DISORDERS OF THE CARDIOVASCULAR SYSTEM

Amputation

  1. General information
    1. Surgical procedure done for peripheral vascular disease if medical management is ineffective and the symptoms become worse.
    2. The level of amputation is determined by the extent of the disease process.
      1. Above knee (AK): performed between the lower third to the middle of the thigh
      2. Below knee (BK): usually done in middle third of leg, leaving a stump of 12.5-17.5 cm
  2. Nursing interventions: preoperative
    1. Provide routine pre-op care.
    2. Offer support/encouragement and accept client's response of anger/grief.
    3. Discuss
      1. Rehabilitation program and use of prosthesis
      2. Upper extremity exercises such as push-ups in bed
      3. Crutch walking
      4. Amputation dressings/cast
      5. Phantom limb sensation as a normal occurrence
  3. Nursing interventions: postoperative
    1. Provide routine post-op care.
    2. Prevent hip/knee contractures
    3. Avoid letting client sit in chair with hips flexed for long periods of time.
    4. Have client assume prone position several times a day and position hip in extension (unless otherwise ordered).
    5. Avoid elevation of the stump after 12-24 hours.
    6. Observe stump dressing for signs of hemorrhage and mark outside of dressing so rate of bleeding can be assessed.
    7. Administer pain medication as ordered.
    8. Ensure that stump bandages fit tightly and are applied properly to enhance prosthesis fitting.
    9. Initiate active ROM exercises of all joints (when medically advised), crutch walking, and arm/shoulder exercises.
    10. Provide stump care.
      1. Inspect daily for signs of skin irritation.
      2. Wash thoroughly daily with warm water and bacteriostatic soap; rinse and dry thoroughly.

Avoid use of irritating substances such as lotions, alcohol, powders.

Varicose Veins

  1. General information
    1. Dilated veins that occur most often in the lower extremities and trunk. As the vessel dilates, the valves become stretched and incompetent with resultant venous pooling/edema
    2. Most common between ages 30 and 50
    3. Predisposing factor: congenital weakness of the veins, thrombophlebitis, pregnancy, obesity, heart disease
  2. Medical management: vein ligation (involves ligating the saphenous vein where it joins the femoral vein and stripping the saphenous vein system from groin to ankle)
  3. Assessment findings
    1. Pain after prolonged standing (relieved by elevation)
    2. Swollen, dilated, tortuous skin veins
    3. Diagnostic tests
      1. Trendelenburg test: varicose veins distend very quickly (less than 35 seconds)
      2. Doppler ultrasound: decreased or no blood flow heard after calf or thigh compression
  4. Nursing interventions
    1. Elevate legs above heart level.
    2. Measure circumference of ankle and calf daily.
    3. Apply knee-length elastic stockings.
    4. Provide adequate rest.
    5. Prepare client for vein ligation, if necessary.
      1. Provide routine pre-op care.
      2. In addition to routine post-op care
        1. keep affected extremity elevated above the level of the heart to prevent edema.
        2. apply elastic bandages and stockings, which should be removed every 8 hours for short periods and reapplied.
        3. assist out of bed within 24 hours, ensuring that elastic stockings are applied.
        4. assess for increased bleeding, particularly in the groin area.
    6. Provide client teaching and discharge planning: same as for thrombophlebitis (see Thrombophlebitis).

Pulmonary Embolism

  1. General information
    1. Most pulmonary emboli arise as detached portions of venous thrombi formed in the deep veins of the legs, right side of the heart, or pelvic area.
    2. Distribution of emboli is related to blood flow; emboli involve the lower lobes of the lung because of higher blood flow.
    3. Embolic obstruction to blood flow increases venous pressure in the pulmonary artery and pulmonary hypertension.
    4. Risk factors: venous thrombosis, immobility, pre- and post-op states, trauma, pregnancy, CHF, use of oral contraceptives, obesity
  2. Medical management
    1. Drug therapy
      1. Anticoagulants (see Thrombophlebitis)
      2. Thrombolytics: streptokinase or urokinase
      3. Dextran 70 to decrease blood viscosity and aggregation of blood cells
      4. Narcotics for pain relief
      5. Vasopressors (in the presence of shock)
    2. Surgery: embolectomy (surgical removal of an embolus from the pulmonary arteries)
  3. Assessment findings
    1. Chest pain (pleuritic), severe dyspnea, feeling of impending doom
    2. Tachypnea, tachycardia, anxiety, hemoptysis, shock symptoms (if massive)
    3. Decreased pCO2; increased pH (due to hyperventilation)
    4. Increased temperature
    5. Intensified pulmonic S2; rales or crackles
    6. Diagnostic tests
      1. Pulmonary angiography: reveals location/extent of embolism
      2. Lung scan reveals adequacy/ inadequacy of pulmonary circulation
  4. Nursing interventions
    1. Administer medications as ordered; monitor effects and side effects.
    2. Administer oxygen therapy to correct hypoxemia.
    3. Assist with turning, coughing, deep breathing, and passive ROM exercises.
    4. Provide adequate hydration to prevent hypercoagulability.
    5. Offer support/reassurance to client/family.
    6. Elevate head of bed to relieve dyspnea
    7. Provide client teaching and discharge planning: same as for thrombophlebitis.

Thrombophlebitis

  1. General information
    1. Inflammation of the vessel wall with formation of a clot (thrombus); may affect superficial or deep veins.
    2. Most frequent veins affected are the saphenous, femoral, and popliteal.
    3. Can result in damage to the surrounding tissues, ischemia, and necrosis.
    4. Risk factors: obesity, CHF, prolonged immobility, MI, pregnancy, oral contraceptives, trauma, sepsis, cigarette smoking, dehydration, severe anemias, venous cannulation, complication of surgery
  2. Medical management
    1. Anticoagulant therapy
      1. Heparin
        1. blocks conversion of prothrombin to thrombin and reduces formation or extension of thrombus
        2. side effects: spontaneous bleeding, injection site reactions, ecchymoses, tissue irritation and sloughing, reversible transient alopecia, cyanosis, pain in arms or legs, thrombocytopenia
      2. Warfarin (coumadin)
        1. blocks prothrombin synthesis by interfering with vitamin K synthesis
        2. side effects
          1. GI: anorexia, nausea and vomiting, diarrhea, stomatitis
          2. hypersensitivity: dermatitis, urticaria, pruritus, fever
          3. other: transient hair loss, burning sensation of feet, bleeding complications
    2. Surgery
      1. Vein ligation and stripping (see Thrombophlebitis)
      2. Venous thrombectomy: removal of a clot in the iliofemoral region
      3. Plication of the inferior vena cava: insertion of an umbrella-like prosthesis into the lumen of the vena cava to filter incoming clots
  3. Assessment findings
    1. Pain in the affected extremity
    2. Superficial vein: tenderness, redness, induration along course of the vein
    3. Deep vein: swelling, venous distension of limb, tenderness over involved vein, positive Homan's sign, cyanosis
    4. Elevated WBC and ESR
    5. Diagnostic tests
      1. Venography (phlebography): increased uptake of radioactive material
      2. Doppler ultrasonography: impairment of blood flow ahead of thrombus
      3. Venous pressure measurements: high in affected limb until collateral circulation is developed
  4. Nursing interventions
    1. Provide bed rest, elevating involved extremity to increase venous return and decrease edema.
    2. Apply continuous warm, moist soaks to decrease lymphatic congestion.
    3. Administer anticoagulants as ordered
      1. Heparin
        1. monitor PTT; dosage should be adjusted to keep PTT between 1.5-2.5 times normal control level.
        2. use infusion pump to administer IV heparin.
        3. ensure proper injection technique.
          1. use 26- or 27-gauge syringe with 1/2-5/8-in needle, inject into fatty layer of abdomen above iliac crest.
          2. avoid injecting within 2 inches of umbilicus.
          3. insert needle at 90° to skin.
          4. do not withdraw plunger to assess blood return.
          5. apply gentle pressure after removal of needle, avoid massage.
        4. assess for increased bleeding tendencies (hematuria; hematemesis; bleeding gums; petechiae of soft palate, conjunctiva, retina; ecchymoses, epistaxis, bloody sputum, melena) and instruct patient to observe for and report these.
        5. have antidote (protamine sulfate) available.
        6. instruct client to avoid aspirin, antihistamines, and cough preparations containing glyceryl guaiacolate, and to obtain physician's permission before using other OTC drugs.
      2. Warfarin (Coumadin)
        1. assess PT daily; dosage should be adjusted to maintain PT at 1.5-2.5 times normal control level; INR of 2.
        2. obtain careful medication history (there are many drug-drug interactions).
        3. advise client to withhold dose and notify physician immediately if bleeding or signs of bleeding occur (see Heparin, above).
        4. instruct client to use a soft toothbrush and to floss gently.
        5. have antidote (vitamin K) available.
        6. alert client to factors that may affect the anticoagulant response (high-fat diet or sudden increases in vitamin K-rich foods).
        7. instruct client to wear Medic-Alert bracelet.
    4. Assess vital signs every 4 hours.
    5. Monitor for chest pain or shortness of breath (possible pulmonary embolism).
    6. Measure thighs, calves, ankles, and instep every morning.
    7. Provide client teaching and discharge planning concerning
      1. Need to avoid standing, sitting for long periods; constrictive clothing; crossing legs at the knees; smoking; oral contraceptives
      2. Importance of adequate hydration to prevent hypercoagulability
      3. Use of elastic stockings when ambulatory
      4. Importance of planned rest periods with elevation of the feet
      5. Drug regimen
      6. Plan for exercise/activity
        1. begin with dorsiflexion of the feet while sitting or lying down
        2. swim several times weekly
        3. gradually increase walking distance
      7. Importance of weight reduction if obese

Venous Stasis Ulcers

  1. General information
    1. Usually a complication of thrombophlebitis and varicose veins.
    2. Ulcers result from incompetent valves in the veins, causing high pressure with rupture of small skin veins and venules.
  2. Medical management
    1. Antibiotic therapy (specific to organism cultured); topical bacteriocidal solutions
    2. Skin grafting
    3. Enzymatic or surgical debridement
  3. Assessment findings
    1. Pain in the limb in dependent position or during ambulation
    2. Skin of leathery texture, brownish pigment around ankles; positive pulses but edema makes palpation difficult.
  4. Nursing interventions
    1. Provide bed rest, elevating extremity.
    2. Provide a balanced diet with added protein and vitamin supplements.
    3. Administer antibiotics as ordered to control infection.
    4. Promote healing by cleansing ulcer with prescribed agents.
    5. Provide client teaching and discharge planning concerning
      1. Importance of avoiding trauma to affected limb
      2. Skin care regimen
      3. Use of elastic support stockings (after ulcer is healed)
      4. Need for planned rest periods with elevation of the extremities
    6. Adherence to balanced diet with vitamin supplements.

Femoral-Popliteal Bypass Surgery

  1. General information
    1. Most common type of surgery to correct arterial obstructions of the lower extremities
    2. Procedure involves bypassing the occluded vessel with a graft, such as Teflon, Dacron, or an autogenous artery or vein (saphenous).
  2. Nursing interventions: preoperative
    1. Provide routine pre-op care.
    2. Monitor and correct potassium imbalances to prevent cardiac arrhythmias.
    3. Assess for focus of infection (infected tooth) or infectious processes (urinary tract infections).
    4. Mark distal peripheral pulses.
  3. Nursing interventions: postoperative
    1. Provide routine post-op care.
    2. Assess the following
      1. Circulation, noting rate, rhythm, and quality of peripheral pulses distal to the graft; color; temperature; and sensation
      2. Signs and symptoms of thrombophlebitis (see below)
      3. Neuro checks
      4. Hourly outputs
      5. CVP
      6. Wound drainage, noting amount, color, and characteristics
    3. Elevate legs above the level of the heart.
    4. Encourage turning, coughing, and deep breathing while splinting incision.

Abdominal Aortic Aneurysm

  1. General information
    1. Most aneurysms of this type are saccular or dissecting and develop just below the renal arteries but above the iliac bifurcation
    2. Occur most often in men over age 60
    3. Caused by atherosclerosis, hypertension, trauma, syphilis, other types of infectious processes
  2. Medical management: surgical resection of the lesion and replacement with a graft (extracorporeal circulation not needed)
  3. Assessment findings
    1. Severe mid- to low-abdominal pain, low-back pain
    2. Mass in the periumbilical area or slightly to the left of the midline with bruits heard over the mass
    3. Pulsating abdominal mass
    4. Diminished femoral pulses
    5. Diagnostic tests: same as for thoracic aneurysms
  4. Nursing interventions: preoperative
    1. Prepare client for surgery: routine pre-op care.
    2. Assess rate, rhythm, character of the peripheral pulses and mark all distal pulses.
  5. Nursing interventions: postoperative
    1. Provide routine post-op care
    2. Monitor the following parameters
      1. Hourly circulation checks noting rate, rhythm, character of all pulses distal to the graft
      2. CVP/PAP/PCWP
      3. Hourly outputs through Foley catheter (report less than 30 ml/hour)
      4. Daily BUN/creatinine/electrolyte levels
      5. Presence of back pain (may indicate retroperitoneal hemorrhage)
      6. IV fluids
      7. Neuro status including LOC, pupil size and response to light, hand grasp, movement of extremities
      8. Heart rate and rhythm via monitor
    3. Maintain client flat in bed without sharp flexion of hip/knee (avoid pressure on femoral/popliteal arteries).
    4. Auscultate lungs and encourage turning, coughing, and deep breathing.
    5. Assess for signs and symptoms of paralytic ileus (See Intestinal Obstructions).
    6. Prevent thrombophlebitis.
      1. Encourage client to dorsiflex foot while in bed.
      2. Use elastic stockings or sequential compression boots as ordered.
      3. Assess for signs and symptoms (see Thrombophlebitis).
    7. Provide client teaching and discharge planning concerning
      1. Importance of changes in color/temperature of extremities
      2. Avoidance of prolonged sitting, standing, and smoking
      3. Need for a gradual progressive activity regimen
      4. Adherence to low-cholesterol, low-saturated-fat diet

Aneurysms


An aneurysm is a sac formed by dilation of an artery secondary to weakness and stretching of the arterial wall. The dilation may involve one or all layers of the arterial wall.

Classification

  1. Fusiform: uniform spindle shape involving the entire circumference of the artery
  2. Saccular: outpouching on one side only, affecting only part of the arterial circumference
  3. Dissecting: separation of the arterial wall layers to form a cavity that fills with blood
  4. False: the vessel wall is disrupted, blood escapes into surrounding area but is held in place by surrounding tissue.
Thoracic Aortic Aneurysm
  1. General information
    1. An aneurysm, usually fusiform or dissecting, in the descending, ascending, or transverse section of the thoracic aorta.
    2. Usually occurs in men ages 50-70
    3. Caused by arteriosclerosis, infection, syphilis, hypertension
  2. Medical management
    1. Control of underlying hypertension
    2. Surgery: resection of the aneurysm and replacement with a Teflon/Dacron graft; clients will need extracorporeal circulation (heart-lung machine).
  3. Assessment findings
    1. Often asymptomatic
    2. Deep, diffuse chest pain; hoarseness; dysphagia; dyspnea
    3. Pallor, diaphoresis, distended neck veins, edema of head and arms
    4. Diagnostic tests
      1. Aortography shows exact location of the aneurysm
      2. X-rays: chest film reveals abnormal widening of aorta; abdominal film may show calcification within walls of aneurysm
  4. Nursing interventions: see Cardiac Surgery.

Raynaud's Phenomenon

  1. General information
    1. Intermittent episode of arterial spasms, most frequently involving the fingers
    2. Most often affects women between the teenage years and age 40
    3. Cause unknown
    4. Predisposing factors: collagen diseases (systemic lupus erythematosus, rheumatoid arthritis), trauma (e.g., from typing, piano playing, operating a chain saw)
  2. Medical management: vasodilators, catecholamine-depleting antihypertensive drugs (reserpine, guanethidine monosulfate [Ismelin])
  3. Assessment findings
    1. Coldness, numbness, tingling in one or more digits; pain (usually precipitated by exposure to cold, emotional upsets, tobacco use)
    2. Intermittent color changes (pallor, cyanosis, rubor); small ulcerations and gangrene at tips of digits (advanced)
  4. Nursing interventions
    1. Provide client teaching concerning
      1. Importance of stopping smoking
      2. Need to maintain warmth, especially in cold weather
      3. Need to use gloves when handling cold objects/opening freezer or refrigerator door
      4. Drug regimen

Thromboangiitis Obliterans (Buerger's Disease)

  1. General information
    1. Acute, inflammatory disorder affecting medium/smaller arteries and veins of the lower extremities. Occurs as focal, obstructive process; results in occlusion of a vessel with subsequent development of collateral circulation.
    2. Most often affects men ages 25-40
    3. Disease is idiopathic; high incidence among smokers.
  2. Medical management: see Arteriosclerosis Obliterans, above; only really effective treatment is cessation of smoking.
  3. Assessment findings
    1. Intermittent claudication, sensitivity to cold (skin of extremity may at first be white, changing to blue, then red)
    2. Decreased or absent peripheral pulses (posterior tibial and dorsalis pedis), trophic changes, ulceration and gangrene (advanced)
    3. Diagnostic tests: same as in Arteriosclerosis Obliterans except no elevation in serum triglycerides
  4. Nursing interventions
    1. Prepare client for surgery.
    2. Provide client teaching and discharge planning concerning
      1. Drug regimen (vasodilators, anticoagulants, analgesics) to include names, dosages, frequency, and side effects
      2. Need to avoid trauma to the affected extremity
      3. Need to maintain warmth, especially in cold weather
      4. Importance of stopping smoking.

Arteriosclerosis Obliterans

  1. General information
    1. A chronic occlusive arterial disease that may affect the abdominal aorta or the lower extremities. The obstruction to blood flow with resultant ischemia usually affects the femoral, popliteal, aortal, and iliac arteries.
    2. Occurs most often in men ages 50-60
    3. Caused by atherosclerosis
    4. Risk factors: cigarette smoking, hyperlipidemia, hypertension, diabetes mellitus
  2. Medical management
    1. Drug therapy
      1. Vasodilators: papaverine, isoxsuprine HCl (Vasodilan), nylidrin HCl (Arlidin), nicotinyl alcohol (Roniacol), cyclandelate (Cyclospasmol), tolazoline HCl (Priscoline) to improve arterial circulation; effectiveness questionable
      2. Analgesics to relieve ischemic pain
      3. Anticoagulants to prevent thrombus formation
      4. Lipid-reducing drug: cholestyramine (Questran), colestipol HCl (Cholestid), dextrothyroxine sodium (Choloxin), clofibrate (Atromid-S), gemfibrozil (Lopid), niacin, lovastatin (Mevacor) (see Unit 2)
    2. Surgery: bypass grafting, endarterectomy, balloon catheter dilation; lumbar sympathectomy (to increase blood flow), amputation may be necessary
  3. Assessment findings
    1. Pain, both intermittent claudication and rest pain, numbness or tingling of the toes
    2. Pallor after 1-2 minutes of elevating feet, and dependent hyperemia/rubor; diminished or absent dorsalis pedis, posterior tibial and femoral pulses; trophic changes; shiny, taut skin with hair loss on lower legs
    3. Diagnostic tests
      1. Oscillometry may reveal decrease in pulse volume
      2. Doppler ultrasound reveals decreased blood flow through affected vessels
      3. Angiography reveals location and extent of obstructive process
    4. Elevated serum triglycerides; sodium
  4. Nursing interventions
    1. Encourage slow, progressive physical activity (out of bed at least 3-4 times/day, walking 2 times/day).
    2. Administer medications as ordered.
    3. Assist with Buerger-Allen exercises q.i.d.
      1. Client lies with legs elevated above heart for 2-3 minutes
      2. Client sits on edge of bed with legs and feet dependent and exercises feet and toes--upward and downward, inward and outward--for 3 minutes
      3. Client lies flat with legs at heart level for 5 minutes
    4. Assess for sensory function and trophic changes.
    5. Protect client from injury.
    6. Provide client teaching and discharge planning concerning
      1. Restricted kcal, low-saturated-fat diet; include family (see Related Links: Special Diets)
      2. Importance of continuing with established exercise program
      3. Measures to reduce stress (relaxation techniques, biofeedback)
      4. Importance of avoiding smoking, constrictive clothing, standing in any position for a long time, injury
      5. Importance of foot care, immediately taking care of cuts, wounds, injuries
    7. Prepare client for surgery if necessary.

