Cardiovascular Disorders Vocabulary

Nursing Decision Making and Priority Defaults

Clinical prioritization relies on a specific hierarchical assessment to ensure patient safety and effective intervention. The priority default for nursing entails the following sequence:

• Determine if there is an issue with the ABCs: Airway, Breathing, or Circulation.
• Identify if the patient is unstable.
• Determine if assessment is required prior to intervening.
• Identify the clinical option that is the safest and least invasive.

Anatomy of Cardiac Circulation

The flow of blood through the heart follows a precise path involving thirteen specific checkpoints to ensure oxygenation and systemic delivery:

• $1$: Superior vena cava and $2$: Inferior vena cava deliver oxygen-poor blood to the heart.
• $3$: Right atrium receives the oxygen-poor blood.
• $4$: Tricuspid valve opens to allow flow into the next chamber.
• $5$: Right ventricle receives blood from the right atrium.
• $6$: Pulmonary valve opens to allow blood to exit the heart.
• $7$: Pulmonary arteries transport blood to the lungs.
• $8$: Pulmonary veins return oxygen-rich blood from the lungs.
• $9$: Left atrium receives oxygen-rich blood.
• $10$: Mitral valve (also known as the bicuspid valve) allows blood to enter the left ventricle.
• $11$: Left ventricle pumps oxygen-rich blood to the body.
• $12$: Aortic valve allows blood to exit the left ventricle.
• $13$: Aorta distributes oxygen-rich blood to the rest of the body.

Cardiovascular Assessment Guidelines

Assessing Orthostatic Blood Pressure and Pulse

To determine postural changes and orthostatic hypotension, the following steps must be followed:

• The client must lie down for at least $3\,\text{minutes}$.
• Assess the client’s blood pressure (BP) and pulse while in the supine position.
• Assist the client to a sitting position, remaining prepared to steady them if they become dizzy or faint.
• Reassess the BP and pulse within $30\,\text{seconds}$ after the client sits.
• Repeat the assessments while the client is standing.
• Determine the difference in systolic and diastolic BP, as well as the heart rate difference, between positions.
• A manifestation of postural changes is confirmed if the BP is lower than $10\,mmHg$ from the previous measurement and the heart rate increases by $10\%$ or more.

Data Collection for Arterial and Venous Systems

Arterial data collection utilizes the P-A-T-C-H-E-S mnemonic to assess distal perfusion:

• P (Pulses): Verification of arterial pulse presence and strength.
• A (Appearance): Visual inspection of the extremity.
• T (Temperature): Assessment of skin warmth.
• C (Capillary Refill): Speed of color return after pressure.
• H (Hardness/Texture): Observation of whether vessels have become stiff over time.
• E (Edema): Presence of swelling.
• S (Sensation): Client's ability to feel touch or perceive stimuli.

Venous data collection focuses on subjective reports of "heavy" sensations and histories of Deep Vein Thrombosis (DVT), cellulitis, or trauma. Objective findings for venous disorders include:

• Edema and skin coloration changes (dark purply and blue).
• Visible dilated veins or protruding blue and greenish veins.
• Presence of ulcers and assessment of whether pulses remain present.
• Varicose veins arise when valves are damaged, allowing blood to flow in both directions rather than the normal one-way flow.

Hypertension Classification and Medical Management

Blood pressure is determined by Cardiac Output and Peripheral Vascular Resistance. Systole represents the contraction of the left ventricle forcing oxygenated blood through the body, while diastole represents the relaxation of the heart. Assessment of hypertension requires three separate readings across three separate visits to confirm a diagnosis.

Blood Pressure Classification for Adults

Essential (Primary) Hypertension

Primary hypertension accounts for $95\%$ of all cases and is a lifelong journey. Significant causes include aging, genetics (heredity), being overweight, sedentary lifestyle, high sodium intake, and alcohol intake. If unmanaged, the prognosis includes increased risk for Myocardial Infarction (MI) and stroke.

