Cardiovascular System Part Three
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CARDIOVASCULAR NCLEX REVIEW PART THREE 3- CARE OF THE CLIENT UNDERGOING CARDIAC SURGERY
CARE OF THE CLIENT UNDERGOING CARDIAC SURGERY WITH CARDIOPULMONARY BYPASS
Monitor hemodynamics for lower cardiac output or excess fluid Measure fluid intake and output Monitor specific gravity of urine Monitor ECG (EKG) rate and rhythm Monitor peripheral perfusion Monitor neurological status Administer IV fluids as ordered Administer oxygen as ordered Care of the client on a ventilator Administer medications as ordered
Provide comfort measures Limit fluid intake as ordered Weigh client daily Monitor for signs of cardiac tamponade Administer blood and blood products as ordered Provide emotional support Observe incision sites for signs of infection Care of the client with chest tubes Monitor arterial blood gases as ordered
Nursing interventions
avoid activities known to cause angina physical activities for two hours after meals very cold and very hot weather or environments alcohol and caffeine drinks diet pills, nasal decongestants, or any remedy that can raise heart rate or blood pressure use of nitroglycerin tablets; carry at all risks times in pocket, not purse review the risk factors for CAD (coronary prevent from being in heat or artery disease) sunlight encourage client to lose weight; review if necessary, use nitroglycerin low-fat, low-cholesterol diet patch review actions for smoking cessation replace opened NTG meds every review expected side effects of drugs for three to six months CAD report reinforce stress reduction techniques to how to access EMS be used daily angina changes angina > 15 minutes with meds or rest, call EMS or have someone take to hospital Nursing interventions assist client with ADL (activities of daily living) maintain partial bed rest as prescribed assist with turning, coughing and deep breathing exercises relieve chest pain by oxygen and medication as ordered during angina attacks, monitor BP, heart rate, pain, meds, findings; get electrocardiogram . have fresh nitroglycerin available for immediate use reinforce client and family teaching regarding:
Shock
Definition - tissue or cellular hypoxia; body cells need more oxygen than blood is supplying. Cells and then organs fail. Shock has many different causes. It is a medical emergency.
Etiology: five types of shock - cardiogenic, hypovolemic, anaphylactic, septic, neurogenic
Findings: progression of shock initial stage: decreased cardiac output and perfusion cellular function interrupted anaerobic metabolism increases no clinical symptoms at this stage
continue findings
continue findings
Chemical compensation: decreased pulmonary blood flow causes hypoxemia; hypoxemia is sensed by chemoreceptors that increase rate and depth of respirations, which results in respiratory alkalosis Findings of compensatory stage of shock altered level of consciousness (L.O.C): anxiety, restlessness tachypnea tachycardia skin cool and clammy diaphoresis thirst pupils dilated weak peripheral pulses decreased urine output concentrated urine decreased bowel sounds decompensate stage of shock - compensatory mechanisms can no longer maintain perfusion severe hypoperfusion massive cell death organs begin to fail
findings of decompensation consciousness - L.O.C. severely depressed, drowsy, lethargic, semi-comatose lungs - hypoventilation, moist crackles cardiovascular - decreased BP: systolic below 90 mm Hg, narrowing pulse pressure, tachycardia, irregular pulse, peripheral pulses weak, thready, may be absent elimination - urine volume below 20 cc/hour, urine osmolality dilute, absent bowel sounds with paralytic ileus refractory stage: shock irreversible: death from multisystem organ failure is evident findings cardiac failure respiratory failure renal shutdown liver dysfunction or failure loss of consciousness comatose
Angina
Angina
surgical treatments intra-aortic balloon counterpulsation left and right ventricular assist pumping heart transplant hypovolemic shock: rapid fluid replacement therapy to replace lost volume crystalloids such as 0.9% normal saline provide quick but temporary volume expansion colloids such as Hetastarch (Hespan) give longer-lasting volume expansion blood products such as packed red blood cells expand volume and improve oxygen carrying capacity of the circulation anaphylactic shock: epinephrine (Adrenalin) antihistamines aminophylline (Truphylline) neurogenic treat according to cause minimize spinal cord trauma with stabilization of the vertebral column septic shock antiinfective agents based on culture results fluid replacement improve cardiac output with positive inotropes and vasopressors
