1. The first heart sound (S1) is heard as the atrioventricular valves close and is heard loudest at the apex of the heart.

2. The second heart sound (S2) is heard when the semilunar valves close and is heard loudest at the base of the heart.

3. A third heart sound (S3) may be heard if ventricular wall compliance is decreased and structures in the ventricular wall vibrate; this can occur in conditions such as heart failure or valvular regurgitation. However, a third heart sound may be normal in individuals younger than

30 years.

4. A fourth heart sound (S4) may be heard on atrial systole if resistance to ventricular filling is present; this is an abnormal finding, and the causes include cardiac hypertrophy, disease, or injury to the ventricular wall.

1. The faster the heart rate, the less time the heart has for filling, and the cardiac output decreases.

2. An increase in heart rate increases oxygen consumption.

3. The normal sinus heart rate is 60 to 100 beats/minute.

4. Sinus tachycardia is a rate more than 100 beats/minute.

5. Sinus bradycardia is a rate less than 60 beats/minute. 

1. Baroreceptors, also called pressoreceptors, are located in the walls of the aortic arch and

carotid sinuses.

2. Baroreceptors are specialized nerve endings affected by changes in the arterial BP.

3. Increases in arterial pressure stimulate baroreceptors, and the heart rate and arterial pressure decrease.

4. Decreases in arterial pressure reduce stimulation of the baroreceptors and vasoconstriction occurs, as does an increase in heart rate.

5. Stretch receptors, located in the vena cava and the right atrium, respond to pressure changes that affect circulatory blood volume.

6. When the BP decreases as a result of hypovolemia, a sympathetic response occurs, causing an increased heart rate and blood vessel constriction; when the BP increases as a result of hypervolemia, an opposite effect occurs.

7. Antidiuretic hormone (vasopressin) influences BP indirectly by regulating vascular volume.

8. Increases in blood volume result in decreased antidiuretic hormone release, increasing diuresis, decreasing blood volume, and thus decreasing BP.

9. Decreases in blood volume result in increased antidiuretic hormone release; this promotes an increase in blood volume and therefore BP.

10. Renin, a potent vasoconstrictor, causes the BP to increase.

11. Renin converts angiotensinogen to angiotensin I; angiotensin I is then converted to angiotensin II in the lungs.

12. Angiotensin II stimulates the release of aldosterone, which promotes water and sodium retention by the kidneys; this action increases blood volume and BP.

1. Baroreceptors, also called pressoreceptors, are located in the walls of the aortic arch and

carotid sinuses.

2. Baroreceptors are specialized nerve endings affected by changes in the arterial BP.

3. Increases in arterial pressure stimulate baroreceptors, and the heart rate and arterial pressure decrease.

4. Decreases in arterial pressure reduce stimulation of the baroreceptors and vasoconstriction occurs, as does an increase in heart rate.

5. Stretch receptors, located in the vena cava and the right atrium, respond to pressure changes that affect circulatory blood volume.

6. When the BP decreases as a result of hypovolemia, a sympathetic response occurs, causing an increased heart rate and blood vessel constriction; when the BP increases as a result of hypervolemia, an opposite effect occurs.

7. Antidiuretic hormone (vasopressin) influences BP indirectly by regulating vascular volume.

8. Increases in blood volume result in decreased antidiuretic hormone release, increasing diuresis, decreasing blood volume, and thus decreasing BP.

9. Decreases in blood volume result in increased antidiuretic hormone release; this promotes an increase in blood volume and therefore BP.

10. Renin, a potent vasoconstrictor, causes the BP to increase.

11. Renin converts angiotensinogen to angiotensin I; angiotensin I is then converted to angiotensin II in the lungs.

12. Angiotensin II stimulates the release of aldosterone, which promotes water and sodium retention by the kidneys; this action increases blood volume and BP.

1. CK-MB (creatine kinase, myocardial muscle)

a. An elevation in value indicates myocardial damage.

b. An elevation occurs within hours and peaks at 18 hours following an acute ischemic attack.

c. Normal value is 0% to 5% of total; total CK is 26 to 174 units/L.

2. Troponin

a. Troponin is composed of three proteins—troponin C, cardiac troponin I, and cardiac troponin T.

b. Troponin I especially has a high affinity for myocardial injury; it rises within 3 hours and persists for up to 7 to 10 days.

c. Normal values are low, with troponin I being lower than 0.6 ng/mL and troponin T lower than 0.1 ng/mL; thus, any rise can indicate myocardial cell damage.

