Angelite Nurses

Health History

1. Presenting problem
1. Nonspecific symptoms may include fatigue, shortness of breath, cough, dizziness, syncope, headache, palpitations, weight loss/gain, anorexia, difficulty sleeping.
2. Specific signs and symptoms
1. Chest pain: note character, quality, location, radiation, frequency, and whether it is associated with precipitating factors (exertion, eating, excitement).
2. Dyspnea (shortness of breath): note kind and extent of precipitating activities.
3. Orthopnea (form of dyspnea that develops when client lies down): determine how many pillows are used when sleeping; note any paroxysmal nocturnal dyspnea (PND) (client awakens suddenly in the night, breathing with difficulty).
4. Palpitations (awareness of heartbeat, fluttering feeling): assess precipitating factors (anxiety, caffeine, nicotine, stress); ask client to tap out the rhythm.
5. Edema (abnormal accumulation of fluid in tissues): note whether unilateral/bilateral, location, time of day when most apparent.
6. Cyanosis (dusky, bluish coloration to the skin): note whether peripheral or central.
2. Lifestyle: occupation, hobbies, financial status, stressors, unusual life patterns, relaxation time, exercise, living conditions, smoking, sleep habits
3. Use of medications: OTC drugs, contraceptives, cardiac drugs
4. Personality profile: Type A, manic-depressive, anxieties
5. Nutrition: dietary habits; calorie, cholesterol, salt intake; alcohol consumption
6. Past medical history
1. Heart murmurs, rheumatic fever, sexually transmitted diseases, angina, myocardial infarction (MI), hypertension, CVA, alcoholism, obesity, hyperlipidemia, varicose veins, claudication
2. Pregnancies, contraceptive use
7. Family history: heart disease (congenital, acute, chronic); risk factors (diabetes, hypertension, obesity)

Physical Examination

1. Skin and mucous membranes: note color/texture, temperature, hair distribution on extremities, atrophy or edema, venous pattern, petechiae, lesions, ulcerations or gangrene; examine nails.
2. Peripheral pulses: palpate and rate all arterial pulses (temporal, carotid, brachial, radial, femoral, popliteal, dorsalis pedis, and posterior tibial) on scale of: 0 = absent, 1 = palpable, 2 = normal, 3 = full, 4 = full and bounding.
3. Assess for arterial insufficiency and venous impairment.
4. Measure and record blood pressure.
5. Inspect and palpate the neck vessels.
1. Jugular veins: note location, characteristics; measure jugular venous pressure.
2. Carotid arteries: note location, characteristics
6. Precordium
1. Inspect and palpate sternoclavicular, aortic, pulmonic, Erb's point, tricuspid, apical, epigastric sites.
2. Note point of maximum impulse (PMI), pulsations, thrills.
7. Auscultate aortic, pulmonic, Erb's point, tricuspid, mitral or apical, xiphoid areas; note heart rate and rhythm (see Figure 4.8).
1. Normal heart sounds (S₁ and S₂): note location, intensity, splitting.
2. Abnormal heart sounds (S₃, S₄): note location, occurrence in cardiac cycle
3. Murmurs: note location, occurrence in cardiac cycle
4. Friction rubs

FIGURE 4.8 Heart valves and areas of auscultation: (1) aortic area; (2) pulmonic area; (3) Erb's point; (4) tricuspid area; (5) mitral area