Angina
Nursing interventions for shock: The Cardio-Care Six except
do not elevate head: maintain complete bed rest in flat position with or without legs elevated - called modified Trendelenberg do not move client; no bedside commode keep client warm administer / monitor parenteral therapy, drugs, and O2 as ordered monitor hemodynamic indicators as ordered monitor blood plasma expanders or packed cells, if ordered maintain communication with family members regarding client progress
Dysrhythmias and Lesser Vascular Disorders Dysrhythmias Dysrhythmias Definition: disturbance in heart rate or rhythm
Types of dysrhythmia supraventricular: sinus, atrial, and junctional sinus tachycardia sinus bradycardia sinus arrhythmia premature atrial complexes atrial tachycardia atrial flutter atrial fibrillation premature junctional complex junctional tachycardia ventricular premature ventricular contraction ventricular tachycardia*
ventricular fibrillation*
ventricular fibrillation*
asystole*
atrioventricular block
first degree A-V block
second degree A-V block
third degree A-V block
* dysrhythmias associated with death
Nursing interventions
PHARMACOLOGIC INTERVENTIONS FOR DYSRHYTHMIAS
A. Adenosine Narrow complex paroxysmal supravenntricular tachycardia; WolffParkinson-White Syndrome
B. Amiodarone hydrochloride Ventricular & supraventricular tachycardia; atrial fibrillation & flutter
C. Atropine sulfate Symptomatic bradycardia (hypotension, ventricular ectopy, chest pain, change in mentation)
D. Beta-Adrenergic blocking agent Wolff-Parkinson-White and digitalis toxic rhythms; Ventricular rhythms refractory to other drugs
E. Bretylium tosylate Ventricular fibrillation resistant to defibrillation and Lidocaine; ventricular tachycardia resistant to lidocaine and procainamide (Pronestyl)
F. Digoxin Congestive heart failure; Atrial flutter or fibrillation; supraventricular tachycardias
G. Diltiazem Atrial fibrillation or flutter with rapid ventricular response; Narrowcomplex PSVT refractory to other medications
H. Disopyramide Premature ventricular contractions; ventricular tachycardia not requiring cardioversion; Atrial fibrillation or flutter
PHARMACOLOGIC INTERVENTIONS FOR DYSRHYTHMIAS
I. Epinephrine Ventricular fibrillation; pulseless ventricular tachycardia; Asystole J. Lidocaine hydrochloride Frequent, multifocal, paired, or Ron-T premature ventricular contractions; Ventricular tachycardia; Ventricular fibrillation K. Magnesium sulfate Torsade de pointes; Refractory ventricular fibrillation; Cardiac arrest or ventricular dysrhythmias due to digitalis toxicity, tricyclic overdose, or hypomagnesemia L. Procainamide hydrochloride Symptomatic ventricular ectopy when lidocaine is ineffective or contraindicated; in ventricular fibrillation/pulseless VT when lidocaine and bretylium are ineffective M. Quinidine Atrial fibrillation and flutter; PSVT N. Tocainide Symptomatic ventricular dysrhythmias when lidocaine not effective O. Verapamil Supraventricular tachyarrhythmias with heart rate >120
EKG MEASURES ELECTRICAL ACTIVITY OF HEART
Electrocardiogram = (ECG) = (EKG) Do not confuse with Echocardiogram (Echo)
An EKG is a graphic recording of the electrical currents of the heart. It may be a one-lead, which is used for continuous monitoring, or a 12-lead, which is used for diagnostic purposes.
The EKG records two basic events - depolarization and repolarization as a series of waves: P-wave: associate with atrial contraction P-R Interval QRS complex: associate with ventricular contraction T wave S- T interval U wave PVCs: premature ventricular contractions
An EKG can show these conditions:
Sinus tachycardia Ventricular tachycardia* Sinus bradycardia Atrial fibrillation Ventricular fibrillation* Asystole*
*death producing
EKG MEASURES ELECTRICAL ACTIVITY OF HEART
monitor hemodynamic indicators as ordered
administer oxygen as ordered
provide a restful environment
prepare the client for cardioversion, as indicated
initiate cardiopulmonary resuscitation as indicated
provide emotional support to client/family
reinforce client teaching regarding
medications and side effects
importance of dysrhythmia identification jewelry
atrio-ventricular (AV) conduction disturbances
asymptomatic: no nursing interventions indicated
symptomatic
administer medications as ordered
PACEMAKERS
A battery-powered device that provides electric stimulation for:
Atrial pacing
Ventricular pacing
Atrioventricular sequential and physiologic pacing
Pacemakers can be set to:
Sense the client's intrinsic rhythm and pace only if intrinsic rate declines below rate set on pacemaker