3. Myoglobin

a. Myoglobin is an oxygen-binding protein found in cardiac and skeletal muscle.

b. The level rises within 2 hours after cell death, with a rapid decline in the level after 7 hours.

1. Potassium

a. Hypokalemia causes increased cardiac electrical instability, ventricular dysrhythmias, and increased risk of digoxin toxicity.

b. In hypokalemia, the electrocardiogram shows flattening and inversion of the T wave, the appearance of a U wave, and ST depression.

c. Hyperkalemia causes asystole and ventricular dysrhythmias.

d. In hyperkalemia, the electrocardiogram may show tall peaked T waves, widened QRS complexes, prolonged PR intervals, or flat P waves.

2. Sodium

a. The serum sodium level decreases with the use of diuretics.

b. The serum sodium level decreases in heart failure, indicating water excess.

I. Calcium

1. Hypocalcemia can cause ventricular dysrhythmias, prolonged ST and QT intervals, and cardiac arrest.

2. Hypercalcemia can cause a shortened ST segment and widened T wave, atrioventricular block, tachycardia or bradycardia, digitalis hypersensitivity, and cardiac arrest.

J. Phosphorus level: Phosphorus levels should be interpreted with calcium levels because the kidneys retain or excrete one electrolyte in an inverse relationship to the other.

K. Magnesium

1. A low magnesium level can cause ventricular tachycardia and fibrillation.

2. Electrocardiographic changes that may be observed with hypomagnesemia include tall T waves and depressed ST segments.

3. A high magnesium level can cause muscle weakness, hypotension, and bradycardia.

4. Electrocardiographic changes that may be observed with hypermagnesemia include a prolonged PR interval and widened QRS complex.

Electrolyte and mineral imbalances can cause cardiac electrical instability that can result in life-threatening dysrhythmias.

An electrocardiogram (ECG) reflects the electrical activity of cardiac cells and records electrical activity at a speed of 25 mm/second.

An electrocardiographic strip consists of horizontal lines representing seconds and vertical lines representing voltage.

Each small square represents 0.04 second.

Each large square represents 0.20 second.

The P wave represents atrial depolarization.

The PR interval represents the time it takes an impulse to travel from the atria through the

atrioventricular node, bundle of His, and bundle branches to the Purkinje fibers.

Normal PR interval duration ranges from 0.12 to 0.2 second.

The PR interval is measured from the beginning of the P wave to the end of the PR segment.

The QRS complex represents ventricular depolarization.

Normal QRS complex duration ranges from 0.04 to 0.1 second.

The Q wave appears as the first negative deflection in the QRS complex and reflects initial ventricular septal depolarization.

The R wave is the first positive deflection in the QRS complex.

The S wave appears as the second negative deflection in the QRS complex.

The J point marks the end of the QRS complex and the beginning of the ST segment.

The QRS duration is measured from the end of the PR segment to the J point.

The ST segment represents early ventricular repolarization.

The T wave represents ventricular repolarization and ventricular diastole.

The U wave may follow the T wave.

A prominent U wave may indicate an electrolyte abnormality, such as hypokalemia.

The QT interval represents ventricular refractory time or the total time required for ventricular depolarization and repolarization.

The QT interval is measured from the beginning of the QRS complex to the end of the T wave.

The QT interval normally lasts 0.32 to 0.4 second but varies with the client’s heart rate, age, and gender.

1. Description

a. In this noninvasive test, the client wears a Holter monitor and an electrocardiographic tracing is recorded continuously over a period of 24 hours or more while the client performs his or her activities of daily living.

b. The Holter monitor identifies dysrhythmias if they occur and evaluates the effectiveness of antidysrhythmics or pacemaker therapy.

2. Interventions

a. Instruct the client to resume normal daily activities and to maintain a diary documenting activities and any symptoms that may develop for correlation with the electrocardiographic tracing.

b. Instruct the client to avoid tub baths or showers because they will interfere with the electrocardiographic recorder device.

1. Description

a. This noninvasive test studies the heart during activity and detects and evaluates coronary artery disease.

b. Treadmill testing is the most commonly used mode of stress testing.

c. Stress testing may be used with myocardial radionuclide testing (perfusion imaging), at which point the procedure becomes invasive because a radionuclide must be injected.

d. If the client is unable to tolerate exercise, an intravenous (IV) infusion of dipyridamole (Persantine), dobutamine hydrochloride, or adenosine (Adenocard) is given to dilate the coronary arteries and simulate the effect of exercise.

e. An informed consent is required if a radionuclide is to be injected.

