ATI – Medical Surgical – Unit 4 Nursing Care of Clients with Cardiovascular Disorders

Cardiovascular Disorders – Diagnostic Procedures : Overview
Cardiovascular diagnostic procedures evaluate the functioning of the heart by monitoring for enzymes in the blood; using ultrasound to visualize the heart; determining the heart’s response to exercise; and using catheters to determine blood volume, perfusion, fluid
status, how the heart is pumping, and degree of artery blockage.
Cardiovascular Disorders – Diagnostic Procedures : Procedures that Nurses should be familiar with
o Cardiac enzymes (cardiac markers) and lipid profile
o Echocardiogram
o Stress testing (exercise electrocardiography)
o Angiography
Cardiovascular Disorders – Diagnostic Procedures : Cardiac Markers
• Cardiac enzymes are released into the bloodstream when the heart muscle suffers ischemia.
• Cardiac enzymes are a specific marker in diagnosing an MI.
Cardiovascular Disorders – Diagnostic Procedures : Lipid Profile
A lipid profile provides information regarding cholesterol levels and is used for early detection of heart disease.
Cardiovascular Disorders – Diagnostic Procedures : Cardiac Markers : Indications
o Angina
o MI
o Heart disease
o Hyperlipidemia
Cardiovascular Disorders – Diagnostic Procedures : Interpretation of findings: Cardiac Enzyme: CREATINE KINASE MB isoenzyme (CK-MB) – more sensitive to Myocardium
EXPECTED REFERENCE RANGE: 0% of total CK (30 to 170 units/L)
ELEVATED LEVELS
(First detectable following myocardial injury) : 4 to 6 hours
EXPECTED DURATION OF ELEVATED LEVELS: 3 days
Cardiovascular Disorders – Diagnostic Procedures : Interpretation of findings: Cardiac Enzyme: TROPONIN T
EXPECTED REFERENCE RANGE: less than 0.2 ng/L
ELEVATED LEVELS
(First detectable following myocardial injury) : 3 to 5 hours
EXPECTED DURATION OF ELEVATED LEVELS: 14 to 21 days
Cardiovascular Disorders – Diagnostic Procedures : Interpretation of findings: Cardiac Enzyme: TROPONIN I
EXPECTED REFERENCE RANGE: less than 0.03 ng/L
ELEVATED LEVELS
(First detectable following myocardial injury) : 3 hours
EXPECTED DURATION OF ELEVATED LEVELS: 7 to 10 days
Cardiovascular Disorders – Diagnostic Procedures : Interpretation of findings: Cardiac Enzyme: MYOGLOBIN
EXPECTED REFERENCE RANGE: less than 90 mcg/L
ELEVATED LEVELS
(First detectable following myocardial injury) : 2 hours
EXPECTED DURATION OF ELEVATED LEVELS: 24 hours
Cardiovascular Disorders – Diagnostic Procedures : Interpretation of findings: Lipid Profile Test: Cholesterol Total
EXPECTED REFERENCE RANGE: Less than 200 mg / dl
PURPOSE: Screening Test for heart disease
Cardiovascular Disorders – Diagnostic Procedures : Interpretation of findings: Lipid Profile Test: HDL
EXPECTED REFERENCE RANGE: Greater than 40 mg / dl
PURPOSE: “Good” cholesterol produced by the liver
Cardiovascular Disorders – Diagnostic Procedures : Interpretation of findings: Lipid Profile Test: LDL
EXPECTED REFERENCE RANGE: Less than 130 mg /dl
PURPOSE:
Cardiovascular Disorders – Diagnostic Procedures : Interpretation of findings: Lipid Profile Test: TRIGLYCERIDES
EXPECTED REFERENCE RANGE: less than 150 mg/dl
PURPOSE: Evaluating test for atherosclerosis
Cardiovascular Disorders – Diagnostic Procedures : Cardiac Enzymes: Pre, Intra and Post
• Preprocedure
o Nursing actions
• Explain the reason for the test to clients.
• Intraprocedure
o A blood specimen is drawn from the client via venipuncture.
• Postprocedure
o Laboratory findings will be discussed with clients by the provider, and choice of treatment will be determined.
Cardiovascular Disorders – Diagnostic Procedures : Echocardiogram
An echocardiogram is an ultrasound of the heart. The test is used to diagnose valve disorders and cardiomyopathy.
Cardiovascular Disorders – Diagnostic Procedures : Echocardiogram : Indications
o Cardiomyopathy
o Heart failure
o Angina
o MI
Cardiovascular Disorders – Diagnostic Procedures : Echocardiogram : Interpretation of Findings
An echocardiogram can be used to determine blood flow insufficiency, cardiac tissue damage, and valve disorders. This test can also be used to measure the size and depth of the heart, ejection fraction and cardiac output.
Cardiovascular Disorders – Diagnostic Procedures : Echocardiogram : Preprocedure
Nursing actions
• Explain the reason for the test to clients. The test is pain-free and takes up to 1 hour
Cardiovascular Disorders – Diagnostic Procedures : Echocardiogram : Intraprocedure
Nursing actions
• Position clients on left side with the head of the bed elevated 15° to 20° and instruct them to remain still.
Cardiovascular Disorders – Diagnostic Procedures : Echocardiogram : Postprocedure
Nursing actions
• Inform clients that the results of the test and a plan for follow-up care will be provided by the provider. There are no specific post procedure instructions that need to be followed.
Cardiovascular Disorders – Diagnostic Procedures : Stress Testing (Exercise Electrocardiography)
• The cardiac muscle is exercised by clients walking on a treadmill. This provides information regarding the workload of the heart. Once the client’s heart rate reaches a certain rate, the
test is discontinued.
Cardiovascular Disorders – Diagnostic Procedures : Pharmacological Stress Test
A pharmacological stress test may be used for clients who are disabled or unable to be physically challenged. A medication such as adenosine (Adenocard), is given to stress the heart instead of walking on the treadmill.
Cardiovascular Disorders – Diagnostic Procedures : Stress Test – Indications
o Angina
o Heart failure
o MI
o Dysrhythmia
Cardiovascular Disorders – Diagnostic Procedures : Stress Test – Interpretation of Findings
During the stress test, the client’s heart will increase due to the workload of the heart. This is an expected finding for this test. Abnormal findings can include arrhythmias while the test is being completed, signs of coronary artery disease such as angina, and
shortness of breath.
Cardiovascular Disorders – Diagnostic Procedures : Stress Test – Preprocedure
Nursing actions
• Verify that informed consent has been obtained.
• Explain to clients that they will be walking on a treadmill, and comfortable shoes and clothing are recommended.
• Clients are instructed to fast 2 to 4 hr before the procedure according to agency policy, and to avoid tobacco, alcohol, and caffeine before the test.
Cardiovascular Disorders – Diagnostic Procedures : Stress Test – Intraprocedure
Nursing Actions
• Remind clients that once the heart reaches a certain rate, the test will be discontinued.
Cardiovascular Disorders – Diagnostic Procedures : Stress Test – Postprocedure
Nursing Actions
• Clients are monitored by ECG and their blood pressure is checked frequently until they are stable.
• Monitor ECG and vital signs.
• The provider will discuss findings with client.
Cardiovascular Disorders – Diagnostic Procedures : ANGIOGRAPHY
A coronary angiogram, also called a cardiac catheterization, is an invasive diagnostic procedure used to evaluate the presence and degree of coronary artery blockage.
o Angiography can also be done on the lower extremities to determine blood flow and areas of blockage.
o Angiography involves the insertion of a catheter into a femoral (sometimes a brachial) vessel and threading it into the right or left side of the heart. Coronary artery narrowings and/or occlusions are identified by the injection of contrast media under fluoroscopy.
Cardiovascular Disorders – Diagnostic Procedures : ANGIOGRAPHY: Indications
o Unstable angina and ECG changes (T wave inversion, ST segment elevation, depression)
o Confirm and determine location and extent of heart disease.
Cardiovascular Disorders – Diagnostic Procedures : ANGIOGRAPHY: Interpretation of Findings
Angiography can be performed to view the coronary arteries. This allows the provider to see if narrowing of the coronary arteries has occurred or if plaque has accumulated. These findings can be related to heart disease or a myocardial infarction.
Cardiovascular Disorders – Diagnostic Procedures : ANGIOGRAPHY: Preprocedure: Nursing Actions
• Verify that the consent form is signed.
• Maintain clients on NPO status for at least 8 hr (risk for aspiration when lying flat for the procedure).
• Check for iodine/shellfish allergy (contrast media).
• Administer premedications as prescribed [methylprednisone (Solu-Medrol), diphenhydramine (Benadryl and a mild sedative)].
• Shave and antiseptically prepare the catheterization site according to agency policy
Cardiovascular Disorders – Diagnostic Procedures : ANGIOGRAPHY: Preprocedure: Client Education
Instruct clients that they can be awake and sedated during procedure. A local anesthetic should be used. A small incision is made, often in the groin to insert the catheter. Clients can feel warm and flushed when the dye is inserted. After the procedure, clients must keep the affected leg straight. Pressure (a sandbag) can be placed on the incision to prevent bleeding.
Cardiovascular Disorders – Diagnostic Procedures : ANGIOGRAPHY: Postprocedure: Nursing Actions
• Check vital signs every 15 min x 4, every 30 min x 2, every hour x 4, and then every 4 hr (follow hospital protocol).
• Check the groin site at the same intervals for:
– Bleeding and hematoma formation
– Thrombosis; document pedal pulse, color, temperature
• Maintain bed rest in prescribed position (supine or head of the bed to be elevated 30° to 45° with extremity straight for prescribed time.
– A vascular closure device may be used to hasten hemostasis following catheter removal.
• Assist with continuous cardiac monitoring for dysrhythmias (reperfusion following angioplasty can cause dysrhythmias).
• Monitor urine output and monitor IV fluids for hydration.
– Monitor pressure dressing after sheath removal.
Cardiovascular Disorders – Diagnostic Procedures : ANGIOGRAPHY: Postprocedure: Nursing Actions: Administer medications as prescribed
1) Administer medications as prescribed to prevent clot formation and restenosis.
– Aspirin
– Clopidogrel (Plavix), ticlopidine (Ticlid)
– Heparin
– Low molecular weight heparin (Enoxaparin, Lovenox)
– GP lIb/IlIa inhibitors, such as eptifibatide (Integrilin)
2) Administer anxiolytics (Ativan) and analgesia (morphine) as needed.
Cardiovascular Disorders – Diagnostic Procedures : ANGIOGRAPHY: Client Education
• Instruct clients to:
– Avoid strenuous exercise for the prescribed period of time.
– Immediately report bleeding from the insertion site, chest pain, shortness of breath, and changes in the color or temperature of the extremity.
– Restrict lifting (less than 10 lb) for the prescribed period of time.
– Clients with stent placement will receive anticoagulation therapy for 6 to 8 weeks. Instruct clients to:
– Take the medication at the same time each day.
– Have regular laboratory tests to determine therapeutic levels.
– Avoid activities that could cause bleeding (use soft toothbrush, wear shoes when out of bed).
• Encourage clients to follow lifestyle guidelines (manage weight, consume a low fat/ low-sodium diet, get regular exercise, stop smoking, decrease alcohol intake).
Cardiovascular Disorders – Diagnostic Procedures : ANGIOGRAPHY: Complications – Cardiac Tamponade
• Cardiac tamponade can result from fluid accumulation in the pericardial sac.
– Signs include hypotension, jugular venous distention, muffled heart sounds, and paradoxical pulse (variance of 10 mm Hg or more in systolic blood pressure between expiration and inspiration).
– Hemodynamic monitoring will reveal intracardiac and pulmonary artery pressures similar and elevated (plateau pressures).
• Nursing actions
– Notify the provider immediately.
– Administer IV fluids to combat hypotension as prescribed.
Cardiovascular Disorders – Diagnostic Procedures : ANGIOGRAPHY: Complications – Hematoma Formation
Hematoma formation
• Blood clots may form near the insertion site.
• Nursing actions
– Check the groin at prescribed intervals and as needed.
– Hold pressure for uncontrolled oozing/bleeding
– Monitor peripheral circulation.
– Notify the provider.
Cardiovascular Disorders – Diagnostic Procedures : ANGIOGRAPHY: Complications – Restenosis of treated vessel
• Clot reformation in the coronary artery can occur immediately or several weeks after procedure.
• Nursing actions
o Check ECG patterns and check for occurrence of chest pain.
o Notify the provider immediately.
o Prepare clients for return to the cardiac catheterization laboratory.
Cardiovascular Disorders – Diagnostic Procedures : Electrocardiography and Dysrhythmia Monitoring
Cardiac electrical activity can be monitored by using an ECG. The heart’s electrical activity can be monitored by a standard 12-lead ECG (resting ECG), ambulatory ECG (Holter monitoring), continuous cardiac monitoring, or by telemetry
Cardiovascular Disorders – Diagnostic Procedures : Cardiac Dysrhythmia
• Cardiac dysrhythmias are heartbeat disturbances (beat formation, beat conduction, or myocardial response to beat).
• Nurses should be familiar with cardioversion and defibrillation procedures for treating dysrhythmias.
Cardiovascular Disorders – Diagnostic Procedures : Electrocardiography
Electrocardiography uses an electrocardiograph to record the electrical activity of the heart over time. The electrocardiograph is connected by wires (leads) to skin electrodes placed on
the chest and limbs of a client.
o Continuous cardiac monitoring requires clients to be in close proximity to the monitoring system.
o Telemetry allows clients to ambulate while maintaining proximity to the monitoring system.
