Angelite Nurses

• Coronary Artery Disease (CAD)
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• Angina Pectoris
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• Sinus Tachycardia
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• Sinus Bradycardia
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• Atrial Fibrillation
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• Premature Ventricular Contractions (PVCs)
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• Ventricular Tachycardia
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• Myocardial Infarction (MI)
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• Percutaneous Transluminal Coronary Angioplasty
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• Coronary Artery Bypass Surgery
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• Congestive Heart Failure (CHF)
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• Pulmonary Edema
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• Pacemakers
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• Cardiac Arrest
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• Cardiopulmonary Resuscitation (CPR)
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• Endocarditis
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• Pericarditis
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• Cardiac Tamponade
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• Hypertension
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• Arteriosclerosis Obliterans
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• Thromboangiitis Obliterans (Buerger's Disease)
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• Raynaud's Phenomenon
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• Aneurysms
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• Abdominal Aortic Aneurysm
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• Femoral-Popliteal Bypass Surgery
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• Venous Stasis Ulcers
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• Thrombophlebitis
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• Pulmonary Embolism
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• Varicose Veins
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• 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.

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).

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.

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

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.

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.

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

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.

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.

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

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.

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.

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

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.

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.

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.

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

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.

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

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