2. Preprocedure interventions

a. Obtain an informed consent if required.

b. Provide adequate rest the night before the procedure.

c. Instruct the client to eat a light meal 1 to 2 hours before the procedure.

d. Instruct the client to avoid smoking, alcohol, and caffeine before the procedure.

e. Instruct the client to ask the HCP about taking prescribed medication on the day of the procedure; theophylline products are usually withheld 12 hours before the test and calcium channel blockers and β-blockers are usually withheld on the day of the test to allow the heart rate to increase during the stress portion of the test.

f. Instruct the client to wear nonconstrictive, comfortable clothing and supportive rubber-soled shoes for the exercise stress test.

g. Instruct the client to notify the HCP if any chest pain, dizziness, or shortness of breath occurs during the procedure.

3. Postprocedure interventions: Instruct the client to avoid taking a hot bath or shower for at least 1 to 2 hours.

1. Description

a. An invasive test involving insertion of a catheter into the heart and surrounding vessels

b. Obtains information about the structure and performance of the heart chambers and valves and the coronary circulation

2. Preprocedure interventions

a. Obtain informed consent.

b. Assess for allergies to seafood, iodine, or radiopaque dyes; if allergic, the client may be premedicated with antihistamines and corticosteroids to prevent a reaction.

c. Withhold solid food for 6 to 8 hours and liquids for 4 hours as prescribed to prevent vomiting and aspiration during the procedure.

d. Document the client’s height and weight because these data will be needed to determine the amount of dye to be administered.

e. Document baseline vital signs and note the quality and presence of peripheral pulses for postprocedure comparison.

f. Inform the client that a local anesthetic will be administered before catheter insertion.

g. Inform the client that he or she may feel fatigued because of the need to lie still and quiet on a hard table for up to 2 hours.

h. Inform the client that he or she may feel a fluttery feeling as the catheter passes through the heart, a flushed, warm feeling when the dye is injected, a desire to cough, and palpitations caused by heart irritability.

i. Prepare the insertion site by shaving and cleaning with an antiseptic solution if prescribed.

j. Administer preprocedure medications such as sedatives if prescribed.

k. Insert an IV line if prescribed.

If a client taking metformin (Glucophage) is scheduled to undergo a procedure requiring the administration of iodine dye, the metformin is withheld 24 hours prior because of the risk of lactic acidosis. The medication is not resumed until directed to do so by the HCP (usually 48 hours after the procedure or after renal function studies are done and the results are evaluated).

3. Postprocedure interventions

a. Monitor vital signs and cardiac rhythm for dysrhythmias at least every 30 minutes for 2 hours initially.

b. Assess for chest pain and, if dysrhythmias or chest pain occurs, notify the HCP.

c. Monitor peripheral pulses and the color, warmth, and sensation of the extremity distal to the insertion site at least every 30 minutes for 2 hours initially.

d. Notify the HCP if the client complains of numbness and tingling, if the extremity becomes cool, pale, or cyanotic, or if loss of the peripheral pulses occurs.

e. Monitor the pressure dressing for bleeding or hematoma formation.

f. Apply a sandbag or compression device (if prescribed) to the insertion site to provide additional pressure if required.

g. Monitor for bleeding; if bleeding occurs, apply manual pressure immediately and notify the HCP.

h. Monitor for hematoma; if a hematoma develops, notify the HCP.

i. Keep extremity extended for 4 to 6 hours, as prescribed, keeping the leg straight to prevent arterial occlusion.

j. Maintain strict bed rest for 6 to 12 hours, as prescribed; however, the client may turn from side to side. Do not elevate the head of the bed more than 15 degrees.

k. If the antecubital vessel was used, immobilize the arm with an armboard.

l. Encourage fluid intake, if not contraindicated, to promote renal excretion of the dye and to replace fluid loss caused by the osmotic diuretic effect of the dye.

m. Monitor for nausea, vomiting, rash, or other signs of hypersensitivity to the dye.

1. Description

a. An invasive, nonsurgical technique in which one or more arteries is (are) dilated with a balloon catheter to open the vessel lumen and improve arterial blood flow

b. PTCA may be used for clients with an evolving myocardial infarction (MI), alone or in combination with medications to achieve reperfusion.

c. The client can experience reocclusion after the procedure; thus, the procedure may need to be repeated.

d. Complications can include arterial dissection or rupture, embolization of plaque fragments, spasm, and acute MI.

e. Firm commitment is needed on the client’s part to stop smoking, adhere to diet restrictions, lose weight, alter his or her exercise pattern, and stop any behaviors that lead to progression of artery occlusion.