Cardiovascular Disorders – Diagnostic Procedures : Electrocardiography: Indications
Diagnoses
-Bradycardia
-Heart block
-Atrial fibrillation
-Supraventricular tachycardia
-Ventricular tachycardia
– Ventricular fibrillation
– Myocardial Infarction (size and extent)
Cardiovascular Disorders – Diagnostic Procedures : Electrocardiography: Client Presentation
• Cardiovascular disease
• Myocardial infarction
• Hypoxia
• Acid-base imbalances
• Electrolyte disturbances
• Chronic renal failure, liver, or lung disease
• Pericarditis
• Drug or alcohol abuse
• Hypovolemia
• Shock
Cardiovascular Disorders – Diagnostic Procedures : Electrocardiography: Interpretation of Findings
An electrocardiography can identify dysrhythmias, heart ischemia, cardiac injury, chamber enlargement, or conduction abnormalities
Cardiovascular Disorders – Diagnostic Procedures : Electrocardiography: Preprocedure
Nursing actions
• Prepare clients for a 12-lead ECG by:
o Positioning clients in a supine position with chest exposed.
o Washing the client’s skin to remove oils.
o Attaching one electrode to each of the client’s extremities by applying electrodes to flat surfaces above the wrists and ankles and the other six electrodes to the chest, avoiding chest hair. (Chest hair may need to be shaved on male clients).
Cardiovascular Disorders – Diagnostic Procedures : Electrocardiography: Intraprocedure
Nursing actions
• Instruct clients to remain still and breathe normally while the 12-lead ECG is performed.
• Monitor clients for signs and symptoms of dysrhythmia (chest pain, decreased level of consciousness, and shortness of breath) and hypoxia.
Cardiovascular Disorders – Diagnostic Procedures : Electrocardiography: Postprocedure
Nursing actions
• Remove leads from client, print ECG report, and notify the provider.
• Apply a Holter monitor if clients are on a telemetry unit and/or need continuous cardiac monitoring.
• Continue to monitor clients for symptoms of dysrhythmia (chest pain, decreased level of consciousness, and shortness of breath) and hypoxia.
• Dysrhythmia treatment is based on the client’s symptoms and the cardiac rhythm, which can require cardioversion or defibrillation after an ECG has been completed and a diagnosis has been found.
Cardiovascular Disorders – Diagnostic Procedures : Electrocardiography:Dysrhythmias
• Dysrhythmias are classified by the:
o Site of origin – sinoatrial (SA) node, atria, atrioventricular node, or ventricle.
• Electrophysiological study determines the area of the heart causing the dysrhythmia. Ablation of the area is possible.
o Effect on the rate and rhythm of the heart – bradycardia, tachycardia, heart block, premature beat, flutter, fibrillation, or asystole.
• Dysrhythmias can be benign or life-threatening.
• The life-threatening effects of dysrhythmias are generally related to decreased cardiac output and ineffective tissue perfusion.
• Dysrhythmias can present atypically in older adult clients.
• Risks for heart disease, hypertension, dysrhythmias, and atherosclerosis increase with age.
• Assist with the care of clients experiencing dysrhythmias
Cardiovascular Disorders – Diagnostic Procedures : Electrocardiography:Dysrhythmias -Bradycardia (any rhythm less than 60/min) Treat if clients are symptomatic
MEDICATION: Atropine and isoproterenol
ELECTRICAL MANAGEMENT: Pacemaker
Cardiovascular Disorders – Diagnostic Procedures : Electrocardiography:Dysrhythmias – Atrial fibrillation, supraventricular tachycardia, or ventricular tachycardia with pulse
MEDICATION: Amiodarone (Cordarone), adenosine, and verpamil (Calan)
ELECTRICAL MANAGEMENT: Synchronized cardioversion
Cardiovascular Disorders – Diagnostic Procedures : Electrocardiography:Dysrhythmias – Ventricular tachycardia without pulse or ventricular fibrillation
MEDICATION: Amiodarone, Lidocaine, and epinephrine
ELECTRICAL MANAGEMENT: Defibrillation
Cardiovascular Disorders – Diagnostic Procedures : Electrocardiography: CARDIOVERSION AND DEFIBRILLATION
• Cardioversion is the delivery of a synchronized, direct countershock to the heart.
• Defibrillation is the delivery of an asynchronous countershock to the heart. Defibrillation stops all electrical activity of the heart, allowing the SA node to take over and re-establish a perfusing rhythm. The earlier it is performed, the greater the chance of survival.
Cardiovascular Disorders – Diagnostic Procedures : Electrocardiography: CARDIOVERSION AND DEFIBRILLATION: Indications
o Cardioversion – elective treatment of atrial dysrhythmias, supraventricular tachycardia, and ventricular tachycardia with a pulse. Cardioversion is the treatment of choice for clients who are symptomatic.
o Defibrillation – ventricular fibrillation or pulseless ventricular tachycardia.
Cardiovascular Disorders – Diagnostic Procedures : Electrocardiography: CARDIOVERSION AND DEFIBRILLATION: Preprocedure
o Clients who have atrial fibrillation of unknown duration must receive adequate anticoagulation prior to cardioversion therapy to prevent dislodgement of thrombi into the bloodstream. An anesthesiologist may administer a short acting anesthetic IV bolus for sedation.
o Nursing actions
• Prepare clients for cardioversion, if prescribed.
• Explain the procedure to clients and verify consent.
• Administer oxygen.
• Document preprocedure rhythm.
• Have emergency equipment available.
Cardiovascular Disorders – Diagnostic Procedures : Electrocardiography: CARDIOVERSION AND DEFIBRILLATION: Postprocedure
o Nursing actions
• After cardioversion or defibrillation, check the client’s vital signs, check airway patency, and obtain an ECG.
• Provide clients and their families with reassurance and emotional support.
o Client education
• Teach clients and families how to check pulse rate.
• Advise clients to report palpitations or irregularities.
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures
Overview
• Invasive cardiovascular procedures are methods used to maintain an acceptable cardiac rhythm or improve blood flow for arteries and veins that have become occluded.
• Invasive cardiovascular procedures are indicated if symptoms persist after non-invasive interventions have been tried, such as diet, exercise, and medications.
• Invasive cardiovascular procedures that nurses should be knowledgeable about include:
o Pacemaker insertion and care
o Angioplasty
o Coronary artery bypass grafts
o Peripheral bypass grafts
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – Pacemakers
Overview
• An artificial pacemaker is a battery-operated device that electrically stimulates the heart when the natural pacemaker of the heart fails to maintain an acceptable rhythm.
• Pacemakers may be temporary or permanent.
• Nurses should be familiar with the various types of pacemakers, how they function, and the care involved with their placement/insertion.
• Conduction of electrical impulses through the sinoatrial node may be slowed with aging, causing bradycardia and conduction defects.
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – Pacemakers: Two parts
Pacemakers are composed of two parts:
o The pulse generator houses the energy source (battery) and the control center.
o The electrodes are wires that attach to the myocardial muscle on one side and connect to the pulse generator on the other.
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – Pacemakers: Temporary Pacemakers
Temporary Pacemakers (the energy source is provided by an external battery pack)
1. External (transcutaneous)
2. Epicardial
3. Endocardial (transvenous)
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – Pacemakers: Temporary Pacemakers – External (transcutaneous)
• Pacing energy is delivered transcutaneously through the thoracic musculature to the heart via two electrode patches placed on the skin.
• It requires large amounts of electricity, which can be painful for a client.
• It is only used in emergency resuscitation of a client who does not have pacing wires inserted.
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – Pacemakers: Temporary Pacemakers – Epicardial
• Pacemaker leads are attached directly to the heart during open heart surgery. Wires run externally through the chest incision .and may be attached to an external impulse generator if needed.
• It is commonly used during and immediately following open heart surgery.
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – Pacemakers: Temporary Pacemakers – Endocardial (transvenous)
• Pacing wires are threaded through a large central vein (subclavian, jugular, or femoral) and lodged into the wall of the right ventricle (ventricular pacing), right atrium (atrial pacing), or both chambers (dual chamber pacing).
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – Pacemakers: Permanent Pacemakers (contain an internal pacing unit)
o Indicated for chronic or recurrent dysrhythmias due to sinus or atrioventricular (AV) node malfunction
o Can be programmed to pace the atria, ventricles, or both (AV sequential pacing)
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – Pacemakers: Permanent Pacemakers – Pacemaker modes
Pacemaker modes
• Fixed rate (asynchronous) – fires at a constant rate without regard for the heart’s electrical activity
• Demand mode (synchronous) – detects the heart’s electrical impulses and fires at a preset rate only if the heart’s intrinsic rate is below a certain level
• Antidysrhythmic function – can overpace a tachydysrhythmia or deliver an electrical shock
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – Pacemakers: Placement – Indications
o Diagnoses
• Symptomatic bradycardia
• Complete heart block
• Sick sinus syndrome
• Sinus arrest
• Asystole
• Atrial tachydysrhythmias
• Ventricular tachydysrhythmias
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – Pacemakers: Placement – Client presentation
Symptoms
0 Dizziness
0 Palpitations
0 Chest pain or pressure
0 Anxiousness
0 Fatigue
0 Nausea
o Breathing difficulties
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – Pacemakers: Placement – Signs
0 Bradycardia
0 Tachycardia
0 Abnormal ECG
0 Dyspnea, tachypnea
0 Restlessness
0 Distended jugular vein
0 Vomiting
0 Hypotension
0 Diaphoresis
0 Decreased cardiac output
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – Pacemakers: Client Outcomes
o The client will be able to tolerate activities of daily living free of cardiac symptoms.
o The client will use strategies to reduce stress and improve cardiac health.
o The client will recognize cardiac symptoms and seek medical attention immediately when needed.
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – Pacemakers: Preprocedure – Nursing Actions
• Determine the client’s knowledge of the procedure and need for pacemaker (if nonemergent situation).
• Verify informed consent.
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – Pacemakers: Preprocedure -Client Education
• Reinforce to clients about the type of pacemaker that is to be inserted and information about the procedure.
o Temporary pacemaker
~ Explain that wires and a pacemaker box will be on the client’s chest after the procedure.
~ Instruct clients not to touch the dials on the pacemaker box.
~ The wires and box will need to be kept dry. Clients will not be able to shower.
o Permanent pacemaker
~ Explain that a small incision will be made using a local anesthetic and IV sedation.
~ The pacemaker may be reprogrammed externally after the procedure.
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – Pacemakers: Postprocedure – Nursing Actions
• Document the time and date of insertion, model (permanent pacemaker), settings, rhythm strip, presence of adequate pulse and blood pressure, and client response.
• Continually monitor heart rate and rhythm.
• Obtain chest x-ray as prescribed to assess lead placement and for pneumothorax, hemothorax, or pleural effusion.
• Provide analgesia as prescribed.
• Minimize shoulder movement initially and provide a sling (if prescribed) to allow leads to anchor.
• Check clients for hiccups, which may indicate that the generator is pacing the diaphragm.
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – Pacemakers: Postprocedure – Nursing Actions – Safety
• Maintain the client’s safety.
– Ensure that all electrical equipment has grounded connections.
– Remove any electrical equipment that is damaged.
– For a temporary pacemaker:
~ Wear gloves when handling pacemaker leads.
~ Insulate pacemaker terminals and leads with nonconductive material when not in use (rubber gloves).
~ Keep spare generator, leads, and batteries at the client’s bedside.
~ Secure the pacemaker battery pack. Take care when moving clients and ensure that there is enough wire slack.
– For a permanent pacemaker:
~ Provide clients with a pacemaker identification card including
the manufacturer’s name, model number, mode of function, rate
parameters, and expected battery life.
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – Pacemakers: Postprocedure – Client Education – Permanent pacemaker discharge teaching, Part I
• Temporary pacemakers are only used in a controlled facility-like environment with telemetry for continuous ECG monitoring. If needed, a permanent pacemaker is inserted before discharge to home.
• Permanent pacemaker discharge teaching
– Instruct clients to carry a pacemaker identification card at all times.
– Reinforce to clients that batteries last 10 years on average.
– Tell clients to wear a sling when out of bed, if prescribed.
– Reinforce to clients not to raise the arm on the surgical side above the shoulder for 1 to 2 weeks.
– Reinforce to clients to take pulse daily at the same time.
– Reinforce to clients to set the rate of the pacemaker. Notify the provider if the heart rate is less than 5 beats below the pacer rate.
– Instruct clients to report signs of dizziness, fainting, fatigue, weakness, chest pain, hiccupping, or palpitations.
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – Pacemakers: Postprocedure – Client Education – Permanent pacemaker discharge teaching, Part II
– For clients with pacer-defibrillators, inform clients and their families that anyone touching the client when the device delivers a shock will feel a slight electrical impulse but that the impulse will not harm the person.
– Inform clients of activity restrictions as prescribed, including no contact sports or heavy lifting for 2 months.
– Inform clients that they can resume sexual activity as desired, avoiding positions that put stress on the incision site.
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – Pacemakers: Postprocedure – Client Education – Permanent pacemaker discharge teaching, Part III
o Inform clients that household appliances should not affect pacemaker function unless held directly over pacer generator. This includes garage door openers, burglar alarms, microwave ovens, and antitheft devices.
o Instruct clients to inform airport security agents that airport security detectors will be set off. Inform clients that this should not affect pacemaker functioning.
o Instruct clients to inform other providers and dentists about the pacemaker. Some tests, such as magnetic resonance imaging and therapeutic diathermy (heat therapy), may be contraindicated
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – Pacemakers: Insertion Complications – Infection or hematoma
o The insertion site can develop an infection or hematoma.
o Nursing actions
~ Monitor the incision site for redness, pain, drainage, or swelling.
~ Treat an infection with antibiotics as prescribed.
~ Monitor coagulation and CBC.
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – Pacemakers: Insertion Complications – Pneumothorax or hemothorax
o Trauma during the procedure can cause a pneumothorax or hemothorax.
o Nursing actions
~ Monitor the client’s breath sounds and chest movement.