Hypertension

  1. General information
    1. According to the World Health Organization, hypertension is a persistent elevation of the systolic blood pressure above 140 mm Hg and of the diastolic above 90 mm Hg.
    2. Types
      1. Essential (primary, idiopathic): marked by loss of elastic tissue and arteriosclerotic changes in the aorta and larger vessels coupled with decreased caliber of the arterioles
      2. Benign: a moderate rise in blood pressure marked by a gradual onset and prolonged course
      3. Malignant: characterized by a rapid onset and short dramatic course with a diastolic blood pressure of more than 150 mm Hg
      4. Secondary: elevation of the blood pressure as a result of another disease such as renal parenchymal disease, Cushing's disease, pheochromocytoma, primary aldosteronism, coarctation of the aorta
    3. Essential hypertension usually occurs between ages 35 and 50; more common in men over 35, women over 45; African-American men affected twice as often as white men/women
    4. Risk factors for essential hypertension include positive family history, obesity, stress, cigarette smoking, hypercholesteremia, increased sodium intake
  2. Medical management
    1. Diet and weight reduction (restricted sodium, kcal, cholesterol)
    2. Life-style changes: alcohol moderation, exercise regimen, cessation of smoking
    3. Antihypertensive drug therapy (see Table 2.17, in Unit 2)
  3. Assessment findings
    1. Pain similar to anginal pain; pain in calves of legs after ambulation or exercise (intermittent claudication); severe occipital headaches, particularly in the morning; polyuria; nocturia; fatigue; dizziness; epistaxis; dyspnea on exertion
    2. Blood pressure consistently above 140/90, retinal hemorrhages and exudates, edema of extremities (indicative of right-sided heart failure)
    3. Rise in systolic blood pressure from supine to standing position (indicative of essential hypertension)
    4. Diagnostic tests; elevated serum uric acid, sodium, cholesterol levels
  4. Nursing interventions
    1. Record baseline blood pressure in three positions (lying, sitting, standing) and in both arms.
    2. Continuously assess blood pressure and report any variables that relate to changes in blood pressure (positioning, restlessness).
    3. Administer antihypertensive agents as ordered; monitor closely and assess for side effects.
    4. Monitor intake and hourly outputs.
    5. Provide client teaching and discharge planning concerning
      1. Risk factor identification and development/implementation of methods to modify them
      2. Restricted sodium, kcal, cholesterol diet; include family in teaching (see Related Links: Special Diets)
      3. Antihypertensive drug regimen (include family); see Table 2.17, in Unit 2
        1. names, actions, dosages, and side effects of prescribed medications
        2. take drugs at regular times and avoid omission of any doses
        3. never abruptly discontinue the drug therapy
        4. supplement diet with potassium-rich foods if taking potassium-wasting diuretics
        5. avoid hot baths, alcohol, or strenuous exercise within 3 hours of taking medications that cause vasodilation
      4. Development of a graduated exercise program
      5. Importance of routine follow-up care

Cardiac Tamponade

  1. General information
    1. An accumulation of fluid/blood in the pericardium that prevents adequate ventricular filling; without emergency treatment client will die in shock.
    2. Caused by blunt or penetrating chest trauma, malignant pericardial effusion; can be a complication of cardiac surgery
  2. Medical management: emergency treatment of choice is pericardiocentesis (insertion of a needle into the pericardial sac to aspirate fluid/blood and relieve the pressure on the heart)
  3. Assessment findings
    1. Chest pain
    2. Hypotension, distended neck veins, tachycardia, muffled or distant heart sounds, paradoxical pulse, pericardial friction rub
    3. Elevated CVP, decreased Hgb and Hct if massive hemorrhage
    4. Diagnostic test: chest x-ray reveals enlarged heart and widened mediastinum.
  4. Nursing interventions
    1. Administer oxygen therapy
    2. Monitor CVP/IVs closely
    3. Assist with pericardiocentesis.
      1. Monitor ECG, blood pressure, and pulse.
      2. Assess aspirated fluid for color, consistency.
      3. Send specimen to lab immediately.

Pericarditis

  1. General information
    1. An inflammation of the visceral and parietal pericardium
    2. Caused by a bacterial, viral, or fungal infection; collagen diseases; trauma; acute MI; neoplasms; uremia; radiation therapy; drugs (procainamide, hydralazine, doxorubicin HCl [Adriamycin])
  2. Medical management
    1. Determination and elimination/control of underlying cause
    2. Drug therapy
      1. Medication for pain relief
      2. Corticosteroids, salicylates (aspirin), and indomethacin (Indocin) to reduce inflammation
      3. Specific antibiotic therapy against the causative organism may be indicated.
  3. Assessment findings
    1. Chest pain with deep inspiration (relieved by sitting up), cough, hemoptysis, malaise
    2. Tachycardia, fever, pleural friction rub, cyanosis or pallor, accentuated component of S2, pulsus paradoxus, jugular vein distension
    3. Elevated WBC and ESR, normal or elevated AST (SGOT)
    4. Diagnostic tests
      1. Chest x-ray may show increased heart size if effusion occurs
      2. ECG changes: ST elevation (precordial leads and 2- or 3-limb heads), T wave inversion
  4. Nursing interventions
    1. Ensure comfort: bed rest with semi- or high-Fowler's position.
    2. Monitor hemodynamic parameters carefully.
    3. Administer medications as ordered and monitor effects.
    4. Provide client teaching and discharge planning concerning
      1. Signs and symptoms of pericarditis indicative of a recurrence (chest pain that is intensified by inspiration and position changes, fever, cough)
      2. Medication regimen including name, purpose, dosage, frequency, side effects.

Endocarditis

  1. General information
    1. Inflammation of the endocardium; platelets and fibrin deposit on the mitral and/or aortic valves causing deformity, insufficiency, or stenosis.
    2. Caused by bacterial infection: commonly S. aureus, S. viridans, B-hemolytic streptococcus, gonococcus
    3. Precipitating factors: rheumatic heart disease, open-heart surgery procedures, GU/Ob-Gyn instrumentation/surgery, dental extractions, invasive monitoring, septic thrombophlebitis
  2. Medical management
    1. Drug therapy
      1. Antibiotics specific to sensitivity of organism cultured
      2. Penicillin G and streptomycin if organism not known
      3. Antipyretics
    2. Cardiac surgery to replace affected valve
  3. Assessment findings
    1. Fever, malaise, fatigue, dyspnea and cough (if extensive valvular damage), acute upper quadrant pain (if splenic involvement), joint pain
    2. Petechiae, murmurs, edema (if extensive valvular damage), splenomegaly, hemiplegia and confusion (if cerebral infarction), hematuria (if renal infarction)
    3. Elevated WBC and ESR, decreased Hgb and Hct
    4. Diagnostic tests: positive blood culture for causative organism
  4. Nursing interventions
    1. Administer antibiotics as ordered to control the infectious process.
    2. Control temperature elevation by administration of antipyretics.
    3. Assess for vascular complications (see Thrombophlebitis, and Pulmonary Embolism).
    4. Provide client teaching and discharge planning concerning
      1. Types of procedures/treatments (e.g., tooth extractions, GU instrumentation) that increase the chances of recurrences
      2. Antibiotic therapy, including name, purpose, dose, frequency, side effects
      3. Signs and symptoms of recurrent endocarditis (persistent fever, fatigue, chills, anorexia, joint pain)
      4. Avoidance of individuals with known infections.