2. Preprocedure interventions

a. Maintain NPO status after midnight.

b. Obtain informed consent, allergy assessment to iodine, and withhold metformin (as for cardiac catheterization).

c. Prepare the groin area with antiseptic soap and shave per institutional procedure and as prescribed.

d. Assess baseline vital signs and peripheral pulses.

e. Instruct the client that chest pain may occur during balloon inflation and to report it if it does occur.

3. Postprocedure interventions

a. Monitor vital signs closely.

b. Assess distal pulses in both extremities.

c. Maintain bed rest as prescribed, keeping the limb straight for 6 to 8 hours.

d. Administer anticoagulants such as intravenous heparin and antiplatelet agents as prescribed to prevent thrombus formation.

e. Intravenous nitroglycerin may be prescribed to prevent coronary artery vasospasm.

f. Encourage fluids, if not contraindicated, to enhance renal excretion of dye.

g. Instruct the client in the administration of nitrates, calcium channel blockers, antiplatelet agents, and anticoagulants as prescribed.

h. Instruct the client to take acetylsalicylic acid (aspirin) daily permanently if prescribed.

i. Assist the client with planning lifestyle modifications.

1. Description

a. Coronary artery stents (bare metal or drug-eluting) are used in conjunction with PTCA to provide a supportive scaffold to eliminate the risk of acute coronary vessel closure and to improve long-term patency of the vessel.

b. A balloon catheter bearing the stent is inserted into the coronary artery and positioned at the site of occlusion; balloon inflation deploys the stent.

c. When placed in the coronary artery, the stent reopens the blocked artery.

2. Preprocedure and postprocedure interventions

a. Care is similar to that for PTCA.

b. Acute thrombosis is a major concern following the procedure; the client is placed on antiplatelet therapy such as clopidogrel (Plavix) and acetylsalicylic acid (aspirin) for several months following the procedure. Length of time of antiplatelet therapy is determined

by the type of stent that has been deployed.

c. Monitor for complications of the procedure such as stent migration or occlusion, coronary artery dissection, and bleeding resulting from anticoagulation.

1. Description

a. Performed to increase arterial blood flow to the affected limb

b. Inflow procedures involve bypassing the arterial occlusion above the superficial femoral arteries

c. Outflow procedures involve bypassing the arterial occlusions at or below the superficial femoral arteries.

d. Graft material is sutured above and below the occlusion to facilitate blood flow around the occlusion.

2. Preoperative interventions

a. Assess baseline vital signs and peripheral pulses.

b. Insert an IV line and urinary catheter as prescribed.

c. Maintain a central venous catheter and/or arterial line if inserted.

3. Postoperative interventions

a. Assess vital signs.

b. Monitor the BP and notify the HCP if changes occur.

c. Monitor for hypotension, which may indicate hypovolemia.

d. Monitor for hypertension, which may place stress on the graft and cause clot formation.

e. Maintain bed rest for 24 hours as prescribed.

f. Instruct the client to keep the affected extremity straight, limit movement, and avoid bending the knee and hip.

g. Monitor for warmth, redness, and edema, which often are expected outcomes because of increased blood flow.

h. Monitor for graft occlusion, which often occurs within the first 24 hours.

i. Assess peripheral pulses and for adverse changes in color and temperature of the extremity.

j. Encourage coughing, deep breathing, and the use of incentive spirometry.

k. Maintain NPO status, with progression to clear liquids as prescribed.

l. Use strict aseptic technique when in contact with the incision.

m. Assess the incision for drainage, warmth, or swelling.

n. Monitor for excessive bleeding (a small amount of bloody drainage is expected).

o. Monitor the area over the graft for hardness, tenderness, and warmth, which may indicate infection; if this occurs, notify the HCP immediately.

p. Instruct the client about proper foot care and measures to prevent ulcer formation.

q. Instruct the client to take medications as prescribed.

r. Instruct the client in how to care for the incision.

s. Assist the client in modifying lifestyle to prevent further plaque formation.

Following arterial revascularization, monitor for a sharp increase in pain because pain is frequently the first indicator of postoperative graft occlusion. If signs of graft occlusion occur, notify the HCP immediately.

