MED SURG Cardiovascular

7/28/2019 MED SURG Cardiovascular

1/10

MED SURG UNIT 3 EXAM REVIEW (CH35,36,37)

CHAPTER 35

1. Hypertension preload versus after loadThree factors affect stroke volume: preload, contractility, and afterload.

Preload.

Preload is the amount of blood remaining in a ventricle at the end of diastole or the pressuregenerated at the end of diastole. Increased preload results in increased stroke volume and,

therefore, increased cardiac output. Factors that increase preload include increased venous

return to the heart and overhydration. Factors that decrease preload include dehydration,hemorrhage, and venous vasodilation.

Contractility.

Contractility is the ability of cardiac muscle fibers to shorten and produce a muscle contraction.

Inotropy is a term used to refer to the contractile state of the cell. Factors that increasecontractility are said to have a positive inotropic effect, and factors that decrease contractility

create a negative inotropic effect.

Afterload.Afterload is the amount of pressure the ventricles must overcome to eject the blood volume. It is

determined primarily by the pressure in the arterial system. Afterload is decreased by

vasodilation and increased by vasoconstriction.

2. KNOW WHAT IS MODIFIABLE AGE P631Risk Factors.

Factors that increase the risk of atherosclerosis include increased serum lipids, high bloodpressure, cigarette smoking (nicotine), diabetes mellitus with elevated blood glucose, obesity,

sedentary lifestyle, age, gender, race, and heredity. These risk factors are divided into two

categories: risk factors that can be modified and those that cannot be modified. Risk factors thatcannotbe modified are age, gender, heredity, and race. The focus of patient education is onreducing the risk factors that can be modified. Other factors that may also contribute to the

development of coronary heart disease are stress, sex hormones, birth control pills, excessive

alcohol intake, and high homocysteine levels.Healthy People 2010 has set several goals related to serum lipid levels. One of these is to reduce

the mean total blood cholesterol in adults from 206 mg/dL to 199 mg/dL. In addition, efforts will

be made to reduce the proportion of adults with high blood cholesterol, increase the proportion ofadults who have had their blood cholesterol checked within the past 5 years, and increase the

proportion of individuals with CAD who have LDL levels treated to the goal of equal to or less

than 100 mg/dL

3. TEE DIAGNOSTIC TESTTRANSESOPHAGEAL ECHOCARDIOGRAM

At times, the echocardiogram is not diagnostic and a transesophageal echocardiogram (TEE) is

used. A flexible endoscopic probe with an ultrasound transducer is passed down the back of thethroat into the esophagus. A local anesthetic to the throat decreases the gag reflex. Occasionally,

an intravenous sedative is needed to reduce patient anxiety. Images are obtained from behind the

heart as the probe moves down into the stomach. The probe is down for approximately 15 to 20

1


2/10

minutes. The TEE provides information useful in the evaluation of ventricular wall motion and

function and possible heart valve disorders.

4. NURSING INTERVENTION WILL BE IMPORTANT WITH THE TEE TEST

FOR PT SAFETY

Used when conventional echocardiogram not diagnostic.Probe inserted through esophagus into stomach (behind heart).

Same purpose as echocardiogram

Tell patient what to expect: throat will be anesthetized, may have IV.Signed consent required.

Monitor vital signs, gag reflex, and, if sedated, level of consciousness

5. FIVE CHARACTERISTICS OF A NORMAL SINUS RHYTHM

The normal finding is called a normal sinus rhythm, which is characterized by the following:

1.A rate of 60 to 100 bpm

2.A regular rhythm 3.A P wave preceding each QRS complex

o 4.A PR interval that is within 0.12 to 0.20 second

5.A QRS complex that is 0.10 second or less

6. WHAT MEDS ARE ACE INHIBITORS AND HOW IT AFFECTS THE

ARTERIAL SYSTEM ON PATIENTS

ACEinhibitors may be prescribed for some patients to minimize the abnormal shaping or

remodeling that can occur in the damaged ventricular muscle.

ACEinhibitors decrease preload and afterload by blocking the RAA system, resulting in

vasodilation, decreased blood volume, and lower blood pressure. In addition, ACEinhibitors

are thought to limit the progression of ventricular remodeling.

Angiotensin-converting enzyme (ACE) inhibitors (ACEI) work against the renin-angiotensin-

aldosterone system to dilate arteries and decrease the resistance to blood flow in the arteries

(reduced afterload). In addition, less fluid is retained because aldosterone release is blocked.

ACEinhibitors are prescribed for patients with heart failure, some cases of hypertension, and in

some cases after myocardial infarction Examples of these medications are captopril (Capoten),

enalapril (Vasotec), and quinapril (Accupril).

7. ATHEROSCLEROSIS :KNOW THE CONDITION

Atherosclerosis, a form of arteriosclerosis, is an inflammatory disease that begins withendothelial injury and progresses to the complicated lesion seen in advanced stages of the disease

process. Atherosclerosis begins with injury to the endothelial cells that line the wall of thearteries. Endothelial injury, which leads to inflammation and dysfunction of the endothelial cells,

results in the deposit of LDLs along the intima of arteries. These deposits are calledfoam cells.

When enough foam cells accumulate, they progress to the lesions associated with

atherosclerosis: fatty streaks, fibrous plaque, and complicated (advanced) lesions.

2


3/10

Progression of Lesions.

Fatty Streak.

The fatty streak is the earliest lesion to develop in atherosclerosis. Yellow-colored lipids (fat)fill smooth muscle cells, producing streaks of fat that cause no obstruction to the affected vessel.

It is commonly found in the aorta by age 10 and in coronary arteries by age 15 regardless of race,

gender, or environmental factors. The fatty streak is thought to be reversible. There are nosymptoms associated with these lesions.

Fibrous Plaque.

The fibrous plaque is the characteristic lesion of progressing atherosclerosis, which developsover time. Smooth muscle cells, chronically stimulated by LDLs and platelet activated growth

factors, proliferate, produce collagen, and migrate over the fatty streak. This forms a fibrous

plaque that protrudes out from the wall of the artery into the lumen. Other substances (WBCs,

platelets, lipids, calcium) adhere to and collect within the plaque. The fibrous plaque is whitishor grayish appearing, may develop in one portion of the artery or circle the entire lumen, and

may have smooth or rough edges. Fibrous plaque contributes to the loss of arterial elasticity and

impairs the vessel's ability to vasodilate to meet increased oxygen needs.

Complicated Lesions.Complicated lesions develop as ulceration or rupture of the plaque occurs and platelets adhere to

the lesion. Platelet adherence can trigger the coagulation cascade with the development of athrombus that obstructs (occludes) the artery.

Collateral Circulation.

If plaque formation occurs slowly, collateral circulation may develop. Collateral blood vesselsare new branches that grow from existing arteries to provide increased blood flow.

Risk Factors.

Factors that increase the risk ofatherosclerosis include increased serum lipids, high blood

pressure, cigarette smoking (nicotine), diabetes mellitus with elevated blood glucose, obesity,sedentary lifestyle, age, gender, race, and heredity. These risk factors are divided into two

categories: risk factors that can be modified and those that cannot be modified. Risk factors that

cannotbe modified are age, gender, heredity, and race. The focus of patient education is onreducing the risk factors that can be modified. Other factors that may also contribute to the

development of coronary heart disease are stress, sex hormones, birth control pills, excessive

alcohol intake, and high homocysteine levels.Healthy People 2010 has set several goals related to serum lipid levels. One of these is to reduce

the mean total blood cholesterol in adults from 206 mg/dL to 199 mg/dL. In addition, efforts will

be made to reduce the proportion of adults with high blood cholesterol, increase the proportion of

adults who have had their blood cholesterol checked within the past 5 years, and increase theproportion of individuals with CAD who have LDL levels treated to the goal of equal to or less

than 100 mg/dL (Centers for Disease Control and Prevention/National Institutes of Health,

2005).

8. EXPLAIN UNSTABLE ANGINA ; DIFFERENCE BETWEEN STABLE AND

UNSTABLE

Angina pectoris (shortened to angina), or chest pain, the most common symptom of CAD,

results when the demand for oxygen by the myocardial cells exceeds the supply of oxygendelivered. There are different types ofangina: stable, unstable, and variant. Stable angina (also

called chronic angina orexertionalangina) occurs most often with exercise or activity and

3
http://evolveebooks.elsevier.com/books/978-1-4160-3114-7/content/id/B9781416031147500675_bib130http://evolveebooks.elsevier.com/books/978-1-4160-3114-7/content/id/B9781416031147500675_bib130http://evolveebooks.elsevier.com/books/978-1-4160-3114-7/content/id/B9781416031147500675_bib130http://evolveebooks.elsevier.com/books/978-1-4160-3114-7/content/id/B9781416031147500675_bib130


4/10

usually subsides with rest. Other precipitating factors are smoking, physical exertion, emotional

stress, and heavy meals. The pain is usually substernal and described by the patient as viselike,

burning, squeezing, or smothering. The pain may radiate to either arm, the shoulder, the jaw, theneck, or the epigastrium. Accompanying symptoms are diaphoresis, dyspnea, nausea, and

vomiting.

