Cardiovascular disorders CVS disorder.pptx

CVS Disorder

1. 1 CARDIOVASCULAR DISORDERS 11/28/2023 CVS Disorders 1 FOR NGUC 3 RD YEAR BSC NURSING STUDENTS BY Dereje T. (MSc, lecturer @ WU)

2. ANATOMY AND PHYSIOLOGY OVERVIEW OF CVS 2 2 CVS is composed of:  Heart  Blood  Blood vessels 11/28/2023 CVS Disorders 2

3. The heart 3 The heart is a hollow, muscular organ located in the center of the thorax, between the lungs It weighs ~ 300g and size is a person’s closed fist The weight and size of heart is influenced by age, gender, body weight, heart disease etc 11/28/2023 CVS Disorders 3

4. Functions of the heart Th e h e art p u mps bl o o d to th e t is s u es , su p plyi n g th e m with oxygen and other nutrients . Its p u mpi n g a c ti o n i s a cc o mplished b y the rhythmic contraction and relaxation of its muscular wall. V ent r icle e j ect s ~ 7 m L o f blo o d p e r b e at and has an output of ~ 5 -6 L / minute . 4 11/28/2023 CVS Disorders 4

5. Layers of the heart The hea r t is composed of th r ee l a y ers . Inner layer, or endocardium : endothelial tissue, lin e s the insid e of the hea r t and val v es . M i d dle l a y er or m y oca r diu m : m u s cle f i bers , r esponsible f or the pumping actio n . E xterior l a y er or ep i ca r dium : su r r ounds the other l a y ers o f the hea r t 5 11/28/2023 CVS Disorders 5

6. Layers of heart … The heart is encased in a thin, fibrous sac called the pericardium ( double layered). The space between these two layers (pericardial space) is filled with about 30 ml of fluid . 6 11/28/2023 CVS Disorders 6

7. Heart Chambers 7 Th e hea r t has fou r cham b ers ◦ Right atr i um ◦ Lef t atr i um ◦ Right v entr i cle ◦ Lef t v ent r ic l e 11/28/2023 CVS Disorders 7

8. Cardiac Chambers,Valves, and Circulation 8 11/28/2023 CVS Disorders 8

9. Heart Chambers… The right atrium and right ventricle, distributes venous blood to the lungs via the pulmonary artery for oxygenation . Left atrium and left ventricle, distributes oxygenated blood to the remainder of the body via the aorta . The left atrium receives oxygenated blood from the pulmonary circulation via the pulmonary veins . 9 11/28/2023 CVS Disorders 9

10. 11 11/28/2023 CVS Disorders 10

11. He a r t V al v es 11 ⚫ V alves of the heart permit blood to flow in only one direction. ⚫ There are two types of valves: 1. A trioventricular (AV) and 2. S emilunar valves 11/28/2023 CVS Disorders 11

12. A TRI O VENTRI C ULAR V A L VES 12 ⚫ S eparate the atria from the ventricles .  The tricuspid valve ( right )  The mitral, or bicuspid valve, ( left ) 11/28/2023 CVS Disorders 12

13. SEMILU N AR V A L VES The valve between the right ventricle and the pulmonary artery is called the pulmonic valve ; T he valve between the left ventricle and the aorta is called the aortic valve . 13 11/28/2023 CVS Disorders 13

14. Co r ona r y A r t e ries  The left and right coronary arteries and their branches supply arterial blood to the heart .  The heart has large metabolic requirements, extracting ~ 70% to 80% of the oxygen delivered.  Res t in g co r on a r y blo o d fl o w i s r ou g h l y 225 ml/min wh i ch r esults i n 4 - 5% of the t o tal ca r diac o u tput. 14 11/28/2023 CVS Disorders 14

15. Conduction system of the heart G ene r ate a n d c o ordi n ate the tr a ns mi s sion of electrical impulses to the myocardial cells. The result is sequential atrioventricular cont r act i on , w h ich lead s t o effe c tive fl o w of blood, thereby optimizing cardiac output CVS Disorders 11/28/2023 15

16. Conduction system The SA node The sino -atrial (SA) node : primary pacemaker of the heart, located at the junction of the superior vena cava and right atrium. The SA node in normal resting heart has an inherent firing rate of 60 to 100 impulses per minute The heart rate is determined by the myocardial cells with the fastest inherent firing rate ( SA node ) . CVS Disorders 11/28/2023 16

17. Conduction system… 17  Under normal circumstances, the SA node has the highest inhe r en t rate, the A V nod e has the second highest inherent rate (40 to 60), and the ventricular pacemaker sites have lowest inherent rate (30 to 40 ) 11/28/2023 CVS Disorders 17

18. Th e Imp u lse T r a v el path in the h e a r t 20 SA node  Internodal pathways  Atrioventricular node (AV node)  Impulse is delayed slightly AV bundle (bundle of his)  Left and right bundle branches  Purkinje fibers  All parts of the ventricles  Contraction 11/28/2023 CVS Disorders 18

19. 1 1 / 1 6 / 2 01 6 Purkinje fibers 21 SA node Inter-nodal pathway A V n o d e Bundle of His Bundle Branches 11/28/2023 CVS Disorders 19

20. Characteristics of heart muscle 11/28/2023 CVS Disorders 20 5 physiologic characteristics of the cardiac muscle include: Automaticity : ability to initiate an electrical impulse. Excitability : ability to respond to an electrical impulse Conductivity : ability to transmit an electrical impulse from one cell to another Rhythmicity : ability of cardiac cells & pacemakers to generate and transmit an electrical impulse at specific pattern/rhythm/ Contractibility : ability to shorten cardiac muscle fibers length in response to electrical stimulation

21. Cardiac cycle It has t w o phases: D i astole – v entricles r el a x & f il l wit h blood ( 2/3 of the ca r diac c y c l e .) Systolic – hea r t con t racts & pushes blood out of the v entricles ( 1/3 of t he ca r diac c y cl e ) to :  th e l u ngs  syste m i c a r ter i es CVS Disorders 11/28/2023 21

22. Blood Vessels 26 Composed of:  Arteries  Arterioles  Veins  Venules  Capillaries 11/28/2023 CVS Disorders 22

23. Blood Vessels… 2 2 7 7 11/28/2023 CVS Disorders 23

24. 28 11/28/2023 CVS Disorders 24

25. 29 11/28/2023 CVS Disorders 25

26. Blood Functions - Distribution 30 🢅 S u p p lie s O x ygen f r om lu n gs to cells 🢅 Supplies nutrients from digestive system to cells 🢅 Transports metabolic wastes from cells to disposal sites 🢅 Transports hormones to target tissues/organs … 11/28/2023 CVS Disorders 26

27. Blood Functions - Regulation 31  Regulates b ody temp e r a t u r e  Regulat e s t he pH of b o dy f luids  Regulates b loo d v olu m e to s u p p o r t ef f icient ci r culation to cell s , tis s u e s, org a ns & syst e ms  Prevents blood loss  Prevents infections 11/28/2023 CVS Disorders 27

28. Formed Elements - Cells/Components Erythrocytes ( RBCs) Leukocytes Platelets 32 11/28/2023 CVS Disorders 28

29. 4 - 6 million/mm 3 150,000 to 450,000/mm3 4,000 - 11,000/cm3) 11/28/2023 CVS Disorders 29

30. 34 Assessment of Cardiovascular System 34 11/28/2023 CVS Disorders 30

31. Subjective and objective Data 35 1. Age 2. Gender 3. Chest pain 4. Dyspnea 5. Orthopnea 6. Cough 7. Fatigue 8. Cyanosis or pallor 9. Leg pain 10. Edema 11. Nocturia 12. Dizziness or syncope 13. Palpitation 14. Height and current body weight 15. Past cardiac history 16. Family cardiac history 17. Personal habits 18. Environment 11/28/2023 CVS Disorders 31

32. 36 11/28/2023 CVS Disorders 32

33. Other history to be taken 37  Lifestyle 🖝 Diet 🖝 Weight reduction 🖝 Exercise 🖝 Smoking 🖝 Cholesterol level  Sc r een i ng f or h ype r ten s i o n 11/28/2023 CVS Disorders 33

34. Inspection of the skin: 38  Pallor  Cyanosis  Reduced sk i n tu r g or  Temperature  Moisture 11/28/2023 CVS Disorders 34

35. Peripheral Cyanosis 39 11/28/2023 CVS Disorders 35

36. Arterial Pulses cont’d… 40 11/28/2023 CVS Disorders 36

37. Common diagnostic procedure for CVD History P h ysi c al e x ami n ati o n Blood tests Urine analysis Chest x-rays ECG Angiography Ca r diac cat h e t eriza t io n e t c 41 11/28/2023 CVS Disorders 37

38. MANAGEMENT OF P A TIENT S WITH 42 CARDIOVASCULAR DISORDERS 11/28/2023 CVS Disorders 38

39. Co r ona r y A r te r y Disea s e (CAD)  C AD i s t h e most p r e v a len t c a r di o v a scular disease Coronary Atherosclerosis Arteriosclerosis is thickening or hardening of arteries Athe r o s cle r o s i s i s a type of a r terio s cle r osis caused b y a b uil d -u p of plaq u e (f a t t y s u b s t ance s, cholesterol, cellular wastes, calcium, fibrin ) in the in n er li ni n g of an a r t e r y . 43 11/28/2023 CVS Disorders 39

40. CAD … 44 Coronary Atherosclerosis: blocks or narrows lumen of coronary artery resulting in reduced bl o od fl o w to t h e m y o c a r di u m .  The nature of coronary arteries makes it risky for atherosclerosis  Ath e r oscl e r osis i s t h e major cause o f C AD 11/28/2023 CVS Disorders 40

41. B y : Abebe Abera 45 11/28/2023 CVS Disorders 41

42. CAD … Risk factors: Non modifiable Gender Inc r easing ag e Race 46 Modif i able R i sk f acto r s Family history of CAD Major: High blood cholesterol Hypertension Cig a r e t te sm o ki n g P h ysic a l inactivity 11/28/2023 CVS Disorders 42

