Cardiovascular System Part Three

CARDIOVASCULAR NCLEX REVIEW PART THREE 3- CARE OF THE CLIENT UNDERGOING CARDIAC SURGERY

CARE OF THE CLIENT UNDERGOING CARDIAC SURGERY WITH CARDIOPULMONARY BYPASS 

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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

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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 

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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.

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Etiology: five types of shock - cardiogenic, hypovolemic, anaphylactic, septic, neurogenic

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Findings: progression of shock  initial stage:  decreased cardiac output and perfusion  cellular function interrupted  anaerobic metabolism increases  no clinical symptoms at this stage

 

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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  

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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 

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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

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Nursing interventions for shock: The Cardio-Care Six except 

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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*

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asystole*

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atrioventricular block

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first degree A-V block

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second degree A-V block

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third degree A-V block

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* dysrhythmias associated with death

Nursing interventions

PHARMACOLOGIC INTERVENTIONS FOR DYSRHYTHMIAS 

A. Adenosine Narrow complex paroxysmal supravenntricular tachycardia; WolffParkinson-White Syndrome

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B. Amiodarone hydrochloride Ventricular & supraventricular tachycardia; atrial fibrillation & flutter

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C. Atropine sulfate Symptomatic bradycardia (hypotension, ventricular ectopy, chest pain, change in mentation)

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D. Beta-Adrenergic blocking agent Wolff-Parkinson-White and digitalis toxic rhythms; Ventricular rhythms refractory to other drugs

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E. Bretylium tosylate Ventricular fibrillation resistant to defibrillation and Lidocaine; ventricular tachycardia resistant to lidocaine and procainamide (Pronestyl)

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F. Digoxin Congestive heart failure; Atrial flutter or fibrillation; supraventricular tachycardias

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G. Diltiazem Atrial fibrillation or flutter with rapid ventricular response; Narrowcomplex PSVT refractory to other medications

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H. Disopyramide Premature ventricular contractions; ventricular tachycardia not requiring cardioversion; Atrial fibrillation or flutter

PHARMACOLOGIC INTERVENTIONS FOR DYSRHYTHMIAS 

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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)

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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.

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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

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An EKG can show these conditions:

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Sinus tachycardia Ventricular tachycardia* Sinus bradycardia Atrial fibrillation Ventricular fibrillation* Asystole*

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*death producing

EKG MEASURES ELECTRICAL ACTIVITY OF HEART 

monitor hemodynamic indicators as ordered

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administer oxygen as ordered

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provide a restful environment

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prepare the client for cardioversion, as indicated

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initiate cardiopulmonary resuscitation as indicated

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provide emotional support to client/family

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reinforce client teaching regarding

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medications and side effects

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importance of dysrhythmia identification jewelry

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atrio-ventricular (AV) conduction disturbances

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asymptomatic: no nursing interventions indicated

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symptomatic

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administer medications as ordered

PACEMAKERS 

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A battery-powered device that provides electric stimulation for: 

Atrial pacing

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Ventricular pacing

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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

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Pace at a preset rate, regardless of client's rhythm (asynchronous)

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Overdrive and suppress the underlying rhythm in tachyarrhythmia

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Provide increased rate in bradycardias

Indications for pacing 

Symptomatic bradyarrhythmia

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Symptomatic tachyarrhythmia

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Asystole

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Prophylaxis in clients with high-risk bradycardia

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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

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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

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Aneurysms

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Definition - dilation of an artery due to a weakness in the arterial wall

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Etiology - atherosclerosis

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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 

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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

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Wear medical identification jewelry: "wearer takes oral anticoagulants"

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Use a soft toothbrush; report any bleeding gums

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Use an electric razor, not a straight razor

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Use minimal alcoholic beverages, as directed by care provider

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Report any signs of bleeding, red or black bowel movements, headaches, rashes, red or pink-tinged urine, sputum, persistent sore throat

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Avoid activities with risk of trauma or contact sports

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Have INR serum levels of the anticoagulant effects every four to eight hours

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Check over-the-counter medications for aspirin; take only after care provider consultation

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Avoid drastic changes in diet for green leafy vegetables 

a significant increase in these will decrease the effectiveness of oral anticoagulant

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a significant decrease in these will decrease the effectiveness of anticoagulant

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Know that serum tests for effectiveness are the International Normalized Ratio (INR) or prothrombin time (PT)

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Be aware the effects of drugs will last three to seven days after drug is stopped

surgical treatment

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surgical treatment 

embolectomy

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bypass of affected artery ( illustration )

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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

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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

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Diagnostics - arteriography

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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

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Etiology 

unknown

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more frequently occurs in women

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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

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Skin cool to touch

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Decreased or absent peripheral pulses

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Little or no edema of lower leg, ankles, feet

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Thin, shiny skin and decreased growth of hair

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Thickened nails on toes

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Pain unrelieved by rest and/or activity

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Chronic pain may be either steady or intermittent

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Claudication pain (pain with walking) as tight feeling, burning, fatigue, ache or cramping

Raynaud's phenomenon (arteriospastic disease) 

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Diagnostics  clinical pattern  digital plethysmography  peripheral arteriography Management  pharmacologic agents  

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antihypertensive agents: reserpine (Serpasil) alpha-adrenergic blocking agents: phenoxybenzamine (Dibenzyline), tolazoline (Piscoline) Vasodilators

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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  

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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

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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)

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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

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Etiology  trauma  intravenous catheters  prolonged immobility  IV drug use

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Findings - in an extremity over inflamed site  redness  swelling  tenderness  warmth  complication: thromboembolism - dislodgement and migration of a thrombus

Thrombophlebitis 

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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

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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

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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

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administer medications as ordered

Venous stasis ulcers 

Definition: chronic skin and subcutaneous ulcers usually found on legs, ankles or feet.

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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

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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

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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

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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: