal artery bruits, and absent/weak peripheral pulses

what is the management of hypertension?

lifestyle: maintain normal body weight; adopt DASH diet, reduce sodium intake to no more than 100 mmol/day (or < 2 g/day), engage in 30 minutes of aerobic physical activity most days, stop smoking
first line therapy:
-uncomplicated HTN: thiazine diuretics are the recommended initial drug of choice for most patient
-age <60: ACE inhibitor or ARBs
-age >60: calcium channel blockers or thiazide diuretics

hypertensive emergency

blood pressure level: SBP > 180 mmHg or DBP >120 mmHg
target organ damage: EVIDENCE PRESENT: acute damage to heart, brain, kidneys, or eyes
treatment setting: ICU
therapeutic goal: reduce BP by no more than 25% in the first hour; reduce to 160/100 mmHg within 2 to 6 hours, gradual reduction over 24-48 hours
medication route: continuous IV infusions (Nitropress, nitroglycerin, Nicardipine, Labetalol)
nursing care: strict I&O monitoring, assess for volume depletion, administer IV normal saline if ordered to prevent precipitous BP drops

hypertensive urgency

blood pressure levels: SBP > 180 mmHg or DBP >120 mmHg
target organ damage: NO EVIDENCE; no immediate target organ damage
treatment setting: outpatient or med-sure unit
therapeutic goal: normalize BP within 24 to 48 hours using oral meds
medication route: oral agents (fast-acting oral labetalol, captopril, clonidine)
nursing care: monitor vitals, re-evaluate target organ lab markers, educate on med compliance

atherosclerosis

plaque build up; accumulation of lipids, calcium, blood components, carbs, and fibrous tissue on the intimal layer of the artery

risk factors of atherosclerosis

modifiable factors: nicotine use, diabetes, HTN, hyperlipidemia, diet
non modifiable factors: increasing age, familial predisposition/genetics

common sites of atherosclerotic obstruction

popliteal, left common iliac, external carotid

arteriosclerosis

hardening of the arteries; diffuse process whereby the muscle fibers and the endothelial lining of the walls of small arteries and arterioles become thickened

CW doppler ultrasound

handheld ultrasound device detecting moving RBCs to characterize peripheral vascular flow

ankle-branchial index (ABI)

ratio of ankle systolic BP to arm systolic BP
normal ABI: greater than or equal to 1.0
abnormal ABI: less than 1.0 indicates arterial narrowing/PAD

abdominal aortic aneurysm (AAA)

localized sac or dilation formed at a weak point in the wall of the abdominal aorta (saccular or fusiform)
findings: pulsating abdominal mass in the epigastrium, abdominal or lower back pain, and auscultated abdominal bruits, deep palpation is contraindicated if AAA is suspected

peripheral arterial disease

plaque accumulation (atherosclerosis) narrowing lumen of arteries in extremities

pain symptoms and physical appearance of peripheral arterial disease (PAD)

pain symptoms: intermittent claudication- aching, cramping pain with activity, relieved by rest; critical ischemia- persistent, boring rest pain (worse at night)
physical appearance: cool, pale/pallor upon elevation, rubor (deep redness) when dependent; dry, shiny skin, loss of hair, brittle nails, weak/absent pulses

positioning and pharmacologic of peripheral arterial disease (PAD)

positioning: DANGLE lower extremities in a dependent/neutral position below heart level to promote flow
pharmacologic: phosphodiesterase III inhibitors, antiplatelet, statins

chronic venous insufficiency

incompetence of venous valves leading to venous stasis, pooling, and elevated pressure

pain symptoms and physical appearance of chronic venous insufficiency

pain symptoms: aching, heaving discomfort exacerbated by prolonged standing
physical appearance: warm skin, dark brown pigmentation around ankles, severe edema

positioning and pharmacologic of chronic venous insufficiency

positioning: ELEVATE lower extremities 3 to 6 inches above heart level to assist venous return
pharmacologic: graduated compression stockings, wound debridement, elevation, anti-infectives

Raynaud’s

intermittent arteriolar vaso-occlusion of fingertips or toes triggered by cold exposure or emotional stress

manifestations of Raynaud’s

sequential color changes- white (pallor) from vasoconstriction → blue (cyanosis) from hypoxia → red (rubor) upon hyperemia; numbness, tingling, and burning pain

education of Raynaud’s

wear warm gloves/socks, avoid cold environments ], avoid emotional triggers, and strictly avoid caffeine and nicotine (causes vasoconstriction)

risk factors and preventive interventions of venous thrombosis

risk factors: surgery, age >65, placement of central venous catheters, septicemia, pregnancy, immobility, and hypercoagulable states
preventive interventions: early post-op ambulation, leg exercises, graduated compression stockings (TED hose), intermittent pneumatic compression devices (SCDs) and prophylactic subcutaneous Heparin or low molecular weight heparin (Lovenox)

risk for varicose veins

NURSES, wearing socks that are too tight at the top or that leave marks on the skin, crossing the legs at the thighs, and sitting or standing for long periods- damage to valves

prevention of varicose veins

-elevate the legs 3 to 6 inches higher than heart level
-encourage to walk 30 minutes each day if there are no contraindications
-wear graduated compression stockings
-overweight patients should be encouraged to begin weight reduction plans

lymphedema

swelling of tissues secondary to obstruction of lymphatic fluid drainage

management of lymphedema

constant elevation: keep the affected extremity continuously to promote lymphatic drainage
compression: apply custom compression sleeves or wraps
contraindications: DO NOT apply heating pads, hot packs, or expose the affected extremity to direct sunlight (prevents burns, tissue injury, and increased swelling)

cellulitis

acute bacterial infection of the dermis and subcutaneous tissues originating from skin breaks or insect bites

presentation of cellulitis

localized erythema, swelling, warmth, tenderness, systemic fever, chills, and diaphoresis

management of cellulitis

-administer systemic-oral or IV antibiotics as ordered
-elevate the affected extremity 3 to 6 inches above the heart level
-apply warm, moist packs to the site every 2 to 4 hours
-educate patient on skin hygiene and meticulous foot care to prevent recurrence