43. CAD … 47 Minor  Obesity  DM  S t r e s s f ul li f e s tyle  P ost m en o p a u s al es t r ogen defic i ency  High s atur a ted fat inta k e etc Th e r i sk of C AD is ass o ciate d with:  A serum c h o leste r ol l e vel of >2 0mg / dL  A fast i n g trig l yceri d e l e vel of > 1 5 m g/dl 11/28/2023 CVS Disorders 43

44. Pathophysiology 48 Fatty streaks in the intima of the arterial wall 🠋 Inflammation 🠋 Infiltration of T- lymphocytes and monocytes to ingest the lipids and die 🠋 Prolifiration of smooth muscle cells and formation of fibrous cap 🠋 Atheromas or plaques formation 🠋 Protrusion of Atheromas into the lumen of vessels 🠋 Obstruction to blood flow 🠋 Hemorrhage 🠋 Thrombus 🠋 Myocardial infarction 11/28/2023 CVS Disorders 44

45. Lipids 49 High density lipoproteins (HDL)  Ca r ries lipids a w a y f r om a r teries a nd to the li v er for metabolism  Higher i n w omen than in men  Inc r ease b y p h ysi cal acti v it y and es t r o g en  Dec r ease wit h ag e Low density li p op r ot i en (LDL) 🢅 Co n tai n s mo r e cholesterol 🢅 H a v e inc r eased affi n it y f or a r teri a l walls 🢅 Is b a d l i p i d 11/28/2023 CVS Disorders 45

46. 50 11/28/2023 CVS Disorders 46

47. CAD … 51 11/28/2023 CVS Disorders 47

48. 52 11/28/2023 CVS Disorders 48

49. CAD … Clinical Manifestations S/S and com p lic a tio n s d e pe n d on: Locatio n and d e g r ee of n ar r o win g of t he a r t e ri a l lumen Thrombus formation O b s t ructi o n of bl o od fl o w to t h e m y oca r dium  hea r t attack or su dden ca r diac death 53 11/28/2023 CVS Disorders 49

50. 54 11/28/2023 CVS Disorders 50

51. 55 11/28/2023 CVS Disorders 51

52. CAD… Prevention Control of the following four modifiable risk factors: Inc r eased C h ol e s t e r ol Cig a r e t te Sm o ki n g Hypertension DM 56 11/28/2023 CVS Disorders 52

53. N o rma l /op t ima l l e vel of l i p i ds 57  LDL: - < 1 mg / dL f or patie n ts wit h C AD or a CAD risk equivalent  H D L > 4 - 60 mg /dL 11/28/2023 CVS Disorders 53

54. CA D … Contribution of smoking i . CO r eadi l y co mbi n e w it h O 2  availability of O 2 🡲 Decrease heart’s ability to pump ii . Cate cholamine p r oduction 🢁 HR, 🢁 B P , c o n stricti o n o f c o r o na r y a r teries iii . P l atelet a d h e s i on 🡲 thrombus formation ▶ People who stop smoking reduce their risk of heart disease by 30 - 5 % wit h i n th e f ir s t y ear 58 11/28/2023 CVS Disorders 54

55. 59 Management/ Treatment  Many people are able to manage coronary artery di s ea s e wi t h li f e s t y l e changes and m e dicatio n s .  O t h e r people wit h s e v e r e co r o n a r y a r t e r y di s ea s e m a y n e e d angioplasty o r s u r g e r y . 11/28/2023 CVS Disorders 55

56. CAD… Management… Re f er ring to r egist e r ed die t itia n f or die ta r y measures Weight reduction Inc r eased p h ysical activity P r o m o t in g ces s ation of t ob acco u s e Ear l y de t ec t io n and t r eatm e nt of h ype r t e n s ion Con t r olli n g DM 🢫 in s ulin & me t f ormin 60 11/28/2023 CVS Disorders 56

57. CA D … Medications to dec r ease L DL, trig l ycerides & inc r ease HDL Lovastatin Prevastatin Simvastatin Fluvastatin At r o vastat i n ⚫ Inhi b i t a n e nzyme HM G - CoA ( hydroxy -methyl- glutaryl CoA) r ed u ctase w h ich catalyzes early step in the synthesis of cholesterol 61 11/28/2023 CVS Disorders 57

58. CAD … 62 Nicotinic acid  Niacin: Decreased blood lipids  Fibri c a cids: primari l y in h ibit s trig l yceride synthesis.  Fenofibrate  Colofibrate Bile acid sequestrates : bind to bile acids to form an insoluble substance and lowers LDLs  Cholestryramine  Colestipol HCL 11/28/2023 CVS Disorders 58

59. Surgical intervention 1.Stenting: stent is introduced into blood vessel on balloon catheter & advanced into the blocked area  Th e bal l o o n i s then i n fl at ed and c a u se s the s t e n t to expand until it fits the inner wall of the vessel  The balloon is then deflated and drawn back  Th e s t e n t st a y s i n pla c e per m ane n tl y , h o l d ing the vessel open and improving the flow of blood. 63 11/28/2023 CVS Disorders 59

60. Stent Stent is a tube placed in the coronary arteries to keep it open (to treat CAD) 64 11/28/2023 CVS Disorders 60

61. Treatment cont’d… 2. Angioplasty  A balloon catheter is passed through the guiding catheter to the area near the narrowing. A guide wire inside the balloon catheter is then advanced through the artery until the tip is beyond the narrowing .  Balloon is inflated , compressing the plaque against the artery wall  Once plaque has been compressed and the artery has been sufficiently opened, the balloon catheter will be deflated and removed. 65 11/28/2023 CVS Disorders 61

62. Angioplasty … 66 11/28/2023 CVS Disorders 62

63. T reatmen t c ont’d… 3. Bypass surgery  Healthy blood vessel is removed from leg, arm or chest and used to create new blood flow path in t h e h e a r t  T h e “ b ypass g r af t ” e n ables bl o od t o r e a ch t h e h e a r t by flowing around (bypassing) the blocked portion o f t h e dis e ased a r t e r y .  The increased blood flow reduces angina and the risk o f h e a r t attack . 67 11/28/2023 CVS Disorders 63

64. 68 11/28/2023 CVS Disorders 64

65. Coronary Bypass Surgery 69 11/28/2023 CVS Disorders 65

66.  Angina pectoris is a clinical syndrome usually characterized by episodes/paroxysm of pain or pressure in the anterior chest. Cause :  Insufficient coronary blood flow which results in a decreased oxygen supply to meet an increased myocardial demand in response to physical exertion or emotional stress.  Usually caused by atherosclerosis 11/28/2023 CVS Disorders 66

67. Myocardial ischemia can result from:  A r e du c t i on of co r on a ry blood flow c a us ed by epi c ar d ial artery stenosis.  Abnor m al cons t r i ction or deficient re l axation of coronary artery.  Reduced O2 ca r ry i ng capa c i t y of t he blood.  Eith e r  oxygen de m and or  oxygen supply  Inadequate blood and oxygen supply are directly related to blockade or narrowed vessels 11/28/2023 CVS Disorders 67

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69.  Physical exertion (increase myocardial O2 demand).  Exposure to cold (cause elevation of BP increase oxygen demand)  Eating heavy meals  Stress or any emotion-provoking situation 11/28/2023 CVS Disorders 69

70.  Pain  v ary f r om feel i ng o f indigest i on t o ch o cking  Retrosternal area, radiate to neck, jaw, shoulders, inner aspects of upper arms, upper abdomen  5 – 15 min, myocardial ischemia, due to coronary atherosclerosis  Pressing, squeezing, tight, heavy, burning  Weakness or numbness in the arms, wrists and the hands  Shortness of breath  Pallor, Diaphoresis  Dizziness or lightheadedness  Nausea and vomiting ⚫ Weak relationship between severity of pain and degree of oxygen supply 11/28/2023 CVS Disorders 70

71. 11/28/2023 CVS Disorders 71

72.  Stable angina  Unstable angina  Refractory or intractable angina  Microvascular angina  Prinzmetal’s angina/variant angina  Silent angina 11/28/2023 CVS Disorders 72

73.  Als o ca l led “E f fort Angina”  Pain/discomfort is precipitated by activity  Minimal or no symptoms at rest  Symptoms disappear after rest/cessation of activity and when stress is reduced. 11/28/2023 CVS Disorders 73

74. 78 11/28/2023 CVS Disorders 74

75.  Also called “Crescendo angina” - pain increases every time  Symptoms occur more frequently and last longer than stable angina  Acute coronary syndrome in which angina worsens  Pain may occur at rest because the threshold is lower  Severe and of acute onset Refractory or intractable angina  Severe incapacitating angina Silent angina :  Objective evidence of ischemia (such as ECG changes with stress test) but the patient reports no symptoms. 11/28/2023 CVS Disorders 75

76.  Prinzmetal’s angina is a variant form of angina with normal coronary vessels or minimal atherosclerosis  It is probably caused by spasm of coronary artery 11/28/2023 CVS Disorders 76

77. D i a gnosis  History and physical examination  ECG (12-lead) and echocardiogram  Blood test  C-reactive protein ( CRP)  Invasive procedures (cardiac catheterization and coronary artery angiography) 11/28/2023 CVS Disorders 77

78. Aims:  Relief of symptoms  Slowing progression of the disease  Reduction of future events like myocardial infarction 11/28/2023 CVS Disorders 78

79. For treatment of acute attacks:  Organic nitrates/nitrites: nitroglycerin  Oxygen administration Prophylaxis :  Organic nitrates  Beta blockers: Propanolol, Metroprolol, Atenolol  Calcium channel blockers: Amilodipine, Diltiazem  K + channel opener- Nicorandil  Antiplatelet agents: asprin, heparin, clopidogel and ticlopidine Revascularization procedures: percutaneous coronary intervention (PCI) procedures ( percutaneous transluminal coronary angioplasty (PTCA), intracoronary stents, or atherectomy), CABG 11/28/2023 CVS Disorders 79

80.  Ineffective cardiac tissue perfusion secondary to CAD as evidenced by chest pain and symptom  Anxiety related to fear of death  Pain related to disease process  Noncompliance, ineffective management of therapeutic regimen related to failure to accept necessary lifestyle changes  Deficient knowledge about the underlying disease and methods for avoiding complications 11/28/2023 CVS Disorders 80