Pace at a preset rate, regardless of client's rhythm (asynchronous)
Overdrive and suppress the underlying rhythm in tachyarrhythmia
Provide increased rate in bradycardias
Indications for pacing
Symptomatic bradyarrhythmia
Symptomatic tachyarrhythmia
Asystole
Prophylaxis in clients with high-risk bradycardia
Diagnosis of dysrhythmias during electrophysiologic testing
PACEMAKERS
Types of pacemakers Temporary pacemaker Endocardial ( transvenous ) pacemakers Transcutaneous (external) pacemakers Epicardial (applied during cardiac surgery) Permanent pacemakers
Complications of pacemakers Infection Perforation Pneumothorax Hemothorax Dysrhythmias Thrombosis Reinforce client teaching regarding: need to take pulse for one full minute in morning before arising; if it is lower than the lowest set pacemaker rate, client is to notify health care provider avoidance of contact sports / hobbies incision care type and expectations of pacemaker findings of pacemaker malfunction to report when they occur - dizziness, syncope, fatigue, sudden shortness of breath
Aneurysms
Definition - dilation of an artery due to a weakness in the arterial wall
Etiology - atherosclerosis
Four types of aneurysms saccular: outpouching of one wall in a circumscribed area fusiform: involves complete circumference of artery dissecting: accumulation of blood separating the layers of the arterial wall pseudoaneurysm: tear of the full thickness of the arterial wall, leading to a collection of blood contained in the connective tissue
Aneurysms
Arterial occlusive disease
Definition: insufficient blood supply in the arteries; usually in legs - may be acute or chronic Etiology embolism, thrombosis, and trauma (illustration 1 ) femoral artery most often affected Findings pain in affected limb, especially with activity or walking cyanosis in affected limb paresthesia in affected limb if untreated, gangrene Diagnostics - arteriography, doppler studies Management pharmacology : anticoagulants
GUIDELINES FOR CLIENTS TAKING ORAL ANTICOAGULANTS
Take medication at the same time every day - often in the afternoon around 4:00 PM
Wear medical identification jewelry: "wearer takes oral anticoagulants"
Use a soft toothbrush; report any bleeding gums
Use an electric razor, not a straight razor
Use minimal alcoholic beverages, as directed by care provider
Report any signs of bleeding, red or black bowel movements, headaches, rashes, red or pink-tinged urine, sputum, persistent sore throat
Avoid activities with risk of trauma or contact sports
Have INR serum levels of the anticoagulant effects every four to eight hours
Check over-the-counter medications for aspirin; take only after care provider consultation
Avoid drastic changes in diet for green leafy vegetables
a significant increase in these will decrease the effectiveness of oral anticoagulant
a significant decrease in these will decrease the effectiveness of anticoagulant
Know that serum tests for effectiveness are the International Normalized Ratio (INR) or prothrombin time (PT)
Be aware the effects of drugs will last three to seven days after drug is stopped
surgical treatment
surgical treatment
embolectomy
bypass of affected artery ( illustration )
amputation of limb
percutaneous transluminal coronary angioplasty
Chronic Arterial Occlusive Disease
Etiology arteriosclerosis obliterans, aneurysms, hypercoagulability states, tobacco use slow, progressive arteriosclerotic changes give collateral circulation a chance to form collateral circulation cannot give tissues enough oxygen; result is hypoperfusion hypoperfusion leads to ischemia usually affects legs
Findings intermittent claudication indicates mild to moderate obstruction pain at rest indicates severe obstruction affected limb will show edema paresthesia weak or absent pulses skin: waxy, hairless, cool, pale, cyanotic in men, impotence
Diagnostics - arteriography
Medical management pharmacologic
Both Acute and Chronic Arterial Occlusive Disease
Nursing interventions administer medications as ordered monitor peripheral pulses and blanch test for capillary refill < five seconds provide comfort measures such as placing legs in dependent position can improve blood flow and reduce pain help client develop an exercise program provide care for the client undergoing surgery provide regular foot care reinforce for client to change positions frequently avoid crossing legs avoid any constrictive clothing on legs avoid trauma to lower extremities avoid cold temperature extremes have regular foot care place legs in dependent position to increase blood flow
Raynaud's phenomenon (arteriospastic disease)
