Cardiovascular, Respiratory, and Lymphatic Disorders Chapter 42 Cardiovascular, Respiratory, and Lymphatic Disorders Cardiovascular and respiratory system disorders are leading causes of death in the United States. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Cardiovascular Disorders The circulatory (cardiovascular) system delivers blood to the body’s cells. Problems that occur in the heart or blood vessels include: Hypertension Coronary artery disease (CAD) Angina Myocardial infarction Heart failure Dysrhythmias Many people have these disorders. Review the Body Structure and Function Review: the Circulatory System Box on pp. 697-698 in the Textbook. Review the Focus on Children and Older Persons: Cardiovascular Disorders Box on p. 698 in the Textbook. Review Box 42-1 on p. 699 in the Textbook for risk factors. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Cardiovascular Disorders (cont’d) With hypertension, the resting blood pressure is too high. Systolic pressure = 140 mm Hg or higher; or Diastolic pressure = 90 mm Hg or higher Pre-hypertension will likely develop into hypertension in the future. Systolic pressure = 120 – 139 mm Hg; or Diastolic pressure = 80 – 89 mm Hg Causes include: Narrowed blood vessels, kidney disorders, head injuries, some pregnancy problems, and adrenal gland tumors. To have hypertension, such measurements must occur several times. Most people have hypertension at some point during their lives. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Cardiovascular Disorders (cont’d) Hypertension can lead to: Stroke Hardening of the arteries Heart attack Heart failure Kidney failure Blindness Life-style changes can lower blood pressure. A diet low in fat and salt A healthy weight Regular exercise Not smoking Limiting alcohol and caffeine Managing stress and sleeping well Certain drugs can lower blood pressure. A person can be unaware of hypertension for many years. That is why hypertension is called “the silent killer.” Signs and symptoms develop over time. Headache, blurred vision, dizziness, and nosebleeds occur. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Cardiovascular Disorders (cont’d) In coronary artery disease (CAD; coronary heart disease; heart disease), the coronary arteries become hardened and narrow. One or all of the arteries are affected. The heart muscle gets less blood and oxygen The most common cause is atherosclerosis. The major complications of CAD are: Angina Myocardial infarction (heart attack) Irregular heartbeats Sudden death The more risk factors, the greater the chance of CAD and its complications. The coronary arteries are in the heart. They supply the heart with blood. With atherosclerosis, plaque—made up of cholesterol, fat, and other substances—collects on artery walls. The narrowed arteries block blood flow. Blockage may be total or partial. Blood clots can form along the plaque and block blood flow. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Cardiovascular Disorders (cont’d) CAD can be treated. Treatment goals are to: Relieve symptoms. Slow or stop atherosclerosis. Lower the risk of blood clots. Widen or bypass clogged arteries. Reduce cardiac events. CAD requires life-style changes. The person must: Quit smoking. Exercise. Reduce stress. Eat a healthy diet. If over-weight, lose weight. A healthy diet is needed to lower blood pressure, lower blood cholesterol, and maintain a healthy weight. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Cardiovascular Disorders (cont’d) Some persons need drugs to: Decrease the heart’s workload and relieve symptoms. Prevent a heart attack or sudden death. Delay the need for medical and surgical procedures that open or bypass diseased arteries. CAD complications may require cardiac rehabilitation. The cardiac rehab team includes: Doctors (the person’s doctor, heart specialist, heart surgeon) Nurses Exercise specialists, physical and occupational therapists, dietitians, and mental health professionals Cardiac rehab has two parts. Exercise training Education, counseling, and training The person learns how to exercise safely. Exercises are done to strengthen muscles and improve stamina (staying power, endurance). The exercise plan is based on the person’s abilities, needs, and interests. The person learns: about his or her heart condition, how to reduce the risk of future problems, how to adjust to a new life-style, and how to deal with fears about the future. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Cardiovascular Disorders (cont’d) Angina (pain) is chest pain from reduced blood flow to part of the heart muscle (myocardium). It occurs when the heart needs more oxygen. It is described as tightness, pressure, squeezing, or burning in the chest. Symptoms can be relieved. Rest often relieves symptoms in 3 to 15 minutes. A nitroglycerin tablet is taken when angina occurs. Some persons have nitroglycerin patches. Things that cause angina are avoided. Chest pain lasting longer than a few minutes and not relieved by rest and nitroglycerin may signal a heart attack. The person needs emergency care. Pain can occur in the shoulders, arms, neck, jaw, or back. Pain in the jaw, neck, and down one or both arms is common. Nausea, fatigue, and weakness may occur. Some persons complain of “gas” or indigestion. Rest reduces the heart’s need for oxygen. Therefore, normal blood flow is achieved. Heart damage is prevented. Nitroglycerin tablets placed under the tongue dissolve and are rapidly absorbed into the bloodstream. They are kept within the person’s reach at all times. The person takes a tablet and then tells the nurse. The nurse applies and removes nitroglycerin patches. Over-exertion, heavy meals and over-eating, and emotional stress are avoided. Cardiac rehabilitation is helpful. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Cardiovascular Disorders (cont’d) With myocardial infarction (MI), part of the heart muscle dies. Sudden cardiac death (cardiac arrest) can occur. MI also is called: Heart attack Acute myocardial infarction (AMI) Acute coronary syndrome (ACS) Coronary Coronary thrombosis Coronary occlusion In MI, blood flow to the heart muscle is suddenly blocked. A thrombus (blood clot) blocks blood flow in an artery with atherosclerosis. The damaged area may be small or large. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Cardiovascular Disorders (cont’d) CAD, angina, and previous MI are risk factors. MI is an emergency. Efforts are made to: Relieve pain. Restore blood flow to the heart. Stabilize vital signs. Give oxygen. Calm the person. Prevent death and life-threatening problems. The person may need: Medical or surgical procedures to open or bypass the diseased artery Cardiac rehabilitation See Box 42-2 on p. 701 in the Textbook for signs and symptoms. The goals are to recover and resume normal activities, prevent another MI, and prevent complications such as heart failure or sudden cardiac arrest. Review the Focus on Long-Term Care and Home Care: Myocardial Infarction Box on p. 701 in the Textbook. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Cardiovascular Disorders (cont’d) Heart failure or congestive heart failure (CHF) occurs when the weakened heart cannot pump normally. When the left side of the heart cannot pump blood normally, blood backs up into the lungs. Respiratory congestion occurs. The person has dyspnea, increased sputum, cough, and gurgling sounds in the lungs. When the right side of the heart cannot pump blood normally, blood backs up into the venous system. Feet and ankles swell. Neck veins bulge. Liver congestion affects liver function. The abdomen is congested with fluid. A very severe form of heart failure is pulmonary edema (fluid in the lungs). With left-sided failure, the body does not get enough blood. Signs and symptoms occur from the effects on other organs. With right-sided failure, less blood is pumped to the lungs, causing the left side of the heart to receive less blood. The left side then has less blood to pump to the body. As with left-sided heart failure, organs receive less blood. The signs and symptoms of left-sided failure occur. Pulmonary edema is an emergency. The person can die. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Cardiovascular Disorders (cont’d) Common causes of heart failure are: CAD MI Hypertension Diabetes Age Irregular heart rhythms Damaged heart valves Kidney disease A damaged or weak heart usually causes heart failure. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Cardiovascular Disorders (cont’d) Treatment involves: Drugs are ordered to strengthen the heart. Drugs are ordered to reduce the amount of fluid in the body. A sodium-controlled diet is ordered. Oxygen is given. Semi-Fowler’s position is preferred for breathing. The person must reduce CAD risk factors. If acutely ill, the person needs hospital care. Review the list of aspects of the person’s care you assist with on p. 701 in the Textbook. Many older persons have heart failure. Skin breakdown is a risk. Tissue swelling, poor circulation, and fragile skin combine to increase the risk of pressure ulcers. Good skin care and regular position changes are needed. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Cardiovascular Disorders (cont’d) Dysrhythmia is an abnormal heart rhythm. The rhythm may be: Too fast, too slow, or irregular Dysrhythmias are caused by: Changes in the heart’s electrical system CAD, MI, or heart failure Weakening and changes in the heart muscle Drug and alcohol abuse Excess caffeine intake Thyroid problems Some drugs Some dysrhythmias are minor. Others are life-threatening. Changes in the heart’s electrical system may result from hypertension. The person may feel dizzy or light-headed and have fluttering in the chest, chest pain, or dyspnea. The person may faint. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Cardiovascular Disorders (cont’d) Treatment depends on the type of dysrhythmia. Drugs may be given. A procedure may be needed. Defibrillation or cardioversion—an electrical shock is given to stop an abnormal rhythm Ablation—areas of tissue in the heart sending abnormal electrical signals are destroyed Internal devices may be placed. Pacemaker—device that is inserted under the skin near the heart; it monitors and regulates the heart’s rhythm. Implantable cardioverter defibrillator (ICD)—used for life- threatening dysrhythmias; it delivers a shock when the heart is in a life-threatening rhythm; some devices are both a pacemaker and an ICD. With a pacemaker, one or more wires (leads) are placed in the heart muscle and connected to the pacemaker. The pacemaker sends signals through the leads to stimulate the heart to beat normally. The shock from an ICD allows the return of a regular heart rhythm. Review the Focus on Long-Term Care and Home Care: Dysrhythmias Box on p. 702 in the Textbook. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Respiratory Disorders The respiratory system brings oxygen (O2) into the lungs and removes carbon dioxide (CO2) from the body. Respiratory disorders that interfere with this function and threaten life include: Chronic obstructive pulmonary disease (COPD) Chronic bronchitis Asthma Sleep apnea Influenza Pneumonia Tuberculosis Review the Body Structure and Function Review: The Respiratory System Box on p. 703 in the Textbook. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Respiratory Disorders (cont’d) Chronic obstructive pulmonary disease (COPD) involves two disorders that interfere with the exchange of oxygen and carbon dioxide in the lungs. Chronic bronchitis and emphysema Risk factors for COPD include: Cigarette smoking; pipe, cigar, and other tobaccos Exposure to second-hand smoke Not smoking is the best way to prevent COPD. COPD has no cure. COPD affects the airways and alveoli. Airways and alveoli become less elastic. The walls between many alveoli are destroyed. Airway walls become thick, inflamed, and swollen. Airways are clogged by excess mucus secretion. These disorders obstruct airflow. Lung function is gradually lost. With COPD, less air gets into the lungs; less air leaves the lungs. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Respiratory Disorders (cont’d) Chronic bronchitis occurs after repeated episodes of bronchitis. Bronchitis means inflammation of the bronchi. Smoking is the major cause. Infection, air pollution, and industrial dusts are risk factors. Smoker’s cough in the morning is often the first symptom. Treatment involves: The person must stop smoking. Oxygen therapy and breathing exercises are often ordered. Respiratory tract infections are prevented. If one occurs, the person needs prompt treatment. At first, the cough is dry. Over time, the person coughs up mucus. Mucus may contain pus. The cough becomes more frequent. Mucus and inflamed breathing passages obstruct airflow into the lungs. The body cannot get normal amounts of oxygen. The person has difficulty breathing and tires easily. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Respiratory Disorders (cont’d) In emphysema, the alveoli enlarge and become less elastic. As a result, some air is trapped in the alveoli when exhaling. Over time, more alveoli are involved; O2 and CO2 exchange cannot occur in affected alveoli, trapping more air in the lungs. Smoking is the most common cause. Air pollution and industrial dusts are risk factors. The person has shortness of breath and a cough. Breathing is easier when the person sits upright and slightly forward. Treatments The person must stop smoking. Respiratory therapy, breathing exercises, oxygen, and drug therapy are ordered. Trapped air is not exhaled. The person develops a barrel chest. At first, shortness of breath occurs with exertion. Over time, it occurs at rest. Sputum may contain pus. Fatigue is common. The person works hard to breathe in and out. The body does not get enough oxygen. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Respiratory Disorders (cont’d) With asthma, the airway becomes inflamed and narrow. Extra mucus is produced. Signs and symptoms include: Dyspnea Wheezing and coughing Pain and tightness in the chest Asthma usually is triggered by allergies. Other triggers include air pollutants, smoking, second-hand smoke, respiratory infections, exertion, cold air. Sudden attacks (asthma attacks) can occur. Asthma is treated with drugs. Severe attacks may require emergency care. Repeated attacks can damage the respiratory system. Symptoms are mild to severe. In a sudden attack, there is shortness of breath, wheezing, coughing, rapid pulse, sweating, and cyanosis. The person gasps for air and is very frightened. Fear makes the attack worse. The person and family learn how to prevent asthma attacks. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Respiratory Disorders (cont’d) In sleep apnea, pauses in breathing occur during sleep. Pauses last from a few seconds to over a minute. They can occur many times during sleep. The most common cause is blockage of the airway. Obstructive sleep apnea—during sleep, muscles in the throat relax and soft tissues collapse, closing the airway. Central sleep apnea (less common)—occurs when the brain does not send signals to the muscles to breathe. Some persons have both obstructive and central sleep apnea. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Respiratory Disorders (cont’d) Signs and symptoms of sleep apnea include: Pauses in breathing during sleep Loud snoring Waking during sleep with a gasp or shortness of breath Difficulty staying asleep Daytime sleepiness Headache in the morning Dry mouth or sore throat after sleeping Treatment includes: Mild sleep apnea Life-style changes, weight loss, quitting smoking, and avoiding alcohol and sedatives before sleep More severe sleep apnea Surgery Positive airway pressure device: CPAP or BiPAP Continuous positive airway pressure (CPAP) involves a mask attached to a pump. Air pressure is forced through the mask, keeping the airway open. The same amount of pressure goes through the mask when the person inhales and exhales. Bilevel positive airway pressure (BiPAP) also involves a mask to keep the airway open but the amount of pressure changes when the person inhales and exhales. The change in pressure is more comfortable for some persons. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Respiratory Disorders (cont’d) Influenza is a respiratory infection caused by viruses. Older persons are at great risk. Pneumonia is a common complication. Treatment involves: Fluids and rest Drugs ordered by the doctor for symptom relief and to shorten the flu episode. Coughing and sneezing spread flu viruses. Follow Standard Precautions. The flu vaccine is the best prevention. Review the contents of Table 42-1 on p. 704 in the Textbook for the differences between a cold and the flu. The flu season is November through March. With treatment, most people are better in about one week. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Respiratory Disorders (cont’d) The Centers for Disease Control and Prevention (CDC) recommends the flu vaccine for persons who: Are 6 months to 4 years of age Are 50 years of age and older Have chronic heart, lung, liver, or kidney diseases Have diabetes Have immune system, nervous system, or blood disorders Are pregnant or will be pregnant during the flue season Are 6 months–18 years old and receiving long-term aspirin therapy Are nursing center or other long-term care residents Are American Indians or Alaska Natives Are very obese Are in close contact with children under 5 years of age (especially those in contact with children under 6 months) Are in close contact with adults 50 years of age and older Are health care workers Have contact with persons at high risk for flu-related complications Review the Focus on Children and Older Persons: Influenza Box on p. 705 in the Textbook. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Respiratory Disorders (cont’d) Pneumonia is an inflammation and infection of lung tissue. Affected tissues fill with fluid. O2 and CO2 exchange is affected. Bacteria, viruses, and other microbes are causes. Microbes reach the lungs by being: Inhaled Aspirated Carried in the blood to the lungs from an infection in the body Children under 2 years of age and adults over 65 years of age are at risk. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Respiratory Disorders (cont’d) Factors that increase the risk of pneumonia include: Smoking Aging Stroke Bedrest Immobility Chronic diseases Tube feedings Treatment may include: Drugs for infection and pain Increased fluid intake to treat fever and to thin secretions Intravenous therapy and oxygen Semi-Fowler’s position to ease breathing Onset may be sudden. The person is very ill. Review Box 42-3 on p. 705 in the Textbook for the signs and symptoms of pneumonia. Thin secretions are easier to cough up. Rest is important. Standard Precautions are followed. Isolation Precautions are used depending on the cause. Mouth care is important. Frequent linen changes are needed because of fever. Review the Focus on Children and Older Persons: Pneumonia Box on p. 705 in the Textbook. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Respiratory Disorders (cont’d) Tuberculosis (TB) is a bacterial infection in the lungs. It also can occur in other parts of the body. If TB is not treated, the person can die. TB is spread by airborne droplets with coughing, sneezing, speaking, singing, or laughing. Those who have close, frequent contact with an infected person are at risk. Risk factors include: Living in close, crowded areas Age Poor nutrition HIV (human immunodeficiency virus) Nearby persons can inhale the bacteria. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Respiratory Disorders (cont’d) TB can be present in the body but not cause signs and symptoms. Only persons with an active infection can spread the disease to others. Chest x-rays and TB testing can detect the disease. Signs and symptoms include: Tiredness, loss of appetite, weight loss, fever, and night sweats. Treatment involves: Drugs for TB Standard Precautions and Isolation Precautions The person covering his or her mouth and nose with tissues when sneezing, coughing, or producing sputum Flushing tissues down the toilet, placing them in a biohazard bag, or in a paper bag to be burned Hand washing after contact with sputum is essential. An active infection may not occur for many years. Cough and sputum increase over time. Sputum may contain blood. Chest pain occurs. Review the Focus on Children and Older Persons: Tuberculosis Box on p. 706 in the Textbook. Review the Focus on Long-Term Care and Home Care: Tuberculosis Box on p. 706 in the Textbook. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Lymphatic Disorders The lymphatic system drains extra fluid from the tissues, helps fight infection, and absorbs and transports fats. Lymphatic disorders that affect these functions include: Lymphedema Lymphoma Review the Body Structure and Function Review: The Lymphatic System Box on p. 707 in the Textbook. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Lymphatic Disorders (cont’d) Lymphedema is a build-up of lymph in the tissues causing edema (swelling). It occurs when there is a blockage or damage to the lymph system. Causes include: Cancer Infection Surgical removal of lymph nodes Scar tissue from radiation therapy or surgery Absent or abnormal lymph nodes present at birth Lymphedema usually affects an arm or leg. Daily activities are often affected. Damage to the lymph system cannot be reversed. Other body parts can be involved. The person may have a tight or heavy feeling and have trouble moving the body part. Thickening of the skin, pain, itching or burning, and hair loss are also common. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Lymphatic Disorders (cont’d) Treatment for lymphedema includes: Elastic garments or bandages Exercise Good skin care Massage therapy The goals are to: Control swelling. Decrease pain. Improve movement and use of the body part. Allow daily activities. Pressure applied by elastic garments or bandages helps move fluid and prevents fluid build-up. Review the Promoting Safety and Comfort: Lymphedema Box on p. 708 in the Textbook. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Lymphatic Disorders (cont’d) Lymphoma is cancer involving cells in the immune system (lymphocytes). Lymphocytes are a type of WBC that protect the body from infection. They are found in lymph nodes and other lymph tissues. In lymphoma, these cells do not function normally. There are two main types of lymphoma: Hodgkin lymphoma Non-Hodgkin lymphoma Lymphoma begins with an abnormal lymphocyte. The abnormal cell divides and makes more abnormal cells. A mass of abnormal cells develops into a tumor. Hodgkin and non-Hodgkin lymphoma differ in the types of cells involved and how they spread and respond to treatment. These cells cannot protect the body. They also live longer than normal. Signs and symptoms of lymphoma are also caused by other health problems or infections. See Box 42-4 on p. 708 in the Textbook. Tests are done for diagnosis. Treatment may include chemotherapy, radiation, or both. Psychological, social, and spiritual support are needed. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.