~ Monitor oxygen saturation.
~ Obtain a chest x-ray after the procedure.
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – Pacemakers: Insertion Complications – Arrhythmias
o Irritation of a ventricle from a pacing electrode may cause ectopiC beats, such as premature ventricular contractions.
o Nursing actions
~ Monitor ECG and blood pressure.
~ Assist with emergency care of clients.
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – Pacemakers: Complications – Failure to Capture
o The pacemaker initiates a stimulus, but depolarization of the myocardium does not happen.
~ An ECG shows pacing spikes without the expected P wave or QRS complex.
~ Failure to capture causes include dislodgement of the electrode, MI or ischemia, antidysrhythmic medications, electrolyte imbalances
(hypokalemia, hyperkalemia), and too low of a voltage (rnA).
~ Treatment depends on the cause. A dislodged electrode may reattach by turning clients onto the left side. The provider may need to increase the voltage delivered if the voltage is too low to capture.
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – Pacemakers: Complications – Failure to Sense
The pacemaker fails.to sense the heart’s intrinsic electrical activity, resulting
in the delivery of an unnecessary stimulus.
~ An ECG shows pacemaker spikes at intervals different from the
programmed interval.
~ Discharge of an impulse during the T wave can lead to life-threatening ventricular dysrhythmias.
~ Treatment involves decreasing the amplitude at which the pacemaker recognizes intrinsic electrical activity (my).
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – Pacemakers: Complications – Failure to pace (no output)
Failure to pace (no output)
o Failure to pace may be caused by a broken lead wire.
~ Treatment involves replacing the battery or lead.
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – Pacemakers: Complications – Oversensing
Oversensing
o The pacemaker is oversensitive and sensing excessive electrical activity.
~ The provider may need to increase the voltage delivered (rnA) to reduce sensitivity.
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – Pacemakers: Complications – Stimulation of Chest Wall or Diaphragm
The pacemaker’s electrical charge may stimulate the client’s chest wall or diaphragm.
~ Stimulation is indicated by muscle twitching or hiccups.
~ It is often caused by lead wire perforation with high electrical current.
~ Stimulation can lead to cardiac tamponade.
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – Pacemakers: Complications – Stimulation of Chest Wall or Diaphragm – Nursing actions
~ Monitor clients for signs of cardiac tamponade such as dyspnea, chest pain, hypotension, and distended neck veins.
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – Pacemakers: Complications – Stimulation of Chest Wall or Diaphragm – Client Education
Instruct clients to notify the provider with symptoms of chest muscle twitching or hiccups. The pacemaker wires may need to be repositioned.
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – Pacemakers: Complications – Microshock
A small electrical current is sent through unattached external pacemaker wires and may cause cardiac arrhythmias or ventricular fibrillation . This may occur with pacemaker wires that are not attached to a pacemaker generator.
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – Pacemakers: Complications – Microshock – Nursing actions
~ Cover wires with nonconductive insulation (rubber gloves) and
nonconductive tape.
~ Made sure all equipment is grounded with a three-pronged plug.
Contact the engineering department for all ungrounded or unsafe
electrical equipment (frayed wires).
~ Wear rubber gloves when handling pacing wires. Static electricity
may be transmitted to the pacing wires from hands, causing serious
arrhythmias
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – Pacemakers: Complications – Microshock – Client Education
~ Instruct clients not to touch the pacemaker wires. If wires are exposed, clients should alert a provider to secure them.
~ Tell clients not to plug in or unplug electrical items. Advise clients not to use an electric razor or blow dryer.
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – ANGIOPLASTY
Overview
• Percutaneous transluminal coronary angioplasty (PTCA) involves inflating a balloon to dilate the arterial lumen and the adhering plaque, thus widening the arterial lumen. A stent (mesh-wire device) is often placed to prevent restenosis of the artery.
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY – Indications
o PTCA can be performed on an elective basis to treat coronary artery disease when there is greater than 50% occlusion of one to two coronary arteries. The area of occlusion is confined, not scattered, and easy to access (proximal).
o PTCA may reduce ischemia during the occurrence of an acute MI, and it is most effective if it is done within 90 min of chest pain.
o PTCA with stent placement, to prevent artery reocclusion, may be used to dilate the left main coronary artery, which supplies blood flow to a large area of the heart.
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY – Client Presentation – Subjective Data
o Chest pain may occur with or without exertion. Pain may radiate to the jaw, left arm, through the back, or to the shoulder. Symptoms may increase in cold weather or with exercise. Other symptoms may include dyspnea, nausea, fatigue, and diaphoresis.
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY – Client Presentation – Objective Data
o ECG changes may include ST elevation, depression, or nonspecific ST changes. Other signs may include bradycardia, tachycardia, hypotension, elevated blood pressure, vomiting, and mental disorientation.
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY – Client Outcomes
o The client will be able to perform activities of daily living free of pain or shortness of breath.
o The client will use strategies to reduce stress and modify lifestyle habits.
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY – Preprocedure – Nursing Actions
• Verify informed consent.
• Maintain clients on NPO status for at least 8 hr if possible (risk for aspiration when lying flat for the procedure).
• Determine that clients and their families understand the procedure.
• Check clients for an iodine/shellfish allergy. (Use contrast dye instead of contrast media for consistency.)
• Administer premedications as prescribed (antiplatelet medications, antianxiety agents).
• Perform surgical preparation and shaving of the catheterization site.
• Insert an indwelling urinary catheter if ordered.
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY – Preprocedure – Client
Education
Instruct clients that they may be awake and sedated for the procedure. A local anesthetic should be used. A small incision is made – often in the groin – to insert the catheter. Clients may feel warmth and flushed when the dye is inserted. After
the procedure, clients will be asked to keep the affected leg straight. Pressure (a sandbag) may be placed on the incision to prevent bleeding.
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY – Postprocedure – Nursing Actions, Part I
• Monitor the client’s vital signs every 15 min x 4, every 30 min x 2, every hour x 4, and then every 4 hr (or per facility protocol).
• Check the groin site at the same intervals for:
– Bleeding and hematoma formation.
– Thrombosis – document pedal pulse, color, and temperature.
• Maintain clients on bed rest in a supine position with leg straight for a prescribed time.
• Conduct continuous cardiac monitoring for dysrhythmias (reperfusion following angioplasty may cause dysrhythmias).
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY – Postprocedure – Nursing Actions, Part II
Monitor clients receiving:
– Antiplatelet or thrombolytic agents to prevent clot formation and
restenosis.
– Aspirin.
– Clopidogrel (Plavix), tirofiban (Aggrastat).
– Heparin.
– . Low molecular weight heparin enoxaparin (Lovenox).
– Glycoprotein (GP lIb/IlIa) inhibitors (antiplatelet), such as eptifibatide
(Integrilin).
– Diltiazem (Cardizem) by IV bolus to prevent coronary vasospasm.
– Anxiolytics for sedation.
– Analgesics for pain.
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY – Postprocedure – Nursing Actions, Part III
• Monitor urine output and IV fluids for hydration.
– Contrast dye acts as an osmotic diuretic.
• Monitor clients for signs and symptoms of hypokalemia.
• Assist with sheath removal from the insertion site (artery or vein).
– The catheter sheath is a short hollow tube placed inside the artery or vein at the insertion site. It is used as a guide for the balloon catheter. After the angioplasty, the catheter sheath may be left in for access, so that the angioplasty may be repeated, if needed (for restenosis or perforation).
– Apply pressure to arterial/venous sites for the prescribed period of time (varies depending upon the method used for vessel closure).
– Observe for vagal response (hypotension, bradycardia) from compression of vagus nerve.
– Apply a pressure dressing.
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY – Postprocedure – Client Education
• Instruct clients to:
o Avoid strenuous exercise for the prescribed period of time.
o Immediately report bleeding from the insertion site, chest pain, shortness of breath, and changes in the color or temperature of the extremity.
o Restrict lifting (less than 10 lb) for the prescribed period of time.
• Clients with stent placement will receive anticoagulation therapy for 6 to 8 weeks (Clopidogrel may be needed for as long as 6 to 9 months). Instruct clients to:
o Take the medication at the same time each day.
o Have regular laboratory tests to determine therapeutic levels.
o Avoid activities that could cause bleeding (use a soft toothbrush, wear shoes when out of bed).
• Encourage clients to follow lifestyle guidelines (manage weight, consume a low fat/ low-cholesterol diet, exercise regularly, stop smoking, and decrease alcohol intake).
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY – Complications – HEMATOMA FORMATION
A blood clot may form near the insertion site.
• Nursing Actions
o Monitor for sensation, color, and peripheral pulses in the extremity distal to the insertion site.
o Check the groin for signs of a hematoma at prescribed intervals and as needed.
o Hold pressure for uncontrolled oozing/bleeding.
o Notify the provider.
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY – Complications – EMBOLISM
• Plaque or a clot could become dislodged.
• Nursing Actions
o Monitor clients for chest pain during and after the procedure.
o Monitor the client’s vital signs and SaO2′
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY – Complications – RESTENOSIS OF TREATED VESSEL
• Clot reformation in the coronary artery may occur immediately or several weeks after the procedure.
• Nursing Actions
o Monitor ECG patterns and for the occurrence of chest pain.
o Notify the provider immediately.
o Prepare clients for return to the cardiac catheterization laboratory.
• Client Education
o Advise clients to notify the provider of cardiac symptoms and to take all medications as prescribed.
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – CORONARY ARTERY BYPASS GRAFTS – Overview
Coronary artery bypass grafting (CABG) is an invasive surgical procedure that aims to restore vascularization of the myocardium.
o Performed to bypass an obstruction in one or more of the coronary arteries, CABG does not alter the atherosclerotic process, but improves the quality of life for clients restricted by painful coronary artery disease.
o Older adult clients are more likely to experience transient neurological changes, toxic effects from cardiac medications, and dysrhythmias.
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – CORONARY ARTERY BYPASS GRAFTS – Indications – DIAGNOSIS
• Over 50% blockage of the left main coronary artery with anginal episodes (blockage inaccessible to angioplasty and stenting)
• Significant two-vessel or triple-vessel disease
• Coronary artery disease nonresponsive to medical management
• Heart valve disease
• Ischemia with heart failure
• Coronary vessels unsuitable for PTCA
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – CORONARY ARTERY BYPASS GRAFTS – Indications – CLIENT PRESENTATION – Subjective Data
Chest pain may occur with or without exertion. Pain may radiate to the jaw, left arm, through the back, or to the shoulder. Symptoms may increase in cold weather or with exercise. Other symptoms may include dyspnea, nausea, fatigue, and diaphoresis.
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – CORONARY ARTERY BYPASS GRAFTS – Indications – CLIENT PRESENTATION – Objective Data
ECG changes may include ST elevation, depression, or nonspecific ST changes. Other signs may include bradycardia, tachycardia, hypotension, elevated blood pressure, vomiting, and mental disorientation
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – CORONARY ARTERY BYPASS GRAFTS – CLIENT OUTCOMES
o The client will be able to perform activities of daily living free of pain or shortness of breath.
o The client will use strategies to reduce stress and modify lifestyle habits.
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – CORONARY ARTERY BYPASS GRAFTS – Preprocedure – Nursing Actions, Part I
• A CABG may be an elective procedure or done as an emergency. When planned, preparation begins before clients come to the facility for the procedure.
• Verify that clients have signed the informed consent form.
• Confirm that recent chest x-ray, ECG, and blood work results are available if needed.
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – CORONARY ARTERY BYPASS GRAFTS – Preprocedure – Nursing Actions, Part II
• Administer preoperative medications as prescribed.
o Anxiolytics, such as lorazepam (Ativan) and diazepam (Valium)
o Prophylactic antibiotics
o Anticholinergics, such as scopolamine, to reduce secretions
• Provide safe transport of clients to the operating suite. Monitor heart rate and rhythm, oxygenation, and other vital indicators
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – CORONARY ARTERY BYPASS GRAFTS – Preprocedure – Client Education, Part I
o Inform clients of the importance of coughing and deep breathing and splinting the incision after the procedure to prevent complications.
o Instruct clients to report any pain to the nursing staff. The majority of pain stems from the harvest site for the vein.
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – CORONARY ARTERY BYPASS GRAFTS – Preprocedure – Client Education, Part II
Inform clients and their families to expect the following postoperatively:
– Endotracheal tube and mechanical ventilator for airway management for several hours following surgery
– Inability to talk while the endotracheal tube is in place
– Sternal incision and possible leg incision
– One to 2 chest tubes
– Indwelling urinary catheter
– Pacemaker wires
– Hemodynamic monitoring devices (pulmonary artery catheter, arterial line
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – CORONARY ARTERY BYPASS GRAFTS – Preprocedure – Client Education, Part III – Discontinued Medications for CABG
Instruct clients to alter or discontinue regular medications as prescribed by the provider.
~ Medications frequently discontinued for CABG
* Diuretics 2 to 3 days before surgery
* Aspirin and other anticoagulants 1 week before surgery
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – CORONARY ARTERY BYPASS GRAFTS – Preprocedure – Client Education, Part III – Continued Medications for CABG
~ Medications often continued for CABG
* Potassium supplements
* Scheduled antidysrhythmics, such as amiodarone (Cordarone)
* Scheduled antihypertensives, such as metoprolol (Lopressor), a
beta-blocker, and diltiazem (Cardizem), a calcium-channel blocker
* Insulin (clients who have diabetes mellitus and are insulin dependent usually receive half the regular insulin dose)
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – CORONARY ARTERY BYPASS GRAFTS – Postprocedure – Nursing Actions
Provide postoperative care to prevent complications – usually in a specialty postoperative unit. Clients will receive mechanical ventilation for 3 to 6 hours.