81.  Oxygen administration  Relieving anxiety  Relieving pain  Encourage rest  Avoid precipitating factors 11/28/2023 CVS Disorders 81

82. Myocardial Infarction (MI)  MI refers to the process by which areas of myocardial cells in the heart are permanently destroyed.  As the cells are deprived of oxygen, ischemia develops, cellular injury occurs, and over time, the lack of oxygen results in infarction, or cell death. 87 11/28/2023 CVS Disorders 82

83. M I .. 88 Causes  Reduced blo o d fl o w i n a co r o n a r y a r teries due to:  Thrombus (80-90% Cases)  Vasospasm  Atherosclerosis  Decreased O2 supply  Inc r eased O 2 dem a nd  In each case, imbalance exists b/n myocardial O2 demand & supply 11/28/2023 CVS Disorders 83

84. Risk factors 89  Adv a nced a g e  Gender (men)  D i a b etes mel l it u s, Obesity (B M I >30 kg/m²)  High blood pressure, Lack of physical activity  Dyslipidemia/hypercholesterolemia - high LDL, low HDL  T o b acco s m ok i n g , A l coh o l , O C P + s m ok i ng  Air p o l l utio n : C O , N 2 O ,  Fam i l y h i s t o r y of isc h a e mic he a r t d i sea s e or MI 11/28/2023 CVS Disorders 84

85. Pathophysiology of MI  Disrupti on of an athe r oscle r otic plaque i n a n epi c a r dial co r on a r y a r te r y clot t in g cascade t otal occ l usion of the a r te r y  Plaques can become unstable, rupture, and additionally promote a thrombus that occludes the artery  It lead s to m y oca r dial inf a r c t io n (n e c r osis)  Ischemic cascade: death of the heart cells near the occlusion  A collagen scar f or m s and a poptosis 90 11/28/2023 CVS Disorders 85

86. M I … Myocardial Infarction 91 11/28/2023 CVS Disorders 86

87. M y oca r dial Inf a r ction 92 11/28/2023 CVS Disorders 87

88. CVS Disorders 11/28/2023 88

89. Clinical Manifestations Pain  Su d den & not r el i e v ed b y r est or nit r at e - - hallmark  Common locations: substernal or retrosternal, radiating to the neck, jaw, and arms or to the back  May occur while the patient is active or at rest, asleep or w alk Us u al l y last s f or 20 mi n utes 93 11/28/2023 CVS Disorders 89

90. Rough diagram of pain zones in myocardial infarction; 94 11/28/2023 CVS Disorders 90

91. Other s/s  SOB, dyspnea , tac h y p n e a , crackles, pu l mona r y edema  Nausea & V omit i ng  Coo l , clam m y , d i a p h o r eti c , an d p a l e a p p eara nc e  Peripheral vasoconstriction  T ac h yca r d i a, bra d yca r d i a , an d dysr h ythmia s .  Fever  Hea d ac h e , visual d i s t ur b a n c es, a l te r ed speech, alte r ed motor fu n ctio n , a n d fu r ther ch a n g es i n L OC 11/28/2023 CVS Disorders 91

92. Other s/s …  Disc o m f o r t, p alpitatio n s.  S3 , S4 , and n e w on s et of a m ur m u r .  Increased jugular venous distention  Blood pressure changes.  Pulse deficit may indicate atrial fibrillation.  Decreased urinary output  Anxiety, restlessness, light-headedness 96 11/28/2023 CVS Disorders 92

93. M I … Diagnosis HX P h ysic a l E x amination Lab tests e.g. – Increased myoglobin ECG changes Echocardiogram Cardiac biomarkers:Troponin level 97 11/28/2023 CVS Disorders 93

94. M I … 98 Medical Mgt Goals:- ⚫ Minimizing m y oca r dial dam age ⚫ Preserving myocardial function ⚫ P r e v e n ti n g com p lications 11/28/2023 CVS Disorders

95. M I … 99 Pharmacologic therapy  T h r ombo l ytics e .g . st r e p toki n a s e  Analgesics e.g. morphine sulphate & meperidine  ASA  ACE in h ibitor s e .g . c a pt opril  Antidysrhythmic drugs ( eg . amiodarone,bretylium  B - bloc k ers , Calcium chan n e l bloc k ers  Stool s o fte n er s : Bi s ac o d y l  Nu tritional Mgt, supp o r t & p h y s ica l activity as n e eded  Risk reduction by education of individuals & group 11/28/2023 CVS Disorders

96. Nursing Diagnoses 100 ◦ Pain r elate d to po o r O 2 su p p ly to the m y oca r dium ◦ Risk for impaired gas exchange related to fluid overload from left ventricular dysfunction ◦ Risk f or al t e r ed perip h eral ti ssue perfusion r elate d to decreased CO from left ventricular dysfunction ◦ A n xiety r elated to f ear o f death ◦ Defic ien t kn o w l ed ge ab o ut post - M I self - ca r e 11/28/2023 CVS Disorders

97. M I … 101 Nursing Interventions Rel i e v i ng p a in – Oxygen administration – Morphine & thrombolytics administration as prescribed – Monitoring V/S e v e r y 1 - 2 hrs – P h y s ica l r est i n bed wi t h ba c k r est el e vate d P r e v ent i ng i m p a i r ed gas e xcha n ge • Regular & careful assessment of respiratory status • En co urage d eep b r eathing & co ug hing • F r eq u e nt p o s i t i o n ing • El e v a te h e ad o f bed 11/28/2023 CVS Disorders

98. M I … Reducing anxiety Developing trusting & caring relationship with patient Ensu r in g quite e n vi r o n ment T eaching r elaxation t e chni ques Using hum o r(fun) & as s istin g t he patient to lau g h Addressing the patient’s spiritual need Music therapy 102 11/28/2023 CVS Disorders

99. M I … Potential Complications Acute pulm o na r y ede m a HF Cardiogenic shock Dysr h yt hmias and ca r diac ar r est P erica r dial effusi o n & c a r diac tam p o n ade Myocardial rapture 103 11/28/2023 CVS Disorders

100. I N FEC T IO U S DISOR D ERS OF TH E HEA R T ⚫ Rheumatic heart disease, Infective endocarditis, myocarditis, and pericarditis are among the most common infections of the heart. ⚫ T h e idea l manageme n t i s p r e v e n ti o n 104 11/28/2023 CVS Disorders

101. Acute Rheumatic Fever (ARF) and Rheumatic Heart Disease (RHD)  RF i s a n inflam m a t o r y disease of the h e a r t potentially involving all the layers of the heart.  The resulting damage to the heart from RF is called rheumatic heart disease , a chronic condition characterized by scaring and deformity of the hea r t v a l v e s . 105 11/28/2023 CVS Disorders 101

102. Rheumatic Heart Disease… Rh e umatic hea r t disease a f f ects the hea r t v a l v e s . As blood flows, bacteria can infect the heart valves Mit r al and ao r tic v a l v es a r e most comm o n l y a f f ec t ed b y the rheu matic endoc a r diti s , l e s s commonly tricuspid valve 106 11/28/2023 CVS Disorders 102

103. Rheumatic Heart Disease… Etiology and Epidemiology  ARF occurs m o st oft e n i n scho ol a ge child r en ( 5 - 1 8 yrs) f oll owin g g r oup A - beta h emolyt i c streptococcal pharyngitis  Spread/transmission 🡲 contact with oral or respiratory secretions 107 11/28/2023 CVS Disorders 103

104. Rheumatic Heart Disease… 108 Risk factors  Malnutrition  Overcrowding  Low socio- economic status  Fam i l i al tend e ncy  Skin ( s u b cutaneo u s ) nod u l es  Lu n gs ( f i b r o u s p l eur i sy)  joint ( po l ya r thriti s ) 11/28/2023 CVS Disorders

105. Pathophysiology 109  As blood flows, bacteria that lie in URT can infect the heart valves  Without proper treatment of rheumatic fever, the disease progresses to RHD and leads to autoimmune attack on hea r t val v e s .  Leukocytes accumulate in the affected tissues and form n o dules, which e v entual ly r eplaced b y scar tissu e .  Rheumatic myocarditis develops, which temporarily weakens the contractile power of the heart. 11/28/2023 CVS Disorders

106. Clinical Manifestations 110  Fever  Arthritis  J oi n t p ain, s w elli n g, r ed n e s s and w arm t h  Skin r a sh (e r yth e matic ma r ig i natu m )  Skin n o dul e s  Syden ham ’ s ch o r ea  Nose bleeds  SOB, ch e st pain, m ur m u r , ca r dio m egal l y 11/28/2023 CVS Disorders 106

107. Clinical Manifestations… Skin nodules 111 11/28/2023 CVS Disorders 107

108. Arthritis 🖛 Mo s t co m m on f eat u r e: p r es e nt i n 8 % of p atie n ts 🖛 Painful, migratory, short duration, excellent response for salicylates 🖛 Usually >5 joints affected and large joints preferred  Knees  Ankles  Wrists  Elbows  Shoulders 112 11/28/2023 CVS Disorders 108

109. Carditis 113  Most serious manifestation which affect any cardiac tissue  May lead to death in acute phase or at later stage  Clinical signs:  High pulse r a te  Murmurs  Cardiomegaly  R h y t hm dis t urb a nce s  P erica r dial fricti on rubs  Cardiac failure  Mitral a nd ao r ti c r egur gi t ation most comm o n  Chest pain 11/28/2023 CVS Disorders 109

110. Di a gnosis 114 🖛 Hist o r y La b t e s t s Chest X-ray 🖛 P h ysical E x am 🖛 🖛 ECG 🖛 🖛 Sy n o vial fl u i d a na l ysis 11/28/2023 CVS Disorders 110

111. J one s C r ite ria f o r t h e di a gnosis o f ARF  T wo m a jor or  One ma j or and tw o mi n or Major criteria  Carditis  Polyarthritis  Chorea  Erythematic mariginatum  S u b c utan eous nodules Minor criteria  F e v er  P r e vious o c c u r r enc e of RF or RHD  A r thralgia  P r ol o nged PR inte r val  La b findings 1 15 11/28/2023 CVS Disorders 111

