10/6/2009

Inflammation

• Pericarditis Inflammatory Disorders of the – Inflammation of the outer layer, may include effusion, excessive fluid accumulation, which Heart imppgairs filling. • Myocarditis Pericarditis, Endocarditis, – Inflammation develops as localized lesions on the Myocarditis heart muscle, may interfere with conduction • Endocarditis – Most common, affects valves; inflammation disrupts blood flow and the effectiveness of the left ventricle. Eventually, valve scarred, leading to stenosis or incompetence.

Endocarditis Endocarditis Pathophysiology • Subacute • Etiology – Defective heart valves invaded by organisms such – Abnormal tissue in heart predisposes to - as strep (part of normal flora of mouth, low congenital defects, mitral prolapse, artificial virulence) valves, rheumatic fever. •Acute – Microbes in blood - abscesses or other sources of – Heart valves are attached by highly virulent infection need to be treated. organisms, like staph, which tend to cause tissue damage and are difficult to treat. – Reduced host defense - immunocompromised, persons taking corticosteroids or those with AIDS • Regardless of the organism, the effect is the same – Risk of cardiac both bacterial and fungal – Microorganisms invade heart valves, causing inflammation and vegetation on the cusps

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Heart Valve Defects Aortic Stenosis

Endocarditis Mital Valve Regurgitation Signs/Symptoms • Various heart murmurs most common •Acute MR • Subacute – develops suddenly, presents with a new a – Insidious onset, low grade fever or fatigue systolic murmur, and results in the rapid • AilAnorexia, splenomega ldiflddlthly, and painful red nodules on the dldevelopment tfl of pulmonary ed ema and dhk shock. fingers called Osler’s nodes •Acute • Chronic MR – Sudden onset – happens more slowly, and presents with • Spiking fever, chills, and drowsiness weakness, fatigue, palpitations, peripheral – Torn heart valve can cause severe impairment of heart edema, S gallop, and holosystolic murmur. function 3 • Subacute and Acute may cause septic emboli leading to infarctions or abscess in other organs

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Endocarditis Pericarditis Treatment • Blood culture • Acute or Chronic – Identify causative organism • Secondary to another condition • Antimicrobial drugs • Classified by cause or type of exudate – 4kttttdit4 week treatment to eradicate compl ltletely associtdiated w ithiflith inflamma tion • Other medications to support heart function •Acute • Surgical replacement – Simple inflammation of pericardium – valvuloplasty or replacement with a mechanical or – Tough swollen surfaces cause sharp chest pain biologic valve. and a friction rub – Susceptible to thrombus formation, daily ASA – Effusion may develop, with a large volume of fluid – Risk of infectious endocarditis, prophylactic in the pericardial sac antibacterial drugs prior to invasive or dental procedures

Pericardial Effusion Pericarditis

• Large volume that accumulates rapidly compresses the heart and impairs exppg,gansion and filling, thus decreasing CO • Right side affected first – Increased pressure in systemic –Acute-JVD

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Pericarditis Pericarditis Etiology Signs/Symptoms • MI, OHS, rheumatic fever, lupus, • Tachycardia • Acute: cardiac tamponade: – JVD, faint heart sounds, & cancer, renal failure, trauma, or viral • Sharp chest pain pulsus paradoxus (SBP infection •Dyypspnea drops 10mm Hg during inspiration • Radiation to the mediastinum results in • Cough • Chronic: development of fibrous tissue • Friction rub – Fatigue, weakness, & abdominal discomfort r/t • Effusion secondary to hypoproteinemia venous congestion from liver or kidney disease

Pericarditis Treatment • Pericardiocentesis – Aspirate fluid from pericardium and culture Peripheral Vascular Disease • Treat primary problem • Severe effusion Atheromas in peripheral circulation – Prevent tamponade and shock – pericardiocentesis

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Atherosclerotic Aorta Occlusion

• Partial • Total • Impaired muscle • Necrosis, ulcers, activity & sensory gangrene (bacterial function in the legs infection of necrotic tissue