Definition: episodic vasospasm of the small cutaneous arteries that results in intermittent pallor or cyanosis of the skin - usually affects the fingers bilaterally, but occasionally affects the toes, nose, or tongue that result in intermittent pallor or cyanosis of the skin
Etiology
unknown
more frequently occurs in women
may be triggered by stress, cold or products that cause vasoconstriction such as tobacco, caffeine, and chocolate
SIGNS OF ARTERIAL INSUFFICIENCY IN THE EXTREMITIES
Pale color on elevation, dusky red color when lowered
Skin cool to touch
Decreased or absent peripheral pulses
Little or no edema of lower leg, ankles, feet
Thin, shiny skin and decreased growth of hair
Thickened nails on toes
Pain unrelieved by rest and/or activity
Chronic pain may be either steady or intermittent
Claudication pain (pain with walking) as tight feeling, burning, fatigue, ache or cramping
Raynaud's phenomenon (arteriospastic disease)
Diagnostics clinical pattern digital plethysmography peripheral arteriography Management pharmacologic agents
antihypertensive agents: reserpine (Serpasil) alpha-adrenergic blocking agents: phenoxybenzamine (Dibenzyline), tolazoline (Piscoline) Vasodilators
surgery sympathectomy in advanced stages amputation of fingers showing gangrene modification of lifesytle behaviors and the environment
Nursing interventions administer medications as ordered provide care of the client undergoing surgery reinforce client teaching regarding:
managment of stress avoidance of tobacco products, caffeine, and chocolate avoidance of temperature extremes Protection from extreme cold and heat
Varicose veins
Definition: dilation of superficial veins of the legs and feet Etiology usually found in greater saphenous vein (leg) incompetent valves (incompetence, vavular) in the superficial veins increased pressure in veins causing them to distend risk factors: standing for long periods, pregnancy Findings pain after period of standing foot and ankle swelling at end of day distended leg veins
Varicose veins
Diagnostics - venography
Management goal is to reduce pain and halt underlying condition medical: sclerotherapy (injection of sclerosing agent that causes vein thrombosis) surgical: vein ligation (vein stripping)
Nursing interventions provide care to the client undergoing surgery post-operative care includes: application of elastic stocking or bandages elevation of legs reinforce client teaching regarding not crossing legs elevation of legs as much as possible avoidance of prolonged sitting or standing
Thrombophlebitis
Definition: a thrombus (clot) accompanied by the inflammation of the wall of a superficial blood vessel. It differs from phlebothrombosis, which is a clot (thrombus) with minimal inflammation of the vessel
Etiology trauma intravenous catheters prolonged immobility IV drug use
Findings - in an extremity over inflamed site redness swelling tenderness warmth complication: thromboembolism - dislodgement and migration of a thrombus
Thrombophlebitis
Diagnostics history and physical ultrasonography plethysmography Management bed rest with elastic stockings elevation of affected extremity anticoagulants - to prevent clot formation analgesics - to control discomfort Nursing interventions keep affected extremity elevated monitor for signs of pulmonary embolism (sudden pain, cyanosis, hemoptysis, shock) vital signs, including bilateral peripheral pulses for signs of vascular impairment (pallor, cyanosis, coolness) administer analgesics as ordered reinforce client teaching regarding: avoidance of tight or constricting clothing need to stop cigarette smoking and caffeine use avoidance of maintaining one position for long periods
Deep venous thrombosis
Definition: clotting in a deep vein Etiology and risk immobilization sepsis hematological and clotting disorders malignancies heart failure myocardial infarction pregnancy venipuncture surgeries: orthopedic, neurologic, urologic and gynecologic risk of pulmonary embolus Findings: unilateral edema of an entire extremity Diagnostics - venography Management goal is to eliminate the clot and prevent complications bed rest anticoagulant therapy - to prevent new clots thrombolytic therapy - to dissolve thrombus compression stockings surgery - thrombectomy
Deep venous thrombosis
Nursing interventions maintain bed rest follow guidelines for anticoagulation monitor coagulation lab studies (APTT for heparin, PT/INR for warfarin) observe for evidences of bleeding (bruises, nosebleeds, bleeding gums, blood in urine or stool advise the client to use electric razors and soft-bristled toothbrushes
administer medications as ordered
Venous stasis ulcers
Definition: chronic skin and subcutaneous ulcers usually found on legs, ankles or feet.
Etiology chronic venous insufficiency incompetent valves (vavular, incompetence) in perforating veins or deep veins cause venous stasis pressure of blood pooling causes capillaries to leak ulcer begins as small, inflamed, tender area any trauma causes tissue to break or it may break spontaneously most common sites: pretibial and medial supramalleolar areas of ankle
Findings open skin lesion with irregular border skin around ulcer usually brown and leathery pain in affected area
Venous stasis ulcers
Diagnostics - history and physical exam of site
Management goal is to correct venous hypertension and both prevent and correct ulceration local wound care antibiotics and analgesics as indicated surgery debridement skin grafting removal of veins with incompetent valves
Nursing interventions keep client's legs elevated, with feet above level of heart as much as possible apply elastic bandages as ordered, usually bilateral cleanse and dress ulcer as ordered administer drugs as ordered reinforce client teaching regarding:
CARE OF THE CLIENT UNDERGOING CARDIAC SURGERY WITH CARDIOPULMONARY BYPASS
Monitor hemodynamics for lower cardiac output or excess fluid Measure fluid intake and output Monitor specific gravity of urine Monitor ECG (EKG) rate and rhythm Monitor peripheral perfusion Monitor neurological status Administer IV fluids as ordered Administer oxygen as ordered Care of the client on a ventilator Administer medications as ordered
Provide comfort measures Limit fluid intake as ordered Weigh client daily Monitor for signs of cardiac tamponade Administer blood and blood products as ordered Provide emotional support Observe incision sites for signs of infection Care of the client with chest tubes Monitor arterial blood gases as ordered
Nursing interventions
avoid activities known to cause angina physical activities for two hours after meals very cold and very hot weather or environments alcohol and caffeine drinks diet pills, nasal decongestants, or any remedy that can raise heart rate or blood pressure use of nitroglycerin tablets; carry at all risks times in pocket, not purse review the risk factors for CAD (coronary prevent from being in heat or artery disease) sunlight encourage client to lose weight; review if necessary, use nitroglycerin low-fat, low-cholesterol diet patch review actions for smoking cessation replace opened NTG meds every review expected side effects of drugs for three to six months CAD report reinforce stress reduction techniques to how to access EMS be used daily angina changes angina > 15 minutes with meds or rest, call EMS or have someone take to hospital Nursing interventions assist client with ADL (activities of daily living) maintain partial bed rest as prescribed assist with turning, coughing and deep breathing exercises relieve chest pain by oxygen and medication as ordered during angina attacks, monitor BP, heart rate, pain, meds, findings; get electrocardiogram . have fresh nitroglycerin available for immediate use reinforce client and family teaching regarding:
Shock
Definition - tissue or cellular hypoxia; body cells need more oxygen than blood is supplying. Cells and then organs fail. Shock has many different causes. It is a medical emergency.
Etiology: five types of shock - cardiogenic, hypovolemic, anaphylactic, septic, neurogenic
Findings: progression of shock initial stage: decreased cardiac output and perfusion cellular function interrupted anaerobic metabolism increases no clinical symptoms at this stage
continue findings
continue findings
Chemical compensation: decreased pulmonary blood flow causes hypoxemia; hypoxemia is sensed by chemoreceptors that increase rate and depth of respirations, which results in respiratory alkalosis Findings of compensatory stage of shock altered level of consciousness (L.O.C): anxiety, restlessness tachypnea tachycardia skin cool and clammy diaphoresis thirst pupils dilated weak peripheral pulses decreased urine output concentrated urine decreased bowel sounds decompensate stage of shock - compensatory mechanisms can no longer maintain perfusion severe hypoperfusion massive cell death organs begin to fail
findings of decompensation consciousness - L.O.C. severely depressed, drowsy, lethargic, semi-comatose lungs - hypoventilation, moist crackles cardiovascular - decreased BP: systolic below 90 mm Hg, narrowing pulse pressure, tachycardia, irregular pulse, peripheral pulses weak, thready, may be absent elimination - urine volume below 20 cc/hour, urine osmolality dilute, absent bowel sounds with paralytic ileus refractory stage: shock irreversible: death from multisystem organ failure is evident findings cardiac failure respiratory failure renal shutdown liver dysfunction or failure loss of consciousness comatose
Angina
Angina