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – CORONARY ARTERY BYPASS GRAFTS – Postprocedure – Client Education: Part I
• Instruct clients to monitor and report signs of infection such as fever, incisional drainage, and redness.
• Instruct clients to adhere to the pharmacological regimen.
• Instruct clients who have diabetes mellitus to closely monitor blood glucose levels.
• Encourage clients to consume a heart-healthy diet (low-fat, low-cholesterol, high fiber, and low-salt).
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – CORONARY ARTERY BYPASS GRAFTS – Postprocedure – Client Education: Part II
• Encourage physical activity. Consult the cardiac rehabilitation program or a physical therapist to devise a specific program.
• Instruct clients to remain home during the first week after surgery and to resume normal activities slowly.
o Week 2 – possible return to work part time, increase in social activities
o Week 3 -lifting of up to 15 lb, avoidance of heavier lifting for 6 to 8 weeks
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – CORONARY ARTERY BYPASS GRAFTS – Postprocedure – Client Education: Part III
• Inform clients that they can resume sexual activity based on the advice of the provider.
o Walking 1 block or climbing 2 flights of stairs symptom-free generally indicates that it is safe for clients to resume normal sexual activity.
• Encourage clients to verbalize their feelings.
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – CORONARY ARTERY BYPASS GRAFTS – Complications
Pulmonary complications
• Atelectasis is a primary complication of a CABG. Other complications include pneumonia and pulmonary edema.
• Nursing Actions
o Tum clients every 2 hr and advance them out of bed as soon as possible.
o Monitor breath sounds, SaO2′ ABGs, pulmonary artery pressures, cardiac output, and urine output, and obtain a chest x-ray as indicated.
• Client Education
o Encourage coughing, deep breathing, and use of an incentive spirometer.
o Explain to clients that increasing activity reduces postoperative
complications
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – PERIPHERAL BYPASS GRAFT
Bypass graft surgery aims to restore adequate blood flow to the areas affected by peripheral artery disease.
o A peripheral bypass graft involves suturing graft material or autogenous saphenous veins proximal and distal to an occluded area of an artery. This procedure improves blood supply to the area normally served by the blocked artery.
o If bypass surgery fails to restore Circulation, clients may need to undergo amputation of the limb.
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – PERIPHERAL BYPASS GRAFT – Indications
o Acute circulatory compromise in limb
o Severe pain at rest that interferes with ability to work
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – PERIPHERAL BYPASS GRAFT – Indications: Client Presentation – Subjective Data
o Numbness or burning pain to the lower extremity with exercise, and may stop with rest (intermittent claudication)
o Numbness or burning pain to the lower extremity at rest, and may wake client at night; pain may be relieved by lowering the extremity below heart
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – PERIPHERAL BYPASS GRAFT – Indications: Client Presentation – Objective Data
Decreased or absent pulses to feet. Dry, hairless, shiny skin on calves. Muscles may atrophy with advanced disease. Skin may be cold and dark colored. Feet and toes may be mottled and dusky, and toenails may be thick. Skin may become reddened (rubor) when extremity is dropped to a dependent position. Ulcers or lesions may be noted on toes (arterial ulcers) or ankles (venous ulcers).
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – PERIPHERAL BYPASS GRAFT – Client Outcomes
o The client will have increased circulation in the extremity/foot.
o The client will be pain free, and the foot will be intact without ulcerations or lesions.
o The client will follow a recommended diet, exercise, and maintain foot care.
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – PERIPHERAL BYPASS GRAFT – Preprocedure – Nursing Actions
• Determine the client/family’s understanding of the procedure.
• Verify that clients have signed the informed consent form.
• Check clients for allergies.
• Document the client’s baseline vital signs and peripheral pulses.
• Administer prophylactic antibiotic therapy to clients as prescribed.
• Instruct clients to maintain NPO status for at least 8 hr prior to surgery.
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – PERIPHERAL BYPASS GRAFT – Preprocedure – Client Education
• Include information about postoperative pain management and teach clients deep breathing/ incentive spirometer exercises.
• Advise clients not to cross their legs.
• Clients may have an arterial line inserted for blood work and blood pressure monitoring.
• Explain to clients that pedal pulses will be checked frequently
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – PERIPHERAL BYPASS GRAFT – Postprocedure
o Nursing Actions
• Provide postoperative care to prevent complications.
o Client Education
• Reinforce activity restrictions.
• Remind clients to avoid crossing their legs.
• Advise clients to avoid risk factors for atherosclerosis (smoking, sedentary life style, uncontrolled diabetes mellitus).
• Reinforce to clients techniques of foot inspection and care. Encourage clients to:
o Keep feet dry and clean.
o Avoid extreme temperatures.
o Use lotion.
o Avoid constraining garments.
o Wear clean, white, cotton socks and always wear shoes
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – PERIPHERAL BYPASS GRAFT – COMPLICATIONS – Graft Occlusion
• The graft may occlude due to reduced blood flow and clot formation.
• Nursing Actions
o Notify the provider immediately for any noted changes in pedal pulse, extremity color, or temperature.
o Prepare clients for thrombectomy or thrombolytic therapy.
o Monitor for bleeding with thrombolytics.
o Monitor coagulation studies.
o Monitor for anaphylaxis.
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – PERIPHERAL BYPASS GRAFT – COMPLICATIONS – Compartment Syndrome
• Pressure from tissue swelling or bleeding within a compartment or a restricted space causes reduced blood flow to the area. Untreated, the affected tissue will become necrotic and die.
• Nursing Actions
o Check for worsening pain, swelling, and tense or taut skin.
o Report abnormal findings to the provider immediately.
o Prepare clients for a fasciotomy to relieve compartmental pressure.
Cardiovascular Disorders – Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures – PERIPHERAL BYPASS GRAFT – COMPLICATIONS – Infection
• Infection of the surgical site may result in the loss of the graft and increased ischemia.
• Nursing Actions
o Monitor the wound for increased redness, swelling, and drainage.
o Monitor WBC count and temperature.
o Collect specimens (wound or blood cultures).
o Administer antibiotic therapy.
• Client Education
o Advise clients to notify the provider of decreased sensation, increased ischemic pain, redness, or swelling at the incisional site or in the affected limb
Cardiovascular Disorders – Angina and Myocardial Infarction
• The continuum from angina to myocardial infarction (MI) is termed acute coronary syndrome. Symptoms of acute coronary syndrome are due to an imbalance between myocardial oxygen supply and demand.
• Angina pectoris is a warning sign of an impending acute MI.
• Women and older adults do not always experience symptoms typically associated with angina or MI.
• The majority of deaths from an MI occur within 1 hr of symptom onset.
• When blood flow to the heart is compromised, ischemia causes chest pain. Anginal pain is often described as a tight squeezing, heavy pressure, or constricting feeling in the chest. The pain can radiate to the jaw, neck, or arm.
Cardiovascular Disorders – Angina and Myocardial Infarction – Three Types of Angina
o Stable angina (exertional angina) occurs with exercise or emotional stress and is relieved by rest or nitroglycerin (Nitrostat).
o Unstable angina (preinfarction angina) occurs with exercise or emotional stress, but it increases in occurrence, severity, and duration over time. It may be poorly relieved by rest or nitroglycerin.
o Variant angina (Prinzmetal’s angina) is due to a coronary artery spasm, often occurring during periods of rest.
Cardiovascular Disorders – Angina and Myocardial Infarction – Myocardial Ischemia
An abrupt interruption of oxygen to the heart muscle produces myocardial ischemia. Ischemia can lead to tissue necrosis (infarction) if blood supply and oxygen are not restored. Ischemia is reversible, while an infarction results in permanent damage.
• Ischemic injury to cardiac muscle results in the release of cardiac enzymes into the bloodstream, providing specific markers of MI.
Cardiovascular Disorders – Angina and Myocardial Infarction – Myocardial Ischemia – Classification
MIs are classified based on:
o The affected area of the heart (anterior, anterolateral).
o The depth of involvement (transmural versus nontransmural).
o The ECG changes produced (Q wave, non-Q wave). Non-Q-wave MIs are more common in older adults, women, and clients who have diabetes mellitus.
Cardiovascular Disorders – Angina and Myocardial Infarction – Triggering Events
ANGINA: Precipitated by exertion or stress
MYOCARDIAL INFARCTION : Can occur without cause, often in the morning after rest
Cardiovascular Disorders – Angina and Myocardial Infarction – Relief of pain
ANGINA: Relieved by rest or nitroglycerin
MYOCARDIAL INFARCTION : Relieved only by opioids
Cardiovascular Disorders – Angina and Myocardial Infarction – Duration of Symptoms
ANGINA: Symptoms usually last less than 15 min
MYOCARDIAL INFARCTION : Symptoms usually last greater than 30 min
Cardiovascular Disorders – Angina and Myocardial Infarction – Signs and Symptoms
ANGINA: Not associated with nausea, epigastric distress, dyspnea, anxiety, diaphoresis
MYOCARDIAL INFARCTION : Associated with nausea, epigastric distress, dyspnea, anxiety, diaphoresis
Cardiovascular Disorders – Angina and Myocardial Infarction – Risk Factors
o Male gender or postmenopausal women
o Hypertension
o Tobacco use
o Hyperlipidemia
o Metabolic disorders (diabetes mellitus, hyperthyroidism)
o Methamphetamine or cocaine use
o Stress (occupational, physical exercise, and sexual activity)
o The incidence of cardiac disease increases with age, especially in the presence of hypertension, diabetes mellitus, hypercholesterolemia, elevated homocysteine, and highly sensitive C-reactive protein
Cardiovascular Disorders – Angina and Myocardial Infarction – Subjective Data
o Women and older adults may not experience typical symptoms associated with angina or an MI.
o Anxiety, feeling of impending doom
o Chest pain (substernal or precordial)
• Pain can radiate down the shoulder or arm or may present in the form of jaw pain.
• Pain may be described as a crushing or aching pressure, tightness, or burning sensation.
o Nausea
o Dizziness
o Shortness of breath
Cardiovascular Disorders – Angina and Myocardial Infarction – Objective Data
o Physical Assessment Findings
• Pallor and cool, clammy skin
• Tachycardia and/or heart palpitations
• Diaphoresis
• Vomiting
• Decreased level of consciousness
Cardiovascular Disorders – Angina and Myocardial Infarction – Laboratory Tests
Cardiac enzymes released with cardiac muscle injury:
o Myoglobin – Levels no longer evident after 24 hr
o Creatine kinase-MB – Levels no longer evident after 3 days
o Troponin I – Levels no longer evident after 7 days
o Troponin T – Levels no longer evident after 14 to 21 days
Cardiovascular Disorders – Angina and Myocardial Infarction – Diagnostic Procedures – Electrocardiograms (ECG)
o Electrocardiography uses an electrocardiograph to record the electrical activity of the heart over time. The electrocardiograph is connected by wires (leads) to skin electrodes placed on various areas of the body.
o Nursing Actions
~ Position clients in a supine position with the chest exposed.
~ Wash the client’s skin to remove oils.
~ Attach one electrode to each extremity by applying electrodes to flat surfaces above the wrists and ankles and the other six electrodes to the chest, avoiding chest hair. (On male clients, chest hair may need to be shaved.)
~ Check for changes on serial ECGs.
~ Angina – ST depression and/or T-wave inversion (ischemia)
~ MI – T-wave inversion (ischemia), ST-segment elevation (injury), and an abnormal Q wave (necrosis)
Cardiovascular Disorders – Angina and Myocardial Infarction – Diagnostic Procedures – Thallium Scans
o Assess for ischemia or necrosis. Radioisotopes cannot reach areas with decreased or absent perfusion and they appear as “cold spots.”
– Nursing Actions
~ Instruct clients to avoid smoking and consuming caffeinated beverages 4 hr prior to the procedure.
Cardiovascular Disorders – Angina and Myocardial Infarction – Diagnostic Procedures – Cardiac catherization
A coronary angiogram, also called a cardiac catheterization, is an invasive diagnostic procedure used to evaluate the presence and degree of coronary artery blockage.
Cardiovascular Disorders – Angina and Myocardial Infarction – Nursing Care
o Monitor:
• Vital signs every 15 min until stable, then every hour
• Serial ECG, continuous cardiac monitoring
• Location, severity, quality, and duration of pain
• Hourly urine output – greater than 30 mL/hr indicates renal perfusion
• Laboratory data (cardiac enzymes, electrolytes, ABGs)
o Administer oxygen (2 to 4 L via nasal cannula)
o Assist with administration of IV fluids.
o Promote energy conservation (cluster nursing interventions).
Cardiovascular Disorders – Angina and Myocardial Infarction – Medication – Vasodilators
Nitroglycerin (Nitrostat) prevents coronary artery vasospasm and reduces preload and afterload, decreasing myocardial oxygen demand.
Cardiovascular Disorders – Angina and Myocardial Infarction – Medication – Vasodilators – Nursing Considerations
– Administer to treat angina and help control blood pressure.
– Monitor for orthostatic hypotension.
Cardiovascular Disorders – Angina and Myocardial Infarction – Medication – Vasodilators – Client Education
Client education regarding response to chest pain:
~ Instruct clients to:
t> Stop activity.
t> Take a dose of rapid-acting nitroglycerin immediately.
t> Wait 5 min.
t> Call 9-1-1, or be driven to an emergency department if pain is
unrelieved.
t> Take another dose.
[> Wait 5 min.
[> Take another dose if pain unrelieved.
o Remind clients that a headache is a common side effect of this medication.
o Encourage clients to change positions slowly.
Cardiovascular Disorders – Angina and Myocardial Infarction – Medication – Analgesics
• Morphine sulfate is an opioid analgesic used to treat moderate to severe pain.
• Use cautiously with clients who have asthma or emphysema due to the risk of respiratory depression.