112. MEDICAL MGT Objectives 116 🖛 Eradic a ting c a usati v e org a nis m s 🖛 Preventing additional complications Pharmacologic therapy includes:  Lo n g t e rm an t ibi o tic t r eatm e nt  ASA  Corticosteroids 11/28/2023 CVS Disorders 112

113. According to DACA of Ethiopia For Rheumatic fever  Benzanthine penicillin G, IM 1.2 mil units stat F or t h ose al l ergic to pe n icillins  E r yt h r o m ycin 2 5 m g PO QI D f or 10 d a ys Plus  Aspirin up to 2 g QI D f or 4 - 6 w e e ks And/or  P r ed n isolo n e up to 30 mg PO Q I D 117 11/28/2023 CVS Disorders 113

114. For Rheumatic heart disease /RHD (Secondary prophylaxis) 118  First line: Benzanthine penicillin G, 1.2 mil units IM e v e r y 3 - 4 wks , f or a mini m um of 1 y ears or u n til the ag e of 4 y ears Alternatives  Penicillin, 2 5 mg PO da i l y Or  Sulfadiazine 1gm PO once daily 11/28/2023 CVS Disorders 114

115. Nursing Mgt Patient education about  The disease  Its treatment  The p r e v en ti v e s t eps ne e ded to a v oid po t en t ial complications **Antibiotics administration before invasive procedures 119 11/28/2023 CVS Disorders 115

116. Infective Endocarditis 120 It is an infection of the valves and endothelial surface of t he h e a r t Causes  Bacteria  St r eptococci (60%)  S t a p h yloc occi (20%)  Rickettsiae  Fungi  Chlamydia 11/28/2023 CVS Disorders 116

117. In f ecti v e endoda r ditis … 121 Risks/incidence  M o r e comm o n i n o lde r pe o ple  IV/injection drug users, immunosuppressive drugs  The combination of invasive procedure, bacteremia, and ca r diac de f ect  Those with prosthetic (artificial) heart valves, previous endocarditis, congenital malformations  Pts wit h RHD or mitral val v e p r ol a psed ( i nsufficienc y ). 11/28/2023 CVS Disorders

118. A mitral valve vegetation caused by bacterial endocarditis 122 11/28/2023 CVS Disorders

119. Pathophysiology 123  Bacteria or other infectious microorganism can e nt e r t h e bl o od s t r eam duri n g ce r tain p r oce du res  Bacteria can grow and form infected clots that break off and travel to the brain, lungs, kidneys, or spleen.  Direct invasion of the endocardium by microbes.  Causes deformity of the valve leaflets, and sometimes affect other cardiac structures. 11/28/2023 CVS Disorders

120. Clinical Manifestations  Fever  Chills, anorexia, weight loss  Arthralgias, myalgias, back pain, weakness, malaise, fatigue  Clubbing of fingers  Splinter hemorrhages occur in nail beds  Petechiae in conjuctiva & mucus membranes  Cardiomegally & heart failure  Cerebral ischemia, stroke, headache  Embolization to brain, kidneys, liver, limb & spleen 124 11/28/2023 CVS Disorders 120

121. Clinical Manifestations …  Abn o rmal uri n e colo r , Bloo d i n t h e urine  E x cessi v e s w eating (Ni g ht s w eats)  S h o r t n ess of b r eath w it h activity  S w elling of f ee t , legs , abdomen  Blee d in g i n t h e r e t in a (Ro t h's s p o t s) 125 11/28/2023 CVS Disorders 121

122. P etechiae 1. Nonspecific 2. Often located on extremities or mucous membranes 126 11/28/2023 CVS Disorders 122

123. Splinter Hemorrhages 1. Linear reddish-brown lesions found under the nail bed 2. Usually do NOT extend the entire length of the nail 127 11/28/2023 CVS Disorders 123

124. Osler’s Nodes 1. More specific 2. Painful and erythematous nodules 3. Located on pulp of fingers and toes 4. More common in subacute IE 128 11/28/2023 CVS Disorders 124

125. Jan e w a y Lesi o ns 1. More specific 2. Nonpainful Erythematous, blanching macules 3. Locate d o n palms a nd soles 129 11/28/2023 CVS Disorders 125

126. Diagnosis 130  History  P h ysical e x amination  Blood culture (positive in 90-95% of patients)  ESR  Chest X-ray  ECG  Echocardiography  Inc r eased WBCs  U/A 11/28/2023 CVS Disorders 126

127. Prevention  Antibiotics prophylaxis before and after dental , oral, respiratory, urinary or esophageal procedures  Con ti n u e d med i cal f oll o w - up Medical Mgt  Appropriate parenteral antibiotics for 2-6 wks Eg. vancomycin and ceftriaxone, pencillin, aminoglycoside  Antifungal agents like amphotericin- if fungal endocarditis  Anti p y r etics : PCM Surgical Mgt  Surgical valve repair or replacement for sever valve case 131 11/28/2023 CVS Disorders 127

128. Nursing Management  Mon it o ring 132  Body temp  S/S of sy s t e mic em b olization  S/S of p u lmo n a r y infa r ction & i n filtr a tes  Asse s s f or S/S of o r g an dama g e s u ch a s s t r o k e , H F , MI, meningitis, glomerulonephritis & spleenomegally  P r e & p o st – op ca re i f t h e pati e nt r ece i v ed surgic a l treatment 11/28/2023 CVS Disorders 128

129. Nursing Management… 133  Bed r est  T each t h e f ami l y and patie n t abo u t:  A n y activity r es t rictio n , m e dicatio n s & s/s o f infection  Need of prophylactic antibiotics before and after de n tal, r es p ir a t o r y , G I & GU p r oce du res  P r o vide em o ti o nal s u p p o r t 11/28/2023 CVS Disorders

130. Potential Complications 134  Blood clo t s o r e m b o l i to b r a in , ki dn e ys, lu n gs, e t c  Br ai n absce s s, St r o k e  Conges t i v e h ea r t failu r e  Glomer u lo n ep hritis  Neurological changes  Dysr h yt h e m ias  S e v e r e val v e dam age 11/28/2023 CVS Disorders

131. 135 11/28/2023 CVS Disorders 131

132. HEART FAILURE (HF) 136  HF, often referred to as congestive HF (CHF), is the inability of the heart to pump sufficient blood to meet the needs of the tissues for oxygen and nutrients  It is a p r o b lem with c o n trac t i o n ( s y s t o l ic d y s f unct i on) o r fi l li n g o f t h e h eart ( d iast o li c dysfunction) and may or may not cause pulmonary or systemic congestion 11/28/2023 CVS Disorders 132

133. HEART FAILURE… Incidence  T h e incid e nce o f HF inc r eases wi t h ag e .  Nearly 5 million people in the US have HF, with more than one-half million new cases diagnosed each y ea r .  High p r e vale n ce i n blacks  Most common reason for hospitalization of older people. 137 11/28/2023 CVS Disorders 133

134. Classification of HF Systol i c V s D iastol i c dysfun c tion  Systo l ic Dysfu n ctio n : the v entricle i s unab l e to con t ract f o r ceful ly enough during syst ole  Diastol i c dysfun c t ion: the l e f t v entricle is unable to r elax adequa t e l y du r in g d iastole Based on the side of the heart involved  lef t h ea r t fai l u r e  ri ght he a r t fai l u r e 138 11/28/2023 CVS Disorders 134

135. Left heart failure 139  LH F r es u lt s f r om L V dysfunc t io n ,  Cause Inc r eased P u lmo n a r y p r es s u r e  Fluid extravagation from the pulmonary capillary bed int o t h e intersti t ia l s p a c es & t h e a l v eoli  Pul m o n a r y con gesti o n & E de m a occu rs 11/28/2023 CVS Disorders 135

136. Pathophysiology of Left sided HF 140  LV dysfunction , causes blood to back up in the left atri u m a n d p u lmo n a r y v ei n s  The increased left ventricular end-diastolic blood volume increases the left ventricular end-diastolic pressure  Decreases blood flow from the left atrium into the left v entr i cle d u ri n g d i astole  The b l ood v ol u me an d p r e s s u r e in the l eft atrium increases, 11/28/2023 CVS Disorders

137. Pathophysiology … 141  Dec r eases bl o od fl o w f r om t h e p u lm o na r y v es s els  Pulmonary venous blood volume and pressure rise, forcing fluid from the pulmonary capillaries into t h e p u lm o na r y tis s u e s and al v e o li,  Impairme n t o f ga s e x - chang e .  Backward failure 11/28/2023 CVS Disorders

138. Or Pathophysiology…  The dec r e a se in S V s t i m u l ation of the s y mpa thetic ne r v o u s sy s tem im p edes perf u sion t o ma n y org a ns .  Blood flow to the kidneys decreases reduced urine o u tp u t ( o l i g ur i a ) .  Renal per f usion p r e s su r e fal l s r elease of r e n i n aldosterone secretion Sodium and fluid retention i n c r eases i n tr a vascular v ol u m e .  Some t ime s c al l ed f orwa r d fai l u r e . 142 11/28/2023 CVS Disorders

139. 143 11/28/2023 CVS Disorders

140. II. Right s i ded failu r e 144  RHF r es u lt s f r om a diseased R V t h at c a us e s b a ck wa r d fl o w of b lo o d to t h e RA a n d v e n o u s circulation. Causes  Left ventricular failure (the usual cause)  C AD e .g . R V MI  Pulm o na r y h ype r te n sion 11/28/2023 CVS Disorders 140

141. Pathophysiology RV failure 🠋 I n ability of R V to em p ty completely 🠋 I n c r eased v olume & p r ess u r e i n th e sy s temic v ei n s 🠋 Systemic venous congestion Systemic Congestion  P erip h eral edema  Hepatomegally  Spleenomegally  Con gestion of t h e GI tra c t 145 11/28/2023 CVS Disorders 141

142. F unctional cla s si f i c ati o n - N Y H A Class I : no limitation is experienced in any activities there are no symptoms from ordinary activities Class II : slight, mild limitation of activity; the patient is comfortable at rest or with mild exertion Class III : marked limitation of any activity; the patient is comfortable only at rest Class IV : any physical activity brings on discomfort and symptoms occur at rest 146 11/28/2023 CVS Disorders 142