1. Description

a. The occluded coronary arteries are bypassed with the client’s own venous or arterial blood vessels.

b. The saphenous vein, internal mammary artery, or other arteries may be used to bypass lesions in the coronary arteries.

c. Coronary artery bypass grafting is performed when the client does not respond to medical management of coronary artery disease or when vessels are severely occluded.

2. Preoperative interventions

a. Familiarize the client and family with the cardiac surgical critical care unit.

b. Inform the client to expect a sternal incision, possible arm or leg incision(s), one or two chest tubes, a Foley catheter, and several IV fluid catheters.

c. Inform the client that an endotracheal tube will be in place and that he or she will be unable to speak.

d. Advise the client that he or she will be on mechanical ventilation and to breathe with the ventilator and not fight it.

e. Instruct the client that postoperative pain is expected and that pain medication will be available.

f. Instruct the client in how to splint the chest incision, cough and deep-breathe, use the incentive spirometer, and perform arm and leg exercises.

g. Encourage the client and family to discuss anxieties and fears related to surgery.

h. Note that prescribed medications may be discontinued preoperatively (usually, diuretics 2 to 3 days before surgery, digoxin 12 hours before surgery, and aspirin and anticoagulants 1 week before surgery).

i. Administer medications as prescribed, which may include potassium chloride, antihypertensives, antidysrhythmics, and antibiotics.

3. Cardiac surgical unit postoperative interventions

a. Mechanical ventilation is maintained for 6 to 24 hours as prescribed.

b. The heart rate and rhythm, pulmonary artery and arterial pressures, urinary output, and

neurological status are monitored closely.

c. Mediastinal and pleural chest tubes to the water seal drainage system with prescribed suction are present; drainage exceeding 100 to 150 mL/hour is reported.

d. Epicardial pacing wires are covered with sterile caps or connected to a temporary pacemaker generator; all equipment in use must be properly grounded to prevent microshock.

e. Fluid and electrolyte balance is monitored closely; fluids are usually restricted to 1500 to 2000 mL because the client usually has edema.

f. The blood pressure is monitored closely because hypotension can cause collapse of a vein graft; hypertension can cause increased pressure promoting leakage from the suture line, causing bleeding.

g. Temperature is monitored and rewarming procedures are initiated using warm or thermal blankets if the temperature drops below 96.8° F; rewarm the client no faster than 1.8° F/hour to prevent shivering, and discontinue rewarming procedures when the temperature approaches 98.6° F.

h. Potassium is administered intravenously as prescribed to maintain the potassium level between 4 and 5 mEq/L to prevent dysrhythmias.

i. The client is monitored for signs of cardiac tamponade, which will include sudden cessation of previously heavy mediastinal drainage, jugular vein distention with clear lung sounds, equalization of right atrial pressure and pulmonary artery wedge pressure, and pulsus paradoxus.

j. Pain is monitored, differentiating sternotomy pain from anginal pain, which would indicate graft failure.

4. Alarm safety and alarm fatigue: Refer to Chapter 58.

5. Transfer of the client from the cardiac surgical unit

a. Monitor vital signs, level of consciousness, and peripheral perfusion.

b. Monitor for dysrhythmias.

c. Auscultate lungs and assess respiratory status.

d. Encourage the client to splint the incision, cough, deep-breathe, and use the incentive spirometer to raise secretions and prevent atelectasis.

e. Monitor temperature and white blood cell count, which, if elevated after 3 to 4 days, indicate infection.

f. Provide adequate fluids and hydration as prescribed to liquefy secretions.

g. Assess suture line and chest tube insertion sites for redness, purulent discharge, and signs of infection.

h. Assess sternal suture line for instability, which may indicate an infection.

i. Guide the client to gradually resume activity.

j. Assess the client for tachycardia, postural (orthostatic) hypotension, and fatigue before, during, and after activity.

k. Discontinue activities if the BP drops more than 10 to 20 mm Hg or if the pulse increases more than 10 beats/minute.

l. Monitor episodes of pain closely.

■ Progressive return to activities at home

■ Limiting of pushing or pulling activities for 6 weeks following discharge

■ Maintenance of incisional care and recording signs of redness, swelling, or drainage

■ Sternotomy incision heals in about 6 to 8 weeks

■ Avoidance of crossing legs; wearing elastic hose as prescribed until edema subsides, and elevating the surgical limb (if used to obtain the graft) when sitting in a chair

■ Use of prescribed medications

■ Dietary measures, including the avoidance of saturated fats and cholesterol and the use of salt

■ Resumption of sexual intercourse on the advice of the HCP after exercise tolerance is assessed (usually, if client can walk one block or climb two flights of stairs without symptoms, he or she can resume sexual activity safely)

1. A donor heart from an individual with a comparable body weight and ABO compatibility is transplanted into a recipient within less than 6 hours of procurement.

