SEMIFINALS | MEDSURG

CARDIOVASCULAR SYSTEM
3. Bundle of His - branches into the Right and the
Left bundle branch
CARDIOVASCULAR SYSTEM 4. Purkinjie fibers - fastest conduction
NORMAL ANATOMY
● The heart is located in the LEFT side of the
HEART SOUND
mediastinum
● Consist of three layers: epicardium, 1. S1 - due to closure of the AV valves
myocardium and endocardium 2. S2 - due to the closure of the semi-lunar valves
● Epicardium covers the outer surface of the 3. S3 - due to increase ventricular filling
heart 4. S4 - due to forceful atrial contraction
● Myocardium is the middle muscular layer of the
heart HEART RATE
● Endocardium lines the chambers and the
● Normal range is 60-100 bpm
valves
● Tachycardia is greater than 100 bpm
● The layers that covers the heart is the
● Bradycardia is less than 60 bpm
PERICARDIUM
● Sympathetic system INCREASES HR
● There are two parts - parietal and visceral
● Parasympathetic system (Vagus) DECREASES
pericardium
HR
● The space between the two pericardial layers is
the pericardial space
● The heart also has four chamber - two atria LABORATORY PROCEDURE
and two ventricles CARDIAC Proteins and enzymes
● The left atrium and right atrium ● CK-MB ( creatine kinase )
● The left ventricle and right ventricle - elevates in MI within 4 hours, peaks in
18 hours and then declines till 3 days
The heart chambers are guarded by valves ● Lacric Dehydrogenase (LDH)
● The atrio-ventricular valves - elevates in MI in 24 hours, peaks in
Tricuspid and bicuspid 48-72 hours
● The semi-lunar valves - normally LDH is greater than LDH2
Pulmonic and aortic valves - MI - LDH2 greater than LDH1 (flipped
LDH pattern)
The blood supply of the heart comes from the - NORMAL values is 70-200 IU/L
CORONARY arteries ● Myoglobin
1. Right coronary artery- supplies the RIGHT - rises within 1-3 hours
atrium and RIGHT ventricle, inferior portion of - peaks in 4-12 hours
the LEFT ventricle, the POSTERIOR septal wall - returns to normal in a day
and the two nodes - AV (90%) and SA node - not used alone
(55%) - muscular and renal disease can have
2. Left coronary artery - supplies blood to the elevated myoglobin
arterior wall of the LEFT ventricle, the anterior ● Troponin I and T
septum and the Apex of the left ventricle - Troponin I is usually utilized for MI
● The CIRCUMFLEX branch supplies the - elevates within 3-4 hours, peaks in 4-24
left atrium and the posterior LEFT hours and persist for 7 days to 3 weeks
ventricle - normal valve for Troponin I is less than
0.6 ng/mL
CONDUCTING SYSTEM OF THE HEART - REMEMBER TO AVOID IM injection
before obtaining blood sample
Consist of the
- Early and late diagnosis can be made
1. SA node - pacemaker
2. AV node - slowest conduction

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● Serum lipids - determines the structure and
- Lipid profile measures the serum performance of the heart valves and
cholesterol, triglycerides and lipoprotein surrounding vessels
levels - used to diagnosed CAD, assess
- Cholesterol = 200 mgldL coronary artery patency and determine
- Triglycerides = 40-150 mg/dL extent of atherosclerosis
- LDH = 130mg/dL - PRE test: ensure consent, assess for
- HDL = 30-70 mg allergy to seafood and iodine, NPO,
- NPO post midnight (usually 12 hours) document weight and heaightm
● Electrocardiogram (ECG) baseline VS, blood test and document
- a non-invasive procedure that evaluates the peripheral pulses
the electrical activity of the heart - fast for 8-12 hours, tecahings,
- electrodes and wires are attached to medications to allay anxiety
the patient - INTRA-test: inform patient of a flutter
● Holter monitoring feeling
- non-invasive test in which the client - POST-test: Monitor VS and cardiac
wears a Holter monitor and an ECG rhythm
tracing recorded continuously over a - Monitor peripheral pulses, color and
period of 24 hours warmth and sensation of the extremity
- Instruct the client to resume normal distal to insertion site
activities and maintain a diary of a - Maintain sandbag to the insertion site if
activities and any symptoms that may required to maintain pressure
develop - Monitor for bleeding and hematoma
● Echocardigram formation
- non-invasive test that studies the - Maintain strict bed rest for 6-12 hours
structural and functional chnages of the Client may turn from side to side but
heart with the use of ultrasound bed should not be elevated more than
● Stress test 30 degrees and legs always straight
- non-invasive test that studies the heart - Encourage fluid intake to flush out the
during activity and detects and dye
evaluates CAD - Immobilize the arm if the antecubital
- exercise test, pharmacological test and vein is use
emotional test - Monitor for dye allergy
*Treadmill testing is most commonly ● CVP
used stress test - The CVP is the pressure within the SVC
- used to determine CAD, chest pain - Reflects the pressure under which blood is
causes, drug effects and dysrhythmia in returned to the SVC and right atrium
exercise - Normal CVP is 0 to 8 mmHg/ 4-10 cm H20
- PRE test: consent may be requires, - Elevated CVP indicates increase in blood
adequate rest, eat a light meal or fast volume, excessive IVF or heart/renal failure
for 4 hours and avoid smoking, alcohol - Low CVP may indicate hypovolemia,
and caffeine hemorrhage and severe vasodilatation
- POST test: Instruct the client to notify Measuring CVP
the physician if any chest pain, 1. Position the client supine with bed elevated at
dizziness or shortness of breath. 45 degrees
Instruct client to avoid taking a hot 2. Position the zero point of the CVP line at the
shower for 10-12 hours after the test level of the right atrium. Usually this is at the
● Cardiac Catheterization MAL, 4th ICS
- insertion of a catheter into the heart and 3. Instruct the client to be relaxed and avoid
surrounding vessels coughing and straining.

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 CARDIAC ASSESSMENT VASCULAR DISEASES
Laboratory and diagnostic studies ● Hypertension
● СВС ● Buerger's disease
● cardiac catheterization ● Varicose veins
● Lipid profile ● Deep vein thrombosis
● arteriography ● Aneurysm
● Cardiac enzymes and proteins
● CXR CARDIAC DISEASE
● CVP
● EEG CORONARY ARTERY DISEASE ( CAD )
● Holter monitoring ● arteries due to deposition of hope in the CAD
● Exercise ECG results from the focal narrowing of the large and
medium-sized coronary arteries due to
CARDIAC IMPLEMENTATION deposition of atheromatous plaque in the vessel
wall
1. Assess the cardio-pulmonary status RISK FACTORS
- VS, BP, Cardiac assessment 1. Age above 45/55 and Sex- Males and
2. Enhance cardiac output post-menopausal females
- Establish IV line to administer fluids 2. Family History
3. Promote gas exchange 3. Hypertension
- Administer 02 4. DM
- Position client in SEMI-Fowler's 5. Smoking
- Encourage coughing and deep 6. Obesity
breathing exercises 7. Sedentary lifestyle
4. Increase client activity tolerance Balance rest 8. Hyperlipidemia
and activity periods *Assist in daily activities Most important MODIFIABLE factors
5. Promote client comfort Assess the client's 1. Smoking
description of pain and chest discomfort 2. Hypertension
Administer medication as prescribed 3. Diabetes
6. Promote adequate sleep 4. Cholesterol abnormalities
7. Prevent infection Pathophysiology
- Monitor skin integrity of lower ● Fatty streak formation in the vascular intima→
extremities T-cells and monocytes ingest lipids in the area.
- Assess skin site for edema, redness of deposition atheroma→ narrowing of the
and warmth arterial lumen → reduced coronary blood flow
- Monitor for fever → myocardial ischemia
- Change position frequently ● There is decreased perfusion of myocardial
8. Minimize patient anxiety Encourage tissue and inadequate myocardial oxygen
verbalization of feelings, fears and concerns supply
Answer client questions. Provide information ● If 50% of the left coronary arterial lumen is
about procedures and medications reduced or 75% of the other coronary artery,
this becomes significant
CARDIAC DISEASES ● Potential for Thrombosis and embolism

● Coronary Artery Disease

● Myocardial Infarction Angina Pectoris
● Congestive Heart Failure ● Chest pain resulting from coronary
● Infective Endocarditis atherosclerosis or myocardial ischemia.
● Cardiac Tamponade
● Cardiogenic Shock