Laboratory/Diagnostic Tests

1. Blood chemistry and electrolyte analysis
1. Cardiac enzymes: will be elevated with myocardial infarction
1. creatine phosphokinase (CPK) 50-325 mU/ml
2. CPK-MB 0%
3. lactic acid dehydrogenase (LDH) 100-225 mU/ml
1. LDH₁ 20%-35%
2. LDH₂ 25%-40%
4. aspartate aminotransferase (AST), also called serum glutamic-oxalacetate (SGOT) 7-40 U/ml
2. Electrolytes
1. Sodium (Na): 135-148 mEq/l; reflects relative fluid balance, hyponatremia indicates fluid excess and hypernatremia indicates fluid deficit
2. Potassium (K): 3.5-5 mEq/l; increased and decreased levels can cause dysrhythmias
3. Magnesium (Mg): 1.3-2.1 mEq/l; decreased levels can cause dysrhythmias
4. Calcium (Ca): 4.5-5.3 mEq/l, 9-11 mg/dl; calcium necessary for blood clotting and neuromuscular activity, decreased levels cause tetany, increased levels cause muscle atony, increased and decreased levels can cause dysrhythmias.
3. Serum lipids
1. Total cholesterol: 150-200 mg/dl; elevated levels predispose to atherosclerotic heart disease
2. High density lipids (HDL): 30-85 mg/dl; low levels predispose to cardiovascular disease
3. Low density lipids (LDL): 50-140 mg/dl; high levels predispose to atherosclerotic plaque formation
4. Triglycerides: 10-150 mg/dl; high levels increase risk of atherosclerotic heart disease
2. Hematologic studies
1. CBC (see Hematologic system for values)
2. Coagulation time: 5-15 min.; increased levels indicate bleeding tendency, used to monitor heparin therapy
3. Prothrombin time (PT) 9.5-12 sec.; INR 1.0, increased levels indicate bleeding tendency, used to monitor warfarin therapy
4. Activated partial thromboplastin time (APTT) 20-45 sec., increased levels indicate bleeding tendency, used to monitor heparin therapy
5. Erythrocyte sedimentation rate (ESR) <20>
3. Urine studies: routine urinalysis
4. Electrocardiogram (ECG or EKG)
1. Noninvasive test that produces a graphic record of the electrical activity of the heart. In addition to determining cardiac rhythm, pattern variations may reveal pathologic processes (MI and ischemia, electrolyte and acid-base imbalance, chamber enlargement, block of the right or left bundle branch); see also Cardiac Monitoring.
2. Portable recorder (Holtor monitor) provides continuous recording of ECG for up to 24 hours; client keeps a diary noting presence of symptoms or any unusual activities.
5. Exercise ECG (stress test): the ECG is recorded during prescribed exercise such as climbing a set of stairs, walking a treadmill, or riding a stationary bicycle; stress tests may show heart disease when resting ECG does not.
6. Phonocardiogram: noninvasive device to amplify and record heart sounds and murmurs.
7. Echocardiogram: noninvasive recording of the cardiac structures using ultrasound.
8. Cardiac catheterization: invasive, but often definitive test for diagnosis of cardiac disease.
1. A catheter is inserted into the right or left side of the heart to obtain information.
1. Right-sided catheterization: the catheter is inserted into an antecubital vein and advanced into the vena cava, right atrium, and right ventricle with further insertion into the pulmonary artery.
2. Left-sided catheterization: performed by inserting the catheter into a brachial or femoral artery; the catheter is passed retrograde up the aorta and into the left ventricle.
2. Purpose: to measure intracardiac pressures and oxygen levels in various parts of the heart; with injection of a dye, it allows visualization of the heart chambers, blood vessels, and course of blood flow (angiography).
3. Nursing care: pretest
1. Confirm that informed consent has been signed.
2. Ask about allergies, particularly to iodine, if dye being used.
3. Keep client NPO for 8-12 hours prior to test.
4. Record height and weight, take baseline vital signs, and monitor peripheral pulses.
5. Inform client that a feeling of warmth and fluttering sensation as catheter is passed is common.
4. Nursing care: posttest
1. Assess circulation to the extremity used for catheter insertion.
2. Check peripheral pulses, color, sensation of affected extremity every 15 minutes for 4 hours.
3. If protocol requires, keep affected extremity straight for approximately 8 hours.
4. Observe catheter insertion site for swelling and bleeding; a sandbag or pressure dressing may be placed over insertion site.
5. Assess vital signs and report significant changes from baseline.
9. Aortography
1. Injection of radiopaque contrast medium into the aorta to visualize the aorta, valve leaflets, and major vessels on a movie film.
2. Purpose: to determine and diagnose aortic valve incompetence, aneurysms of the ascending aorta, abnormalities of major branches of the aorta.
3. Nursing care: pretest
1. Confirm that informed consent has been signed.
2. Inform client that a dye will be injected and to report any dyspnea, numbness, or tingling.
4. Nursing care: posttest
1. Assess the puncture site frequently for bleeding or inflammation.
2. Assess peripheral pulses distal to the injection site every hour for 4-8 hours posttest.
10. Coronary arteriography
1. Visualization of coronary arteries by injection of radiopaque contrast dye and recording on a movie film.
2. Purpose: evaluation of heart disease and angina, location of areas of infarction and extent of lesions, ruling out coronary artery disease in clients with myocardial disease
3. Nursing care: same as for Aortography (above).