surgical treatments intra-aortic balloon counterpulsation left and right ventricular assist pumping heart transplant hypovolemic shock: rapid fluid replacement therapy to replace lost volume crystalloids such as 0.9% normal saline provide quick but temporary volume expansion colloids such as Hetastarch (Hespan) give longer-lasting volume expansion blood products such as packed red blood cells expand volume and improve oxygen carrying capacity of the circulation anaphylactic shock: epinephrine (Adrenalin) antihistamines aminophylline (Truphylline) neurogenic treat according to cause minimize spinal cord trauma with stabilization of the vertebral column septic shock antiinfective agents based on culture results fluid replacement improve cardiac output with positive inotropes and vasopressors
Angina
Nursing interventions for shock: The Cardio-Care Six except
do not elevate head: maintain complete bed rest in flat position with or without legs elevated - called modified Trendelenberg do not move client; no bedside commode keep client warm administer / monitor parenteral therapy, drugs, and O2 as ordered monitor hemodynamic indicators as ordered monitor blood plasma expanders or packed cells, if ordered maintain communication with family members regarding client progress
Dysrhythmias and Lesser Vascular Disorders Dysrhythmias Dysrhythmias Definition: disturbance in heart rate or rhythm
Types of dysrhythmia supraventricular: sinus, atrial, and junctional sinus tachycardia sinus bradycardia sinus arrhythmia premature atrial complexes atrial tachycardia atrial flutter atrial fibrillation premature junctional complex junctional tachycardia ventricular premature ventricular contraction ventricular tachycardia*
ventricular fibrillation*
ventricular fibrillation*
asystole*
atrioventricular block
first degree A-V block
second degree A-V block
third degree A-V block
* dysrhythmias associated with death
Nursing interventions
PHARMACOLOGIC INTERVENTIONS FOR DYSRHYTHMIAS
A. Adenosine Narrow complex paroxysmal supravenntricular tachycardia; WolffParkinson-White Syndrome
B. Amiodarone hydrochloride Ventricular & supraventricular tachycardia; atrial fibrillation & flutter
C. Atropine sulfate Symptomatic bradycardia (hypotension, ventricular ectopy, chest pain, change in mentation)
D. Beta-Adrenergic blocking agent Wolff-Parkinson-White and digitalis toxic rhythms; Ventricular rhythms refractory to other drugs
E. Bretylium tosylate Ventricular fibrillation resistant to defibrillation and Lidocaine; ventricular tachycardia resistant to lidocaine and procainamide (Pronestyl)
F. Digoxin Congestive heart failure; Atrial flutter or fibrillation; supraventricular tachycardias
G. Diltiazem Atrial fibrillation or flutter with rapid ventricular response; Narrowcomplex PSVT refractory to other medications
H. Disopyramide Premature ventricular contractions; ventricular tachycardia not requiring cardioversion; Atrial fibrillation or flutter
PHARMACOLOGIC INTERVENTIONS FOR DYSRHYTHMIAS
I. Epinephrine Ventricular fibrillation; pulseless ventricular tachycardia; Asystole J. Lidocaine hydrochloride Frequent, multifocal, paired, or Ron-T premature ventricular contractions; Ventricular tachycardia; Ventricular fibrillation K. Magnesium sulfate Torsade de pointes; Refractory ventricular fibrillation; Cardiac arrest or ventricular dysrhythmias due to digitalis toxicity, tricyclic overdose, or hypomagnesemia L. Procainamide hydrochloride Symptomatic ventricular ectopy when lidocaine is ineffective or contraindicated; in ventricular fibrillation/pulseless VT when lidocaine and bretylium are ineffective M. Quinidine Atrial fibrillation and flutter; PSVT N. Tocainide Symptomatic ventricular dysrhythmias when lidocaine not effective O. Verapamil Supraventricular tachyarrhythmias with heart rate >120
EKG MEASURES ELECTRICAL ACTIVITY OF HEART
Electrocardiogram = (ECG) = (EKG) Do not confuse with Echocardiogram (Echo)
An EKG is a graphic recording of the electrical currents of the heart. It may be a one-lead, which is used for continuous monitoring, or a 12-lead, which is used for diagnostic purposes.
The EKG records two basic events - depolarization and repolarization as a series of waves: P-wave: associate with atrial contraction P-R Interval QRS complex: associate with ventricular contraction T wave S- T interval U wave PVCs: premature ventricular contractions
An EKG can show these conditions:
Sinus tachycardia Ventricular tachycardia* Sinus bradycardia Atrial fibrillation Ventricular fibrillation* Asystole*
*death producing
EKG MEASURES ELECTRICAL ACTIVITY OF HEART
monitor hemodynamic indicators as ordered
administer oxygen as ordered
provide a restful environment
prepare the client for cardioversion, as indicated
initiate cardiopulmonary resuscitation as indicated
provide emotional support to client/family
reinforce client teaching regarding
medications and side effects
importance of dysrhythmia identification jewelry
atrio-ventricular (AV) conduction disturbances
asymptomatic: no nursing interventions indicated
symptomatic
administer medications as ordered
PACEMAKERS
A battery-powered device that provides electric stimulation for:
Atrial pacing
Ventricular pacing
Atrioventricular sequential and physiologic pacing
Pacemakers can be set to:
Sense the client's intrinsic rhythm and pace only if intrinsic rate declines below rate set on pacemaker
Pace at a preset rate, regardless of client's rhythm (asynchronous)
Overdrive and suppress the underlying rhythm in tachyarrhythmia