Stable angina occurs intermittently and is often predictable. Usually, stable angina lastsonly a few minutes and is relieved by rest or with nitroglycerine (NTG).

Unstable angina (categorized and treated as an acute coronary syndrome) is also called

crescendo angina orpreinfarction angina. The pain of unstable angina is more severe,

occurs at rest or with minimal exertion, is often not relieved by NTG or requires more

frequent NTG administration, and is not predictable. Unstable angina may occur in a

patient with a history of stable angina. The patient may describe a change in the pain pattern

or in the severity of the pain. Or, unstable angina may be the first clinical manifestation of CADthat a patient experiences. In either case, unstable angina is considered more serious than stable

angina and will be treated differently. Patients with unstable angina are at higher risk for acute

myocardial infarction (AMI) and are often hospitalized for diagnostic workup and treatment.

9. HEART MURMURS CAUSED BY VALVES THAT DO NOT CLOSE WELL.

READ ABT THE CONDITION

AGE-RELATED CHANGES

It is difficult to separate the normal age-related changes in the heart and blood vessels from thechanges caused by disease. In general, age-related changes progress slowly, whereas pathogenic

changes are more likely to be sudden.

HEART

Changes in the heart muscle include increased density of connective tissue and decreasedelasticity. Cardiac contractility may decline, making the heart less able to adapt to changes in

circulating blood volume. The valves may thicken and stiffen. If they do not close properly, the

patient may have a murmur. The valves may also partially block the path of blood flow, causingincomplete emptying of the chambers.

The number of pacemaker cells in the SA node decreases, as does the number of nerve fibers in

the ventricles. The aging heart takes longer to respond to stress and then responds lessdramatically. It also takes longer to return to normal after exercise or stress. Cardiac

dysrhythmias are more common in older people but should still be evaluated because they can be

dangerous.

Health Promotion ConsiderationsLong-Term Conditioning

Long-term conditioning with an exercise program may help decrease arterial stiffening and

improve the function of the left ventricle in older individuals. Physical exercise does not have to

be strenuous to be helpful. Activity should become a part of an individual's regular routine.Table 35-2 Grading of Heart Murmurs

GRADE DESCRIPTION

I Very faint

II Faint, but recognizable

III Loud, but moderate in intensity

IV Loud and accompanied by a palpable thrill

4


5/10

GRADE DESCRIPTION

VVery loud, accompanied by a palpable thrill, and audible with the stethoscope partially

off the client's chest

VI Extremely loud, may be heard with the stethoscope slightly above the client's chest

Heart Murmurs.

A heart murmur is the sound produced by turbulent blood flow across the valves. Murmurs are

recorded as having high, low, or medium pitch, and they are located using the anatomiclandmarks where they are heard best. The timing of a murmur relates to when it is heard in the

cardiac cycle: systole or diastole. Murmurs are graded according to intensity or loudness (Table

35-2).

10.& 11 .WHY IS IT IMPORTANT TO CK FOR BLEEDING AT THE PUNCTURE

SITE WITH CARDIAC CATHERIZATION PTS?

A catheter is passed through a vein or artery and dye is injected.

Radiographs are taken to visualize heart structures and blood vessels.The procedure is done in a special room.

Blood pressure, pulse, and ECG are monitored throughout test.Tell patient what to expect. Assess allergies to seafood or iodine and inform radiologist. NPO for

specified time before procedure.

Tell patient to expect flushing sensation when dye is injected. Give sedative if ordered.

Signed consent required.Check puncture site; maintain pressure per protocol if a vascular sealing device is not used.

Monitor vital signs and peripheral pulses on affected extremity.

Enforce bed rest as ordered.

CARDIACCATHETERIZATION (CARDIAC ANGIOGRAPHY, CORONARY

ARTERIOGRAPHY)Cardiaccatheterization is a procedure in which a catheter is inserted into a vein or artery and isthreaded into the heart chambers, coronary arteries, or both, under fluoroscopy (Fig. 35-6). A

contrast dye is injected through the catheter, and films are made of the visualized heart

structures. Vital signs and ECG are monitored during the procedure.