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 ● Another tablet can be taken (third
Angina Pectoris: Clinical Syndromes tablet)
Three Common Types of ANGINA ● If unrelieved after THREE tablets→
1. STABLE ANGINA seek medical attention
● The typical angina that occurs during 3. Obtain a 12-lead ECG
exertion, relieved by rest and drugs and 4. Promote myocardial perfusion
the severity does not change ● Instruct patient to maintain bed rest
2. UNSTABLE ANGINA ● Administer 02 @ 3 lpm
● occurs unpredictably during exertion ● Advise to avoid valsalva maneuvers
and emotion, severity increases with ● Provide laxatives or high fiber diet to
time and pain may not be relieved by lessen constipation
rest and drug ● Encourage to avoid increased physical
3. VARIANT ANGINA activities
● Prinzmetal angina, results from 5. Assist in possible treatment modalities
coronary artery VASOSPASMS, may ● PTCA- percutaneous transluminal
occur at rest coronary angioplasty
- To compress the plaque against
ASSESSMENT FINDINGS the vessel wall, increasing the
1. Chest pain - ANGINA arterial lumen
● The most characteristic symptom ● CABG- coronary artery bypass graft
● PAIN is described as mild to severe - To improve the blood flow to the
retrosternal pain, squeezing, tightness myocardial tissue
or burning sensation 6. Provide information to family members to
● Radiates to the jaw and left arm minimize anxiety and promote family
2. Diaphoresis cooperation
3. Nausea and vomiting 7. Assist client to identify risk factors that can be
4. Cold clammy skin modified
5. Sense of apprehension and doom 8. Refer patient to proper agencies
6. Dizziness and syncope
LABORATORY FINDINGS
MYOCARDIAL INFARCTION
1. ECG may show normal tracing if the patient is
pain-free. Ischemic changes may show ST ● Death of myocardial tissue in regions of the
depression and T wave inversion heart with abrupt interruption of coronary blood
2. Cardiac catheterization supply
● Provides the MOST DEFINITIVE ETIOLOGY and Risk factors
source of diagnosis by showing the 1. CAD
presence of the atherosclerotic lesion 2. Coronary vasospasm
NURSING MANAGEMENT 3. Coronary artery occlusion by embolus and
1. Administer prescribed medications thrombus
● Nitrates- to dilate the coronary arteries 4. Conditions that decrease perfusion-
● Aspirin- to prevent thrombus formation hemorrhage, shock
● Beta-blockers- to reduce BP and HR Risk factors
● Calcium-channel blockers- to dilate 1. Hypercholesterolemia
coronary artery and reduce vasospasm 2. Smoking
2. Teach the patient management of anginal 3. Hypertension
attacks 4. Obesity
● Advise patient to stop all activities 5. Stress
● Put one nitroglycerin tablet under the 6. Sedentary lifestyle
tongue ● Myocardial Infarction as a result of a blocked
● Wait for 5 minutes left anterior descending coronary artery
● If not relieved, take another tablet and
wait for 5 minutes PATHOPHYSIOLOGY
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 ● Interrupted coronary blood flow→ myocardial 7. Assist in treatment modalities such as PTCA
ischemia anaerobic myocardial metabolism for and CABG
several hours myocardial death → depressed 8. Monitor for complications of MI- especially
cardiac function → triggers autonomic nervous dysrhythmias, since ventricular tachycardia can
system response further imbalance of happen in the first few hours after MI
myocardial 02 demand and supply 9. Provide client teaching
MEDICAL MANAGEMENT
ASSESSMENT FINDINGS 1. ANALGESIC
1. CHEST PAIN ● The choice is MORPHINE= narcotic
● Chest pain is described as severe, analgesic/opiate type analgesic
persistent, crushing substernal (fentanyl, codeine)
discomfort ● It reduces pain and anxiety
● Radiates to the neck, arm, jaw and ● Relaxes bronchioles to enhance
back oxygenation
● Occurs without cause, primarily early 2. ACE = angiotensin converting enzyme inhibitor
morning ● Prevents formation of angiotensin II=
● NOT relieved by rest or nitroglycerin vasoconstrictor, SN stimulation
● Lasts 30 minutes or longer ● Limits the area of infarction
2. Dyspnea 3. THROMBOLYTICS
3. Diaphoresis ● Streptokinase, alteplase
4. cold clammy skin ● Dissolve clots in the coronary artery
5. N/V allowing blood to flow
6. restlessness, sense of doom
7. tachycardia or bradycardia NURSING INTERVENTIONS AFTER ACUTE
8. hypotension EPISODE
9. S3 and dysrhythmias 1. Maintain bed rest for the first 3 days
LABORATORY FINDINGS 2. Provide passive ROM exercises
1. ECG- the ST segment is ELEVATED. T wave 3. Progress with dangling of the feet at side of bed
inversion, presence of Q wave 4. Proceed with sitting out of bed, on the chair for
2. Myocardial enzymes- elevated CK- MB, LDH 30 minutes TID
and Troponin levels 5. Proceed with ambulation in the room —> toilet
3. CBC- may show elevated WBC count →hallway TID
4. Test after the acute stage- Exercise tolerance Cardiac Rehabilitation
test, thallium scans, cardiac catheterization ● to extend and improve quality of the life
NURSING INTERVENTIONS ● physical conditioning
1. Provide Oxygen at 2 Ipm, Semi-fowler's ● Patient who are able to work 3-4 mph are
2. Administer medications usually ready to resume sexual activities
● Morphine to relieve pain nitrates,
thrombolytics, aspirin and
CARDIOMYOPATHIES
anticoagulants
● Stool softener and hypolipidemics ● heart muscle disease associated with cardiac
3. Minimize patient anxiety dysfunction
● Provide information as to procedures ● Myopathy = disorder of muscle structure or
and drug therapy metabolism
4. Provide adequate rest periods 1. Dilated Cardiomyopathy
5. Minimize metabolic demands 2. Hyperthropic Cardiomyopathy
● Provide soft diet 3. Restrictive Cardiomyopathy
● Provide a low-sodium, low cholesterol
and low fat diet DILATED CARDIOMYPATHY
6. Minimize anxiety Associated factors
● Reassure client and provide information 1. heavy alcohol intake
as needed 2. pregnancy
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 3. viral infection 1. Improve cardiac output
4. idiopathic ● adequate rest
PATHOPHYSIOLOGY ● oxygen therapy
● Diminished contractile protein → poor ● low sodium diet
contraction → decreased blood ejection → 2. Increase pt tolerance
increased blood remaining in the ventricle → ● schedule activities with the rest periods
ventricular stretching and dilatation in between
● SYSTOLIC DYSFUNCTION 3. Reduce pt anxiety
● support
HYPERTROPHIC CARDIOMYOPATHY ● offer information about transplantations
Associated factors ● support family in anticipatory grieving
1. genetic
2. idiopathic
INFECTIVE ENDOCARDITIS
PATHOPHYSIOLOGY
● Increase in size of myocardium → reduced ● infections of the heart valves ad the endothelial
ventricular volume → increased resistance to surface of the heart
ventricular filling → diastolic dysfunction ● can be acute or chronic