143. Common causes of CHF 147  CAD  Cardiomyopathy  S y s t emi c or pu lmona r y hypertension  V alv u la r he a r t dis e ase  🠉 ed CO (anemia , h yp o xia)  Rh eu matic he a r t di s ease  C ongeni t al hea r t dis e ase  Compensato r y mechanisms f or 🠋 ed CO:  Inc r eased HR  Imp r o v ed SV (st r o k e V olume)  Arterial vasoconstriction  Sodium & wate r r et e nti on  Myocardial hypertrophy 11/28/2023 CVS Disorders 143

144. Clinical Manifestations tolerance  O l iguri a d uring the d a y  Nocturia  Angina  Confusion, r estlessn e ss Left sided HF Decreased CO  Dizziness  Fatigue,  T ac h yc a r dia, palpitation  Dec r eased acti v ity  Apical impuls e displacement  Pallor  Cyanosis  W eak peripher a l p ulse  Cool ext r emit ie s at r est 148 11/28/2023 CVS Disorders 144

145. C/M LHF cont’d… Pulmonary congestion  Co u gh - hacking, w orsen at night  Dy s p n ea , o r t h o p n ea, p a r o x ys m al n o c t u rnal dy s p n ea (ca r diac ast h ma)  Crackl e s / rales or w h e e zes i n lu n gs  Tachypnea  Dullness Murmurs S3/S4 149 11/28/2023 CVS Disorders 145

146. C/Ms Right sided HF Systemic Congestion 150  J u gular v ein dist e nsi o n (JVD)  He p atom e g a l l y & s p le e n o m e g a l l y  Ano r exia, naus e a  De p e nde n t ed e ma - leg s & sacrum  Ascites  Nocturia  Weight gain  Change i n PB 11/28/2023 CVS Disorders 146

147. C/Ms Cont’d… 151 11/28/2023 CVS Disorders 147

148. Di a gno s is 152  His t o r y  P h ysi c al Ex a minati o n  La b tes t s  ECG  Che st X - r a y  Echoca r dio g r a m  Pulse o ximet r y  B - t y pe natriu r et i c peptide ( BNP)  Ca r diac cathet e riz a ti on 11/28/2023 CVS Disorders 148

149. Medical Mgt 153 Objectives  T o elimi n ate o r r ed u ce eti o logi c or con trib u ti n g factors  To reduce the workload on the heart by r ed u cing a fter loa d & p r eload 11/28/2023 CVS Disorders 149

150. Phar m acolo g i c Th e ra p y 154 ACE - inhibitors (ACE-Is)  Promotes vasodilatation & diuresis  Include:  Captopril  Enalapril  Lisinopril Angiotensin II receptor blockers (ARBs): Losartan  Decreases BP & systemic vascular resistance Hydralazine  Decreases systemic vascular resistance Beta blockers e.g. propranolol 11/28/2023 CVS Disorders 150

151. Pha r ma c olo g i c Th e ra p y C o n t ’d… 155 Digitalis e .g . di go xin  Increases the force of myocardial contraction & slow conduc t io n th r ou g h the A V node Diuretics  Thiazides e.g. Chlorothiazide, hydrochlorothiazide  Loop diuretics e.g. furosemide (lasix)  Potassium sparing e.g. spironolactone  Combination agents e.g. spironolactone + hydrochlorothiazide Other medications  Anticoagulants  Ant i anginal medi catio n s 11/28/2023 CVS Disorders 151

152. DACA of Ethiopia 156 Digoxin 0.125-0.375 mg Po daily Plus Furosemide , 40-240 mg, Po divided in to 2-3 doses daily Plus P o tassi u m chloride , 6 00 mg P o once o r tw i ce dai l y And/or Enalopril 5-40 mg Po once or divided in to two dose daily And/or Spironolactone 25-100mg Po once daily or divided into two 11/28/2023 CVS Disorders 152

153. Nutritional therapy L o w so d iu m diet ( < 2g - 3g /d a y) A v oid exc e ssi v e fluid inta k e 157 11/28/2023 CVS Disorders 153

154. Potential complications Hypokalemia/Hyperkalemia Hypotension Re n al dysfu n cti o n Cardiogenic shock Dysrhythmias Pericardial effusion and cardiac tamponade 158 11/28/2023 CVS Disorders 154

155. NURSING DIAGNOSES Activity intol e r ance r elated to imbalanc e b e t w e e n o xygen su p p ly and dem a nd b ecau s e of dec r eased CO Excess fluid volume related to excess fluid or sodium intake and r ete n tion of flu i d b ecau s e of HF and it s med i cal th e r a p y Risk for impaired skin integrity related to edema Anx iet y r elated to b r eat h less n e ss and r estles s n e ss f r om inade quate o xygen ation Powerlessness related to inability to perform role responsibilities because of chronic illness and hospitalizations Non compliance r elated to lac k of k n o wl e dge 159 11/28/2023 CVS Disorders 155

156. Nursing Interventions 1 . Maintai n in g normal body fluid: Dai l y measu r eme nt of abdo m ina l gi r th Administering drugs as prescribed Mon itor i ng inta k e & out p u t and dai l y body w eight Re st r icti o n of so d iu m d i ets & fl u id 2. Im p r o ving activity tolerance: A v oid p r olonge d b e d r est Moderate p h y s ica l e x e r ci s e f or a total of 30 min wit h 3 - 5 times p e r w e e k Monitoring patient’s response to activity 160 11/28/2023 CVS Disorders 156

157. Nsg mgt…cont’d… 161 3. M aintaining sk i n int e g r i t y  M o nitor s i gns of edema  Met i cul ous skin ca r e  Pad bo n y p r o m inen c es  Passi v e R O M to ext r emit ies e v e r y 4 hou r s t o facili tate venous return  T urning & r epositi oning the patient q 2 hrs 4. I mp r o ving s e l f ca re  A s sisting the p a tient wit h all ADLs  T eaching the f a m i l y ab o ut self ca r e a c t iv i ti es 11/28/2023 CVS Disorders 157

158. INTE R VENTI O N S OF P A TI E NT S WITH VASCULAR DISORDERS 162 11/28/2023 CVS Disorders 158

159. 163 HYPERTENSION 11/28/2023 CVS Disorders 159

160. 164 Blood pressure  I n n o r m al ci r cu l ati o n, p r essu r e i s e x e r ted b y the flow of blood through the heart and blood vessels.  High blood pressure can result from a change in cardiac output, peripheral resistance, or both.  High BP can be viewed in three ways: as a sign, a risk f a ctor f or athe r oscle r otic CV D , or a disease 11/28/2023 CVS Disorders 160

161. 165 11/28/2023 CVS Disorders 161

162. BP Regulation Involves: 166 1. Nervous System Regulation I. Autonomic Nervous System II. Baroreceptors (pressero receptors) 2. Renal System 3. Endocrine system  Defect in one of the regulating mechanisms may result in HTN 11/28/2023 CVS Disorders 162

163. Hypertension 167 H y perte n s i o n - i s defi n ed as:  systolic BP (SBP) > 140 mmHg and  diast o li c BP (DBP ) > 9 mmHg  based on t h e a v era g e of t w o o r mo r e co r r e c t B P measu r ement s ta k en d uring t w o o r mo r e contacts with the health care provider 11/28/2023 CVS Disorders 163

164. Classification of BP for Adults (age > 18 years) Category Systolic BP (mmHg) Diastolic BP (mmHg) Normal <120 And <80 Pre-hypertension 120-139 Or 80-89 Stage 1 or Mild HTN 140-159 Or 90-99 Stage 2/Moderate HTN 160-179 Or 100-109 Stage 3 Sever HTN > 180 Or > 110 168 11/28/2023 CVS Disorders 164

165. 169 11/28/2023 CVS Disorders 165

166. Hypertension may be caused by: 170  Increased sympathetic nervous system activity  Increased renal reabsorption of sodium, chloride, and water  Increased activity of renin-angiotensin-aldosterone system,  Decreased vasodilation of the arterioles  Resistance to insulin action 11/28/2023 CVS Disorders 166

167. Etiology of Hypertension 171 Can be primary (essential) or secondary hypertension I. Primary (Essential) hypertension 🡆 Ac co u nts f or 90 - 9 5 % of a l l c a ses 🡆 Has no known causes 🡆 Onse t usual l y bet w een the age of 30 & 50 yrs 🡆 Associated risk factors include: ✄ Advanced age ✄ F a mi l y histo r y ✄ Obesity ✄ High sodium intake ✄ Cigarette smoking ✄ Sedentary lifestyle ✄ Excessi v e a l cohol i n ta k e ✄ Diabetes ✄ Stress and increased serum lipid level 11/28/2023 CVS Disorders 167

168. II. Secon d a r y h ype r tension 172  Has spe c ifi c cause  Accounts f or <5% of cases  Ident ifiabl e causes include:  Coarctation or con g enital a bn o r m alities of a o r ta  Renal disease  Ren o vascul ar HTN  Pheochromocytoma  Cushing’s syndrome  Brain tum o rs  Pregnancy  Medi c ations:  Estrogen  Glucocorticoids  Sympathomimetics ( e .g . d op a min e , dobutamine) 11/28/2023 CVS Disorders 168

169. Clinical manifestations 174  HTN i s often called “ silent ki l le r ”  With severe hypertension symptoms developed secondary to effect on blood vessels in various organs and tissues or to increased work load of t h e h e a r t 11/28/2023 CVS Disorders 169

170. These C/Ms may include: 175  Headache  Dizziness  Weakness  Faintness (sudden fall)  Sudden hemiplegia  St r o k e o r TIA  Blu r ring of vi sion  Nocturia  Increased BUN & creatinine  Epistaxis  Spe ech & vis i on alternation  O c casion a l l y , r et i nal changes  Hemorrhages  Exudates  sm a l l infa r c t ion 11/28/2023 CVS Disorders 170

171. Hypertensive crises  Present as hypertensive urgency or hypertensive emergency  Systolic reading of 180mmHg or higher OR diastolic reading of 110mmHG or higher, on two separate occasions at minutes interval  Needs immediate emergency medical treatment 176 11/28/2023 CVS Disorders