Clinical Cues and Nursing Care

Hypertension is often called the "silent killer" because it can remain asymptomatic until damage occurs. Priority cues include:

• Headaches and blurred vision.
• Spontaneous nose bleeds.
• Potential loss of consciousness.
• Assessment screenings and diagnostic tests evaluate how hypertension has affected other body organs to establish a baseline health profile.

Non-pharmacologic management includes weight management, exercise, reduction of fats and sodium, limiting alcohol, smoking cessation, and relaxation techniques. Pharmacologic management often begins with Diuretics, followed by ACE inhibitors, Angiotensin II Receptor Blockers, Alpha Blockers, Beta-blockers, and Direct Vasodilators (Calcium Channel Blockers).

Hypertensive Emergency: Malignant Hypertension

Malignant hypertension is an emergency characterized by severe, rapidly progressive elevations in blood pressure where the diastolic measurement exceeds $120\,mmHg$. This condition involves inflammation of the arterioles in the eyes. The patient must be hospitalized immediately.

Heart Failure Pathophysiology and Manifestations

Heart failure occurs when the heart cannot sustain the body's needs, often appearing after an MI, hypertension, diabetes mellitus (DM), or valve disease. General cues include fatigue, angina, oliguria (low urine output), weight gain, restlessness, and respiratory manifestations.

Left-Sided Heart Failure

In left-sided failure, the left ventricle is weak, leading to systemic oxygenation deficits. Fluid backs up into the lungs. Cues are primarily respiratory:

• Paroxysmal nocturnal dyspnea and orthopnea (inability to lay flat).
• Coughing blood (blood-tinged sputum) and pulmonary edema.
• Crackles, wheezes, and an $S3$ heart sound (gallop).
• Tachycardia, exertional dyspnea, cyanosis, restlessness, and confusion.

Right-Sided Heart Failure (Cor Pulmonale)

Right-sided failure involves a weak right ventricle unable to accommodate venous return, resulting in peripheral congestion. The most common cause is left-sided heart failure. Cues include:

• Pitting edema (cardiac edema) and dependent edema.
• Peripheral venous pressure elevation and distended jugular veins (JVD).
• Ascites (third-spacing) and enlarged liver and spleen.
• Anorexia and complaints of GI distress.

Diagnostic and Nursing Management of Heart Failure

Diagnostic measures include Ejection Fraction (EF) assessment, EKG, Echocardiogram, and serum blood tests, specifically the Brain Natriuretic Peptide (BNP) enzyme; a higher BNP number indicates worse heart failure. Arterial blood gases (ABGs) and electrolyte profiles are also monitored.

Medical and Nursing Interventions

• Medications: Cardiac Glycosides such as Digoxin to increase cardiac efficiency, and Diuretics like Furosemide to reduce pulmonary edema.
• Dietary Restrictions: Limitations on salt and caffeine.
• Safety: Patients are a high fall risk and should participate in low-demand activities.
• Fluid Management: Patients should generally NOT be on IV fluids. Nurses must monitor daily weight, vital signs, urinary output, abdominal girth, and lung sounds (listening for baseline "wet" sounds).
• Psychological Support: Anxiety therapy and oxygen therapy.
• Anticoagulation: Required for patients with Atrial fibrillation (A-fib).

Specific Cardiac Disorders

Rheumatic Carditis

This condition arises from antibodies produced during group A streptococcal pharyngitis, which subsequently cause valve damage, particularly to the mitral valve. Nursing management focuses on the history of illness and monitoring for complications like heart failure.

Cardiomyopathy

Structural changes in heart muscle characterize cardiomyopathy, classified into three primary types:

1. Dilated: Defined as "floppy" muscle with enlarged ventricles.
2. Hypertrophic: Defined as "thickened" muscle, often with a stiff septum.
3. Restrictive: Defined as "stiffened" ventricle walls.