Cardiopulmonary Resuscitation (CPR)

  1. General information: process of externally supporting the circulation and respiration of a person who has had a cardiac arrest
  2. Nursing interventions: unwitnessed cardiac arrest
    1. Assess LOC.
      1. Shake victim's shoulder and shout.
      2. If no response, summon help.
    2. Position victim supine on a firm surface.
    3. Open airway.
      1. Use head tilt, chin lift maneuver.
      2. Place ear over nose and mouth.
        1. look to see if chest is moving.
        2. listen for escape of air.
        3. feel for movement of air against face.
      3. If no respiration, proceed to #4.
    4. Ventilate twice, allowing for deflation between breaths.
    5. Assess circulation: palpate for carotid pulse; if not present, proceed to #6.
    6. Initiate external cardiac compressions
      1. Proper placement of hands: lower half of the sternum
      2. Depth of compressions: 1 1/2-2 inches for adults
      3. One rescuer: 15 compressions (at rate of 80-100 per minute) with 2 ventilations
      4. Two rescuers: 5 compressions (at rate of 80-100 per minute) with 1 ventilation

Cardiac Arrest

  1. General information: sudden, unexpected cessation of breathing and adequate circulation of blood by the heart
  2. Medical management
    1. Cardiopulmonary resuscitation (CPR); see below
    2. Drug therapy
      1. Lidocaine, procainamide, verapamil
      2. Dopamine (Intropin), isoproterenol (Isuprel), norepinephrine (Levophed): see also Drugs Used to Treat Shock, Table 4.9
      3. Epinephrine to enhance myocardial automaticity, excitability, conductivity, and contractility
      4. Atropine sulfate to reduce vagus nerve's control over the heart, thus increasing the heart rate
      5. Sodium bicarbonate: administered during first few moments of a cardiac arrest to correct respiratory and metabolic acidosis
      6. Calcium chloride: calcium ions help the heart beat more effectively by enhancing the myocardium's contractile force
    3. Defibrillation (electrical countershock)
  3. Assessment findings: unresponsiveness, cessation of respiration, pallor, cyanosis, absence of heart sounds/blood pressure/palpable pulses, dilation of pupils, ventricular fibrillation (if client on a monitor)
  4. Nursing interventions: monitored arrest caused by ventricular fibrillation
    1. Begin precordial thump and, if successful, administer lidocaine.
    2. If unsuccessful, defibrillation.
    3. If defibrillation unsuccessful, initiate CPR immediately.
    4. Assist with administration of and monitor effects of additional emergency drugs.

Pacemakers

  1. General information
    1. A pacemaker is an electronic device that provides repetitive electrical stimulation to the heart muscle to control the heart rate.
    2. Artificial pacing system consists of a battery-powered generator and a pacing wire that delivers the stimulus to the heart.
  2. Indications for use
    1. Adams-Stokes attack
    2. Acute MI with Mobitz II AV block
    3. Third-degree AV block with slow ventricular rate
    4. Right bundle branch block
    5. New left bundle branch block
    6. Symptomatic sinus bradycardia
    7. Sick sinus syndrome
    8. Arrhythmias (during or after cardiac surgery)
    9. Drug-resistant tachyarrhythmia
  3. Modes of pacing
    1. Fixed rate: pacemaker fires electrical stimuli at preset rate, regardless of the client's rate and rhythm.
    2. Demand: pacemaker produces electrical stimuli only when the client's own heart rate drops below the preset rate per minute on the generator.
  4. Types of pacemakers
    1. Temporary
      1. Used in emergency situations and performed via an endocardial (transvenous) or transthoracic approach to the myocardium.
      2. Performed at bedside or using fluoroscopy.
    2. Permanent
      1. Endocardial or transvenous procedure involves passing endocardial lead into right ventricle with subcutaneous implantation of pulse generator into right or left subclavian areas. Usually done under local anesthesia.
      2. Epicardial or myocardial method involves passing the electrode transthoracically to the myocardium where it is sutured in place. The pulse generator is implanted into the abdominal wall.
  5. Nursing interventions
    1. Assess pacemaker function
      1. Monitor heart rate, noting deviations from the preset rate.
      2. Observe the presence of pacemaker spikes on ECG tracing or cardiac monitor; spike before P wave with atrial pacemaker; spike before QRS complex with ventricular pacemaker
      3. Assess for signs of pacemaker malfunction, such as weakness, fainting, dizziness, or hypotension.
    2. Maintain the integrity of the system
      1. Ensure that catheter terminals are attached securely to the pulse generator (temporary pacemaker)
      2. Attach pulse generator to client securely to prevent accidental dislodgment (temporary pacemaker)
    3. Provide safety and comfort
      1. Provide safe environment by properly grounding all equipment in the room.
      2. Monitor electrolyte level periodically, particularly potassium.
    4. Prevent infection
      1. Assess vital signs, particularly temperature changes.
      2. Assess catheter insertion site daily for signs of infection.
      3. Maintain sterile dressing over catheter insertion site.
  6. Provide client teaching and discharge planning concerning
    1. Fundamental concepts of cardiac physiology
    2. Daily pulse check for one minute
    3. Need to report immediately any sudden slowing or increase in pulse rate
    4. Importance of adhering to weekly monitoring schedule during first month after implantation and when battery depletion is anticipated (depending on type of battery)
    5. Wear loose-fitting clothing around the area of the pacemaker for comfort
    6. Notify physician of any pain or redness over incision site
    7. Avoid trauma to area of pulse generator
    8. Avoid heavy contact sports
    9. Carry an identification card/bracelet that indicates physician's name, type and model number of pacemaker, manufacturer's name, pacemaker rate
    10. Display identification card and request scanning by hand scanner when going through weapons detector at airport
    11. Remember that periodic hospitalization is necessary for battery changes/pacemaker unit replacement

