Chapter 4 – Cardiovascular Nursing Process

Cardiac assessment: rate and rhythm

• Normal rate:  60-100 (+/-) bpm
• Bradycardia:  < 60 bpm
• Tachycardia:  > 100 bpm
• Regular
• Irregular
  • Regular-irregular
  • Irregular-irregular

Cardiac assessment:  pulses

• Assessment of all pulses indicates (1) effectiveness of the pump and (2) effectiveness of the vasculature system
• Carotid
• Brachial
• Radial
• Ulnar
• Femoral
• Popliteal
• Dorsalis pedis
• Posterior tibialis

Cardiac assessment:  general circulation

• Warmth
• Color
• Edema
• Skin integrity
• Evidence of non-healing wounds
• Compare right to left

Hypertension 

• A major risk factor for developing other cardiovascular conditions because:
  • It does not always produce its own symptoms
  • Many are unaware they have hypertension
  • It is easily ignored

JNC 8 (2014) Guidelines

• After age 50, SBP >140 is a more important risk factor than DBP
• A 90% risk of developing HTN exists even in those age 55 who are normotensive
• 120-139/80-89 is prehypertensive; patients should begin lifestyle modifications
• Most patients with HTN need 2+ medications
• Thiazide diuretics should be used to treat uncomplicated HTN
• Effective therapy requires patient motivation
• Empathy builds trust and promotes motivation

JNC 8 Hypertension Management

• Lifestyle interventions apply throughout all treatment recommendations
• Blood pressure goals and medication treatment based on
  • Age
  • Diabetes
  • Chronic kidney disease

“Instant” teaching points regarding HTN

• It is not the same as anxiety
• Once you are diagnosed, you are on medication for life*
• It is defined as systolic blood pressure > 140 mmHg
• Most cases of HTN are classified  as primary HTN—the underlying cause is not known

*some exceptions!

Results of untreated hypertension

• Atherosclerosis of the aorta and large vessels accelerates
• Left ventricular hypertrophy develops
• Proteinuria due to increased renal arteriole pressure
• Vascular changes in the retina (A-V “nicking”)
• Increased stroke risk

Nursing management—patients with HTN

• Evaluate BP bilaterally and in lying, sitting and standing positions
• Blood pressure varies with time of day and with activity
• Respond to “white coat hypertension”
• Home blood pressure monitoring must be confirmed 

Nursing management—patients with HTN

• High blood pressure screening
• Promote healthy lifestyle
• Low fat diet
• Low sodium diets
• Weight control
• Exercise
• Smoking cessation
• Controlled alcohol consumption
• Monitor effects of medication

Medication management of hypertension

• Initial treatment usually involves diuretics
• Second medication selected pertaining to patient’s health status
• β-blockers can cause bradycardia, fatigue, exercise intolerance
• Postural hypotension can occur with adrenergic inhibitors and α-blockers
• Dry cough, hyperkalemia can occur with ACE inhibitors and angiotensin receptor blockers
• Calcium channel blockers (esp. Benzothiazepines) may cause decreased cardiac output and slow conduction

Treatment of cholesterol based on ASCVD, age, and diabetes

• Clinical ASCVD
  • If > age 75, moderate intensity treatment of cholesterol
  • If < age 75, high intensity treatment of cholesterol
• No clinical ASCVD
  • If LDL-C > or = 190 mg/dL, high intensity treatment
  • If LDL-C < 190 mg/dL and patient is diabetic, consider moderate intensity treatment
  • If LDL-C < 190 mg/dL and patient is diabetic and other risk factors are present, consider high intensity treatment

Benefits of the “statins”

• Lower LDL cholesterol
• Anti-inflammatory
• Antithrombotic
• Protect plaque stability
• Generally well tolerated
  • Atorvastatin (Lipitor)
  • Fluvastatin (Lescol XL)
  • Lovastatin (Mevacor)
  • Pravastatin (Pravachol)
  • Rosuvastatin (Crestor)
  • Simvastatin (Zocor)

Characteristics of metabolic syndrome

• Abdominal fat cells secrete hormones promoting heart disease and diabetes
• Patients have below-normal HDL
• Decreased insulin sensitivity (level of insulin required to process glucose)

Long term consequences of Metabolic Syndrome

• Cardiovascular disease
• Stroke
• Diabetes
• Obesity
• Hypertension
• Alzheimer’s disease
• Stroke
• Cancer
• Kidney failure

Treatment plan for metabolic syndrome

• Cholesterol lowering drugs
• Antihypertensives
• Diet high in omega-3 fatty acids
• Avoid processed foods
• Exercise 30-45 minutes moderate intensity

Ischemic heart disease in the elderly

• Chest pain is not always present
• Fatigue
• Weakness
• Shortness of breath
• GI disturbances

Chest pain

• Caused by a mismatch between what the body is able to deliver and what the body requires
• Supply ischemia—due to decreased blood flow to the heart
• Demand ischemia—due to increased demand for oxygen
• In stable angina, chest pain is relieved with rest
• Prinzmetal’s occurs at rest, often between midnight and early morning
• If not relieved by rest, can progress to myocardial infarction

Other causes of chest pain

• Pericarditis
• Heartburn, ulcers
• Chondritis
• Pulmonary embolus, pneumonia
• Herpes zoster

Treatment of angina

• Nitroglycerin is a vasodilator
• NTG is treatment of choice
• Comes in tablets, sprays, patches, ointment, IV, sublingual
• Tablets for acute attacks
• Transdermal, capsules, ointments do not work rapidly enough during acute attacks
• Repeat tablet every 5 minutes for acute attack
• If no resolution after 3 tablets, patient must be transported to hospital

Heart failure

• Heart no longer able to provide sufficient cardiac output
• Men develop after an MI; women after long-standing HTN
• Compensatory events
  • Increased heart rate
  • Renin → angiotensin I → angiotensin II → increased BP and sodium and water retention
• Risk factors:
  • Coronary artery disease
  • Hypertension