172. Hypertensive Urgency 177 ⚫ T h e r e i s n o as s oci a ted org a n d a mag e . ⚫ P a tie n ts m a y or m a y n o t e x p er i e n ce o n e or mo r e of these sy m ptoms:  S e v e r e h e ad a ch e ,  S h o r tn ess of b r eat h ,  Noseble eds, and  Severe anxiety. ⚫ T r e a tment r eq u i r es r ea d j u s t ment a n d/or a d d itio n al dosing of oral medications , without hospitalization 11/28/2023 CVS Disorders

173. Hypertensive emergency "malignant HTN’’ ) 178 ⚫ Is hypertension with acute impairment of one or more organ systems that can result in irreversible organ damage. ⚫ It generally occurs at blood pressure levels exceeding 180 systolic OR 120 diastolic, but can occur at even lower levels in patients whose blood pressure had not been previously high. 11/28/2023 CVS Disorders

174. Mani f esta t ions 179 and/ o r  Eye : retinal hemorrhage or exudate, Papilloedema  Brai n : s/s of I I C P: hea d ac h e, vo m i t i n g, subarachnoid or cerebral hemorrhage.  Kidney : hematuria, proteinuria and acute renal failure ⚫ Heart : left ventricular dysfunction. Other s/s can include : ⚫ Chest pain, Arrhythmias, Epistaxis, Dyspnea, Faintness or ve r t i go, Seve re an x i e t y , Alt e r ed m en t al s ta t us, Pa r e st h e sia 11/28/2023 CVS Disorders

175. Diagnosis of hypertension History P h ysi cal Exa m ination Measu r in g blood p r essu r e (a t leas t 1 w eek a pa r t) Ophthalmologic examination Lab tests ( U/A, blood chemictry, Creatine, BUN, FBG, Lipoprotein ) ECG Echoca r dio g r a p h y & che st X - r a y 180 11/28/2023 CVS Disorders 175

176. Medical Management 181 Goals  P r e v ent i ng de a th a n d comp l ic a tio n s  Ach i e vi n g an d mainta i n i ng the a r terial BP at:  1 4 0/9 mmH g or l o w er  < 1 3 0/8 m m Hg f or p e ople wit h DM & ch r onic kidn e y diseases The managements of hypertension include :  Li f es t yle mod i ficat i o n s  P h armaco l ogic ther a p y 11/28/2023 CVS Disorders 176

177. Ma n a g em e nt… Indications of Life style modification:  P erson w it h ei t her bo r der lin e or su s taine d HTN Lifestyle modifications Weight reduction Modera t io n of al c ohol in t a k e Regular p h ys i c al act i vi ty R e du c ti on of sod i um i nta k e Smoking cessation Dietary management (reduce salt, calories, cholesterol, and saturated fats; sufficient intake of pota 1 s 8 s 2 ium, magnesium, calcium, and vitamin C ) 11/28/2023 CVS Disorders 177

178. Medical Management… 183 Indications of drug therapy:  BP r emaining > 1 4 0/90 m mHg a fter 3 - 6 mon t hs of li f e style changes  Presence of target organ damage  Presence of other complications or risk factors 11/28/2023 CVS Disorders

179. Management approach 184 Blood pressure stage (mmHg) R i sk g r o u p A ( n o risk factor, no TOD/CCD) Risk group B (at least 1 risk factor, no DM, no TOD/CCD) Risk group C (TOD/CCD) and/or DM with or without risk factors High normal Lifestyle modification Lifestyle modification Drug therapy Stage 1 Lifestyle modification (up to 6 months) Lifestyle modification (up to 6 months) Drug therapy Stage 2 and 3 Drug therapy Drug therapy Drug therapy 11/28/2023 CVS Disorders

180. Drugs used for the treatment of HTN include: 185  V asodil ating drug s : Hy dr a la z ine  β -adrenergic blocking drugs  Atenolol, M etop r ol o l , P r opr an olol  Antiadrenergic drugs (centrally acting)  Methyldopa  Alpha ( α )-adrenergic blocking drugs  D o xazosi n , Prazosin 11/28/2023 CVS Disorders 180

181. Drugs … 186  Calcium channel blockers  Nifidipin e , V er a pa m il , Dilti a z em  Angiotensin-converting enzyme (ACE) inhibitors  C a ptopril, E nal a pril, L isinopril  Angiotensin II receptor antagonists  Los a r tan , V als a r ta n , Irbesa r tan  Diuretics  Fu r osemide (Lasix)  Spironolactone  Hydrochlorothiazide 11/28/2023 CVS Disorders 181

182. CVS Disorders 11/28/2023 182

183. DACA of Ethiopia Any one of the following classes of drugs could be used as first step agents: Diuretics Beta Blockers Calcium antagonists ACE-Is 188 11/28/2023 CVS Disorders 183

184. First line drugs for non-emergency conditions 189 Hyd r ochlo r othi a z i d e , 1 2 . 5 - 50 mg/d a y PO And/Or Nifedipine 10-40 mg, PO TID And/Or P r op r a n olol 40 - 1 6 mg PO divided i n to 2 - 4 dos e s Alternative Ena lopr i l , 2. 5 - 40 mg P O , o n ce or divided i n to t w o doses daily An/Or Methyldopa , 250-2000 mg PO in divided doses. 11/28/2023 CVS Disorders 184

185. Drugs used to treat hypertensive crisis include: ⚫ Nitroprusside, nifedipine, propranolol, captopril, hydralyzine 1. Treatment of Hypertensive Emergency  Hydralazine, 5 mg IV every 15-min  Depending on the underlying condition/TOD, furosemide , 40 mg IV can be used . 2. Treatment of Hypertensive Urgency  Nifedipine, 20-120 mg p.o in divided doses per day. OR  Captopril , 25-50 mg p.o three times daily 190 11/28/2023 CVS Disorders

186. Nursing Diagnoses ( sample ) Activity intolerance due to exacerbation of symptoms with activity Pain related to hypoxia Def i cient k no w ledge r egar d ing t h e t reat m e n t re g i m en a nd control of the disease process Nonc o m pli a nce with t h er a p e u tic regi m en rel a ted t o side effects of prescribed therapy 191 11/28/2023 CVS Disorders

187. Nursing Interventions 192 1. Improving activity tolerance 2. Alleviating pain (headache) 3. Advice about adherence to treatment 4. Nutritional advice 5. Avoiding potential complications 11/28/2023 CVS Disorders 187

188. Prevention British Hypertension Society suggestions: Dieta r y c han g es - - D ASH d iet W eig h t r educti o n Regular aerobic exercise (e.g., walking) Reduc i ng d i eta r y s u g ar i n ta k e Red u ci n g sodi u m (salt) D i sconti n u i ng tob a cco use and a l coh ol con sumption Red u ci n g s t r ess 193 11/28/2023 CVS Disorders 188

189. DASH Eating Plan L o w i n s a t u r a ted f a t, chol e st e r ol Eating fruits, vegetables, and low fat diary products Red u ced r ed m eat, s w ee t s, and sugar con t aining beverages Rich i n ma g ne s iu m , cal c iu m , po t assium, p r ot e in , and fiber Low sodium intake  Can reduce BP in 2 weeks 194 11/28/2023 CVS Disorders 189

190. Potential Complications 195  Lef t v e n tricular h ype r t r op h y  Myocardial infarction  HF  Ce r eb r o vasular accident (st r o k e or brain attacks):  Re n al ins u ffi c ienc y & f a ilu r e:  Re t ina l h e m o r rha g e: 11/28/2023 CVS Disorders 190

191. DISEASES OF TH E VE I NS Varicose vein (varicosities) Enlarged, weakened, twisted and dilated veins that have permanently lost ability to carry blood from the legs back up to the heart against the force of gravity . Most commonly occurs in lower extremities Veins in which the one-way valves aren't working well. They don't close properly, causing some of the blood to pool in the legs 11/28/2023 CVS Disorders 191

192. 11/28/2023 CVS Disorders 192

193. Causes/risk factors Heredity Sex – w omen mo r e at risk Pregnancy Obesity, aging Hormone-containing medications S t anding f or lon g pe riods T r a um a ti c inju r y to t he leg A b d o mina l s tr a ining , and c r os s in g legs P ost phlebi ti c obstruc t ion Venous and arteriovenous malformations 11/28/2023 CVS Disorders 193

194. Pathophysiology  Varicose veins may be considered primary (without involvement of deep veins) or secondary (resulting from obstruction of deep veins).  A reflux of venous blood in the veins results in venous stasis.  If only the superficial veins are affected, the person may have no symptoms but may be troubled by the appearance of the dilated veins. 199 11/28/2023 CVS Disorders 194

195. Clinical Manifestations Tired, Feeling of heaviness, aching, swollen legs Nighttime leg cramps and leg restlessness Vi si b l e , en large d v ei ns Mild s w ell in g of ankles esp e ci al l y i n e v enin g S k i n at the ank l e di s col o r ed S k i n ul c ers near the ankle In c r eas e d sus c ep ti bil i ty to inju r y and i n f e c ti on 11/28/2023 CVS Disorders 195

196. Clinical Manifestations… Appe a r ance of s p ide r v eins ( tel angi e cta s i a ) i n the af f ec t ed leg. Redness, dryness, and itchiness of areas of skin (stasis derma titi s or v enous eczema). Cramps whe n m a king a su dden m o v e a s s t anding u p . Minor injuries to the area may bleed more and/or take long ti me to heal. Lipoderm a toscl e r osis (s k i n ab o v e the ankle m a y shrink ) 201 11/28/2023 CVS Disorders

197. Varicose vein 202 11/28/2023 CVS Disorders

198. 203 11/28/2023 CVS Disorders

199. Varicose vein and spider vein pictures 204 11/28/2023 CVS Disorders

200. Di a gnosis History P h ys i cal E x am i na t ion V e n ogr ap h y (wit h x - r a y) V e n ous Du p l e x Ul t ra s ound Clot 11/28/2023 CVS Disorders 200

201. Medical management Conse r va t i v e T r ea t ment Wearing compression stockings All e viate s w elli n g & pain Help heal any skin inflammation or ulcerations Sclerotherapy 11/28/2023 CVS Disorders 201