Cardiovascular Disorders – Angina and Myocardial Infarction – Medication – Analgesics – Nursing Considerations
o Assist with client receiving morphine sulfate via IV bolus. Check the client’s pain level every 5 to 15 min.
o Watch clients for signs of respiratory depression, especially older adults. If the respirations are 12/min or less notify the provider immediately.
o Observe clients for nausea and vomiting.
Cardiovascular Disorders – Angina and Myocardial Infarction – Medication – Analgesics – Client Education
If nausea and vomiting persist, advise clients to notify a nurse.
Cardiovascular Disorders – Angina and Myocardial Infarction – Medication – Analgesics – Beta-blockers
Metoprolol tartrate (Lopressor) has antidysrhythmic and antihypertensive properties that decrease the imbalance between myocardial oxygen supply and demand by reducing afterload.
Cardiovascular Disorders – Angina and Myocardial Infarction – Medication – Analgesics – Nursing Considerations
o Hold the medication if the client’s apical pulse is less than 60/min and notify the provider.
o Use with caution in clients who have heart failure.
Cardiovascular Disorders – Angina and Myocardial Infarction – Medication – Analgesics – Client Education
Remind clients to notify the provider immediately if shortness of breath, edema, weight gain, or cough occurs.
Cardiovascular Disorders – Angina and Myocardial Infarction – Medication – Thrombolytic Agents
• Streptokinase (Streptase) and alteplase (Activase) are used to break up blood clots.
• Thrombolytic agents have similar side effects and contra indications as anticoagulants.
• For best results give within 6 hr of infarction.
Cardiovascular Disorders – Angina and Myocardial Infarction – Medication – Antiplatelet agents
Aspirin (Ecotrin) and clopidogrel (Plavix) prevent platelets from forming together, which can produce arterial clotting.
• Nursing Considerations
o Use cautiously with clients who have a history of GI ulcers.
• Client Education
o Remind clients of the risk for bruising and bleeding while on this
medication.
o Encourage clients to use aspirin tablets with enteric coating and to take with food.
Cardiovascular Disorders – Angina and Myocardial Infarction – Medication – Anticoagulants
• Heparin and enoxaparin (Lovenox) are used to prevent clots from becoming larger or other clots from forming.
• Nursing Considerations
o Check for contraindications (active bleeding, peptic ulcer disease, history of CVA, or recent trauma).
o Monitor bleeding times – PT, aPTI, INR, and CBC.
o Monitor for side effects of anticoagulants (thrombocytopenia, anemia, and hemorrhage).
• Client Education
o Remind clients of the risk for bruising and bleeding while on this
medication.
Cardiovascular Disorders – Angina and Myocardial Infarction – Medication – Glycoprotein IIB/IIIA inhibitors
• Eptifibatide (Integrilin) is used to prevent the binding of fibrogen, in turn blocking platelet aggregation. In combination with aspirin therapy, IIB/IIA inhibitors are standard therapy.
• Nursing Considerations
o Monitor clients for bleeding.
• Client Education
o Instruct clients to report signs of bleeding during medication therapy.
Cardiovascular Disorders – Angina and Myocardial Infarction – Interdisciplinary Care
o Request a referral for cardiac rehabilitation care if clients have prolonged weakness and need assistance with increasing level of activity.
o Request a referral for nutritional services for diet modification to promote low-sodium and low-saturated fat food choices.
Cardiovascular Disorders – Angina and Myocardial Infarction – Surgical Interventions – Angioplasty
Percutaneous transluminal coronary angioplasty (PTCA) involves inflating a balloon to dilate the arterial lumen and the adhering plaque, thus widening the arterial lumen. A stent (mesh-wire device) is often placed to prevent restenosis of the artery.
• Nursing Actions
o Verify that the consent form is signed.
o Ensure that clients are kept NPO 8 hr prior to the procedure.
o Check for iodine/shellfish allergy (contrast media).
Cardiovascular Disorders – Angina and Myocardial Infarction – Surgical Interventions – Bypass Graft
Coronary artery bypass graft (CABG) surgery restores myocardial tissue perfusion by the addition of grafts bypassing the obstructed coronary arteries. It is the most common form of cardiac surgery.
• Nursing Actions
o A CABG can be an elective procedure or done in an emergency. When planned, preparation begins before clients come to the hospital for the procedure.
o Verify that the informed consent is Signed.
o Confirm recent chest x-ray, ECG, and blood work results are available or needed.
Cardiovascular Disorders – Angina and Myocardial Infarction – Care after Discharge
Client Education
• Encourage clients to maintain an exercise routine to remain physically active. Clients should consult with a provider before starting any exercise regimen.
• Remind clients to adhere to follow-up appointments to have their cholesterol level and blood pressure checked regularly.
• Encourage clients to consume a diet low in saturated fats and sodium.
• If clients are smokers promote smoking cessation.
• Instruct clients to monitor and report signs of infection, such as fever, incisional drainage, and redness.
• Reinforce to clients to avoid straining, strenuous exercise, or emotional stress when possible.
Cardiovascular Disorders – Angina and Myocardial Infarction – Complications – Heart failure/cardiogenic shock
o Injury to the left ventricle can lead to decreased cardiac output and heart failure.
o Progressive heart failure can lead to cardiogenic shock.
• Symptoms include tachycardia; hypotension; inadequate urinary output; altered level of consciousness; respiratory distress (crackles and tachypnea); cool, clammy
skin; decreased peripheral pulses; and chest pain.
o Nursing Actions
• Assist with emergency management of client.
Cardiovascular Disorders – Angina and Myocardial Infarction – Complications – Dysrhythmias
o An inferior wall MI may lead to an injury to the AV node resulting in bradycardia and second-degree AV heart block.
o An anterior wall MI may lead to an injury to the ventricle resulting in premature ventricular contractions, bundle branch, or a complete heart block.
o Nursing Actions
• Monitor ECG and vital signs.
• Administer oxygen.
• Administer anti dysrhythmic medications as indicated.
• Prepare for cardiac pacemaker if needed.
Cardiovascular Disorders – Heart Failure
• Heart failure (pump failure) occurs when the heart muscle is unable to pump effectively, resulting in inadequate cardiac output, myocardial hypertrophy, and pulmonary/systemic congestion. The heart is unable to maintain adequate circulation to meet tissue needs.
• Heart failure is the result of an acute or chronic cardiopulmonary problem, such as systemic hypertension, myocardial infarction (MI), pulmonary hypertension, dysrhythmias, valvular heart disease, pericarditis, and cardiomyopathy.
Cardiovascular Disorders – Heart Failure – Classification according to NY Heart Association
The severity of heart failure is graded on the New York Heart Association’s functional classification scale indicating how little or how much activity it takes to make clients
symptomatic (chest pain, shortness of breath).
o Class I: Clients exhibit no symptoms with activity.
o Class II: Clients have symptoms with ordinary exertion.
o Class III: Clients display symptoms with minimal exertion.
o Class IV: Clients have symptoms at rest.
Cardiovascular Disorders – Heart Failure – Left and Right Heart Failure
Low-output heart failure can initially occur on either the left or right side of the heart.
o Left-sided heart (ventricular) failure results in inadequate left ventricle (cardiac) output and consequently in inadequate tissue perfusion.
o Right-sided heart (ventricular) failure results in inadequate right ventricle output and systemic venous congestion (peripheral edema).
Cardiovascular Disorders – Heart Failure – Risk Factors – Left-sided
• Hypertension
• Coronary artery disease, angina, MI
• Valvular disease (mitral and aortic)
Cardiovascular Disorders – Heart Failure – Risk Factors -Right-sided
Right-sided heart (ventricular) failure
• Left-sided heart (ventricular) failure
• Right ventricular MI
• Pulmonary problems (COPD, ARDS)
Cardiovascular Disorders – Heart Failure – Subjective and Objective Data – Left-sided failure
• Dyspnea, orthopnea (shortness of breath while lying down), nocturnal dyspnea
• Fatigue
• Displaced apical pulse (hypertrophy)
• S3 heart sound (gallop)
• Pulmonary congestion (dyspnea, cough, bibasilar crackles)
• Frothy sputum (can be blood-tinged)
• Altered mental status
• Symptoms of organ failure, such as oliguria (decrease in urine output)
Cardiovascular Disorders – Heart Failure – Subjective and Objective Data – Right-sided failure
• Jugular vein distention
• Ascending dependent edema (legs, ankles, sacrum)
• Abdominal distention, ascites
• Fatigue, weakness
• Nausea and anorexia
• Polyuria at rest (nocturnal)
• Liver enlargement (hepatomegaly) and tenderness
• Weight gain
Cardiovascular Disorders – Heart Failure – Laboratory Tests
Human B-type natriuretic peptides (hBNP): Elevated in heart failure. Used to differentiate dyspnea related to heart failure versus respiratory problem and to monitor the need for and the effectiveness of aggressive heart failure intervention.
o A level below 100 pg/mL indicates no heart failure.
o Levels between 100 to 300 pg/mL suggest heart failure is present.
o A level above 300 pg/mL indicates mild heart failure.
o A level above 600 pg/mL indicates moderate heart failure.
o A level above 900 pg/mL indicates severe heart failure.
Cardiovascular Disorders – Heart Failure – Diagnostic Procedures – Hemodynamic monitoring
Heart failure generally results in increased central venous pressure (CVP), increased right arterial pressure, increased pulmonary wedge pressure (PAWP), increased pulmonary artery pressure (PAP), and decreased cardiac output (CO).
Cardiovascular Disorders – Heart Failure – Diagnostic Procedures – Ultrasound
An ultrasound (also called cardiac ultrasound or echocardiogram), 2-D (2-dimensional), or 3-D (3-dimensional), is used to measure both systolic and diastolic function of the heart.
~ Left ventricular ejection fraction (LVEF): The volume of blood pumped from the left ventricle into the arteries upon each beat. Normal is 55% to 70%.
~ Right ventricular ejection fraction (RVEF): The volume of blood
pumped from the right ventricle to the lungs upon each beat. Normal
is 45% to 60%.
Cardiovascular Disorders – Heart Failure – Diagnostic Procedures – Chest x-ray
A chest x-ray can reveal cardiomegaly and pleural effusions.
Cardiovascular Disorders – Heart Failure – Diagnostic Procedures – ECG and others
Electrocardiogram (ECG), cardiac enzymes, electrolytes, and ABGs are used to assess factors contributing to heart failure and/or the impact of heart failure.
Cardiovascular Disorders – Heart Failure – Nursing Care
o Monitor daily weight and 1&0.
o Administer oxygen as prescribed.
o Position clients to maximize ventilation (high-Fowler’s position).
o Check ABGs, electrolytes (especially potassium if on diuretics), Sa02, and chest x-ray results.
o Encourage bed rest until clients are stable.
o Encourage energy conservation by assisting with care and ADLs.
o Maintain dietary restrictions as prescribed (restricted fluid intake, restricted sodium intake).
o Provide emotional support to clients and their families.
Cardiovascular Disorders – Heart Failure – Medications – Diuretics
Diuretics are used to decrease preload.
o Loop diuretics, such as furosemide (Lasix), bumetanide (Bumex)
o Thiazide diuretics, such as hydrochlorothiazide (Hydrodiuril)
o Potassium-sparing diuretics, such as spironolactone (Aldactone)
Cardiovascular Disorders – Heart Failure – Medications – Diuretics – Nursing Considerations and Client Education
• Nursing Considerations
o Administer potassium supplements for clients taking loop and thiazide
diuretics to prevent.
• Client Education
o Teach clients taking loop or thiazide diuretics to ingest foods and drinks that are high in potassium to counter the effects of hypokalemia.
Cardiovascular Disorders – Heart Failure – Medications – Afterload-reducing agents
• Afterload-reducing agents help the heart pump more easily by altering the resistance to contraction. These include:
o Angiotensin-converting enzyme (ACE) inhibitors, such as enalapril
(Vasotec), captopril (Capoten)
o Angiotensin receptor II blockers, such as losartan (Cozaar)
• These are contraindicated for clients who have renal deficiency.
Cardiovascular Disorders – Heart Failure – Medications – Afterload-reducing agents – Nursing Considerations
Monitor clients taking ACE inhibitors for hypotension following the initial dose. Monitor clients for 2 hr following first dose.
~ ACE inhibitors can cause angioedema (swelling of the tongue and throat).
~ Monitor for increased levels in potassium.
~ ACE inhibitors can cause a decreased sense of taste or rash on the skin.
Cardiovascular Disorders – Heart Failure – Medications – Afterload-reducing agents – Client Education
Inform clients to monitor and notify the provider for dry cough, rash,
altered taste sensation, or swelling of the tongue and pharynx. Medication should be discontinued.
Cardiovascular Disorders – Heart Failure – Medications – Inotropic Agents
Inotropic agents, such as digoxin (Lanoxin), are used to increase contractility and thereby improve cardiac output.
Cardiovascular Disorders – Heart Failure – Medications – Inotropic Agents – Nursing Considerations
1) For a client taking digoxin, take the apical heart rate for 1 min. Hold the medication if apical pulse is less than 60/min and notify the provider.
2) Observe clients for toxicity such as bradycardia, anorexia, nausea, vomiting fatigue, muscle weakness, and vision changes (blurred vision, diplopia, yellow-green or white halos around objects).
Cardiovascular Disorders – Heart Failure – Medications – Inotropic Agents – Client Education
Reinforce to clients who are self-administering digoxin to:
~ Count pulse for 1 min before taking the medication. If the pulse rate is irregular or the pulse rate is outside of the limitations set by the provider (usually less than 60/min or greater than lOO/min), instruct clients to hold the dose and to contact the provider.
~ Take the digoxin dose at the same time each day.
~ Do not take digoxin at the same time as antacids. Separate the two medications by at least 2 hr.
~ Report signs of toxicity, including fatigue, muscle weakness, confusion, and loss of appetite.