PVD PVD Signs/Symptoms Treatment • Leg weakness and fatigue • Slow the progress • Intermittent claudication (key indicator) – Reduce serum cholesterols • Sensory impairment – Platelet inhibitors or anticoagulant medication – Paresthesias, burning – Stop smoking (promotes platelet adhesion) • Distal pulses to occlusion weak or absent – BP <130/80, HgbA1c<7% • Maintain circulation • Skin appearance – Exercise program – Pallor, cyanosis when legs are elevated – Encourage dependent leg position – Rubor when legs are dependent – Ca channel blockers (peripheral vasodilate) – Dry, hairless skin, toenails-thick & hard – Surgery - bypass grafts using a , – Cold feet to reduce plaques, or (remove intima and obstructive material)

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Nursing Management Nursing Management Nursing Implementation Planning • Acute Intervention • Overall goals for patient with PAD – Frequently monitor after surgery – Adequate tissue perfusion • Skin color and temperature • Cap illary re fill – Relief of pain • Presence of peripheral pulses distal to the operative site – Increased exercise tolerance • Sensation and movement of extremity – Intact, healthy skin on extremities • Avoid knee-flexed positions except during exercise • Turn and position frequently

PVD Nursing Management Treatment Evaluation • Avoid skin trauma • Identify activities that promote circulation – Plans for walking program • Regular foot examination • Maintain adequate peripheral tissue perfusion • Well fitted shoes (avoid pressure) • EiExperience ittkiffiftiintact skin, free of infection, on • Gangrenous ulcers treated lower extremities – Antibiotics, debridement, HBO • Verbalize key elements of therapeutic regimen, knowledge of disease, treatment • Walking program plan, reduction of risk factors, and proper ulcer/foot care

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Fusiform, Sacular, Dissecting

Aortic Aneurysm

Localized dilatation in an arterial wall

Aortic Aneurysm Aortic Aneurysm Signs/Symptoms Diagnostic Studies • Abdominal • X-rays – Palpable pulsatile mass with bruits – Chest - Demonstrate mediastinal silhouette – Large aneurysm may compress nearby structures • Dysphagia - pressure on esophagus and anyyg abnormal widening of thoracic • Pain - compressed spinal nerve aorta • Rupture – Abdomen -May show calcification within – Severe bleeding & death wall of AAA • Dissection • ECG -to rule out MI – Severe pain, organ dysfunction because blood flow disrupted – Many rupture

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Aortic Aneurysm Aortic Aneurysm Diagnostic Studies Diagnostic Studies • Echocardiography • CT scan – Assists in diagnosis of aortic valve – Most accurate test to determine insufficiency • Anterior to ppgosterior length • Related to ascending aortic dilation • Cross-sectional diameter • Ultrasonography • Presence of thrombus in aneurysm – Useful in screening for aneurysms •MRI – Monitor aneurysm size – Diagnose and assess the location and severity

Aortic Aneurysm Aortic Aneurysm Diagnostic Studies Treatment • • Medical Management – Anatomic mapping of aortic system using – Prevent sudden elevate in BP contrast – Avoid exertion, stress, coughing, – Not reliable method of determining constipation diameter or length – Can provide accurate info about – Medications for BP management involvement of intestinal, renal or distal • Surgery vessels – Resection and graft

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Aortic Aneurysm Aortic Aneurysm Collaborative Care Collaborative Care • Surgical Therapy • Surgical Technique – If ruptured, emergent surgical intervention – Incising diseased segment of aorta required – Removing intraluminal thrombus or plaque • 33%-94% mortality with ruptured AAAs – Inserting synthetic graft – Preop • Dacron or polytetrafluoroethylene (PTFE) •Hydration – Suturing the native aortic wall around graft • Electrolyte, coagulation, hematocrit stabilized • Acts as protective cover

Aortic Aneurysm Aortic Aneurysm Collaborative Care Collaborative Care • Autotransfusion reduces need for blood • AAA resections, continued transfusion during surgery – If extends above renal arteries or if cross clamp must be applied above renal arteries • AAA resections • Adequa te rena l per fus ion a fter c lamp remova l – Require cross-clamping of aorta proximal should be ascertained before closure of incision and distal to aneurysm • Risk of postop renal complications ↑ – Can be completed in 30-45 minutes significantly when repair is above renal arteries – Clamps are removed and blood flow to lower extremities restored

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Nursing Management Nursing Management Planning Nursing Implementation • Overall goals include • Acute Intervention – Pre-op teaching – Normal tissue perfusion • Brief explanation of disease process – Intact motor and sensory function •PlPlannedanned susurgicalrgical pprocedurerocedure • Preop routines – No complications related to surgical repair – Bowel prep –NPO – Shower • Expectations after surgery – Recovery room, tubes, drains – ICU