Valvular Heart Disease

Valvular disorders most commonly affect the mitral and aortic valves. Conditions include stenosis (valve does not open properly) and insufficiency or regurgitation (valve does not close properly). Etiologies include congenital defects and rheumatic fever. A critical nursing consideration is the provision of prophylactic antibiotics prior to dental care to prevent endocarditis because the health of the heart is closely related to the mouth.

Coronary and Peripheral Vascular Disorders

Arteriosclerosis and Atherosclerosis

Arteriosclerosis is the hardening of arterial walls, often associated with aging. Atherosclerosis occurs when the arterial lumen fills with lipid plaque (fat and cholesterol), leading to decreased elasticity and Ischemia (reduced oxygen supply to tissues). Patients will have an altered lipid profile and formation of atheromas.

Coronary Artery Disease (CAD)

CAD involves the hardening of coronary arteries over a long period. Cues include angina (chest pain) that is relieved when activity stops. If no oxygen reaches the heart muscle, it results in a Myocardial Infarction. Management includes PTCA (Balloon Angioplasty), stent placement, atherectomy, and Coronary Artery Bypass Graft (CABG) surgery to reroute blood flow.

Myocardial Infarction (MI)

MI is the prolonged total occlusion of coronary arterial blood flow. Emergency management follows the MONA acronym:

• Morphine: For pain and vasodilation; used if pain is unrelieved by Nitroglycerin. Systolic BP must be kept above $90$.
• Oxygen: High flow delivery.
• Nitroglycerin (NTG): Sublingual (SL) or spray vasodilator. Can be given up to $3\,\text{times}$, every $5\,\text{minutes}$. If NTG relieves the pain, it may not be an MI.
• Aspirin: Chewed to thin the blood.

Cardiac markers for diagnosis include Myoglobin, Troponin T, and Troponin I. Troponin I is considered the gold standard. Other markers include CK-MB. Complications of MI include arrhythmias, cardiogenic shock, ventricular rupture, ventricular aneurysm, arterial embolism, venous thrombosis, pulmonary embolism, pericarditis, and mitral insufficiency.

Peripheral Vascular Conditions

Peripheral Arterial Disease (PAD)

PAD results from plaque buildup that reduces blood flow, causing ischemia. Evaluation uses the "$5\,\text{Ps}$":

1. Pain (claudication).
2. Pulselessness (use Doppler to measure pressure and compare with arm).
3. Pallor.
4. Polar (temperature).
5. Paresthesia (numbness and tingling).

Arterial ulcers, typically found on the toes or dorsum of the foot, appear pale in the wound bed and are very painful. Post-cardiac catheterization discharge instructions include resting for $3\,\text{days}$, avoiding heavy lifting or strenuous activity/sports, and no driving or climbing stairs for the first $24\,\text{hours}$.

Raynaud's and Buerger's Disease

Raynaud's Disease involves intermittent arteriole spasms triggered by cold, causing numbness, cyanosis, and throbbing pain. Buerger's Disease (Thromboangiitis obliterans) involves small arteriole inflammation and clotting, primarily linked to tobacco use. It leads to thin skin, poor hair growth, gangrenous areas, and often amputation. Management for both focuses on smoking cessation and avoiding trauma.

Aneurysm

An aneurysm is an enlarged, dilated part of an artery caused by arteriosclerosis, trauma, or congenital defects. A key clinical cue is a pulsating mass. Nurses must not palpate a suspected aneurysm.

Questions & Discussion

Practice Question: Which of the following client teaching points should be included in the discharge planning of a client who has a heart failure? (Select all that apply)

• A) Weigh yourself daily. (Correct: Vital for monitoring fluid retention).
• B) Take your blood pressure before taking digoxin. (Correct: Digoxin affects heart rate and efficiency; monitoring BP is standard).
• C) Increase your carbohydrate intake. (Incorrect: Increased carbohydrate metabolism increases $CO_2$ production, which can strain a heart failure patient's respiratory system).
• D) Take your diuretic early in the morning. (Correct: Prevents nocturia and promotes rest at night).", "title": "Cardiovascular Disorders"}