In a catheterization of the right side of the heart, the catheter is inserted into a vein and threadedinto the vena cava, RA, RV, and pulmonary artery. Pressures in the RA, RV, and pulmonary

artery may be determined. The function of the pulmonic and tricuspid valves may be assessed.

In a catheterization of the left side of the heart, the catheter is inserted into an artery andthreaded against the flow of blood into the coronary arteries or the LV. The femoral vein and

artery are the preferred insertion sites. The function of the coronary arteries and the aortic and

mitral valves may be assessed. Blood samples may be drawn, and pressures in the variousstructures are measured.

Complications of cardiac catheterization include bleeding, hematoma formation, infection,

and embolus or thrombus formation. Nursing care before and after the procedure is very

important.

11. SEE #10 WHAT DO U CK BEFORE GOING TO HAVE THIS PROCEDURE

AND WHAT ALLERGIES?

5
http://evolveebooks.elsevier.com/books/978-1-4160-3114-7/content/id/B9781416031147500407_cetable2http://evolveebooks.elsevier.com/books/978-1-4160-3114-7/content/id/B9781416031147500407_cetable2http://evolveebooks.elsevier.com/books/978-1-4160-3114-7/content/id/B9781416031147500407_f6http://evolveebooks.elsevier.com/books/978-1-4160-3114-7/content/id/B9781416031147500407_cetable2http://evolveebooks.elsevier.com/books/978-1-4160-3114-7/content/id/B9781416031147500407_cetable2http://evolveebooks.elsevier.com/books/978-1-4160-3114-7/content/id/B9781416031147500407_f6


6/10

12. TESTS TO DETECT MYOCARDIAL INFARCTIONS ALSO LDH 3-6 DAYS

Troponin

Troponin is a protein involved in the contraction of muscles. Two subtypes, troponin T (cTnT)

and troponin I (cTnI) are specific to cardiac muscle and are released into the circulation after anacute myocardial infarction. Troponin levels, generally not detectable in healthy individuals, will

elevate significantly after an acute myocardial infarction. Levels may elevate slightly as a resultof lesser insults, such as an episode of angina. Troponin levels rise in 3 to 6 hours from onset

of symptoms, peak in 24 hours, and remain in the circulation for up to 2 weeks. This test is

done in the emergency department because the results are available more quickly than the

cardiac enzymes.

Troponin T (cTnT) and troponin I (cTnI) are proteins released from cardiac muscle when the

muscle is damaged. Troponin levels elevate in 3 hours after myocardial injury, peak in 24 hours,

and remain in the circulation for up to 2 weeks (cTnI remains elevated for 5 to 7 days; cTnT for

10 to 14 days). Troponin levels may be drawn in the emergency room

Creatine Phosphokinase

The creatine phosphokinase enzyme is found in high concentration in three tissues: the brain, the

heart, and the skeletal muscle. The type of creatine phosphokinase (CPK) specific to heart tissue

is CPK-MB. Elevation of the CPK-MB level indicates damage to the myocardial cells. The

CPK-MB can be expected to rise 4 to 6 hours after an AMI, peak in 12 to 24 hours at more

than 6 times the normal value, and return to normal within 2 to 3 days if no new damage

occurs. Serial trends should be observed. The nurse can plot these trends. Musculo-skeletalinjuries (especially fractures and surgery) and recent excessive athletic activity can also elevate

the total CPK level.

Lipid Profile

A lipid profile is a battery of tests that measure the most common serum lipids: cholesterol,triglycerides, and lipoproteins.

Cholesterol is a blood lipid produced by the liver. It is used to form bile salts for the digestion of

fat and for the production of adrenal, ovarian, and testicular hormones. The normal adult serumcholesterol level is less than 200 mg/dL. Elevated cholesterol levels (hypercholesterolemia)

are associated with increased risk of CAD, hypertension, and AMI. The cholesterol

accumulates in the arterial lumen and in time results in decreased blood flow and

occlusion.