202. 207 Sclerotherapy compression stockings 11/28/2023 CVS Disorders 202

203. Sur g e r y Micro-Surgery Phl e b e ct o m y (t o r e m o v e t he a f f ec t ed v ei n s) Li g ation and strip p ing 11/28/2023 CVS Disorders 203

204. Nursing management Discourage Bed rest and encourage ambulation F oot of t h e bed el e v a ted or E l e v a ting legs Discourage standing and sitting for long period P r o m o t in g com f o r t and u nd e rstandi n g Anal g esics can be gi v en Inspect & care for dressing if surgery has performed 11/28/2023 CVS Disorders 204

205. Prevention  E x e r cise - e .g . S w immi n g  C o n t r olli n g w eig h t and di e t  D o n ' t w ear tight clo t h e s a r o u nd wais t , leg s or groin  D o n ' t sit wi t h leg s c r o s s ed 11/28/2023 CVS Disorders 205

206. DI S ORDE R S OF TH E T I SS U E PER F US I ON AND HEMATOLOGICAL SYSTEM 11/28/2023 CVS Disorders 206

207. RBC Disorders 212 11/28/2023 CVS Disorders 207

208. An e mia  Anemia is a qualitative or quantitative deficiency of hemoglobin , in red blood cells that transports oxygen.  It is a lower than normal number of red blood cells, usually measured by a decrease in the amount of hemoglobin.  Is the most common disorder of blood which leads t o h yp o x i a i n org an s .  Not specific disease but a sign of underlying disorder. 11/28/2023 CVS Disorders 208

209. Classification Anemia can be class i fied i n a variety of w a ys, bas e d on: Production vs destruction or loss T h e m o rp h ol o g y of RBCs Underlying etiologic causes Disce rni b l e clinical s p ec t r a , e t c . 11/28/2023 CVS Disorders 209

210. Potential causes 1. Loss of RBCs —bleeding, (eg. GIT, uterus, nose, or wound) 2. Decreased production of RBCs ( ineffective hematopoiesis ): deficiency in cofactors for erythropoiesis; bone marrow suppression or lack of erythropoietin. 3. Hemolysis: overactive RES (e.g. hypersplenism) or production of abnormal RBCs (eg, sickle cell anemia) 215 11/28/2023 CVS Disorders 210

211. Causes & risk Factors  Blood loss, nutritional deficits, diseases, medication, and problems with the bone marrow,  Heavy menstrual periods  Pregnancy  Older age 11/28/2023 CVS Disorders 211

212. Clinical Manifestations Several factors influence anemia-associated symptoms: ⚫ The speed with which the anemia has developed ⚫ The duration of the anemia (ie, its chronicity) ⚫ The metabolic requirements of the individual ⚫ Other concurrent disorders or disabilities 217 11/28/2023 CVS Disorders 212

213. Types and potential causes  V i t - B 12 deficiency Ane m ia  Folate de f ic i ency A n e m ia  I r on deficiency Ane m ia  Anemia due to chronic disease  Hemolytic anemia like Sickle cell anemia  Aplastic anemia  Idiopathic anemia  Pernicious anemia 11/28/2023 CVS Disorders 213

214. Specific types of anemia 1. V i t am i n B12 d ef i ci e ncy A n e m ia Caused by a lack of vitamin B 12 . Also called Macrocytic anemia. Vitamin B 12 is essential for normal nervous system function and blood cell production . For vitamin B 12 to be absorbed by the body, it must bind to intrinsic factor , a protein secreted by cells in the stomach. 11/28/2023 CVS Disorders 214

215. Causes Diet low in vit B 12 (e.g. strict vegetarian) Chronic alcoholism Abdominal or intestinal surgery Crohn's disease Intestinal malabsorption disorders Tape worm Pernicious anemia 11/28/2023 CVS Disorders 215

216. 2. F olat e - deficiency anemia Folate, also called folic acid, is necessary for RBC formation and growth. Referred to as megaloblastic anemia Folate is not stored in the body in large amounts Occurs in about 4 out of 100,000 people. Folate - obtained from green leafy vegetables and liver. 11/28/2023 CVS Disorders 216

217. Cause/Risk factors Poor dietary intake of folic acid or Eating overcooked food Malabsorption diseases: celiac disease (sprue) Certain medications e.g. phenytoin Third trimester of pregnancy Alcoholism 11/28/2023 CVS Disorders 217

218. 3 . I r o n defic i ency anemia It is the most common form of anemia Decrease number of RBC in blood due to too little iron RBCs are not providing adequate oxygen to body tissues Girls going through puberty are high risk because of onset of menstruation Cause Too little iron in the diet Poor absorption of iron by the body Loss of blood (including from heavy menstrual bleeding) 11/28/2023 CVS Disorders 218

219. Risky groups ♣ W o m en of c hi l d -bearing age ♣ Pregnant or lactating women ♣ Infants, children, and adolescents in rapid growth ♣ People with a poor dietary intake of iron ♣ Blood lo s s: pept i c ulc e r , long te r m A S A use, c olon ca 11/28/2023 CVS Disorders 219

220. 4. Hemo l y t ic a n emia circ u la t i n g RBC s caused by Inadeq ua te nu m ber of premature destruction . It can be autoimmune , hereditary or mechanical The bon e mar r ow is unable to com p ensa t e for p r ematu r e destruction . T ype s : S i ckl e - c e ll ane m ia, Idiop a t h ic autoi mm une hemolytic anemia, Thalassemia , etc 11/28/2023 CVS Disorders 220

221. Normal and Sickle shaped RBC 226 11/28/2023 CVS Disorders

222. Causes 227  Abnormal hemoglobin: Sickle cell anemia, Thalassemia  Enzyme deficiencies: Glucose-6-phosphate dehydrogenase deficiency  Acquired Hemolytic Anemia: Antibody-related  Iso-antibody/transfusion reaction  Autoimmune hemolytic anemia 11/28/2023 CVS Disorders

223. Cause … 228  Liver disease  Trauma/ Mechanical heart valve  Hypersplenism  Infection  Certain medications  Inherited disorders 11/28/2023 CVS Disorders

224. Common Symptoms of sickle cell anemia 229  Paleness  Yellow eyes/skin  Fatigue  Breathlessness  Rapid heart rate  Delayed growth and puberty  Susceptibility to infections  Ulcers on the lower legs  Jaundice  Bone pain  Attacks of abdominal pain  Fever 11/28/2023 CVS Disorders

225. The patient may also have:  Bloody urine (hematuria )  Frequent urination  Excessive thirst  Chest pain  Poor eyesight/blindness  Painful erection (priapism) 230 11/28/2023 CVS Disorders

226. There are several types of crises: ۩ He m olyt i c cr i sis ۩ Splen i c seque st ration cr i sis ۩ A p las t ic cr i sis 11/28/2023 CVS Disorders 226

227. 5. I d i o pathic Aplas t ic Ane m ia Is a failure of the bone marrow to properly form all types of blood cells Results from injury to the stem cell Also called pancytopenia Cause is unknown, but is thought to be an autoimmune process. 11/28/2023 CVS Disorders 227

228. It may be related to: Chemotherapy, Radiation therapy, Toxins, Drugs, Pregnancy, Congenital disorder or Systemic lupus erythematosus , etc 11/28/2023 CVS Disorders 228

229. 234 11/28/2023 CVS Disorders 229

230. Assessment and Diagnostic Findings Physical Exam & history CBC Hgb concentration, Hct, ESR, RBC folate level, serum vit B 12 , RFT Iron tests (serum level, binding capacity, % saturation) Bone marrow aspiration and biopsy Urinary casts or blood in the urine Elevated bilirubin Erythropoietin levels 11/28/2023 CVS Disorders 230

231. Treatments for anemia Treatment depends on severity and the cause. Treatment goals:  to get RBC counts or Hgb levels back to normal  to treat the underlying cause of the anemia 11/28/2023 CVS Disorders 231

232. Iron deficiency anemia I r on su p p l e me n t s - f or s e v eral months or l o n g er If the underlying cause of iron deficiency is loss of b l oo d , the sou r ce of b l eedi n g m ust be locate d an d stopped . Meat, p o ult r y , fish, e g gs, d a i r y p rod u cts, or i r o n - f o r tifi e d f o o ds a r e the b est so ur ces of i r on f o u n d in food. F er r u s sulfate 11/28/2023 CVS Disorders 232

233. Vitamin B 12 deficiency anemias Pernicious anemia is treated with injections — often lifetime injections — of vitamin B 12 . Folic acid deficiency anemia is treated with folic acid supplements 11/28/2023 CVS Disorders 233

234. Anemia of chronic disease There's no specific treatment for this type of anemia. It can be focused on treating the underlying disease. Iron and vitamin supplements don't help If symptoms become severe, a blood transfusion or injections of synthetic erythropoietin , may help stimulate RBC production. 11/28/2023 CVS Disorders 234

235. Blood transfusions to boost levels of RBC Bone marrows transplantation- Immune-suppressing medications after bone marrow transplantation Aplastic anemia 11/28/2023 CVS Disorders 235

236. Hemolytic anemias  Avoiding suspect medications  Treating related infections  Drugs that suppress immune system like steroids or gamma globulin .  Spleen removal 11/28/2023 CVS Disorders 236

237. Sickle cell anemia ⚫ Rx for this incurable anemia include: ♣ Administration of oxygen ♣ Pain-relieving drugs ♣ Oral and intravenous fluids ♣ Blood transfusions ♣ Folic acid and antibiotics ♣ A bone marrow transplant ♣ Cancer drug hydroxyurea (Droxia) 11/28/2023 CVS Disorders 237

238. Prevention of anemia  Eat foods high in iron  Eat and drink foods that help your body absorb iron,  Don't drink coffee or tea with meals.  Make sure to consume enough folic acid and vit. B12.  Make balanced food choices.  Avoid food fads and dieting  Talk to doctor about taking iron pills (supplements): ferrous and ferric. 11/28/2023 CVS Disorders 238

239. Possible complications of Anemia  Diminishes the capability to perform physical activities.  Hypoxemia  Brittle or rigid fingernails,  Cold intolerance,  Possible behavioral disturbances in children.  Exacerbation of pre-existing cardio-pulmonary problems 11/28/2023 CVS Disorders 239

