Some classifications
separate this system into two distinct systems:
the cardiac system and the vascular system. However, they are so interconnected that they
are more frequently studied and assessed at the same time. The cardiovascular system is comprised of
the heart and all vessels within the body called arteries and veins to the
smallest units called arterioles and capillaries, respectively, where
oxygen transfer occurs.
The heart is a two-sided, four-chambered muscular organ. The left side of the heart pumps the
oxygen-rich blood it receives from the lungs to all parts of the body. The right side receives oxygen-depleted blood
back from the body and returns it to the lungs where it can be
re-oxygenated.
The vessels that
distribute oxygenated blood from the left side of the heart are arteries. Veins return deoxygenated blood to the right
side of the heart, which sends it to the lungs for oxygen replenishment. This system allows for a constant cycling and
replenishing of oxygen to the blood which is vital for cellular life.
Some of the various
cardiac and vasculature system conditions and care considerations appear below:
Heart Disease (also called Cardiovascular
Disease): is a general descriptive term used to indicate
an illness or condition that affects any part of the heart and its normal
functioning. It may include the
coronary arteries (the arteries that provide oxygen solely to the heart), the
electrical conduction system which effects and regulates the heart rhythm, the
valves of the heart chambers which regulate blood flow, or the actual muscle of
the heart (myocardium).
Commonly, heart disease
is diagnosed after a heart attack (myocardial infarction or “MI”), which occurs
when blood flow to coronary arteries is blocked. MIs usually result from coronary artery
disease (CAD), the most common form of heart disease. Narrowing of the coronary arteries’ lumens is
caused by a build-up of plaque (atherosclerosis). The narrowing of these vessels decreases
blood flow to the heart tissue (myocardium).
As the openings, lumens, of the cardiac arteries become blocked, the
supply of oxygen to the heart decreases.
Ultimately, the heart itself doesn’t have enough oxygen to continue its
function. Heart attacks (MIs) usually
result from these blockages, causing ischemia, injury and death of cardiac
muscle.
This disease could also
include angina,
which often presents as a heart attack with the associated symptoms of burning,
crushing pressure, or squeezing tightness.
Often these symptoms exacerbate with exertion, emotions, increased food
consumption, and cold air, and could be preemptive signs of potential heart
attacks.
Defects of any of the four heart valves
(which act as two-way toggle switches) can also be included in this
category. Heart valves regulate the
amount of blood flow into and out of the heart.
They open and close based upon pressures of the fluid within each heart
chamber, as well as working with other anatomical structures. Like any pump, the heart requires intake and
output values that regulate the pressures in the chambers of the heart to
direct flow from one chamber to the next. Once the pressure on one side is
maximized, fluid is released and allowed to enter the next chamber.
When the valves no
longer hold complete seals, blood can leak in or seep out of the chamber, making it
difficult to pump blood effectively and completely. Sometimes, valve malfunctions can be detected
during regular medical check-ups, due to the sounds picked up using a
stethoscope, “heart murmurs.” Deficits due to heart valve dysfunction
diminish the effectiveness of the heart because blood is not contained and
regulated completely causing a decrease in blood that is pumped to the body.
Arrhythmias (irregular
and abnormal heart beatings and rhythms), and other cardiac conduction issues may also
contribute to heart disease but rarely cause the disease itself. Arrhythmias can result from myocardial
infarctions, stress, increased caffeine consumption, and various other
factors. Over time, they can cause
cardiomyopathy (enlarged heart tissue growth), eventually leading to heart
failure.
Care
Considerations for Cardiovascular Disease:
1) Weight loss and
dietary changes prove most effective.
Decreasing salt decreases potential water weight retention and edema and
possible hypertension, thus lessening stress on the heart. Weight loss
decreases risk for diabetes, paramount in ensuring small blood vessels can
provide oxygenated blood to small capillaries that supply the eyes, feet,
heart, etc. Extra fluid retention causes exertion by the
heart muscle, which increases oxygen demand and increases edema into tissues. Dietary changes, such as minimizing
fats and cholesterol, as well as eating vegetables, fruits, and whole grains,
provide additional benefits beside weight loss.
These include the decrease or elimination of the need for anti-cholesterol
medication (statins) when dietary cholesterol is decreased. With increased fiber, cholesterol is
eliminated in the stool. Decreases of
sugar and processed sodium allow decreases in hypertensive medication and
improved diabetes management.
2) Smoking cessation is key, and various
aids are available on the market to assist in this endeavor. Even if full elimination is not achieved,
decreasing the daily intake of tobacco products is worthwhile.
3) Regular exercise
and decreasing stress often work together.