Pulmonary Edema

  1. General information
    1. A medical emergency that usually results from left-sided heart failure. The capillary pressure within the lungs becomes so great that fluid pours from the blood into the alveoli, bronchi, and bronchioles. Death occurs by suffocation if this condition is untreated.
    2. Caused by left-sided heart failure, rapid administration of IV fluids.
  2. Medical management
    1. Oxygen therapy
    2. Endotracheal/nasotracheal intubation (possible)
    3. Drug therapy
      1. Morphine sulfate to induce vasodilation and decrease anxiety; 5 mg IV, administer slowly
      2. Digitalis to improve cardiac output
      3. Diuretics (furosemide [Lasix] is drug of choice) to relieve fluid retention
      4. Aminophylline to relieve bronchospasm and increase cardiac output; 250-500 mg IV, administer slowly
      5. Vasodilators (nitroglycerin, isosorbide dinitrate) to dilate the vessels, thereby reducing amount of blood returned to the heart
    4. Rotating tourniquets or phlebotomy
  3. Assessment findings
    1. Dyspnea
    2. Cough with large amounts of blood-tinged sputum
    3. Tachycardia, pallor, wheezing, rales or crackles, diaphoresis
    4. Restlessness, fear/anxiety
    5. Jugular vein distension
    6. Decreased pO2, increased pCO2, elevated CVP
  4. Nursing interventions
    1. Assist with intubation (if necessary) and monitor mechanical ventilation.
    2. Administer oxygen by mask in high concentrations (40%-60%) if not intubated.
    3. Place client in semi-Fowler's position or over bedside table to ease dyspnea.
    4. Administer medications as ordered.
    5. Apply and monitor rotating tourniquets.
      1. Occlude vessels of each limb for no more than 45 minutes at a time.
      2. Rotate in a clockwise fashion every 15 minutes.
      3. Assess continuously for presence of arterial pulses.
      4. Observe skin for signs of irritation.
      5. When discontinuing, remove 1 tourniquet every 15 minutes to avoid rapid influx of fluid to the heart.
    6. Assist with phlebotomy (removal of 300-500 ml of blood from a peripheral vein) if performed.
    7. CVP/hemodynamic monitoring.
    8. Provide client teaching and discharge planning concerning
      1. Prescribed medications, including name, purpose, schedule, dosage, and side effects
      2. Dietary restrictions: low sodium, low cholesterol
      3. Importance of adhering to planned rest periods with gradual progressive increase in activities
      4. Daily weights
      5. Need to report the following symptoms to physician immediately: dyspnea, persistent productive cough, pedal edema, restlessness

Congestive Heart Failure (CHF)

  1. General information: inability of the heart to pump an adequate supply of blood to meet the metabolic needs of the body.
  2. Types
    1. Left-sided heart failure
      1. Left ventricular damage causes blood to back up through the left atrium and into the pulmonary veins. Increased pressure causes transudation into the interstitial tissues of the lungs with resultant pulmonary congestion.
      2. Caused by left ventricular damage (usually due to an MI), hypertension, ischemic heart disease, aortic valve disease, mitral stenosis
      3. Assessment findings
        1. dyspnea, orthopnea, PND, tiredness, muscle weakness, cough
        2. tachycardia, PMI displaced laterally, possible S3, bronchial wheezing, rales or crackles, cyanosis, pallor
        3. decreased pO2, increased pCO2
        4. diagnostic tests
          1. chest x-ray: shows cardiac hypertrophy
          2. PAP and PCWP usually increased; however, this is dependent on the degree of heart failure
        5. Echocardiography: shows increased size of cardiac chambers
    2. Right-sided heart failure
      1. Weakened right ventricle is unable to pump blood into the pulmonary system; systemic venous congestion occurs as pressure builds up.
      2. Caused by left-sided heart failure, right ventricular infarction, atherosclerotic heart disease, COPD, pulmonic stenosis, pulmonary embolism.
      3. Assessment findings
        1. anorexia, nausea, weight gain
        2. dependent pitting edema, jugular venous distension, bounding pulses, hepatomegaly, cool extremities, oliguria
        3. elevated CVP, decreased pO2, increased ALT (SGPT)
        4. diagnostic tests
          1. chest x-ray: reveals cardiac hypertrophy
          2. echocardiography: indicates increased size of cardiac chambers
    3. High-output failure
      1. Cardiac output is adequate but exceeded by the metabolic needs of the tissues; the exorbitant demands made on the heart eventually cause ventricular failure.
      2. Caused by hyperthyroidism, anemia, AV fistula, pregnancy
  3. Medical management (all types)
    1. Determination and elimination/control of underlying cause
    2. Drug therapy: digitalis preparations, diuretics, vasodilators
    3. Sodium-restricted diet to decrease fluid retention
    4. If medical therapies unsuccessful, mechanical assist devices (intra-aortic balloon pump), cardiac transplantation, or mechanical hearts may be employed.
  4. Nursing interventions
    1. Monitor respiratory status and provide adequate ventilation (when CHF progresses to pulmonary edema).
      1. Administer oxygen therapy.
      2. Maintain client in semi- or high-Fowler's position.
      3. Monitor ABGs.
      4. Assess for breath sounds, noting any changes.
    2. Provide physical and emotional rest.
      1. Constantly assess level of anxiety.
      2. Maintain bed rest with limited activity.
      3. Maintain quiet, relaxed environment.
      4. Organize nursing care around rest periods.
    3. Increase cardiac output.
      1. Administer digitalis as ordered and monitor effects.
      2. Monitor ECG and hemodynamic monitoring.
      3. Administer vasodilators as ordered.
      4. Monitor vital signs.
    4. Reduce/eliminate edema.
      1. Administer diuretics as ordered.
      2. Daily weights.
      3. Maintain accurate I&O.
      4. Assess for peripheral edema.
      5. Measure abdominal girths daily.
      6. Monitor electrolyte levels.
      7. Monitor CVP and Swan-Ganz readings.
      8. Provide sodium-restricted diet as ordered.
      9. Provide meticulous skin care.
    5. Provide client teaching and discharge planning concerning
      1. Need to monitor self daily for signs and symptoms of CHF (pedal edema, weight gain of 1-2 kg in a 2-day period, dyspnea, loss of appetite, cough)
      2. Medication regimen including name, purpose, dosage, frequency, and side effects (digitalis, diuretics)
      3. Prescribed dietary plan (low sodium; small, frequent meals)
      4. Need to avoid fatigue and plan for rest periods.