~ Regularly have digoxin and potassium levels checked.
Cardiovascular Disorders – Heart Failure – Medications – Vasodilators
Nitroglycerin (Nitrostat) and isosorbide mononitrate (lmdur) prevent coronary artery vasospasm and reduce preload and afterload, decreasing myocardial oxygen demand.
Cardiovascular Disorders – Heart Failure – Medications – Vasodilators – Nursing Considerations
– Administer vasodilators to treat angina and help control blood pressure.
– Use cautiously with other antihypertensive medications.
– Monitor for orthostatic hypotension
Cardiovascular Disorders – Heart Failure – Medications – Vasodilators – Client Education
– Remind clients that a headache is a common side effect of this medication.
– Encourage clients to change slowly.
Cardiovascular Disorders – Heart Failure – Medications – Human B-type natriuretic peptides (hBNP)
hBNPs, such as nesiritide (Natrecor), are used to treat acute heart failure by causing natriuresis (loss of sodium and vasodilation).
Cardiovascular Disorders – Heart Failure – Medications – Human B-type natriuretic peptides (hBNP) – Nursing Considerations and Client Education
• Nursing Considerations
– hBNPs can cause hypotension, as well as a number of cardiac effects that include, ventricular tachycardia and bradycardia.
– BNP levels will increase while on this medication.
– Monitor ECG and blood pressure.
• Client Education
D Remind clients to change positions slowly. PN
Cardiovascular Disorders – Heart Failure – Medications –
• Anticoagulants, such as warfarin (Coumadin), can be prescribed if clients have a history of thrombus formation.
• Nursing Considerations
o Check for contraindications (active bleeding, peptic ulcer disease, history of cerebrovascular accident, recent trauma).
o Monitor bleeding times – PT, aPTf, INR, and CBC.
• Client Education
o Remind clients of the risk for bruising and bleeding while on this
medication.
o Remind clients to have blood monitored routinely to check bleeding times.
Cardiovascular Disorders – Heart Failure – Interdisciplinary Care
o Request a referral for respiratory services to assist with inhalers, breathing treatments, and suctioning for airway management.
o Request a referral for cardiac rehabilitation services if clients have prolonged weakness and need assistance with increasing level of activity.
o Request a referral for nutritional services for diet modification to promote low-sodium and low-saturated fat food choices.
Cardiovascular Disorders – Heart Failure – Surgical Interventions – Ventricular assist device (VAD)
A VAD is a mechanical pump that assists a heart that is too weak to pump blood through the body. A VAD is used in clients who are eligible for heart transplants or who have severe end-stage heart failure and are not candidates for heart transplants. Heart transplantation is the treatment of choice for clients who have severe dilated cardiomyopathy.
Cardiovascular Disorders – Heart Failure – Surgical Interventions – Ventricular assist device (VAD) – Nursing Actions
o Prepare clients for the procedure (NPO status and informed consent).
o Monitor postoperatively (vital signs, Sa02, incision drainage, and pain management).
Cardiovascular Disorders – Heart Failure – Surgical Interventions – Heart Transplantation
Heart transplantation is a possible option for clients who have end-stage heart failure. Immunosuppressant therapy is required posttransplantation to prevent rejection.
Cardiovascular Disorders – Heart Failure – Surgical Interventions – Heart Transplantation – Nursing Actions
o Prepare clients for the procedure (NPO status and informed consent).
o Monitor postoperatively (vital signs, Sa02, incision drainage, and pain management).
Cardiovascular Disorders – Heart Failure – Surgical Interventions – Heart Transplantation – Client Education
o Take medications as prescribed.
o Take diuretics in the early morning and early afternoon.
o Maintain fluid and sodium restriction – A dietary consult can be useful.
o Increase dietary intake of potassium (cantaloupe or bananas) if clients are taking potassium-losing diuretics, such as loop and thiazide diuretics.
o Check weight daily at the same time and notify the provider for a weight gain of 2 lb in 24 hr or 5 lb in 1 week.
o Schedule regular follow-up visits with the provider.
o Get vaccinations (pneumococcal and yearly influenza vaccines).
Cardiovascular Disorders – Heart Failure – Surgical Interventions – Care after discharge – Client Education
• Encourage clients to maintain an exercise routine to remain physically active and consult with the provider before starting any exercise regimen.
• Recommend clients consume a diet low in sodium, along with fluid restrictions and consult with the provider regarding diet specifications.
• Promote smoking cessation.
• Instruct clients to follow medication regimen and follow up with the provider as needed.
Cardiovascular Disorders – Heart Failure – Surgical Interventions – Client Outcomes
o The client will have adequate gas exchange.
o The client will have a decrease in anxiety.
o The client will maintain fluid balance.
o The client will improve tolerance to activity.
o The client will have an increase in cardiac output.
Cardiovascular Disorders – Heart Failure – Surgical Interventions – COMPLICATIONS – Cardiomyopathy
Cardiomyopathy is an impaired cardiac function leading to heart failure. Blood circulation is impaired to the lungs or body when the cardiac pump is compromised. Of the three types (dilated cardiomyopathy, hypertrophic cardiomyopathy, restrictive
cardiomyopathy), dilated cardiomyopathy is the most common.
• Dilated – Decreased contractility and increased ventricular filling pressures
• This can be a result of:
o Coronary artery disease
o Infection or inflammation of the heart muscle
o Various cancer treatments
o Prolonged alcohol abuse
Cardiovascular Disorders – Heart Failure – Surgical Interventions – COMPLICATIONS – Cardiomyopathy – Subjective and Objective Data
o Fatigue, weakness
o Heart failure (left with dilated type, right with restrictive type)
o Dysrhythmias (heart block)
o S3 gallop
o Cardiomegaly (enlarged heart)
Cardiovascular Disorders – Heart Failure – Surgical Interventions – COMPLICATIONS – Cardiomyopathy – Nursing Actions
• Monitor clients for increased fatigue, weakness, and dysrhythmias.
• Notify provider of findings .
• Provide quiet, calm environment and promote rest.
Cardiovascular Disorders – Heart Failure – Surgical Interventions – COMPLICATIONS – Cardiomyopathy – Client Education
Reinforce to clients about measures to improve tolerance to activity, such as alternating periods of activity with periods of rest.
Cardiovascular Disorders – Heart Failure – Surgical Interventions – COMPLICATIONS – Acute Pulmonary Edema
o Acute pulmonary edema is a life-threatening medical emergency.
o Nursing Actions
• Administer prescribed medications to improve cardiac output.
• Symptoms include anxiety, tachycardia, acute respiratory distress, dyspnea at rest,change in level of consciousness, and an ascending fluid level within the lungs
(crackles, cough productive of frothy, blood-tinged sputum).
• Assist with emergency care.
– Position clients in high-Fowler’s position.
– Administer oxygen, positive airway pressure, and/or intubation and
mechanical ventilation.
– Monitor clients receiving IV medications.
– Morphine (to decrease anxiety, respiratory distress, and decrease venous return)
– Rapid-acting loop diuretics, such as furosemide (Lasix)
Cardiovascular Disorders – Heart Failure – Surgical Interventions – COMPLICATIONS – Cardiogenic Shock
o Symptoms include tachycardia, hypotension, inadequate urinary output, altered level of consciousness, respiratory distress, (crackles, tachypnea) cool, clammy skin, decreased peripheral pulses, and chest pain.
o Nursing Actions
• Monitor breath sounds. Check for crackles or wheezing.
• Monitor heart sounds.
• Administer oxygen; possible intubation and ventilation may be required.
• Assist with emergency care (IV administration of morphine, diuretics, and/or nitroglycerin to decrease preload; and IV administration of vasopressors and/or positive inotropes to increase cardiac output and to maintain organ perfusion).
Cardiovascular Disorders – Heart Failure – Surgical Interventions – COMPLICATIONS – Pericardial Tamponade
o Cardiac tamponade can result from fluid accumulation in the pericardial sac.
o Signs include hypotension, jugular venous distention, muffled heart sounds, and paradoxical pulse (variance of 10 mm Hg or more in systolic blood pressure between expiration and inspiration).
o Nursing Actions
• Notify the provider immediately.
• Obtain a chest x-ray or echocardiogram to confirm diagnosis.
• Prepare clients for pericardiocentesis (informed consent, gather materials, administer medications as appropriate).
• Assist with emergency care.
Cardiovascular Disorders – Valvular Heart Disease and Inflammatory Disorders – Overview
Valvular heart disease and inflammatory conditions of the heart (pericarditis, myocarditis, rheumatic endocarditis, infective endocarditis) may result in dysfunction that impacts clients’ ability to meet tissue and oxygen demands.
Cardiovascular Disorders – Valvular Heart Disease – Overview
Valvular heart disease describes an abnormality or dysfunction of any of the heart’s four valves: the mitral and aortic valves (left side) and the tricuspid and pulmonic valves (right side) .
Cardiovascular Disorders – Valvular Heart Disease – is Classified as
o Stenosis – Narrowed opening that impedes blood moving forward.
o Insufficiency – Improper closure – Some blood flows backwards (regurgitation).
Cardiovascular Disorders – Valvular Heart Disease – Congenital
Congenital valvular heart disease can affect all four valves and cause either stenosis or insufficiency.
Cardiovascular Disorders – Valvular Heart Disease – Acquired valvular heart disease
Acquired valvular heart disease is classified as one of three types:
• Degenerative disease – Due to damage over time from mechanical stress. The most common cause is hypertension.
• Rheumatic disease – Gradual fibrotic changes, calcification of valve cusps. The mitral valve is most commonly affected.
• Infective endocarditis – Infectious organisms destroy the valve. Streptococcal infections are a common cause.
Cardiovascular Disorders – Valvular Heart Disease – Risk Factors
o Hypertension
o Rheumatic fever (mitral stenosis and insufficiency)
o Infective endocarditis
o Congenital malformations
o Female gender
o Marfan syndrome (connective tissue disorder that affects the heart and other areas of the body)
o In older adult clients, the predominant causes of valvular heart disease are degenerative calcification, papillary muscle dysfunction, and infective endocarditis.
o A murmur is heard with turbulent blood flow. The location of the murmur and timing (diastolic versus systolic) help determine the valve involved. Murmurs are graded on a scale of I (very faint) to VI (extremely loud).
Cardiovascular Disorders – Valvular Heart Disease – Subjective and Objective Data – Left Sided Damage
LEFT-SIDED VALVE DAMAGE RESULTS IN DYSPNEA, FATIGUE, INCREASED PULMONARY ARTERY PRESSURE, AND DECREASED CARDIAC OUTPUT.
Cardiovascular Disorders – Valvular Heart Disease – Subjective and Objective Data – Left Sided Damage – Mitral Stenosis
* Palpitations
* Hemoptysis
* Hoarseness
* Dysphagia
* Jugular vein distention
* Orthopnea
* Cough
* Diastolic murmur
* Atrial Fibrillation
Cardiovascular Disorders – Valvular Heart Disease – Subjective and Objective Data – Left Sided Damage – Mitral Insufficiency
* Proximal nocturnal
* Dyspnea
* Orthopnea
* Palpitations
* S3 and/or S4 sounds
* Crackles in lungs
* Possible diminished lung sounds
* Systolic murmur
* Atrial fibrillation
Cardiovascular Disorders – Valvular Heart Disease – Subjective and Objective Data – Left Sided Damage – Aortic Stenosis
* Angina
* Syncope
* Decreased SVR
* S3 and/or S4 sounds
* Systolic murmur
* Narrowed pulse pressure
Cardiovascular Disorders – Valvular Heart Disease – Subjective and Objective Data – Left Sided Damage – Aortic Insufficiency
* Angina
* S3 Sounds
* Diastolic murmur
* Widened pulse pressure
Cardiovascular Disorders – Valvular Heart Disease – Subjective and Objective Data – Right Sided Damage
RIGHT-SIDED VALVE DAMAGE RESULTS IN DYSPNEA, FATIGUE, INCREASED RIGHT ATRIAL PRESSURE,
PERIPHERAL EDEMA, JUGULAR VEIN DISTENTION, AND HEPATOMEGALY.
Cardiovascular Disorders – Valvular Heart Disease – Subjective and Objective Data – Right Sided Damage – Tricuspid Stenosis
• Atrial dysrhythmias
• Diastolic murmur
• Decreased cardiac output
Cardiovascular Disorders – Valvular Heart Disease – Subjective and Objective Data – Right Sided Damage – Tricuspid Insfficiency
• Conduction delays
• Supraventricular tachycardia
• Systolic murmur
Cardiovascular Disorders – Valvular Heart Disease – Subjective and Objective Data – Right Sided Damage – Pulmonic Stenosis
• Cyanosis
• Systolic murmur
Cardiovascular Disorders – Valvular Heart Disease – Subjective and Objective Data – Right Sided Damage – Pulmonic Insufficiency
• Diastolic murmur
Cardiovascular Disorders – Valvular Heart Disease – Diagnostic Procedures – Chest x-ray
o A chest x-ray shows chamber enlargement, pulmonary congestion, and valve calcification.
Cardiovascular Disorders – Valvular Heart Disease – Diagnostic Procedures – 12-lead electrocardiogram (ECG)
o An ECG shows chamber hypertrophy.
Cardiovascular Disorders – Valvular Heart Disease – Diagnostic Procedures – Echocardiogram
o An echo cardiogram shows chamber size, hypertrophy, specific valve dysfunction, ejection function, and amount of regurgitant flow.
Cardiovascular Disorders – Valvular Heart Disease – Diagnostic Procedures – Exercise tolerance testing/stress echocardiography
o A stress echo cardiography is used to assess the impact of the valve problem on cardiac functioning during stress.
Cardiovascular Disorders – Valvular Heart Disease – Diagnostic Procedures – Radionuclide studies
o Radionuclide studies determine ejection fraction during activity and rest.