240. Shock 245 11/28/2023 CVS Disorders

241. Shock Shock is a serious, life-threatening medical condition where insufficient blood flow reaches the body tissues. R educed blood flow hinders oxygen and nutrients delivery to the tissues, and can stop the tissues from functioning properly . It is a medical emergency and one of the most common causes of death for critically-ill people. 246 11/28/2023 CVS Disorders

242. Stages of shock 247 ⚫ There are four stages of shock, although shock is a com p le x and co n t i n u o us con diti o n ◦ Initial stages ◦ Compensatory (Compensating) ◦ Progressive (Decompensating) ◦ Refractory (Irreversable) 11/28/2023 CVS Disorders

243. Initial stage 248 ⚫ Cha n ges at t ribu t ed to t h i s s t age occur a t the cell u la r l e v el and n o t de t ec t able clinical l y . 11/28/2023 CVS Disorders

244. Compensatory Stage Blood p r es s u r e r e m ains wi t hin n or m al limit s . V asocon s t rictio n , in c r ea s ed HR and cont r actili t y to maintain adequate cardiac output (SNS) The patient displays the “fight or flight” response. The body shunts blood to the brain and heart Skin i s c old and clam m y , b o w el sound s a r e hypoactive, and urine output decreases 249 11/28/2023 CVS Disorders

245. Compensatory… Ana e ro b i c m e tab o lis m and m e tab o li c acidosi s . Respiratory rate increases causing compensatory respiratory alkalosis. Mental status changes, such as confusion I f t r e atm e nt begins i n this s t a ge o f s h oc k , t h e p r ogn o s i s f or t h e pati e nt i s g o o d 250 11/28/2023 CVS Disorders

246. Progressive Stage The m e chanisms that r egulate BP can no lon g er compensate and the MAP falls bel o w no r m a l limi t s , The o v er w or k ed hea r t bec o m es dysfunc ti on a l ; Ischemia and m y oca r dial dep r ession The auto r egulato r y fu n c t io n o f the mic r oci r c ulation fails, inc r eased c a pilla r y per m eabilit y , vas o constricti on Interstitial edema and return of less fluid to the heart. 251 11/28/2023 CVS Disorders

247. Irreversible Stage Organ damage is so severe that the patient does not respond to t r eatment and cannot su r vi v e . Despite treatment, blood pressure remains low. Complete renal and liver failure, compounded by the release of necrotic tissue toxins, metabolic acidosis. Anaerobic metabolism contributes to a worsening lactic acidosis. R e se r v es of A TP a r e almo s t total l y depl e ted . Mu ltipl e o rgan dysf unct i ons p r o g r e s sing to co mpl e te orga n failu r e an d death i s im m ine nt . 252 11/28/2023 CVS Disorders

248. Summary of Clinical Findings in Shock 253 11/28/2023 CVS Disorders

249. Pathophysiology of shock 254 11/28/2023 CVS Disorders

250. Types of shock 255 ⚫ There are four common types of shock: 1. H ypovolaemic, 2. C ardiogenic, 3. D istributive and 4. O bstructive shock 11/28/2023 CVS Disorders

251. Hypovolemic shock 256 T h i s i s th e most c o m m o n type of shock and i s caused b y insufficie n t ci r culating v olum e . Cause and risk factors Ex t ern a l: Flu i d Losses  Trauma  Surgery  Vomiting  Diarrhea  Diuresis Internal: Fluid Shifts  Hemor r ha g e  Severe Burns  Ascites  Dehydration 11/28/2023 CVS Disorders

252. Pathophysiologic events in hypovolemic shock 257 11/28/2023 CVS Disorders

253. Cardiogenic shock T h i s ty pe of s h ock i s c a u s ed b y t h e f a ilu r e of t h e hea r t to p u mp ef f ecti v e l y . Cause Myocardial infarction Arrhythmias Cardiomyopathy Con gesti v e h ea r t failu r e (CHF) Ca r diac v a l v e p r obl e ms 258 11/28/2023 CVS Disorders

254. Pathop h ysio l og i c e v ents i n car diogenic shock 259 11/28/2023 CVS Disorders

255. Distributive shock As in hypovolaemic shock there is an insufficient intravascular volume of blood. This form of " relative " hypovolaemia is the result of dilation of blood vessels which diminishes systemic vascular resistance. 260 11/28/2023 CVS Disorders

256. Distributive shock 261 Examples of this form of shock are: A. Septic shock: is a type of shock caused by infection Cause Infections leading to vasodilatation caused by: – Gram negative bacteria i.e. E.coli , Proteus species, – Gr a m - positi v e coc c i , such a s s t r ept ococci – Certain fungi May be related to: ◦ Im m unosupp r essio n , Ext r emes o f ag e , Malnou r ishmen t , Ch r onic illness , I n vasi v e p r ocedu r es 11/28/2023 CVS Disorders

257. Distributive shock … 262 B. Anaphylactic shock - Caused by a severe anaphylactic reaction to an allergen , antigen , drug or foreign protein :  R elease of histamine : widespread vasodilation, leading to hypotension and increased capillary permeability. May be due to:  Penicillin sensitivity  Transfusion reaction  Bee sting allergy  Latex sensitivity 11/28/2023 CVS Disorders

258. Distributive shock … 263 C. Neurogenic shock : is the rarest form of shock Cause ⚫ Trauma to the spinal cord resulting in the sudden loss of autonomic and motor reflexes below the inj u r y l e v el ⚫ Spi n al a ne s t h esia ⚫ De p r es s ant a cti o n of m edicati o ns ⚫ Glucose deficiency 11/28/2023 CVS Disorders

259. Pathophysiologic events in circulatory shock 264 11/28/2023 CVS Disorders

260. Obstructive shock – In this situation the flow of blood is obstructed which impedes circulation and can result in circulatory arrest. Causes Cardiac tamponade Constrictive pericarditis T ension pneum o thor a x Massive pulmonary embolism Aortic stenosis- obstruct the ventricular outflow tract 265 11/28/2023 CVS Disorders

261. Endocrine shock 266 ⚫ R e c e ntl y a fift h for m o f shock has b e en intr o duced due t o endocrine disturbances 11/28/2023 CVS Disorders

262. Clinical manifestations of shock Type of shock Hypovolemic Cardiog enic Obstructi ve Distributiv e shock Septic shock Neurogenic Anaphyla ctic Sign and Symptoms  Anxiety, restlessness, altered mental state  Hypotension  A rap i d, w ea k , thready pulse  Cool, clammy, mottled skin  Rapid and shallow respirations  Hypothermia  Thirst and dry mouth  Fatigue  Dilated pupil S/S of h y povolae m i c shock PLUS D iste n ded jugular veins, A bse n t pulse S/S of h y povolae m ic shock PLUS Distended j ugular veins, Pulsus paradoxus S/S of h y povolae m ic shock PLUS Pyrexia and fever, or h y per t her m i a - in the initial stage V a s odilat i on & increased cardiac output S/S of h y povolae m ic shock PLUS warm and dry skin Skin eruption L oca l ized edema Weak & rapid pulse Brea t hle s sne s s & cough 11/28/2023 CVS Disorders 262

263. Di a gn o sis 268  Clinical  CBC  Blood cultures 11/28/2023 CVS Disorders

264. Treatment of shock In the early stages, shock requires immediate intervention to preserve life , even before a diagnosis is made. Re-establishing perfusion to the organs is the primary goal through restoring and maintaining the circulating blood volume to effective cardiac function, and preventing complications. 269 11/28/2023 CVS Disorders

265. T r eatmen t … Raising blood pressure to be able to transport "safely"; If surgery is required, it should be performed within the first hour to maximize the patient's chance of survival. 270 11/28/2023 CVS Disorders

266. Treatment … 271 1. Hypov o l a e m ic shock If caused by bleeding  Control bleeding  Restore volume with infusions of balanced salt solutions  Blood transfusions -for loss of large amounts of blood (e.g. > 20% of blood volume) 11/28/2023 CVS Disorders

267. Treatment … If due to burns, diarrhoea, vomiting, etc : Infusions of electrolyte solutions that balance the lost fluid P r e v ent m etabolic ac i d o sis As soon as the airway is maintained and oxygen administered the next step is to commence replacement of fluids via the intravenous route 272 11/28/2023 CVS Disorders

268. T r eatmen t … 273 The most common fluids used are:  Crystalloids - Such as sodium chloride (0.9%), Ringer's lactate  Blood - Essential in severe hemorrhagic shock  Coll o ids 11/28/2023 CVS Disorders

269. T r eatmen t … 2. Cardiogenic shock Depending on the type of MI , one can infuse fluids or in shock refractory to i n f usin g fluid s gi v e dru g s Inotropic agents- (like calcium, Digoxin, Dopamine, Dobutamine,) Flu i d r eplace ment wi t h intr a v enous infusions; Use of vasopressing drugs to induce vasoconstriction; Use o f ant i - shock t r ousers 274 11/28/2023 CVS Disorders

270. T r eatmen t … 275 3. Distributive shock  Treating infection with antibiotics and supportive care  Anaphylaxis is treated with adrenaline & Corticosteroids Neurogenic shock  Trendelenburg position to shunt blood back to the body's core  Vasopressors like adrenaline, noradrenaline, dubutamine, dopamine, ephederine etc. 11/28/2023 CVS Disorders

271. T r endelenburg positi on 276 11/28/2023 CVS Disorders

272. T r eatmen t … 4. Obstruc t i v e shock The only therapy consists of removing the obstruction. Pneumothor a x / haem o thor a x i s t r eated b y inse r ti ng che st tube Pulm o na r y emb o lis m r equi r es th r o m b o l ysis o r embolectomy T a m pon a de i s t r eated b y dr a inin g flu i d f r om t he peric a r dial space th r ou g h peric a r diocen t esis 277 11/28/2023 CVS Disorders

273. T r eatmen t … 5. Endocrine shock C orrect ing the hormone disturbances. Hypothyroidism -supplementation by means of levothyroxine Adrenal insufficiency is treated by supplementing corticosteroids 278 11/28/2023 CVS Disorders

274. Than k you!! 279 11/28/2023 CVS Disorders