Coronary Artery Bypass Surgery

  1. General information
    1. A coronary artery bypass graft is the surgery of choice for clients with severe CAD.
    2. New supply of blood brought to diseased/occluded coronary artery by bypassing the obstruction with a graft that is attached to the aorta proximally and to the coronary artery distally.
    3. Several bypasses can be performed depending on the location and extent of the blockage.
    4. Procedure requires use of extracorporeal circulation (heart-lung machine, cardiopulmonary bypass)
  2. Nursing interventions: preoperative
    1. Explain anatomy of the heart, function of coronary arteries, effects of CAD
    2. Explain events of the day of surgery: length of time in surgery, length of time until able to see family.
    3. Orient to the critical and coronary care units and introduce to staff.
    4. Explain equipment to be used (monitors, hemodynamic procedures, ventilator, endotracheal tube, drainage tubes).
    5. Demonstrate activity and exercises (turning from side to side, dangling, sitting in a chair, ROM exercises for arms and legs, effective deep breathing, and coughing).
    6. Reassure client that pain medication is available.
  3. Nursing interventions: postoperative
    1. Maintain patent airway.
    2. Promote lung reexpansion.
      1. Monitor drainage from chest/mediastinal tubes, and check patency of chest drainage system.
      2. Assist client with turning, coughing, and deep breathing.
    3. Monitor cardiac status.
      1. Monitor vital signs and cardiac rhythm and report significant changes, particularly temperature elevation.
      2. Perform peripheral pulse checks.
      3. Carry out hemodynamic monitoring.
      4. Administer anticoagulants as ordered and monitor hematologic test results carefully.
    4. Maintain fluid and electrolyte balance.
      1. Maintain accurate I&O with hourly outputs; report if less than 30 ml/hour urine.
      2. Assess color, character, and specific gravity of urine.
      3. Daily weights.
      4. Assess lab values, particularly BUN, creatinine, sodium, and potassium levels.
    5. Maintain adequate cerebral circulation: frequent neuro checks.
    6. Provide pain relief.
      1. Administer narcotics cautiously and monitor effects.
      2. Assist with positioning for maximum comfort.
      3. Teach relaxation techniques.
    7. Prevent abdominal distension.
      1. Monitor nasogastric drainage and maintain patency of system.
      2. Assess for bowel sounds every 2-4 hours.
      3. Measure abdominal girths if necessary.
    8. Monitor for and prevent the following complications.
      1. Thrombophlebitis/pulmonary embolism
      2. Cardiac tamponade (see Cardiac Tamponade)
      3. Arrhythmias
        1. maintain continuous ECG monitoring and report changes.
        2. assess electrolyte levels daily and report significant changes, particularly potassium.
        3. administer antiarrhythmics as ordered.
      4. Congestive heart failure (see below)
    9. Provide client teaching and discharge planning concerning
      1. Limitation with progressive increase in activities
        1. encourage daily walking with gradual increase in distance weekly
        2. avoid heavy lifting and activities that require continuous arm movements (vacuuming, playing golf, bowling)
        3. avoid driving a car until physician permits
      2. Sexual intercourse: can usually be resumed by third or fourth week post-op; avoid sexual positions in which the client would be supporting weight
      3. Medical regimen: ensure client/family are aware of drugs, dosages, proper times of administration, and side effects
      4. Meal planning with prescribed modifications (decreased sodium, cholesterol, and possibly carbohydrates)
      5. Wound cleansing daily with mild soap and H2O and report signs of infection
      6. Symptoms to be reported: fever, dyspnea, chest pain with minimal exertion.

Percutaneous Transluminal Coronary Angioplasty

  1. General information
    1. Percutaneous transluminal coronary angioplasty (PTCA) can be performed instead of coronary artery bypass graft surgery in various clients with single-vessel coronary artery disease.
    2. The aim of PTCA is to revascularize the myocardium, decrease angina, and increase survival.
    3. PTCA is performed in the cardiac catheterization lab and is accomplished by insertion of a balloon-tipped catheter into the stenotic, diseased coronary artery. The balloon is inflated with a controlled pressure and thereby decreases the stenosis of the vessel.
  2. Nursing interventions
    Preoperative and postoperative care is similar to the care of the client undergoing cardiac catheterization.

Myocardial Infarction (MI)

  1. General information
    1. The death of myocardial cells from inadequate oxygenation, often caused by a sudden complete blockage of a coronary artery; characterized by localized formation of necrosis (tissue destruction) with subsequent healing by scar formation and fibrosis.
    2. Risk factors: atherosclerotic CAD, thrombus formation, hypertension, diabetes mellitus
  2. Assessment findings (see also Angina Pectoris)
    1. Pain usually substernal with radiation to the neck, arm, jaw, or back; severe, crushing, viselike with sudden onset; unrelieved by rest or nitrates
    2. Nausea and vomiting
    3. Dyspnea
    4. Skin: cool, clammy, ashen
    5. Elevated temperature
    6. Initial increase in blood pressure and pulse, with gradual drop in blood pressure
    7. Restlessness
    8. Occasional findings: rales or crackles; presence of S4; pericardial friction rub; split S1, S2
    9. Diagnostic tests
      1. Elevated WBC
      2. Elevated CPK and CPK-MB
      3. Elevated SGOT or AST
      4. Elevated LDH, LDH1, and LDH2
      5. ECG changes (specific changes dependent on location of myocardial damage and phase of the MI; inverted T wave and ST segment changes seen with myocardial ischemia
      6. Increased ESR, elevated serum cholesterol
  3. Nursing interventions
    1. Establish a patent IV line
    2. Provide pain relief; morphine sulfate IV (given IV because after an infarction there is poor peripheral perfusion and because serum enzymes would be affected by IM injections) as ordered.
    3. Administer oxygen as ordered to relieve dyspnea and prevent arrhythmias.
    4. Provide bed rest with semi-Fowler's position to decrease cardiac workload.
    5. Monitor ECG and hemodynamic procedures.
    6. Administer antiarrhythmias as ordered.
    7. Perform complete lung/cardiovascular assessment.
    8. Monitor urinary output and report output of less than 30 ml/hour; indicates decreased cardiac output.
    9. Maintain full liquid diet with gradual increase to soft; low sodium.
    10. Maintain quiet environment.
    11. Administer stool softeners as ordered to facilitate bowel evacuation and prevent straining.
    12. Relieve anxiety associated with coronary care unit (CCU) environment.
    13. Administer anticoagulants, as ordered.
    14. Administer thrombolytics (tissue-type plasminogen activator or t-pa and streptokinase) and monitor for side effects; bleeding.
    15. Provide client teaching and discharge planning concerning
      1. Effects of MI, healing process, and treatment regimen
      2. Medication regimen including name, purpose, schedule, dosage, side effects
      3. Risk factors, with necessary lifestyle modifications
      4. Dietary restrictions: low sodium, low cholesterol, avoidance of caffeine
      5. Importance of participation in a progressive activity program
      6. Resumption of sexual activity according to physician's orders (usually 4-6 weeks)
      7. Need to report the following symptoms: increased persistent chest pain, dyspnea, weakness, fatigue, persistent palpitations, light-headedness
      8. Enrollment of client in a cardiac rehabilitation program

Ventricular Tachycardia

  1. General information
    1. A run of three or more consecutive PVCs; occurs from repetitive firing of an ectopic focus in the ventricles
    2. Caused by acute MI, CAD, digitalis intoxication, hypokalemia
  2. Assessment findings
    1. Rate
      1. Atrial: 60-100 beats/minute
      2. Ventricular: 110-250 beats/minute
    2. Rhythm: atrial (regular), ventricular (occasionally irregular)
    3. P wave: often lost in QRS complex
    4. P-R interval: usually not measurable
    5. QRS complex: greater than 0.12 seconds, wide
  3. Treatment
    1. IV push of lidocaine (50-100 mg), then IV drip of lidocaine 1-4 mg/minute
    2. Procainamide via IV infusion of 2-6 mg/minute
    3. Direct-current cardioversion
    4. Bretylium, propranolol (Inderal)