Provide increased rate in bradycardias
Indications for pacing
Symptomatic bradyarrhythmia
Symptomatic tachyarrhythmia
Asystole
Prophylaxis in clients with high-risk bradycardia
Diagnosis of dysrhythmias during electrophysiologic testing
PACEMAKERS
Types of pacemakers Temporary pacemaker Endocardial ( transvenous ) pacemakers Transcutaneous (external) pacemakers Epicardial (applied during cardiac surgery) Permanent pacemakers
Complications of pacemakers Infection Perforation Pneumothorax Hemothorax Dysrhythmias Thrombosis Reinforce client teaching regarding: need to take pulse for one full minute in morning before arising; if it is lower than the lowest set pacemaker rate, client is to notify health care provider avoidance of contact sports / hobbies incision care type and expectations of pacemaker findings of pacemaker malfunction to report when they occur - dizziness, syncope, fatigue, sudden shortness of breath
Aneurysms
Definition - dilation of an artery due to a weakness in the arterial wall
Etiology - atherosclerosis
Four types of aneurysms saccular: outpouching of one wall in a circumscribed area fusiform: involves complete circumference of artery dissecting: accumulation of blood separating the layers of the arterial wall pseudoaneurysm: tear of the full thickness of the arterial wall, leading to a collection of blood contained in the connective tissue
Aneurysms
Arterial occlusive disease
Definition: insufficient blood supply in the arteries; usually in legs - may be acute or chronic Etiology embolism, thrombosis, and trauma (illustration 1 ) femoral artery most often affected Findings pain in affected limb, especially with activity or walking cyanosis in affected limb paresthesia in affected limb if untreated, gangrene Diagnostics - arteriography, doppler studies Management pharmacology : anticoagulants
GUIDELINES FOR CLIENTS TAKING ORAL ANTICOAGULANTS
Take medication at the same time every day - often in the afternoon around 4:00 PM
Wear medical identification jewelry: "wearer takes oral anticoagulants"
Use a soft toothbrush; report any bleeding gums
Use an electric razor, not a straight razor
Use minimal alcoholic beverages, as directed by care provider
Report any signs of bleeding, red or black bowel movements, headaches, rashes, red or pink-tinged urine, sputum, persistent sore throat
Avoid activities with risk of trauma or contact sports
Have INR serum levels of the anticoagulant effects every four to eight hours
Check over-the-counter medications for aspirin; take only after care provider consultation
Avoid drastic changes in diet for green leafy vegetables
a significant increase in these will decrease the effectiveness of oral anticoagulant
a significant decrease in these will decrease the effectiveness of anticoagulant
Know that serum tests for effectiveness are the International Normalized Ratio (INR) or prothrombin time (PT)
Be aware the effects of drugs will last three to seven days after drug is stopped
surgical treatment
surgical treatment
embolectomy
bypass of affected artery ( illustration )
amputation of limb
percutaneous transluminal coronary angioplasty
Chronic Arterial Occlusive Disease
Etiology arteriosclerosis obliterans, aneurysms, hypercoagulability states, tobacco use slow, progressive arteriosclerotic changes give collateral circulation a chance to form collateral circulation cannot give tissues enough oxygen; result is hypoperfusion hypoperfusion leads to ischemia usually affects legs
Findings intermittent claudication indicates mild to moderate obstruction pain at rest indicates severe obstruction affected limb will show edema paresthesia weak or absent pulses skin: waxy, hairless, cool, pale, cyanotic in men, impotence
Diagnostics - arteriography
Medical management pharmacologic
Both Acute and Chronic Arterial Occlusive Disease
Nursing interventions administer medications as ordered monitor peripheral pulses and blanch test for capillary refill < five seconds provide comfort measures such as placing legs in dependent position can improve blood flow and reduce pain help client develop an exercise program provide care for the client undergoing surgery provide regular foot care reinforce for client to change positions frequently avoid crossing legs avoid any constrictive clothing on legs avoid trauma to lower extremities avoid cold temperature extremes have regular foot care place legs in dependent position to increase blood flow
Raynaud's phenomenon (arteriospastic disease)
Definition: episodic vasospasm of the small cutaneous arteries that results in intermittent pallor or cyanosis of the skin - usually affects the fingers bilaterally, but occasionally affects the toes, nose, or tongue that result in intermittent pallor or cyanosis of the skin
Etiology
unknown
more frequently occurs in women
may be triggered by stress, cold or products that cause vasoconstriction such as tobacco, caffeine, and chocolate
SIGNS OF ARTERIAL INSUFFICIENCY IN THE EXTREMITIES
Pale color on elevation, dusky red color when lowered
Skin cool to touch
Decreased or absent peripheral pulses
Little or no edema of lower leg, ankles, feet
Thin, shiny skin and decreased growth of hair