RESTRICTIVE CARDIOMYOPATHY RISK FACTORS

Associated factors 1. prosthetic valves
1. Infiltrative disease like AMYLOIDOSIS = 2. congenital malformation
increases CHON build up in an organ making it 3. cardiomyopathy
work improperly 4. IV drug users
2. idiopathic = unknown 5. valvular dysfunction
PATHOPHYSIOLOGY Pathophysiology
● Rigid b=ventricular wall → impaired stretch and ● Direct invasion of microbes → microbes adhere
diastolic filling → decreased output to damaged valve surface and proliferate →
● diastolic dysfunction damage attracts platelets causing clot formation
→ erosion of valvular leaflets and vegetation
can embolize
CARDIOMYOPATHIES
ASSESSMENT FINDINGS ASSESSMENT FINDINGS
1. PND- paroxysmal nocturnal dyspnea = is a 1. intermittent fever
sensation of shortness of breath that awaken 2. anorexia, weight loss
the pt, often after 1 or 2 hrs of sleep, and is 3. cough, back pain and joint pain
usually relieved in the upright position 4. splinter hemorrhage under nails
2. orthopnea 5. osler's nodes - painful nodules on fingerpads
3. edema 6. roth's spots - pale hemorrhage in the retina
4. chest pain 7. heart murmurs = is a blowing, whoosing, or
5. palpitations grasping sound heard during a heartbeat. the
sound is caused by turbulent (rough) blood flow
LABORATORY FINDINGS through the heart valve or near the heart
1. CXR may reveals cardiomegaly 8. heart failure
2. ECHOCARDIOGRAM
3. ECG
4. Myocardial Biopsy
MEDICAL MANAGEMENT
1. surgery PREVENTION
2. pacemaker insertion ● antibiotic prophylaxis if pt is undergoing
3. pharmacological drugs for symptom relief = procedures like dental extractions,
digoxin, valsartan bronchoscopy, surgery, etc.
NURSING MANAGEMENT LABORATORY EXAM
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 ● blood cultures to determine the exact organism period of the right or left ventricle also known as
ventricular gallop
NURSING MANAGEMENT CLASS 3
1. regular monitoring of temperature, heart ● Markedly limitation on ADLs
sounds = are created from blood flowing ● Comfortable at rest But symptoms present in
through the heart chambers as the cardiac Less than ordinary activity
valves open and close during the cardiac cycle Pathophysiology
2. manage infection ● LEFT ventricular pump failure → back up of
blood into the pulmonary veins → increased
MEDICAL MANAGEMENT pulmonary capillary pressure → pulmonary
1. Pharmacotherapy congestion
● IV antibiotic for 2-6 weeks ● LEFT ventricular failure → decreased cardiac
● Anticoagulant agent are given - output → decreased perfusion to the brain,
amphotericin B kidney and other tissues → oliguria, dizziness
2. Surgery ● RIGHT ventricular failure → blood pooling in the
● valvular replacement venous → increased hydrostatic pressure →
peripheral edema