Cardiovascular Disorders – Valvular Heart Disease – Diagnostic Procedures – Angiography
o Angiography reveals chamber pressures, ejection fraction, regurgitation, and pressure gradients.
Cardiovascular Disorders – Valvular Heart Disease – Nursing Care
o Monitor current weight and note any recent changes.
o Monitor heart rate and rhythm. Check for murmurs.
o Administer oxygen and medications as prescribed.
o Maintain fluid and sodium restriction.
o Assist clients to conserve energy.
Cardiovascular Disorders – Valvular Heart Disease – Medications – Diuretics
Diuretics are used to decrease preload.
o Loop diuretics, such as furosemide (Lasix), bumetanide (Bumex)
o Thiazide diuretics, such as hydrochlorothiazide (Hydrodiuril)
o Potassium-sparing diuretics, such as spironolactone (Aldactone)
Cardiovascular Disorders – Valvular Heart Disease – Medications – Diuretics – Nursing Considerations
Monitor for hypokalemia with loop and thiazide diuretics. Administer a potassium supplement as needed.
Cardiovascular Disorders – Valvular Heart Disease – Medications – Diuretics – Client Education
Reinforce to clients who are taking loop or thiazide diuretics to ingest foods and drinks that are high in potassium to counter hypokalemia effect.
Cardiovascular Disorders – Valvular Heart Disease – Medications – Afterload reducing agents
Afterload-reducing agents help the heart pump more easily by altering the resistance to contraction.
o Angiotensin-converting enzyme (ACE) inhibitors, such as enalapril (Vasotec), captopril (Capoten)
o Beta-blockers
o Calcium-channel blockers
Cardiovascular Disorders – Valvular Heart Disease – Medications – Afterload reducing agents – Nursing Considerations
Monitor clients taking ACE inhibitors for initial dose hypotension.
Cardiovascular Disorders – Valvular Heart Disease – Medications – Inotropic Agents
Inotropic agents, such as digoxin (Lanoxin), are used to increase contractility and thereby improve cardiac output
Cardiovascular Disorders – Valvular Heart Disease – Medications – Inotropic Agents – Client Education
Reinforce to clients who are self-administering digoxin to:
~ Count pulse for 1 min before taking the medication. If the pulse rate is irregular or the pulse rate is outside of the limitations set by the provider (usually less than 60/min or greater than lOO/min), clients should hold the dose and contact the provider.
~ Take the dose of digoxin at the same time every day.
~ Do not take digoxin at the same time as antacids. Separate the two medications by at least 2 hr.
~ Report signs of toxicity, including fatigue, muscle weakness, confusion, visual changes, and loss of appetite.
Cardiovascular Disorders – Valvular Heart Disease – Medications – Anticoagulants
Anticoagulation therapy is used for clients who have a mechanical valve replacement, atrial fibrillation, or severe left ventricle dysfunction.
Cardiovascular Disorders – Valvular Heart Disease – Interdisciplinary Care
o Request a referral for respiratory services to assist with inhalers, breathing treatments, and suctioning for airway management.
o Request a referral for nutritional services for weight loss or gain related to medications or diagnosis.
o Request a referral for rehabilitative care if clients have prolonged weakness and need assistance with increasing level of activity.
Cardiovascular Disorders – Valvular Heart Disease – Surgical Interventions – Percutaneous balloon valvuloplasty
• This procedure can open aortic or mitral valves affected by stenosis. A catheter is inserted through the femoral artery and advanced to the heart. A balloon is inflated at the stenotic lesion to open the fused commissures and improve leaflet mobility.
Cardiovascular Disorders – Valvular Heart Disease – Surgical Interventions – Miscellaneous surgical management
Surgeries used in the treatment of valvular disorders include valve repair, chordae tendineae reconstruction, commissurotomy (relieve stenosis on leaflets), annuloplasty ring insertion (correct dilatation of valve annulus), and prosthetic valve replacement.
o Prosthetic valves can be mechanical or tissue. Mechanical valves last longer but require anticoagulation. Tissue valves last 10 to 15 years.
o Medical management is appropriate for many older adult clients; surgery is indicated when symptoms interfere with ADLs. The goal of surgery can be to improve the quality of life rather than to prolong life.
* Nursing Actions
o Postsurgery care is similar to coronary artery bypass surgery (care for sternal incision, activity limited for 6 weeks, report fever).
Cardiovascular Disorders – Valvular Heart Disease – Surgical Interventions – Care After Discharge – Client Education
• Remind clients of the need for prophylactic antibiotics prior to dental work, surgery, or other invasive procedures.
• Encourage clients to follow the prescribed exercise program.
• Encourage clients to consume a diet low in sodium and follow fluid restrictions prescribed by provider to prevent heart failure. Reinforce energy conservation to clients.
Cardiovascular Disorders – Valvular Heart Disease – Surgical Interventions – Client Outcomes
o The client will maintain the prescribed medication treatment regimen.
o The client will maintain an unrestricted activity level without shortness of breath or chest pain.
o The client will be free from anxiety.
o The client will remain free from infection.
o The client will be able to maintain within 10% of the ideal body weight.
PN
Cardiovascular Disorders – Valvular Heart Disease – Surgical Interventions – COMPLICATIONS
Heart Failure
o Heart failure is the inability of the heart to maintain adequate circulation to meet tissue needs for oxygen and nutrients. Ineffective valves result in heart failure.
o Nursing Actions
• Monitor client’s cardiac status
Cardiovascular Disorders – INFLAMMATORY DISORDERS – Overview
• Inflammation related to the heart is an extended inflammatory response that often leads to the destruction of healthy tissue. This primarily includes the layers of the heart.
• Inflammatory disorders related to the cardiovascular system that nurses should be familiar with include:
o Pericarditis
o Myocarditis
o Rheumatic endocarditis
o Infective endocarditis (previously called bacterial endocarditis)
Cardiovascular Disorders – INFLAMMATORY DISORDERS – Health Promotion and Disease Prevention
• Early treatment of streptococcal infections can prevent rheumatic fever.
• Prophylactic treatments (including antibiotics for clients who have cardiac defects) can prevent infective endocarditis.
• Influenza and pneumonia vaccinations are important for all clients in order to decrease the incidence of myocarditis, especially in older adults.
Cardiovascular Disorders – INFLAMMATORY DISORDERS – Risk Factors
o Congenital heart defect/cardiac anomalies
o Immunosuppression
o Rheumatic endocarditis
o School-age children who have long duration of streptococcus infection
o Malnutrition
o Overcrowding
o Lower socioeconomic status
Cardiovascular Disorders – INFLAMMATORY DISORDERS – Subjective and Objective Data – PERICARDITIS – Description of Disease Process
Inflammation of the pericardium
Cardiovascular Disorders – INFLAMMATORY DISORDERS – Subjective and Objective Data – PERICARDITIS – Relevant Information
– Commonly follows a respiratory infection
– Can be due to a Myocardial Infection
– Findings include chest pressure/pain, friction rub auscultated in the lungs, shortness of breath, and pain relieved when sitting and leaning forward
Cardiovascular Disorders – INFLAMMATORY DISORDERS – Subjective and Objective Data – MYOCARDITIS – Description of Disease Process
Inflammation of the Myocardium
Cardiovascular Disorders – INFLAMMATORY DISORDERS – Subjective and Objective Data – MYOCARDITIS – Relevant Information
– Can be due to a viral or fungal infection
– Can be due to a systemic disease (Crohn’s disease)
– Findings include tachycardia, murmur, friction, rub auscultated in the lungs, cardiomegaly and dysrhythmias.
Cardiovascular Disorders – INFLAMMATORY DISORDERS – Subjective and Objective Data – RHEUMATIC ENDOCARDITIS – Description of Disease Process
Infection of the endocardium due to streptococcal bacteria
Cardiovascular Disorders – INFLAMMATORY DISORDERS – Subjective and Objective Data – RHEUMATIC ENDOCARDITIS – Relevant Information
– followed by an upper respiratory infection
– produces lesions in the heart
– occurs with half of the clients with rheumatic heart fever
– findings include fever, chest pain, joint pain, tachycardia, shortness of breath, rash on trunk and extremities, friction rub, murmur and muscle spasms.
Cardiovascular Disorders – INFLAMMATORY DISORDERS – Subjective and Objective Data – INFECTIVE ENDOCARDITIS – Description of Disease Process
Also known as bacterial endocarditis, and is an infection of the endocardium due to streptococcal or staphylococcal bacteria.
Cardiovascular Disorders – INFLAMMATORY DISORDERS – Subjective and Objective Data – INFECTIVE ENDOCARDITIS – Relevant Information
– Most common in IV drug users or clients who have cardiac malformations
– Findings include fever, flu-like symptoms, murmur, petechiae (on the trunk and mucous membrane), positive blood cultures, and splinter hemorrhages (red streaks under the nail beds)
Cardiovascular Disorders – INFLAMMATORY DISORDERS – Laboratory Tests
• Blood cultures can be drawn to detect a bacterial infection.
• An elevated WBC count can be indicative of a bacterial infection.
• Cardiac enzymes can be elevated with pericarditis.
• Throat cultures can be taken to detect a streptococcal infection, which can lead to rheumatic fever.
Cardiovascular Disorders – INFLAMMATORY DISORDERS – Diagnostic Procedures
ECG can detect a murmur or heart block, which is indicative of rheumatic fever.
Cardiovascular Disorders – INFLAMMATORY DISORDERS – Nursing Care
o Monitor vital signs (watch for fever).
o Auscultate heart sounds (listen for murmur).
o Check breath sounds in all lung fields (listen for friction rub).
o Check ABGs, Sa02 , and chest x-ray results.
o Administer oxygen as prescribed.
o Monitor ECG and notify the provider of changes.
o Obtain throat cultures to identify bacteria to treat with antibiotics.
o Administer antibiotics, antipyretics, and analgesics as prescribed.
o Encourage bed rest.
Cardiovascular Disorders – INFLAMMATORY DISORDERS – Medications: ANTIBIOTIC (Penicillin) – Purpose
Given to treat the infection
Cardiovascular Disorders – INFLAMMATORY DISORDERS – Medications: ANTIBIOTIC (Penicillin) – Nursing Considerations
• Monitor for skin rash and hives.
• Monitor electrolyte and kidney levels
Cardiovascular Disorders – INFLAMMATORY DISORDERS – Medications: ANTIBIOTIC -Penicillin – Client Education
• Instruct clients to report signs of skin rash or hives.
• Inform clients that the medication may cause gastrointestinal (GI)
distress.
Cardiovascular Disorders – INFLAMMATORY DISORDERS – Medications: NSAID (non-steroidal anti-inflammatory drug) – Ibuprofen (Advil) – Purpose
Given to treat fever and inflammation
Cardiovascular Disorders – INFLAMMATORY DISORDERS – Medications: NSAID (non-steroidal anti-inflammatory drug) – Ibuprofen (Advil) – Nursing Considerations
• Do not use in clients who have peptic ulcer disease.
• Watch for signs of GI distress.
• Monitor platelets, and liver and kidney levels.
Cardiovascular Disorders – INFLAMMATORY DISORDERS – Medications: NSAID (non-steroidal anti-inflammatory drug) – Ibuprofen (Advil) – Client Education
• Instruct clients to take the medication with food.
• Inform clients that the medication may cause GI distress.
• Instruct clients to avoid alcohol consumption while taking the medication.
Cardiovascular Disorders – INFLAMMATORY DISORDERS – Medications: GLUCOCORTICOSTEROID – Prednisone (Deltasone) – purpose
Given to treat inflammation
Cardiovascular Disorders – INFLAMMATORY DISORDERS – Medications: GLUCOCORTICOSTEROID – Prednisone (Deltasone)- Nursing Considerations
• Use in low doses. .
• Monitor blood pressure
• Monitor electrolytes and blood sugar levels.
• Clients may heal slowly on this medication.
Cardiovascular Disorders – INFLAMMATORY DISORDERS – Medications: GLUCOCORTICOSTEROID – Prednisone (Deltasone) – Client Education
• Instruct clients to take with food.
• Instruct clients to avoid stopping the medication abruptly.
• Instruct clients to report signs of an unexpected weight gain.
Cardiovascular Disorders – INFLAMMATORY DISORDERS – Medications: ANTIFUNGAL – Amphotericin B (Amphocin) – Purpose
Given to treat Fungus
Cardiovascular Disorders – INFLAMMATORY DISORDERS – Medications: ANTIFUNGAL – Amphotericin B (Amphocin) – Nursing Considerations
Monitor liver and kidney levels
Cardiovascular Disorders – INFLAMMATORY DISORDERS – Medications: ANTIFUNGAL – Amphotericin B (Amphocin) – Client Education
Inform clients that medication may cause GI upsets
Cardiovascular Disorders – INFLAMMATORY DISORDERS – Medications: BENZODIAZEPINE – Diazepam (Valium) – Purpose
Given to treat anxiety
Cardiovascular Disorders – INFLAMMATORY DISORDERS – Medications: BENZODIAZEPINE – Diazepam (Valium) – Nursing Considerations
• Start in low doses, and monitor for sleepiness and lightheadedness
• Monitor the client’s liver function
Cardiovascular Disorders – INFLAMMATORY DISORDERS – Medications: BENZODIAZEPINE – Diazepam (Valium) – Client Education
• Instruct clients to take the medication as prescribed.
• Instruct clients to avoid alcohol consumption while taking the medication.
• Instruct clients to avoid stopping the medication abruptly
Cardiovascular Disorders – INFLAMMATORY DISORDERS – Interdisciplinary Care
o Cardiology services may be consulted to manage cardiac dysfunction.
o Request a referral for physical therapy to increase the client’s level of activity once prescribed.
o Request a referral for home health care to assist with IV administration of antibiotics.