Thickened nails on toes
Pain unrelieved by rest and/or activity
Chronic pain may be either steady or intermittent
Claudication pain (pain with walking) as tight feeling, burning, fatigue, ache or cramping
Raynaud's phenomenon (arteriospastic disease)
Diagnostics clinical pattern digital plethysmography peripheral arteriography Management pharmacologic agents
antihypertensive agents: reserpine (Serpasil) alpha-adrenergic blocking agents: phenoxybenzamine (Dibenzyline), tolazoline (Piscoline) Vasodilators
surgery sympathectomy in advanced stages amputation of fingers showing gangrene modification of lifesytle behaviors and the environment
Nursing interventions administer medications as ordered provide care of the client undergoing surgery reinforce client teaching regarding:
managment of stress avoidance of tobacco products, caffeine, and chocolate avoidance of temperature extremes Protection from extreme cold and heat
Varicose veins
Definition: dilation of superficial veins of the legs and feet Etiology usually found in greater saphenous vein (leg) incompetent valves (incompetence, vavular) in the superficial veins increased pressure in veins causing them to distend risk factors: standing for long periods, pregnancy Findings pain after period of standing foot and ankle swelling at end of day distended leg veins
Varicose veins
Diagnostics - venography
Management goal is to reduce pain and halt underlying condition medical: sclerotherapy (injection of sclerosing agent that causes vein thrombosis) surgical: vein ligation (vein stripping)
Nursing interventions provide care to the client undergoing surgery post-operative care includes: application of elastic stocking or bandages elevation of legs reinforce client teaching regarding not crossing legs elevation of legs as much as possible avoidance of prolonged sitting or standing
Thrombophlebitis
Definition: a thrombus (clot) accompanied by the inflammation of the wall of a superficial blood vessel. It differs from phlebothrombosis, which is a clot (thrombus) with minimal inflammation of the vessel
Etiology trauma intravenous catheters prolonged immobility IV drug use
Findings - in an extremity over inflamed site redness swelling tenderness warmth complication: thromboembolism - dislodgement and migration of a thrombus
Thrombophlebitis
Diagnostics history and physical ultrasonography plethysmography Management bed rest with elastic stockings elevation of affected extremity anticoagulants - to prevent clot formation analgesics - to control discomfort Nursing interventions keep affected extremity elevated monitor for signs of pulmonary embolism (sudden pain, cyanosis, hemoptysis, shock) vital signs, including bilateral peripheral pulses for signs of vascular impairment (pallor, cyanosis, coolness) administer analgesics as ordered reinforce client teaching regarding: avoidance of tight or constricting clothing need to stop cigarette smoking and caffeine use avoidance of maintaining one position for long periods
Deep venous thrombosis
Definition: clotting in a deep vein Etiology and risk immobilization sepsis hematological and clotting disorders malignancies heart failure myocardial infarction pregnancy venipuncture surgeries: orthopedic, neurologic, urologic and gynecologic risk of pulmonary embolus Findings: unilateral edema of an entire extremity Diagnostics - venography Management goal is to eliminate the clot and prevent complications bed rest anticoagulant therapy - to prevent new clots thrombolytic therapy - to dissolve thrombus compression stockings surgery - thrombectomy
Deep venous thrombosis
Nursing interventions maintain bed rest follow guidelines for anticoagulation monitor coagulation lab studies (APTT for heparin, PT/INR for warfarin) observe for evidences of bleeding (bruises, nosebleeds, bleeding gums, blood in urine or stool advise the client to use electric razors and soft-bristled toothbrushes
administer medications as ordered
Venous stasis ulcers
Definition: chronic skin and subcutaneous ulcers usually found on legs, ankles or feet.
Etiology chronic venous insufficiency incompetent valves (vavular, incompetence) in perforating veins or deep veins cause venous stasis pressure of blood pooling causes capillaries to leak ulcer begins as small, inflamed, tender area any trauma causes tissue to break or it may break spontaneously most common sites: pretibial and medial supramalleolar areas of ankle
Findings open skin lesion with irregular border skin around ulcer usually brown and leathery pain in affected area
Venous stasis ulcers
Diagnostics - history and physical exam of site
Management goal is to correct venous hypertension and both prevent and correct ulceration local wound care antibiotics and analgesics as indicated surgery debridement skin grafting removal of veins with incompetent valves
Nursing interventions keep client's legs elevated, with feet above level of heart as much as possible apply elastic bandages as ordered, usually bilateral cleanse and dress ulcer as ordered administer drugs as ordered reinforce client teaching regarding:
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