2. The surgeon removes the diseased heart, leaving the posterior portion of the atria to serve as an anchor for the new heart.

3. Because a remnant of the client’s atria remains, two unrelated P waves are noted on the electrocardiogram.

4. The transplanted heart is denervated and unresponsive to vagal stimulation; because the heart is denervated, clients do not experience angina.

5. Symptoms of heart rejection include hypotension, dysrhythmias, weakness, fatigue, and dizziness.

6. Endomyocardial biopsies are performed at regular scheduled intervals and whenever rejection is suspected.

7. The client requires lifetime immunosuppressive therapy.

8. Strict aseptic technique and vigilant hand washing must be maintained when caring for the posttransplantation client because of increased risk for infection from immunosuppression.

9. The heart rate approximates 100 beats/minute and responds slowly to exercise or stress with regard to increases in heart rate, contractility, and cardiac output.

1. Description

a. Atrial and ventricular rhythms are regular.

b. Atrial and ventricular rates are less than 60 beats/minute.

c. PR interval and QRS width are within normal limits.

d. Treatment may be necessary if the client is symptomatic (signs of decreased cardiac output).

e. Note that a low heart rate may be normal for some individuals.

2. Interventions

a. Attempt to determine the cause of sinus bradycardia; if a medication is suspected of causing the bradycardia, withhold the medication and notify the HCP.

b. Administer oxygen as prescribed.

c. Administer atropine sulfate as prescribed to increase the heart rate to 60 beats/minute.

d. Be prepared to apply a noninvasive (transcutaneous) pacemaker initially as prescribed if the atropine sulfate does not increase the heart rate sufficiently.

e. Avoid additional doses of atropine sulfate because this will induce tachycardia.

f. Monitor for hypotension and administer fluids intravenously as prescribed.

g. Depending on the cause of the bradycardia, the client may need a permanent pacemaker.

1. Description

a. Atrial and ventricular rates are 100 to 180 beats/minute.

b. Atrial and ventricular rhythms are regular.

c. PR interval and QRS width are within normal limits.

2. Interventions

a. Identify the cause of the tachycardia.

b. Decrease the heart rate to normal by treating the underlying cause. 

1. Description

a. Multiple rapid impulses from many foci depolarize in the atria in a totally disorganized manner at a rate of 350 to 600 times/minute.

b. The atria quiver, which can lead to the formation of thrombi.

c. Usually no definitive P wave can be observed, only fibrillatory waves before each QRS.

2. Interventions

a. Administer oxygen.

b. Administer anticoagulants as prescribed because of the risk of emboli.

c. Administer cardiac medications as prescribed to control the ventricular rhythm and assist in the maintenance of cardiac output.

d. Prepare the client for cardioversion as prescribed.

e. Instruct the client in the use of medications as prescribed to control the dysrhythmia.

1. Description

a. Early ventricular complexes result from increased irritability of the ventricles.

b. PVCs frequently occur in repetitive patterns such as bigeminy, trigeminy, and quadrigeminy.

c. The QRS complexes may be unifocal or multifocal.

2. Interventions

a. Identify the cause and treat on the basis of the cause.

b. Evaluate oxygen saturation to assess for hypoxemia, which can cause PVCs.

c. Administer oxygen as prescribed.

d. Evaluate electrolytes, particularly the potassium level, because hypokalemia can cause PVCs.

e. Oxygen and amiodarone (Cordarone) may be prescribed in the case of acute myocardial ischemia or myocardial infarction (MI).

For the client experiencing PVCs, notify the HCP if the client complains of chest pain or if the PVCs increase in frequency, are multifocal, occur on the T wave (R on T), or occur in runs of ventricular tachycardia.

1. Description

a. Ventricular tachycardia occurs because of a repetitive firing of an irritable ventricular ectopic focus at a rate of 140 to 250 beats/minute or more.

b. Ventricular tachycardia may present as a paroxysm of three self-limiting beats or more or may be a sustained rhythm.

c. Ventricular tachycardia can lead to cardiac arrest.

2. Stable client with sustained VT (with pulse and no signs or symptoms of decreased cardiac output)

a. Administer oxygen as prescribed.

b. Administer antidysrhythmics as prescribed.