13. LDL(LETHAL) VS HDL( HEALTHY) LEVELS

Several forms of cholesterol are identified; however, the high-density lipoproteins (HDLs) and

the low-density lipoproteins (LDLs) are the two that most closely correlate with coronary

artery disease.The HDLs are desirable because they promote the excretion of cholesterol;

therefore higher levels of HDLs are encouraged. On the other hand, elevated LDL levels areassociated with a higher risk of CAD; therefore lower LDL levels are encouraged. A good way

to remember the difference is that HDLs are healthy and LDLs are lethal . Currently, the

recommendations are for HDL levels greater than 40 mg/dL and for LDL levels less than 100mg/dL (American Heart Association, 2007). Triglycerides are a major contributor to CAD.

They are produced in the liver. Triglyceride levels increase when LDL levels increase. The

normal triglyceride level is less than 150 mg/dL.

6
http://evolveebooks.elsevier.com/books/978-1-4160-3114-7/content/id/B9781416031147500675_bib442http://evolveebooks.elsevier.com/books/978-1-4160-3114-7/content/id/B9781416031147500675_bib442


7/10

Low HDL levels can be raised by being physically active at least 30 minutes every day, by

not smoking, and by losing weight (or maintaining a healthy weight).

14. KNOW THAT ATROPINE INCREASES THE HEART RATE AND MONITOR

PT FOR TACHYCARDIA AND URINE RETENTION

ATROPINE SULFATE

Usage: Vagal blocker. Increases HR and CO in heart blocks and severe bradycardia. Used in

symptomatic bradycardia and bradydysrhythmias.Nursing interventions: Assess HR and rhythm and BP.

15. KNOW THE THERAPEUTIC LIPID LEVELS

Lipid-Lowering Agents

Lipid-lowering medications are frequently part of the overall treatment plan, along with diet and

exercise, for many patients with heart disease. The goal of therapy is for the patient to have

decreased serum triglyceride and LDL levels and an improved HDL level. Patients on this

group of medications need to be encouraged to adhere to diet restrictions, exercise, andquit smoking. Serial laboratory tests (lipid profile and liver function) will be closely monitored.

Selected lipid-lowering medications are included in the Drug Therapy table on p. 645.

LIPID-LOWERING AGENTS

Cholestyramine (Questran)

Prescribed when diet, exercise, and weight loss fail to bring cholesterol levels under control.Lowers LDL cholesterol. Increases HDL cholesterol.

Interferes with absorption of some other drugs, so check drug-drug interactions before giving.

To get the best effect, teach patients:

Continue diet and exercise. Increase fluid intake to counter constipating effects

Gemfibrozil (Lopid)

Decreases synthesis and secretion of VLDL by liver. Decreases triglyceride levels.For best effect, teach patient:

Continue diet and exercise.

Take with meals.

Nicotinic acid (niacin)

Decreases synthesis/secretion of VLDL and LDL by liver. Increases HDL.

For best effect, teach patient:

Continue diet and exercise. Take with meals to decrease GI side effects.

Pravastatin (Pravachol);Simvastatin (Zocor);Lovastatin (Mevacor),Atorvastatin (Lipitor)

Increases rate of removal of LDL from plasma. Decreases synthesis of LDL.Monitor liver function tests.

For best effect, teach patient:

Continue diet and exercise. Report muscle tenderness.

Take as single dose in the evening

Have routine eye examinations

7


8/10

16. KNOW THE S/S OF FUILD VOLUME EXCESS AND CHF

Fluid Volume Excess

related to decreased

glomerular filtration rate,

increased aldosterone,sodium and water

retention, and increased

antidiuretic hormonerelease

The patient will have normal

fluid balance as evidenced

by weight of 145 lbs,

absence of edema, absenceof crackles and wheezes in

lungs, and ability to

participate in activities ofdaily living without dyspnea.

Monitor for jugular venous distentionand peripheral edema. Auscultate heart

and lung sounds q 4 hr. Measure weight

daily and intake and output accurately.

Maintain intravenous lines and correctfluid infusion rate. Administer diuretics

as ordered. Teach about sodium

restriction and rationale. Protectedematous extremities from pressure or

injury.

Fluid Volume Excess

Fluid retention is a response to HF, an attempt to maintain normal cardiac output .

Unfortunately, it compounds the problem by increasing the workload on the heart. Therefore

measures are taken to reduce the fluid volume to normal while improving the function of the

heart. Administer diuretics as ordered, and monitor the patient for adverse effects. The mostcommon adverse effects of diuretic therapy are fluid and electrolyte disturbances. Signs andsymptoms that may indicate fluid or electrolyte disturbances include cardiac dysrhythmias,

muscle weakness or twitching, cramps, changes in mental status, and abdominal distention.