Goals

1. Fluid imbalance will be resolved, edema minimized.
2. Cardiac output will be improved.
3. Cardiopulmonary and peripheral tissue perfusion will be improved.
4. Adequate skin integrity will be maintained.
5. Activity tolerance will progressively increase.
6. Pain in the chest or in the affected extremity will be diminished.
7. Client will use effective coping techniques.
8. Client's level of fear and anxiety will be decreased.

Interventions


Cardiac Monitoring

1. The cardiac monitor provides continuous information regarding the cardiac rhythm and rate (ECG). Constant surveillance and understanding of the basic electrocardiographic system is imperative to avoid/treat arrhythmias (see Figure 4.9).
1. ECG strip: each small square represents 0.04 seconds, each large square 0.2 seconds.
2. P wave: produced by atrial depolarization; indicates SA node function.
3. P-R interval
1. Indicates atrioventricular conduction time or the time it takes an impulse to travel from the atria down and through the AV node
2. Measured from beginning of P wave to beginning of QRS complex
3. Normal: 0.12-0.20 seconds.
4. QRS complex
1. Indicates ventricular depolarization
2. Measured from onset of Q wave to end of S wave
3. Normal: 0.06-0.10 seconds
5. ST segment
1. Indicates time interval between complete depolarization of ventricles and repolarization of ventricles
2. Measured after QRS complex to beginning of T wave
6. T wave
1. Represents ventricular repolarization
2. Follows ST segment

FIGURE 4.9 A typical ECG; all beats appear as a similar pattern, equally spaced, and have three major units: P wave, QRS complex, and T wave.

Hemodynamic Monitoring (Swan-Ganz Catheter)

1. A multilumen catheter with a balloon tip that is advanced through the superior vena cava into the right atrium, right ventricle, and pulmonary artery. When it is wedged it is in the distal arterial branch of the pulmonary artery.
2. Purposes
1. Proximal port: measures right atrial pressure
2. Distal port
1. Measures pulmonary artery (PA) pressure (reflects left and right heart pressures) and pulmonary capillary wedge pressure (PCWP) (reflects left atrial and left ventricular end diastolic pressure).
2. Normal values: PA systolic and diastolic less than 20 mm Hg; PCWP 4-12 mm Hg
3. Balloon port: inflated with 1-2 cc air to obtain PCWP
4. Thermistor lumen: used to measure cardiac output if ordered
3. Nursing care
1. A sterile dry dressing should be applied to site and changed every 24 hours; inspect site daily and report signs of infection.
2. If catheter is inserted via an extremity, immobilize extremity to prevent catheter dislodgment or trauma.
3. Observe catheter site for leakage.
4. Ensure that balloon is deflated with a syringe attached, except when PCWP is read.
5. Continuously monitor PA systolic and diastolic pressures and report significant variations.
6. Irrigate line before each reading of PCWP.
7. Maintain client in same position for each reading.
8. Maintain pressure bag at 300 mm Hg.
9. Record PA systolic and diastolic readings at least every hour and PCWP as ordered, noting position of client.

Central Venous Pressure (CVP)

1. Obtained by inserting a catheter into the external jugular, antecubital, or femoral vein and threading it into the vena cava. The catheter is attached to an IV infusion and H₂O manometer by a three-way stopcock.
2. Purposes
1. Reveals right atrial pressure, reflecting alterations in the right ventricular pressure
2. Provides information concerning blood volume and adequacy of central venous return
3. Provides an IV route for drawing blood samples, administering fluids or medication, and possibly inserting a pacing catheter
3. Normal range is 4-10 cm H₂O; elevation indicates hypervolemia, decreased level indicates hypovolemia.
4. Nursing care
1. Ensure client is relaxed.
2. Maintain zero point of manometer always at level of right atrium (midaxillary line).
3. Determine patency of catheter by opening IV infusion line.
4. Turn stopcock to allow IV solution to run into manometer to a level of 10-20 cm above expected pressure reading.
5. Turn stopcock to allow IV solution to flow from manometer into catheter; fluid level in manometer fluctuates with respiration.
6. Stop ventilatory assistance during measurement of CVP.
7. After CVP reading, return stopcock to IV infusion position.
8. Record CVP reading and position of client.