CONGENITAL HEART FAILURE LEFT SIDED CHF ASSESSMENT FINDINGS

● A syndrome of congestion of both pulmonary 1. Dyspnea on exertion
and systemic circulation caused by inadequate 2. PND
cardiac function and inadequate cardiac output 3. Orthopnea
to meet the metabolic demands of tissues 4. Pulmonary crackles/ rales
● inability of the heart to pump significantly 5. cough with Pinkish, frothy sputum
● the heart is unable to maintain adequate 6. Tachycardia
circulation to meet the metabolic needs of the RIGHT SIDED CHF ASSESSMENT FINDINGS
body 1. Peripheral dependent, pitting edema
● classified according to the major ventricular 2. Weight pain
dysfunction - Left or right 3. Distended neck vein
4. hepatomegaly
ETIOLOGY OF CHF 5. Ascites
1. CAD 6. body weakness
2. Valvular heart disease 7. anorexia, nausea
3. Hypertension 8. pulsus alternans
4. MI LABORATORY FINDINGS
5. cardiomyopathy 1. CXR may reveal cardiomegaly
6. lung diseases 2. ECG may identify Cardiac hyperthrophy
7. post-partum 3. Echo cardiogram may show hypokinetic heart
8. pericarditis and cardiac tamponade 4. ABG and pulse OXIMETRY may show
decreased O2 saturation
NEW YORK HEART ASSOCIATION 5. PCWP ( Pulmonary capillary wedge pressure )
CLASS 1 is frequently used to assessed left ventricular
● ordinary physical activity does Not cause chest filling, represent left atrial pressure, and assess
pain and fatigue mitral valve function is increased in LEFT
● no pulmonary congestion sided CHF and CVP ( CENTRAL VENOUS
● asymptomatic PRESSURE ) is increased in RIGHT sided
● NO elimination of ADLs CHF
CLASS 2 NURSING INTERVENTIONS
● SLIGHT limitation of ADLs 1. Assess pt's cardio-pulmonary status
● NO symptom with Increased activity 2. Assess VS, CVP and PCWP. Weight pt daily to
● Basilar crackles and S3 = is a low frequency, monitor fluid retention
brief vibration occurring in early diastole filling
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 3. Administer medications - usually cardiac LABORATORY FINDINGS
glycosides are given - Digoxin or ● Increased CVP
DIGITOXIN(monitor BP, BRADYCARDIA) - normal is 4-10 cm H2O
TOXICITY (gastro upset (most common) NURSING INTERVENTIONS
-DIARRHEA, n/v, loss of appetite) 1. Place pt in a modified Trendelenburg (shock)
● Diuretics, vasodilators and position
hypolipidemics are prescribed 2. Administer IVF, vasopressors and inotropics
4. Provide a LOW sodium diet. Limit fluid intake as such as DOPAMINE(cathecolamines) = a
necessary peripheral vaso stimulant used to treat low
5. Provide adequate rest periods to prevent fatigue blood pressure, low heart rate, and cardiac
6. Position on Semi-fowler's to Fowler’s for arrest. Low infusion rates (0.5 to 2
adequate chest expansion micrograms/kg per minute) act on the visceral
7. Prevent complications of immobility vasculature to produce vasodilation, including
the kidneys, resulting in increased urinary flow
NURSING INTERVENTIONS AFTER THE ACUTE ● DOBUTAMIN = directly stimulates beta
STAGE 1 receptors of the heart to increase
1. Provide opportunities for verbalization of myocardial contractility and stroke
feelings volume, resulting in increased cardiac
2. Instruct the pt about the medication output
regimen-digitalis, vasodilators and diuretics 3. Administer O2
3. Instruct to avoid OTC drugs, stimulants, 4. Morphine is administered to decrease
smoking and alcohol pulmonary congestion and to relieve pain
4. Provide a LOW fat and Low sodium diet 5. Assist in intubation, mechanical ventilation,
5. Provide potassium supplements PTCA, CABG, insertion of Swan-Ganz cath and
6. Instruct about fluid restriction IABP
7. Provide adequate rest periods and schedule 6. Monitor urinary output, BP and pulses
activities 7. Cautiously Administer diuretics ad nitrates
8. Monitor daily weight and report signs of fluid
retention
CARDIAC TAMPONADE
● A condition where the heart is unable to pump
CARDIOGENIC SHOCK blood due to accumulation of fluid in the
● HEART fails to pump adequately resulting to a pericardial sac (pericardial effusion)
decreased cardiac output and decreased tissue ● This condition restricts ventricular filling
perfusion resulting to decreased cardiac output
ETIOLOGY ● Acute tamponade may happen when there is a
1. massive MI sudden accumulation of more than 50 ml fluid in
2. severe CHF the pericardial sac
3. cardiomyopathy Causative factors
4. Cardiac trauma 1. Cardiac trauma
5. Cardiac tamponade 2. Complication of Myocardial infraction
3. Pericarditis
ASSESSMENT FINDINGS 4. Cancer metastasis
1. HYPOTENSION ASSESSMENT FINDINGS
2. oliguria (less than 30 ml/hr) 1. BECK's Triad - jugular vein distention,
3. tachycardia hypotension and distant/muffled heart sound
4. narrow pulse pressure 2. Pulsus paradoxus = an exaggerated fall in a
5. weak peripheral pulses pt's blood pressure during inspiration by greater
6. cold clammy skin than 10 mm Hg
7. changes in sensrium / LOC 3. Increased CVP
8. Pulmonary congestion 4. decreased cardiac output

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 5. Syncope = transient loss of consciousness Pathophysiology
associated with absence of postural tone, ● Multi-factorial etiology
followed by complete and usually rapid ● BP= CO (SV X HR) x TPR
spontaneous recovery ● Any increase in the above parameters will
6. Anxiety increase BP
7. dyspnea 1. Increased Sympathetic activity
8. Percussion - flatness across the anterior chest 2. Increased absorption of Sodium and
water in the kidney
LABORATORY FINDINGS 3. Increased activity of the RAAS
1. Echocardiogram 4. Increased vasoconstriction of the
2. CXR peripheral vessels
NURSING INTERVENTIONS 5. insulin resistance
1. Assist in PERICARDIOCENTESIS ASSESSMENT FINDINGS
2. Administer IVF 1. headache
3. Monitor ECG, urine output and BP 2. visual changes
4. Monitor for recurrence of tamponade 3. Chest pain
4. dizziness
5. N/V
PERICARDIOCENTESIS
Risk factors for cardiovascular problems in Hypertensive
● Patient is monitored by ECG pt
● Maintain emergency equipments Major Risk Factors
● Elevate head of bed 45-60 degrees 1. Smoking
● ,monitor for complications - coronary artery 2. Hyperlipidemia
rupture, dysrhythmias, pleural laceration and 3. DM
myocardial trauma 4. age older than 60
5. Gender - male and post menopausal
VASCULAR DISEASE 6. family hx