Exercise increases effort by your heart and blood vessels and
directly increases blood flow to all parts of your body, strengthening the
heart muscle and increasing oxygenation of the body even during rest. Exercise also decreases stress because
you increase endorphins, which are “brain hormones” that provide feelings of
well-being. With exercise, the signs and
symptoms of diabetes and excessive fats or lipids in the blood (hyperlipidemia)
can be lessened.
4) Medication is often prescribed and may
alleviate and postpone the adverse symptoms and progression of the
disease. Medications that may be
prescribed include anti-hypertensives (to decrease high blood pressure),
diuretics (water pills), statins (to decrease cholesterol), beta
blockers (to regulate heart rate and rhythms), sublingual nitroglycerin (for
angina pain and symptoms), and aspirin (to decrease platelet
aggregation).
5) In severe cases, surgical
intervention may be required. This
includes coronary artery bypass graft (CABG) or percutaneous transluminal
coronary angioplasty (PTCA) during a cardiac catheterization. Pacemakers may be surgically implanted
to regulate dysrhythmias
Heart Failure (also called Congestive Heart
Failure): is a disease that affects the pumping
action of one side of the heart, the left or right ventricle, such that it
no longer meets the body’s demand for oxygen.
It typically is caused from coronary artery disease or myocardial
infarctions that weaken the heart muscle.
The left
ventricle
of the heart pumps oxygenated blood received from the lungs to the entire body,
via the arteries. When that side of the
heart does not pump effectively, fluid is retained in the left ventricle, backs
up and returns to the lungs. Pulmonary
dysfunction ultimately resulting in loss of oxygen to the body occurs. With diminished oxygenation and pulmonary
congestion, the patient may exhibit shortness of breath, diminished and
adventitious lung sounds as fluid is retained in the lungs, activity
intolerance, high heart rate (tachycardia) due to increased oxygen demand,
faintness and light headedness. Blood oxygen is not available to meet the
needs of the individual.
The
right side of the heart and venous system receives deoxygenated blood
back from the body sending it to the lungs for oxygen recovery. If this side of the heart fails,
because the right ventricle cannot eliminate all the liquid, systemic edema
results. In this case, fluid cannot
be eliminated, so it eventually flows back to where it was received, from the
body, primarily notable by swelling in the extremities. The patient exhibits edema in the extremities
and tissues, unexplained weight gain, abdominal distention, and bloating in
organs such as the liver and spleen. Fluid is trapped. It cannot be eliminated because the right
side of the heart cannot effectively pump the fluid received from body
tissues. Right-sided heart failure is
often secondary to left-sided heart failure.
Care
Considerations for Heart Failure:
1) Patients are usually on fluid restrictions
to decrease the accumulation of fluid that the heart must pump. Strict attention to fluid volume is required
and must be measured. In addition, low-sodium
diets are also key because excess sodium causes the body to hold water.
2) Medication to
improve heart function and to aid the body is often prescribed. These include diuretics (water-pills)
to promote elimination of water via the renal system and cardiac drugs
to increase the heart’s pumping action.
Other medications may include potassium supplements, if diuretics are
used.
3) Because of pulmonary congestion,
numerous actions should be taken. Supplemental
oxygenation may be prescribed due to the patient’s shortness of breath and
may be used especially during exertion. Ambulation
and activities should be increased as much as can be tolerated. Utilize a pulse oximeter (giving blood
oxygen level as well as pulse rate) to ensure adequate oxygen is
obtained. In addition, coughing and
deep breathing exercises should be practiced promoting full expansion of
the lungs. Listen to lung sounds. Often fluid backs up into these organs and is
heard as “crackles”. These sounds are
typically heard in the lung bases first.
Position head of bed to a sitting position to promote oxygenation
4) Due to systemic and portal congestion,
measures are taken to decrease problems associated with edema. Fluid is retained in the lower extremities
first, due to gravity. Pedal pulses
should be checked to ensure continued blood flow. Likewise, check skin color for pallor, cyanosis,
and signs of venous stasis which can lead to skin breakdown. Elevate legs, perform range of motion
exercises, and promote ambulation as tolerated to promote fluid return.
5) If fluid
accumulates in the organs, anorexia and nausea may be present. Promote frequent small meals rather than
large ones. Ensure fluid restrictions
are maintained.