Nursing Management Nursing Management Nursing Implementation Nursing Implementation • Acute Intervention •Postop – Post-op – Maintain graft patency • ICU monitoring • Normal blood pressure – Arterial line • CVP or PA pressure monitoring – CVP, or PA catheter • Urinary o utp ut monitoring – Mechanical ventilation • Avoid severe hypertension – Urinary catheter – Nasogastric tube – Cardiovascular status –ECG • Continuous ECG monitoring – Pulse oximetry • Electrolyte & ABG monitoring – Pain medication • Oxygen administration • Antidysrhythmic/pain medications

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Nursing Management Nursing Management Nursing Implementation Nursing Implementation •Postop – Neurologic status •Postop – Level of consciousness • Renal perfusion status – Pupil size and response to light – Facial symmetry, Speech – Urinary output – Upper extremities movement, HG – Fluid intake • Peripheral perfusion status – Daily weight – Pulse assessment – CVP/PA pressure » Mark pulse locations with felt-tip pen – Extremity assessment – Blood urea nitrogen/Creatinine » Temperature, color, CRT, sensation and movement of extremities

Nursing Management Nursing Management Nursing Implementation Evaluation •Postop – Infection • Expected Outcomes • Antibiotic administration – Patent arterial graft with adequate distal • Assessment of body temperature • Monitoring of WBC perfusion • Adequate nutrition • Observe surgical incision for infection – Adequate urine output – Gastrointestinal status – Normal body temperature • Nasogastric tube • Abdominal assessment – No signs of infection • Passing of flatus -returning bowel function

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Thrombophlebitis Pathophysiology • Development of a thrombus in a vein where Venous Disorders inflammation is present • Platelets adhere and a thrombus develops

Thrombophlebitis & Varicosities • Critical problem – Venous thrombosis can lead to pulmonary emboli

Thrombophlebitis Thrombophlebitis Etiology Signs/Symptoms • Stasis of blood • Superficial veins – Immobility – Aching or burning and tenderness in leg • Endothelial injury – Warm with red area in the inflamed vein – Trauma, chemical injury, IV injection, or • Deep veins inflammation – Aching pain, tenderness, edema • Blood coagulability – Positive Homan’s sign (not always reliable) – Dehydration, cancer, pregnancy, increased – Systemic signs may develop -fever, platelet adhesion malaise, and leukocytosis

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Thrombophlebitis Treatment • Prevention • Irregular, dilated, and tortuous areas of – Reduce stasis superficial or deep veins •Exercise,,g,pg elevate legs, compression stockings • Location • Anticoagulant therapy - heparin – Legs most common – Esophagus -varices • Surgery - thrombectomy – Rectum -hemorrhoids • Varicosities can predispose to thrombus formation in the presence of immobility

Varicose Veins Varicose Veins Pathophysiology Signs/Symptoms • Defect or weakness in vein wall or valves • Edema in feet (rising venous pressure) – Vein wall weakness • Excessive hydrostatic pressure causes the wall to stretch • Fatigue and aching or dilate – Increased interstitial fluid interferes with • Weight of blood damages the valve below, leads to backflow of blood, distending and stretching vein walls arterial flow and nutrient supply • Long periods of standing, crossing legs, tight • Shiny, pigmented, & hairless skin fitting clothing, pregnancy – Increases pressure in the vein

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Varicose Veins Care Planning Treatment • Encourage venous return • Patient will – Elevate legs, support stockings – Have normal cardiac function • Do not cross legs – Perform ADLs without fatigue • Severe Varicosities – Understand therapeutic regimen – Reroute blood to functional veins • Sclerosing agents • Vein stripping

Nursing Implementation Nursing Implementation

• Assessment of history and understanding of • Monitor laboratory data disease process • Teach importance of adherence to treatment • Monitor patency of IV regimen • Compression stockings with immobility • Stress follow-up care •ROM • Avoidance of stress and fatigue • Turn, cough, deep breathe •Rest • Hygiene • Nutrition

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Evaluation

• Vital signs WNL • Absence of chills, diaphoresis, headache • Sufficient cardiac output • Completion of ADLs with no fatigue or physiologic distress • Increased understanding of disease process and self-care management •

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