3. Unstable client with VT (with pulse and signs and symptoms of decreased cardiac output)

a. Administer oxygen and antidysrhythmic therapy as prescribed.

b. Prepare for synchronized cardioversion if the client is unstable.

c. The HCP may attempt cough cardiopulmonary resuscitation (CPR) by asking the client to cough hard every 1 to 3 seconds.

4. Pulseless client with ventricular tachycardia: defibrillation and CPR

1. Description

a. Impulses from many irritable foci in the ventricles fire in a totally disorganized manner.

b. VF is a chaotic rapid rhythm in which the ventricles quiver and there is no cardiac output.

c. VF is fatal if not successfully terminated within 3 to 5 minutes.

d. Client lacks a pulse, BP, respirations, and heart sounds.

2. Interventions

a. Initiate CPR until a defibrillator is available.

b. The client is defibrillated immediately with 120 to 200 joules (biphasic defibrillator) or 360 joules (monophasic defibrillator).

c. CPR is continued for 2 minutes and the cardiac rhythm is reassessed to determine need for further countershock.

d. Administer oxygen as prescribed.

e. Administer antidysrhythmic therapy as prescribed.

1. Description: Vagal maneuvers induce vagal stimulation of the cardiac conduction system and are used to terminate supraventricular tachydysrhythmias.

2. Carotid sinus massage

a. The HCP instructs the client to turn the head away from the side to be massaged.

b. The HCP massages over one carotid artery for a few seconds to determine whether a change in cardiac rhythm occurs.

c. The client should be on a cardiac monitor; an electrocardiographic rhythm strip before, during, and after the procedure should be documented on the chart.

d. Have a defibrillator and resuscitative equipment available.

e. Monitor vital signs, cardiac rhythm, and level of consciousness following the procedure.

a. The HCP instructs the client to bear down or induces a gag reflex in the client to stimulate a vagal response

b. Monitor the heart rate, rhythm, and BP.

c. Observe the cardiac monitor for a change in rhythm.

d. Record an electrocardiographic rhythm strip before, during, and after the procedure.

e. Provide an emesis basin if the gag reflex is stimulated, and initiate precautions to prevent aspiration.

f. Have a defibrillator and resuscitative equipment available.

1. Description

a. Cardioversion is synchronized countershock to convert an undesirable rhythm to a stable rhythm.

b. Cardioversion can be an elective procedure performed by the HCP for stable tachydysrhythmias resistant to medical therapies or an emergent procedure for hemodynamically unstable ventricular or supraventricular tachydysrhythmias.

c. A lower amount of energy is used than with defibrillation.

d. The defibrillator is synchronized to the client’s R wave to avoid discharging the shock during the vulnerable period (T wave).

e. If the defibrillator is not synchronized, it could discharge on the T wave and cause VF.

2. Preprocedure interventions

a. Obtain an informed consent if an elective procedure.

b. Administer sedation as prescribed.

c. If an elective procedure, hold digoxin (Lanoxin) 48 hours preprocedure as prescribed to prevent postcardioversion ventricular irritability.

d. If an elective procedure for atrial fibrillation or atrial flutter, the client should receive anticoagulant therapy for 4 to 6 weeks preprocedure and a transesophageal echocardiogram (TEE) should be performed to rule out clots in the atria prior to the procedure.

3. During the procedure

a. Ensure that the skin is clean and dry in the area where the electrode paddles/hands off pads will be placed.

b. Stop the oxygen during the procedure to avoid the hazard of fire.

c. Be sure that no one is touching the bed or the client when delivering the countershock.

4. Postprocedure interventions

a. Priority assessment includes ability of the client to maintain the airway and breathing.

b. Resume oxygen administration as prescribed.

c. Assess vital signs.

d. Assess level of consciousness.

e. Monitor cardiac rhythm.

f. Monitor for indications of successful response, such as conversion to sinus rhythm, strong peripheral pulses, an adequate BP, and adequate urine output.

g. Assess the skin on the chest for evidence of burns from the edges of the paddles/pads.

1. Description

a. An ICD monitors cardiac rhythm and detects and terminates episodes of VT and VF.

b. The ICD senses VT or VF and delivers 25 to 30 J up to four times, if necessary.

c. An ICD is used in clients with episodes of spontaneous sustained VT or VF unrelated to an MI or in clients whose medication therapy has been unsuccessful in controlling lifethreatening dysrhythmias.

d. Transvenous electrode leads are placed in the right atrium and ventricle in contact with theendocardium; leads are used for sensing, pacing, and delivery of cardioversion ordefibrillation.

e. The generator is most commonly implanted in the left pectoral region.