Peripheral Vascular Disease (PVD ): is a
condition that is caused by partial or complete blood flow blockage, typically
occurring in the lower extremities. It
may affect both venous and arterial flow, causing pain and often evidenced
by changes to the skin and decreases in pulses in the feet (pedal pulses). Because blood flow is obstructed by
atherosclerosis (plaque build-up), a loss of elasticity of the vein walls
(arteriosclerosis), clot formation (deep vein thrombosis), or other disease
processes, such as diabetes, for example, there is a decrease in oxygen to the
extremities if arterial blood flow is obstructed or stasis of blood when
pooling of fluid occurs if venous return is compromised. This condition often results secondary to
hypertension (high blood pressure), stroke, diabetes, and hyperlipidemia (high
blood cholesterol). It is a major
cause of amputation. Pain is the hallmark of the disease and when
the pain occurs identifies the origin of the disease.
Rest pain (pain during
inactivity) occurs with arterial insufficiency because there is a
decrease in the pumping of the blood by the arteries to the lower
extremities. When the body moves, blood
is artificially pumped by activity, thus increasing circulatory flow. Reduced blood flow occurs during rest
without the movement that pushes blood to the legs and feet. This leads to decreased oxygen to the tissues
which results in pain and potential skin breakdown, because tissues die without
enough oxygen. Typically, it’s felt as a
burning pain that increases when the legs are elevated, because gravity doesn’t
aid in the transport of oxygenated blood to these far tissues. Blood flow to
the legs increases when the legs are lowered (dependent), and pain decreases
because the tissues receive oxygen. This
pain has been described as cold and numbing because tissues lack oxygen. Skin is pale when elevated, due to lack of
arterial (oxygenated) blood circulation.
With gravity and movement, the skin color becomes red, circulation
increases, and pain decreases.
Claudication (derived from Latin
meaning lameness) is a pain that occurs during activity and is caused by
the inability of the vessels to return venous blood back to the heart. This is the opposite of “resting pain.” As activity pumps blood to the extremities,
because of the insufficiency of valves in the vein or arteriosclerosis, for
example, the fluid is trapped in the vessels, seeps into the tissues and
does not transport back to the heart.
The stasis of the deoxygenated blood and consequential edema causes
pain. As activity increases, so does
the pooling of the fluid in the lower extremities. When the legs are elevated, cramping and pain
subside. This is classic for this
condition. Skin can become shiny and
swollen (extremely edematous); pedal pulses are not able to be felt; skin
breakdown can occur rapidly.
Signs and symptoms are
quite similar for both conditions and related to oxygen compromise to the
tissues, but they result from different causes. As noted above, what distinguishes these
diseases process is WHEN the pain
occurs – at rest or during activity. Both
have signs that include hair loss in the lower extremities, shiny and
taunt skin, cold feet and lack or diminished pedal pulses, feet and ankles that
are discolored and duskier that other areas of the leg, thick toenails,
potential skin breakdown that quickly leads to gangrene and other infectious
processes that may lead to systemic involvement.
Care
Considerations for Peripheral Vascular Disease (PVD ):
1) Medication is often prescribed to
promote vasodilatation (to open vessels promoting fluid return) as well as
low-dose aspirin to decrease blood clot formation.
2) Smoking cessation and weight reduction
are pivotal in increasing function.
Decreases in smoking readily increase circulatory function as well as
decreasing venous vasospasms. Weight
loss increases ambulatory efficiency in promoting arterial flow and reducing
venous stasis.
3) Assess pedal pulses, extremity and color
changes from toes to legs. Decreases
in circulation can be noted in color changes going from toes to thighs. Check perfusion to lower extremities
bilaterally (both left and right) using pulse oximeter. Effects of PVD
are not bilateral.
4) Position changes are effective to
enhance circulation and positional shifts should be completed often to decrease
skin breakdown. Elevate legs that
exhibit venous claudication. Allow
gravity to assist arterial flow by keeping legs low if they are exhibiting
resting pain. Avoid sitting crossed
legged and the use of knee stockings that decrease blood flow.
5) Warm colder tissues with light
blankets to promote circulation. Caution
should be paramount in using electric or hearted blankets; loss of circulation
often decreases feeling. This can lead
to burns and tissue damage.
6) Exercise
promotes circulation. It promotes
collateral circulation to establish additional vessels to aid in decreasing
edema. If pain develops, rest is
necessary to prevent fluid overload. In
addition, exercise promotes transport of oxygen and nutrients to the
tissues.
7) Skin and foot care should be
meticulous. Wash and dry without
rubbing, which may damage skin. Pay
special attention to the areas between the toes. Use lotion and powder as appropriate. Mirrors can be used to examine feet for
breakdown, ulcers, and necrotic areas, common with arterial insufficiency or
venous stasis. Seek professional help.