HYPERTENSION DIAGNOSTIC STUDIES

● a systolic BP greater than 140 mmHg and a 1. Health hx and PE
diastolic pressure greater than 90 mmHg over a 2. Routine laboratory - UA, ECG, Lipid profile,
sustained period, based on two or more BP BUN, serum creatinine, FBS
measurement 3. Other lab - CXR, creatinine clearance, 24 hour
urine protein
TYPE OF HYPERTENSION MEDICAL MANAGEMENT
1. Primary or ESSENTIAL 1. lifestyle modification
● most common type 2. drug therapy
2. Secondary 3. diet therapy
● due to other conditions like ● DRUG THERAPY
Pheochromocytome, renovascular hpn, - diuretics
Cushing's, Conn's, SIADH - beta blockers
- calcium channel blocker
- Ace inhibitors
- A2 receptor blockers
- vasodilators
NURSING INTERVENTIONS
1. Provide health teaching to patient
● teach about the disease process
● elaborate on lifestyle changes
● Assist in meal planning to lose weight
● Provide list of LOW fat, Low sodium diet
less than 2-3 grams of Na/day
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 ● limit alcohol intake to 30 ml/day NURSING MANAGEMENT
● regular aerobic exercise ● Administer medications
● Advise to completely stop smoking ● emphasize the need to avoid increased
2. Provide information about antihypertensive abdominal pressure
drugs ● no deep abdominal palpation
● Instruct proper compliance and not ● remind the patient the need for serial ultrasound
abrupt cessation of drugs even if pt to detect diameter changes
becomes asymptomatic/ improved
condition
PERIPHERAL ARTERIAL OCCLUSIVE DISEASE
● Instruct to avoid OTC drugs that may
interfere with current medication ● Refers to arterial insufficiency of the extremities
3. Promote home care management usually secondary to peripheral atherosclerosis
● Instruct regular monitoring of BP ● usually found in males age 50 and above
● involve family members in care ● the legs are most often affected
● Instruct regular follow-up Risk factors
4. Manage hypertensive emergency and urgency NON-MODIFIABLE
properly 1. Age
2. Gender
3. Family predisposition
ANEURYSM MODIFIABLE
● Dilation involving an artery formed at a weak 1. smoking
point in the vessel wall 2. HPN
● Saccular = when one side of the vessel is 3. obesity
affected 4. Sedentary lifestyle
● Fusiform = when the entire segment becomes 5. DM
dilated 6. stress
RISK FACTORS
1. Atherosclerosis ASSESSMENT FINDINGS
2. infection=syphilis 1. INTERMITTENT CLAUDICATION - the
3. Connective Tissue disorder hallmark of PAOD
4. Genetic disorder = Marfan's syndrome ● This is PAIN described as aching,
Pathophysiology cramping or fatiguing discomfort
● Damage to the intima and media → weakness consistently reproduced with the same
→ outpouching degree of exercise or activity
● dissecting aneurysm → tear in the intima and ● This pain is Relieved by REST
media with dissection of blood through the ● This commonly affects the arterial
layers occlusion
2. Progressive pain on the extremity as the
ASSESSMENT disease advances
1. Asymptomatic 3. Sensation of cold and numbness of the
2. Pulsatile sensation on the abdomen extremities
3. Palpable bruit 4. skin is pale when elevated and cyanotic/ruddy,
LABORATORY when placed on a dependent position
● CT scan 5. muscle atrophy, leg ulceration and gangrene
● Ultrasound DIAGNOSTIC FINDINGS
● X-ray 1. Unequal pulses between the extremities
● Aortography 2. Duplex ultrasonography
3. Doppler flow studies
MEDICAL MANAGEMENT MEDICAL MANAGEMENT
● Anti-hypertensives 1. Drug therapy
● Synthetic graft