Frequent serum electrolyte measurements are usually ordered. Note the results and notify the

physician of abnormal findings. If hourly urine output is being measured, report an output

of less than 30 mL/hr to the physician as well. The patient should be weighed daily.

An intravenous catheter is usually placed to provide a line for drug administration. Ifintravenous fluids are administered, monitor the rate of administration very carefully. If

fluid retention is not relieved by other means, fluid restriction may be instituted. All staffshould know the exact amount of fluid allowed and must record all intake. Fluid restriction can

be very uncomfortable for the patient. Even with fluid volume excess, the patient may feel thirstybecause of electrolyte imbalances. Present oral fluids in small containers, and offer them atreasonable intervals. Frequently provide mouth care. The patient and family must understand

why fluids are restricted so that the patient does not exceed the prescribed intake.

CHF

The most common therapeutic dietary measure for CHF is sodium restriction. The patient

may be limited to 2 g of sodium/day. In severe cases, a limitation of 500 to 1000 mg/day may be

prescribed. Reduced sodium intake decreases fluid retention, thereby reducing the cardiacworkload. For a 2-g sodium diet, advise the patient to avoid foods high in sodium (a list should

be provided), not to add salt before or after cooking, and to use no more than 2 cups of milk

products daily. Patients often have difficulty changing their use of seasonings. Acknowledge thedifficulty, and explain how sodium limitation contributes to improvement of cardiac function.

It is best to identify the type of diet to be prescribed on discharge as early as possible. This

allows time for a dietary consultation to be arranged, which should be followed by reinforcementby the nurse. The person who prepares the patient's meals at home must be included in the

teaching sessions.

17. WHAT DO U DO BEFORE DIGOXIN?

8


9/10

CARDIAC GLYCOSIDES

Digoxin

(Lanoxin)

Delays impulse conduction throughAV node to slow heart rate (negativechronotropic effect). Increases strength

or force of myocardial contraction

(positive inotropic effect). Increases

stroke volume and CO. Used for HF,atrial fibrillation and flutter, and

paroxysmal atrial tachycardia.

Obtain baseline vital signs, ECG, and

electrolytes before administering first dose.

Assess apical pulse for 1 min; hold and

notify physician if


10/10

Do not discontinue this drug abruptly; taper over 2 weeks.

Take at the same time(s) each day.

While on this drug, use alcohol only in moderation; no smoking; decrease sodium intake. There is not the normal increase in heart rate with exercise and stress; increase activity slowly.

Weigh daily; check for edema.

19. KNOW HOW TO ASSESS FOR ORTHOSTATIC HYPOTENSION (SEE BP)

Orthostatic hypotension, also known as postural hypotension, refers to a condition where the

blood pressure falls rapidly after a change in body position. Patients with orthostatic hypotensionusually experiencesymptoms of low blood pressurewhen they stand up after sitting or lying for

a period of time. The problem is relatively common, and tends to affect primarily older adults,

though younger patients sometimes experience the condition as well. The diagnosis of orthostatic

hypotension requires a blood pressure decline of 20mmHg in the systolic pressure or 10mmHg inthe diastolic pressure within five minutes of rising from a seated or lying position.

Blood Pressure.

The correct-size blood pressure cuff must be used. Position the arm at the heart level, and check

the blood pressure in both arms. Note the pulse pressure (difference between the systolic anddiastolic pressures) because it is a noninvasive measure of cardiac output. Next, measure blood

pressures and pulse rates in the lying, sitting, and standing positions. A blood pressure decreaseof 20 mm Hg or more with a position change indicates decreased blood volume or an autonomic

response. As blood pressure decreases, the pulse should increase as a compensatory mechanism.

10
http://highbloodpressure.about.com/od/lowbloodpressure/a/od/lowbloodpressure/f/low-bp-symptoms.htmhttp://highbloodpressure.about.com/od/lowbloodpressure/a/od/lowbloodpressure/f/low-bp-symptoms.htmhttp://highbloodpressure.about.com/od/lowbloodpressure/a/od/lowbloodpressure/f/low-bp-symptoms.htmhttp://highbloodpressure.about.com/od/lowbloodpressure/a/od/lowbloodpressure/f/low-bp-symptoms.htm

Documents

MED SURG Cardiovascular