Deep Venous Thrombosis (DVT): is a condition caused by a clot (thrombus)
that is usually lodged in a deep tissue of one of the lower extremities. The clot can result in partial or complete
obstruction of the vein’s flow. The
obstruction’s ensuing stasis (stopping of normal flow) of blood can lead to
severe edema, loss of pulses and loss of oxygenation below the clot. This can eventually lead to tissue death,
necrosis, and amputation if prolonged.
However, this is not the major and most life-threatening result of a
DVT.
The venous system returns blood from the
body back to the heart and eventually to the lungs for reoxygenation. A thrombosis can dislodge, travel anywhere in
the venous system, and then settle in a new place where it again halts blood
flow to that tissue. This traveling
thrombosis is called an embolus. Emboli
may lodge in the heart arteries (causing MIs) or the brain (causing
stokes). But more often they terminate
in the lungs, termed a pulmonary embolus, causing respiratory failure and
potentially death.
This condition often occurs during a
post-operative phase,
due to prolonged sitting and inactivity, and any illness that prohibits blood
flow and return to the lower extremities, such as diabetes, right-sided heart
failure, and prolonged episodes of bed rest, as well as use of oral
contraceptives and estrogen therapy.
Care
Considerations for Deep Venous Thrombosis (DVT):
1) The goal is to reduce and eliminate the
thrombus and prevent it from traveling, especially to the lungs. This is achieved by increasing tissue
perfusion, minimizing risks, and administration of anti-coagulants.
2) Check both extremities for skin color,
temperature, and edema. The affected
appendage may show pallor (paleness), warmth, and puffiness which may range
from mild to severe. Check pulses by
applying pulse oximeter to one of the toes on both feet. Perform all tasks to both sides (bilaterally)
and note differences (asymmetry) from one side compared to the other. Ideally, without compromise to the venous
flow, both sides should be equal.
3) Using a tape
measure, measure and record the circumferences of extremities at their
widest point below the thrombus. Then
continue to measure daily. To ensure
consistent placement of the tape, initially mark tape position on both
extremities to provide accurate placement of the tape measure. This provides a baseline and subsequent gauge
of blood flow increases or further obstruction.
4) Anti-coagulant
therapy is often prescribed. These
drugs do not dissolve clots. Rather,
they act in preventing additional clot formations as well as maintaining the
size of existing clots, so they do not increase. These drugs can be taken
orally or injected into the tissues.
This class of drug is also used for a heart arrhythmia problem called
“atrial fibrillation,” to help prevent clots from traveling to the brain
causing stokes. These drugs cause
decreased coagulation and stop clots from forming. Therefore, they increase risks for bleeding
and steps must be taken to minimize these bleeding risks. Simple steps and tender care are required
such as using a soft toothbrush to prevent gum bleeding, shaving with an
electric razor to minimize nicks and cuts, refraining from going barefoot, to
decrease feet and toe injuries, wearing gloves to protect hands during home or
outside activities, and keeping nasal passages moist with humidification to
eliminate dryness and forceful nose blowing.
Additionally, contact sports should be excluded, and use of sharp
instruments such as cooking or gardening tools must be monitored. In
general, decrease ANY and ALL
risks for bleeding while using these drugs.
Lastly, avoid any kinds of OTC medications that may potentiate bleeding
which include aspirin, NSAIDS, ibuprofen, Vitamin E, gingko biloba, and any
other drug that minimizes blood clot formation.
5) At-home therapies to
the affected area may also increase perfusion to tissues. These include warm compresses,
compression stockings, avoiding crossing one’s legs, as continued pressure
behind the knees obstructs blood flow. Do not perform rubbing massages to the
affected extremity, as this may disrupt and move the blood clot.
6) Pain is often exhibited. Administer analgesics, such as Tylenol or
other prescribed medication as needed.
Due to a swollen and painful appendage, provide pain relief before any
physical therapy.
7) It is important to promote deep breathing
to ensure complete lung expansion. This
also assists in utilizing other pulmonary muscles in eliminating fluids. This is especially vital if the patient is on
bed rest due to the injury.
8) As appropriate, increase fluid intake. Fluids
are necessary to prevent dehydration.
In addition, lack of fluid can increase blood thickness (viscosity) and
cause additional risk for clots due to blood pooling (venous stasis).
9) Some
common signs of pulmonary distress, if the DVT dislodges and migrates to
the lungs, include impending doom verbalized by the patient (classic sign),
trouble breathing (dyspnea) with low pulse oximeter reading, high heart rate
(tachycardia), low blood pressure (hypotension), chest pain, and loss of
consciousness. Call 911 immediately!
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Contact information:
Diane R. Beggin, RN
40 Sycamore Drive
Montgomery, NY 12549
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