Cardiovascular Disorders – INFLAMMATORY DISORDERS – Surgical Interventions – Pericarditis – Pericardiocentesis
• Pericardiocentesis
o A needle is inserted into the pericardium to aspirate pericardial fluid. This can be done in the emergency department or a procedure room.
• Nursing Actions
o Pericardia I fluid can be sent to the laboratory for culture and sensitivity.
o Monitor for reoccurrence of cardiac tamponade
Cardiovascular Disorders – INFLAMMATORY DISORDERS – Surgical Interventions – Pericarditis –
Infective endocarditis
o Valve debridement, draining of abscess, and repairing congenital shunts are procedures involved with infective endocarditis.
• Nursing Actions
o Monitor for signs of bleeding, infection, and cardiac output.
Cardiovascular Disorders – INFLAMMATORY DISORDERS – Surgical Interventions – Pericarditis –
Infective endocarditis – Client Education
• Encourage clients to take rest periods as needed.
• Encourage clients to wash hands and practice good oral hygiene to prevent infection.
• Encourage clients to avoid crowded areas to reduce the risk of infection.
• Educate clients about the importance of taking medications as prescribed.
• Promote smoking cessation.
Cardiovascular Disorders – INFLAMMATORY DISORDERS – Complications – CARDIAC TAMPONADE
Pericardial tamponade
• Cardiac tamponade can result from fluid accumulation in the pericardial sac.
o Signs include hypotension, muffled heart sounds, jugular venous distention, and paradoxical pulse (variance of 10 mm Hg or more in systolic blood pressure between expiration and inspiration).
• Nursing Actions
o Notify the provider immediately.
o Obtain a chest x-ray or echo cardiogram to confirm the diagnosis.
o Prepare clients for pericardiocentesis (informed consent, gather materials, administer medications as appropriate).
Cardiovascular Disorders – Vascular Disorders – Peripheral Vascular Disease
Peripheral vascular diseases include peripheral arterial disease (PAD) and peripheral venous disorders, both of which interfere with normal blood flow.
Cardiovascular Disorders – Vascular Disorders – PERIPHERAL ARTERIAL DISEASE (PAD) – Overview
• PAD results from atherosclerosis that usually occurs in the arteries of the lower extremities and is characterized by inadequate flow of blood. Tissue damage occurs below the arterial
obstruction.
• Atherosclerosis is caused by a gradual thickening of the intima and media of the arteries, ultimately resulting in the progressive narrowing of the vessel lumen. Plaques may form on
the walls of the arteries, making them rough and fragile.
• Progressive stiffening of the arteries and narrowing of the lumen decreases the blood supply to affected tissues and increases resistance to blood flow.
• Atherosclerosis is actually a type of arteriosclerosis, which means “hardening of the arteries,” and alludes to the loss of elasticity of arteries over time, due to thickening of their
walls.
• Buerger’s disease, subclavian steal syndrome, thoracic outlet syndrome, Raynaud’s disease and Raynaud’s phenomenon, and popliteal entrapment are examples of PADs.
Cardiovascular Disorders – Vascular Disorders – PERIPHERAL ARTERIAL DISEASE (PAD) – Risk Factors
0 Hypertension
0 Hyperlipidemia
0 Diabetes mellitus
0 Cigarette smoking
0 Obesity
o Sedentary lifestyle
o Familial predisposition
o Age
• Older adult clients have a higher incidence of PAD (rate of occurrence is increased in men over 45 and in women who are postmenopausal) and have a higher mortality rate from complications than younger individuals.
Cardiovascular Disorders – Vascular Disorders – PERIPHERAL ARTERIAL DISEASE (PAD) – Subjective Data
o Burning, cramping, and pain in the legs during exercise (intermittent claudication)
o Numbness or burning pain primarily in the feet when in bed
o Placing legs at rest in a dependent position relieves pain.
Cardiovascular Disorders – Vascular Disorders – PERIPHERAL ARTERIAL DISEASE (PAD) – Objective Data
Physical Assessment Findings
• Bruit over femoral and aortic arteries
• Decreased capillary refill of toes (greater than 3 seconds)
• Decreased or non palpable pulses
• Loss of hair on lower calf, ankle, and foot
• Dry, sca ly, mottled skin
• Thick toenails
• Cold and cyanotic extremity
• Pallor of extremity with elevation
• Dependent rubor
• Muscle atrophy
• Ulcers and possible gangrene of toes
Cardiovascular Disorders – Vascular Disorders – PERIPHERAL ARTERIAL DISEASE (PAD) – Diagnostic Procedures – Arteriography
~ Arteriography of the lower extremities involves arterial injection of
contrast medium to visualize areas of decreased arterial flow on an x-ray.
~ It is usually done only to determine isolated areas of occlusion that can be treated during the procedure with percutaneous transluminal angioplasty and possible stent placement.
Cardiovascular Disorders – Vascular Disorders – PERIPHERAL ARTERIAL DISEASE (PAD) – Diagnostic Procedures – Arteriography – Nursing Actions
~ Monitor clients for bleeding and hemorrhage.
~ Palpate pedal pulses to check for postprocedure occlusions.
Cardiovascular Disorders – Vascular Disorders – PERIPHERAL ARTERIAL DISEASE (PAD) – Diagnostic Procedures – Arteriography – Exercise Tolerance Testing
A stress test is done with or without the use of a treadmill (medications such as dipyridamole (Persantine) and adenosine (Adenocard) may be given to mimic the effects of exercise in clients who cannot tolerate a treadmill) with measurement of pulse volumes and blood pressures prior to and following
the onset of symptoms or 5 min of exercise. Delays in return to normal pressures and pulse waveforms indicate arterial disease. This test evaluates claudication during exercise.
Cardiovascular Disorders – Vascular Disorders – PERIPHERAL ARTERIAL DISEASE (PAD) – Diagnostic Procedures – PLETHYSMOGRAPHY
o Plethysmography is used to determine the variations of blood passing through an artery, thus identifying abnormal arterial flow in the affected limb.
o Blood pressure cuffs are attached to the client’s upper extremities and a lower extremity and attached to the plethysmograph machine. This test records variations in peripheral pulses between the upper and lower extremity.
o A decrease in pulse pressure of the lower extremity indicates a possible blockage in the leg.
Cardiovascular Disorders – Vascular Disorders – PERIPHERAL ARTERIAL DISEASE (PAD) – Diagnostic Procedures – Segmental systolic blood pressure measurements
o A Doppler probe takes various blood pressure measurements (thigh, calf, ankle, brachial) for comparison. In the absence of peripheral arterial disease, pressures in the lower extremities are higher than those of the upper extremities.
o With arterial disease, the pressures in the thigh, calf, and ankle are lower.
Cardiovascular Disorders – Vascular Disorders – PERIPHERAL ARTERIAL DISEASE (PAD) – Nursing Care
o Monitor skin every 8 hour
o Provide skin care with warm water, mild soap, and moisturizing lotions.
o Provide a warm environment for clients, and offer socks and blankets.
o Encourage frequent position changes.
o Do not use the knee-gatch or pillows under the knees.
o Have client avoid 90° hip flexion.
o Keep linens from applying pressure to extremities by using a foot cradle.
o Monitor pain level and treat accordingly.
o Instruct clients to avoid crossing their legs.
o Instruct clients to avoid crossing their legs.
o Tell clients to refrain from wearing restrictive garments.
Cardiovascular Disorders – Vascular Disorders – PERIPHERAL ARTERIAL DISEASE (PAD) – Nursing Care – Medications – Antiplatelet medication
Aspirin, clopidogrel (Plavix), Pentoxifylline (Trental): Antiplatelet medications reduce blood viscosity by decreasing blood
fibrinogen levels, enhancing erythrocyte flexibility, and increasing blood flow in the extremities. Medications, such as aspirin and clopidogrel (Plavix), may be prescribed. Pentoxifylline (Trental) specifically treats intermittent claudication experienced by clients who have PAD.
Cardiovascular Disorders – Vascular Disorders – PERIPHERAL ARTERIAL DISEASE (PAD) – Nursing Care – Medications – Antiplatelet medication – Nursing Considerations and Client Education
• Nursing Considerations
o Give medication with meals.
• Client Education
o Inform clients that the medication’s effects might not be apparent for several weeks.
o Advise clients to monitor for signs of bleeding such as abdominal pain, coffee ground emesis, or black, tarry stools.
Cardiovascular Disorders – Vascular Disorders – PERIPHERAL ARTERIAL DISEASE (PAD) – Therapeutic Procedures – Percuteaneous transluminal angioplasty
• Invasive intra-arterial procedure uses a balloon and stent to open and help maintain the patency of the vessel.
• Use for candidates who are not suitable for surgery or in cases where amputation is inevitable.
Cardiovascular Disorders – Vascular Disorders – PERIPHERAL ARTERIAL DISEASE (PAD) – Therapeutic Procedures – Laser-assisted angioplasty
• Laser-assisted angioplasty is an invasive procedure where a laser probe is advanced through a cannula to the site of stenosis.
• The laser vaporizes atherosclerotic plaque and open the artery.
Cardiovascular Disorders – Vascular Disorders – PERIPHERAL ARTERIAL DISEASE (PAD) – Therapeutic Procedures – Laser-assisted angioplasty – Nursing considerations and Client Education
• Nursing Actions
o Monitor puncture site for bleeding.
o Closely monitor the client’s vital signs, peripheral pulses, and capillary refill.
o If prescribed, keep clients on bed rest with limb straight for 6 to 8 hour before ambulation.
• Client Education
o Inform clients of the need for antiplatelet therapy for 1 to 3 months.
Cardiovascular Disorders – Vascular Disorders – PERIPHERAL ARTERIAL DISEASE (PAD) – Surgical Interventions
Arterial revascularization surgery is used with clients who have severe claudication and/or limb pain at rest, or with clients who are at risk for losing a limb due to poor arterial circulation.
• Bypass grafts reroute the circulation around the arterial occlusion.
• Grafts can be harvested from clients (autologous) or made from synthetic materials.
Cardiovascular Disorders – Vascular Disorders – PERIPHERAL ARTERIAL DISEASE (PAD) – Surgical Interventions – Nursing Actions
o Mark the pedal or dorsalis pulse and note strength.
o Compare pulse, color, temperature, and capillary refill with the contralateral leg on a scheduled basis using a Doppler.
o Look for warmth, redness, and possibly edema of the affected limb as a result of increased blood flow.
o Monitor clients for pain. Pain may be severe due to the re-establishment of blood flow to the extremity.
o Monitor the client’s blood pressure for hypotension or hypertension. Hypotension may result in an increased risk of clotting or graft collapse, while hypertension increases the risk for bleeding from sutures.
o Instruct clients to limit bending of the hip and knee to decrease the risk of clot formation.
Cardiovascular Disorders – Vascular Disorders – PERIPHERAL ARTERIAL DISEASE (PAD) – Care after discharge – Client Education
• Instruct clients to avoid crossing their legs or raising legs above the level of the heart.
• Encourage clients to sit with legs in dependent position to allow gravity to facilitate arterial blood flow to the lower extremities.
• Instruct clients to wear loose clothing.
• Instruct clients on wound care if revascularization surgery was done.
• Discourage smoking and exposure to cold temperatures.
• Instruct clients about foot care (keep feet clean and dry, wash with mild soap and warm water, pat skin dry, especially between the toes, apply moisturizing lotions and powder if desired, wear good-fitting shoes and a clean pair of cotton socks each day, never go barefoot, cut toenails straight across or have the podiatrist cut
nails).
Cardiovascular Disorders – Vascular Disorders – PERIPHERAL ARTERIAL DISEASE (PAD) – Client Outcomes
o The client’s extremity distal to the repaired occlusion will be warm, pink, and have a 2+ pulse.
o The client will report being able to walk without pain in the affected leg.
o Encourage clients to exercise to build up collateral circulation.
o Initiate exercise gradually and increase slowly.
o Instruct clients to walk until the point of pain, stop and rest for 3 min, and then walk a little farther.
o Walk at least 8 times per day.
o Tell clients to never apply direct heat to the affected extremity, as sensitivity is decreased and they may inadvertently burn themselves.
o Instruct clients to avoid exposure to cold (causes vasoconstriction and decreased arterial flow).
o Instruct clients to avoid stress, caffeine, and nicotine, which also cause vasoconstriction.
Cardiovascular Disorders – Vascular Disorders – PERIPHERAL ARTERIAL DISEASE (PAD) – Complications – Graft Occlusion
Graft occlusion may occur within the first 24 hour following arterial
revascularization surgery.
o Nursing Actions
• Promptly notify the surgeon of signs and symptoms of occlusion, such as absent or reduced pedal pulses, increased pain, change in extremity color, or temperature.
• Be prepared to assist with treatment, which may include an emergency thrombectomy (removal of a clot), local intra-arterial thrombolytic therapy with an agent such as tissue plasminogen activator, infusion of a platelet inhibitor, or a combination of the above. With these treatments, closely monitor clients for
manifestations of bleeding.
Cardiovascular Disorders – Vascular Disorders – PERIPHERAL ARTERIAL DISEASE (PAD) – Complications – Compartment Syndrome
Compartment syndrome is considered a medical emergency. Tissue pressure within a confined body space can restrict blood flow and the resulting ischemia can lead to irreversible tissue damage.
Cardiovascular Disorders – Vascular Disorders – PERIPHERAL ARTERIAL DISEASE (PAD) – Complications – Compartment Syndrome – Nursing Action
• Monitor for signs and symptoms of compartment syndrome (tingling, numbness, worsening pain, edema, pain on passive movement, unequal pulses). Immediately report symptoms to the provider.
• Loosen dressings.
• Prepare to assist with fasciotomy (surgical opening into the tissues), which may be necessary to prevent further injury and to save the limb.

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