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 ●pentoxyfylline (Trental) reduces blood 2. Contrast angiography
viscosity and improves supply of O2 NURSING INTERVENTIONS
blood to muscles 1. Assist in the medical and surgical management
● cilostazol (pletaal) inhibits platelet ● Bypass graft
aggregation and increases vasodilation ● amputation
2. Surgery - Bypass pass graft and anastomoses 2. strongly advise to AVOID smoking
NURSING INTERVENTIONS 3. manage complications appropriately
1. Maintain circulation to the extremity
● Evaluate regularly peripheral pulses,
temperature, sensation motor function RAYNAUD'S DISEASE
and capillary refill time ● A form of intermittent arteriolar
● Administer post-operative care to VASOCONSTRICTION that results in coldness,
patient who underwent surgery pain and pallor of the fingertips or toes
2. Monitor and manage complications ● Cause: UNKNOWN
● note for bleeding, hematoma, ● most commonly affects WOMAN, 16-40 yrs old
decreased urine output
● Elevate the legs to diminish edema ASSESSMENT FINDINGS
● Encourage exercise of the extremity 1. RAYNAUD'S phenomenon
while on bed ● A localized episode of vasoconstriction
● teach pt to avoid leg-crossing of the small arteries of the hands and
3. Promote home management feet that causes color and temperature
● encourage lifestyle changes changes
● Instruct to Avoid smoking ● W-B-R
● Instruct to avoid leg crossing ● Pallor - due to vasoconstriction , then
● Blue - due to pooling of deoxygenated
blood
BUERGER'S DISEASE ● Red - due to exaggerated
● thromboangiitis obliterans reflow/hyperemia
● a disease characterized by recurring 2. tingling sensation
inflammation of the medium and small arteries 3. burning pain on the hands and feet
and veins of the lower extremities
● occurs in Men ages 20-35 MEDICAL MANAGEMENT
● RISK FACTOR: SMOKING ● Drug therapy with the use of CALCIUM channel
Pathophysiology blockers
● cause is UNKNOWN - to prevent vasospasm
● Probably an autoimmune disease NURSING INTERVENTIONS
● inflammation of the arteries → thrombus 1. Instruct pt to avoid situations that may be
formation → occlusion of the vessels stressful
2. Instruct to avoid exposure to cold and remain
ASSESSMENT FINDINGS indoors when the climate is cold
1. Leg PAIN 3. Instruct to avoid all kind of nicotine
● foot cramps in the arch (instep 4. Instruct about safety, careful handling of sharp
claudication) after exercise objects
● relieved by rest
● aggregated by smoking, emotional VENOUS DISEASE
disturbance and cold chilling
VARICOSE VEINS
2. digital rest pain not changed by activities or rest
3. Intense RUBOR (reddish-blue discoloration), ● These are Dilated veins usually in the lower
progresses to Cyanosis as disease advances extremities
4. paresthesia Predisposing factors
DIAGNOSTIC DISEASE ● pregnancy
1. Duplex ultrasonography ● prolonged standing or sitting
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 ● constipation ( for hemorrhoids ) 2. Provide skin care to prevent the complication of
● incompetent venous valves leg ulcers
Pathophysiology 3. Provide anti-embolic stockings
● FACTORS → venous stasis → increased 4. Administer anticoagulants as prescribed
hydrostatic pressure → edema 5. Monitor for signs of pulmonary embolism
(sudden respiratory distress)
ASSESSMENT FINDINGS
● tortuous superficial veins on the legs BLOOD DISORDER
● leg pain and heaviness
ANEMIA
● dependent edema
LABORATORY FINDINGS Three broad categories
● venography 1. Loss of RBC- occurs with bleeding
● Duplex scan pletysmography 2. Decreased RBC production
MEDICAL MANAGEMENT 3. Increased RBC destruction
● pharmacological therapy
● leg vein stripping anti-embolic stocking Hypoproliferative Anemia
NURSING MANAGEMENT
1. Advise pt to Elevate the legs ● Iron Deficiency Anemia
2. caution pt to avoid prolonged standing or sitting
3. Provide high-fiber foods to prevent constipation Etiologic Factors
4. teach simple exercise to promote venous return 1. Bleeding- the most common cause
5. caution pt to avoid knee-length stockings and 2. Mal-absorption
constrictive clothings 3. Malnutrition
6. apply massage on the affected area 4. Alcoholism
Pathophysiology
● The body stores of iron decrease, leading to
DEEP VEIN THROMBOSIS depletion of hemoglobin synthesis
● inflammation of the deep veins of the lower ● The oxygen carrying capacity of hemoglobin is
extremities and the pelvic reduced tissue hypoxia
● inflammation results to formation of blood clots
in the area ASSESSMENT FINDINGS
COMPLICATION 1. Pallor of the skin and mucous membrane
● PULMONARY thromboembolism 2. Weakness and fatigue
3. General malaise
ASSESSMENT FINDINGS 4. Pica
● leg tenderness 5. Brittle nails
● leg pain and edema 6. Smooth and sore tongue
● positive HOOMAN's SIGN 7. Angular cheilosis
LABORATORY FINDINGS LABORATORY FINDINGS
● venography 1. CBC- Low levels of Hct, High and RBC count
● Duplex scan 2. low serum iron, low ferritin
MEDICAL MANAGEMENT 3. Bone marrow aspiration- MOST definitive
● antiplatelets MEDICAL MANAGEMENT
● anticoagulants 1. Hematinics
● vein stripping and grafting 2. Blood transfusion
● anti-embolic stockings NURSING MANAGEMENT
NURSING MANAGEMENT 1. Provide iron rich-foods
1. Provide measures to avoid prolonged immobility - Organ meats (liver)
● repositioning q2 - Beans
● Provide passive ROM - Leafy green vegetables
● Early ambulation - Raisins and molasses
2. Administer iron