Premature Ventricular Contractions (PVCs)

  1. General information
    1. Irritable impulses originate in the ventricles
    2. Caused by electrolyte imbalance (hypokalemia); digitalis drug therapy; myocardial disease; stimulants (caffeine, epinephrine, isoproterenol); hypoxia; congestive heart failure
  2. Assessment findings
    1. Rate: varies according to number of PVCs
    2. Rhythm: irregular because of PVCs
    3. P wave: normal; however, often lost in QRS complex
    4. P-R interval: often not measurable
    5. QRS complex: wide and distorted in shape, greater than 0.12 seconds
  3. Treatment
    1. IV push of lidocaine (50-100 mg) followed by IV drip of lidocaine at rate of 1-4 mg/minute
    2. Procainamide (Pronestyl), quinidine
    3. Treatment of underlying cause

Atrial Fibrillation

  1. General information
    1. An arrhythmia in which ectopic foci cause rapid, irregular contractions of the heart
    2. Commonly seen in clients with rheumatic mitral stenosis, thyrotoxicosis, cardiomyopathy, hypertensive heart disease, pericarditis, and coronary heart disease
  2. Assessment findings
    1. Rate
      1. Atrial: 350-600 beats/minute
      2. Ventricular: varies between 100-160 beats/minute
    2. Rhythm: atrial and ventricular regularly irregular
    3. P wave: no definite P wave; rapid undulations called fibrillatory (f) waves
    4. P-R interval: not measurable
    5. QRS complex: generally normal
  3. Treatment: digitalis preparations, propranolol, verapamil in conjunction with digitalis; direct-current cardioversion

Sinus Bradycardia

  1. General information
    1. A slowed heart rate initiated by SA node
    2. Caused by excessive vagal or decreased sympathetic tone, MI, intracranial tumors, meningitis, myxedema, cardiac fibrosis; a normal variation of the heart rate in well-trained athletes
  2. Assessment findings
    1. Rate: less than 60 beats/minute
    2. Rhythm: regular
    3. P wave: precedes each QRS with a normal contour
    4. P-R interval: normal
    5. QRS complex: normal
  3. Treatment: usually not needed; if cardiac output is inadequate, atropine and isoproterenol (Isuprel) are usually prescribed; if drugs are not effective, a pacemaker may need to be inserted (see Pacemakers).

Sinus Tachycardia



  1. General information
    1. A heart rate of over 100 beats/minute, originating in the SA node
    2. May be caused by fever, apprehension, physical activity, anemia, hyperthyroidism, drugs (epinephrine, theophylline), myocardial ischemia, caffeine
  2. Assessment findings
    1. Rate: 100-160 beats/minute
    2. Rhythm: regular
    3. P wave: precedes each QRS complex with normal contour
    4. P-R interval: normal (0.08 second)
    5. QRS complex: normal (0.06 second)
  3. Treatment: correction of underlying cause, elimination of stimulants; sedatives, propranolol (Inderal).

Angina Pectoris

  1. General information
    1. Transient, paroxysmal chest pain produced by insufficient blood flow to the myocardium resulting in myocardial ischemia.
    2. Risk factors: CAD, atherosclerosis, hypertension, diabetes mellitus, thromboangiitis obliterans, severe anemia, aortic insufficiency
    3. Precipitating factors: physical exertion, consumption of a heavy meal, extremely cold weather, strong emotions, cigarette smoking, sexual activity
  2. Medical management
    1. Drug therapy: nitrates, beta-adrenergic blocking agents, and/or calcium-blocking agents, lipid reducing drugs if cholesterol elevated
    2. Modification of diet and other risk factors
    3. Surgery: see Coronary Artery Bypass Surgery
  3. Assessment findings
    1. Pain: substernal with possible radiation to the neck, jaw, back, and arms; relieved by rest
    2. Palpitations, tachycardia
    3. Dyspnea
    4. Diaphoresis
    5. Increased serum lipid levels
    6. Diagnostic tests
      1. ECG may reveal ST segment depression and T-wave inversion during chest pain
      2. Stress test may reveal an abnormal ECG during exercise.
  4. Nursing interventions
    1. Administer oxygen.
    2. Give prompt pain relief with nitrates or narcotic analgesics as ordered.
    3. Monitor vital signs, status of cardiopulmonary function.
    4. Monitor ECG.
    5. Place client in semi- to high-Fowler's position.
    6. Provide emotional support.
    7. Provide client teaching and discharge planning concerning
      1. Proper use of nitrates
        1. nitroglycerin tablets (sublingual)
          1. allow tablet to dissolve.
          2. relax for 15 minutes after taking tablet to prevent dizziness.
          3. if no relief with 1 tablet, take additional tablets at 5-minute intervals, but no more than 3 tablets within a 15-minute period.
          4. know that transient headache is a frequent side effect.
          5. keep bottle tightly capped and prevent exposure to air, light, heat.
          6. ensure tablets are within reach at all times.
          7. check shelf life, expiration date of tablets.
        2. nitroglycerin ointment (topical)
          1. rotate sites to prevent dermal inflammation.
          2. remove previously applied ointment.
          3. avoid massaging/rubbing as this increases absorption and interferes with the drug's sustained action.
      2. Ways to minimize precipitating events
        1. reduce stress and anxiety (relaxation techniques, guided imagery)
        2. avoid overexertion and smoking
        3. maintain low-cholesterol, low-saturated fat diet and eat small, frequent meals
        4. avoid extremes of temperature
        5. dress warmly in cold weather
      3. Gradual increase in activities and exercise
        1. participate in regular exercise program
        2. space exercise periods and allow for rest periods
    8. Instruct client to notify physician immediately if pain occurs and persists, despite rest and medication administration.

Coronary Artery Disease (CAD)

  1. General information
    1. CAD refers to a variety of pathologic conditions that cause narrowing or obstruction of the coronary arteries, resulting in decreased blood supply to the myocardium.
    2. Atherosclerosis (deposits of cholesterol and lipids within the walls of the artery) is the major causative factor.
    3. Occurs most often between ages 30 and 50; men affected more often than women; nonwhites have higher mortality rates.
    4. May manifest as angina pectoris or MI.
    5. Risk factors: family history of CAD, elevated serum lipoproteins, cigarette smoking, diabetes mellitus, hypertension, obesity, sedentary and/or stressful/competitive life-style, elevated serum uric acid levels
  2. Medical management, assessment findings, and nursing interventions: see Angina Pectoris (below) and Myocardial Infarction (MI)).

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