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 ● Oral preparations tablets- Fe fumarate,
MEGALOBLASTIC AΝΕΜΙΑ
sulfate and gluconate
● Advise to take Iron ONE hour before ● Anemias characterized by abnormally large
meals RBC secondary to impaired
● Take it with vitamin C ● DNA synthesis due to deficiency of Folic acid
● Continue taking it for several months and/or vitamin B12
● IM preparation ● Folic Acid deficiency
● Administer DEEP IM using the Z- track
method Causative factors
● Avoid vigorous rubbing 1. Alcoholism
● Can cause local pain and staining 2. Mal-absorption
3. Diet deficient in uncooked vegetables
Pathophysiology of Folic acid deficiency
APLASTIC AΝΕΜΙΑ
● Decreased folic acid → impaired DNA synthesis
● A condition characterized by decreased number in the bone marrow impaired RBC development,
of RBC as well as WBC and platelets → impaired nuclear maturation but
CYTOplasmic maturation continues → large
CAUSATIVE FACTORS size
1. Environmental toxins- pesticides, benzene ● Vitamin B12 deficiency
2. Certain drugsChemotherapeutic agents, Causative factors
chloramphenicol, phenothiazines, Sulfonamides 1. Strict vegetarian diet
3. Heavy metals 2. Gastrointestinal malabsorption
4. Radiation 3. Crohn’s disease
4. Gastrectomy
Pathophysiology
● Toxins cause a direct bone marrow depression
PERNICIOUS AΝΕΜΙΑ
→ acellular bone marrow → decreased
production of blood elements ● Due to the absence of intrinsic factor secreted
by the parietal cells
ASSESSMENT FINDINGS ● Intrinsic factor binds with Vit. B12 to promote
1. Fatigue absorption
2. Pallor
3. dyspnea ASSESSMENT FINDINGS
4. bruising 1. Weakness
5. Splenomegaly 2. Fatigue
6. Retinal hemorrhages 3. listiess
LABORATORY FINDINGS 4. Neurologic manifestations are present only in
1. CBC- decreased blood cell numbers Vit. B12 deficiency
2. Bone marrow aspiration confirms the anemia- - Beefy, red, swollen tongue
hypoplastic or acellular marrow replaced by fats - Mild diarrhea
MEDICAL MANAGEMENT - Extreme pallor
1. Bone marrow transplantation - Paresthesias in the extremities
2. Immunosupressant drugs LABORATORY FINDINGS
3. Rarely, steroids 1. Peripheral blood smear- shows giant RBCs,
4. Blood transfusion WBCs with giant hypersegmented nuclei
NURSING MANAGEMENT 2. Very high MCV
1. Assess for signs of bleeding and infection 3. Schilling’s test
2. Instruct to avoid exposure to offending agents 4. Intrinsic factor antibody test
MEDICAL MANAGEMENT
1. Vitamin supplementation
● Folic acid 1 mg daily
2. Diet supplementation
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 ● Vegetarians should have vitamin intake ● Classified as Primary or Secondary
3. Lifetime monthly injection of IM Vit B12
Causative factor
● unknown
HEMOLYTIC AΝΕΜΙΑ: SICKLE CELL
Pathophysiology
● A severe chronic incurable hemolytic anemia ● The stem cells grow uncontrollably
that results from heritance of the sickle ● The bone marrow becomes HYPERcellular and
hemoglobin gene all the blood cells are increased in number
● The spleen resumes its function of
Causative factor hematopoiesis and enlarges
● Genetic inheritance of the sickle gene- HbS ● Blood becomes thick and viscous causing
gene sluggish circulation
Pathophysiology ASSESSMENT FINDINGS
● Decreased 02, Cold, Vasoconstriction can 1. Skin is ruddy
precipitate sickling process 2. Splenomegaly
● Factors cause defective hemoglobin to acquire 3. Headache
a rigid, crystal-like C-shaped configuration → 4. Dizziness, blurred vision
Sickled RBCs will adhere to endothelium → 5. Angina, dyspnea and thrombophlebitis
pile up and plug the vessels → ischemia results COMPLICATIONS
→ pain, swelling and fever 1. Increased risk for thrombophlebitis, CVA and
ASSESSMENT FINDINGS 2. Bleeding due to dysfunctional blood
1. Jaundice MEDICAL MANAGEMENT
2. Enlarged skull and facial bones 1. To reduce the high blood cell mass-
3. tachycardia, murmurs and cardiomegaly PHLEBOTOMY
● Primary sites of thrombotic occlusion: 2. Allopurinol
spleen, lungs and CNS 3. Dipyridamole
● Chest pain, dyspnea 4. Chemotherapy to suppress bone marrow
NURSING MANAGEMENT
ASSESSMENT FINDINGS 1. Primary role of the nurse is EDUCATOR
1. Sickle cell crises 2. Regularly asses for the development of
● Results from tissue hypoxia and complications
necrosis 3. Assist in weekly phlebotomy
2. Acute chest syndrome 4. Advise to avoid alcohol and aspirin
● Manifested by a rapidly falling 5. Advise tepid sponge bath or cool water to
hemoglobin level, tachycardia, fever manage pruritus
and chest infiltrates in the CXR
MEDICAL MANAGEMENT
1. Bone marrow transplant LEUKEMIA
2. Hydroxyurea ● Malignant disorders of blood forming cells
● Increases the HbF characterized by UNCONTROLLED
3. Long term RBC transfusion proliferation of WHITE BLOOD CELLS in the
NURSING MANAGEMENT bone marrow- replacing marrow elements. The
1. Manage the pain WBC can also proliferate in the liver, spleen and
● Support and elevate acutely inflamed lymph nodes.
joint ● The leukemias are named after the specific
● Relaxation techniques lines of blood cells afffected primarily
● analgesics - Myeloid
- Lymphoid
- Monocytic
POLYCYTHEMIA
● The leukemias are named also according to the
● Refers to an INCREASE volume of RBCs maturation of cells
● The hematocrit is ELEVATED to more than 55%
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ACUTE 2. Maintain skin integrity
● The cells are primarily immature 3. Provide pain relief
CHRONIC 4. Provide information as to therapy- chemo and
● The cells are primarily mature bone marrow transplantation

- ACUTE myelocytic leukemia

- ACUTE lymphocytic leukemia
- CHRONIC myelocytic leukemia
- CHRONIC lymphocytic leukemia
ETIOLOGIC FACTORS
● UNKNOWN
● Probably exposure to radiation
● Chemical agents
● Infectious agents
● Genetic
PATHOPHYSIOLOGY of ACUTE Leukemia
● Uncontrolled proliferation of immature CELLS
→ suppresses bone marrow function → severe
anemia, thrombocytopenia and
granulocytopenia
PATHOPHYSIOLOGY of CHRONIC Leukemia
● Uncontrolled proliferation of DIFFERENTIATED
cells → slow suppression of bone marrow
function → milder symptoms

ASSESSMENT FINDINGS
ACUTE LEUKEMIA
● Pallor
● Fatigue
● Dyspnea
● Hemorrhages
● Organomegaly
● Headache
● vomiting
CHRONIC LEUKEMIA
● Less severe symptoms
● organomegaly

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
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