2. Client education

a. Instruct the client in the basic functions of the ICD.

b. Know the rate cutoff of the ICD and the number of consecutive shocks that it will deliver.

c. Wear loose-fitting clothing over the ICD generator site.

d. Avoid contact sports to prevent trauma to the ICD generator and lead wires.

e. Report any fever, redness, swelling, or drainage from the insertion site.

f. Report symptoms of fainting, nausea, weakness, blackouts, and rapid pulse rates to the HCP.

g. During shock discharge, the client may feel faint or short of breath.

h. Instruct the client to sit or lie down if he or she feels a shock and to notify the HCP.

i. Advise the client to maintain a log of the date, time, and activity preceding the shock, the symptoms preceding the shock, and postshock sensations.

j. Instruct the client and family in how to access the emergency medical system.

k. Encourage the family to learn CPR.

l. Instruct the client to avoid electromagnetic fields directly over the ICD because they can inactivate the device.

m. Instruct the client to move away from the magnetic field immediately if beeping tones are heard, and to notify the HCP.

n. Keep an ICD identification card in the wallet and obtain and wear a Medic-Alert bracelet.

o. Inform all health care providers that an ICD has been inserted; certain diagnostic tests, such as an MRI, and procedures using diathermy or electrocautery interfere with ICD function.

p. Advise the client of restrictions on activities such as driving and operating dangerous equipment.

A. Description: Temporary or permanent device that provides electrical stimulation and maintains the heart rate when the client’s intrinsic pacemaker fails to provide a perfusing rhythm

B. Settings

1. A synchronous (demand) pacemaker senses the client’s rhythm and paces only if the client’s intrinsic rate falls below the set pacemaker rate for stimulating depolarization.

2. An asynchronous (fixed rate) pacemaker paces at a preset rate regardless of the client’s intrinsic rhythm and is used when the client is asystolic or profoundly bradycardic.

3. Overdrive pacing suppresses the underlying rhythm in tachydysrhythmias so that the sinus node will regain control of the heart.

C. Spikes

1. When a pacing stimulus is delivered to the heart, a spike (straight vertical line) is seen on the monitor or electrocardiogram strip.

2. Spikes precede the chamber being paced; a spike preceding a P wave indicates that the atrium is paced and a spike preceding the QRS indicates that the ventricle is being paced.

3. An atrial spike followed by a P wave indicates atrial depolarization and a ventricular spike followed by a QRS complex represents ventricular depolarization; this is referred to as capture.

4. If the electrode is in the atrium, the spike is before the P wave; if the electrode is in the ventricle, the spike is before the QRS complex.

D. Temporary pacemakers

1. Noninvasive transcutaneous pacing

a. Noninvasive transcutaneous pacing is used as a temporary emergency measure in the profoundly bradycardic or asystolic client until invasive pacing can be initiated.

b. Large electrode pads are placed on the client’s chest and back and connected to an external pulse generator.

c. Wash the skin with soap and water before applying electrodes.

d. It is not necessary to shave the hair or apply alcohol or tinctures to the skin.

e. Place the posterior electrode between the spine and left scapula behind the heart, avoiding placement over bone

f. Place the anterior electrode between V2 and V5 positions over the heart (see Fig. 60-11).

g. Do not place the anterior electrode over female breast tissue; rather, displace breast tissue and place under the breast.

h. Do not take the pulse or BP on the left side; the results will not be accurate because of the muscle twitching and electrical current.

i. Ensure that electrodes are in good contact with the skin.

j. Set pacing rate as prescribed; establish stimulation threshold to ensure capture.

k. If loss of capture occurs, assess the skin contact of the electrodes and increase the current until capture is regained.

l. Evaluate the client for discomfort from cutaneous and muscle stimulation; administer analgesics as needed.

2. Invasive transvenous pacing

a. Pacing lead wire is placed through the antecubital, femoral, jugular, or subclavian vein into the right atrium or right ventricle; so that it is in direct contact with the endocardium.

b. Monitor cardiac rhythm continuously.

c. Monitor vital signs.

d. Monitor the pacemaker insertion site.

e. Restrict client movement to prevent lead wire displacement.

3. Invasive epicardial pacing—applied by using a transthoracic approach; the lead wires are threaded loosely on the epicardial surface of the heart after cardiac surgery.

4. Reducing the risk of microshock

a. Use only inspected and approved equipment.

b. Insulate the exposed portion of wires with plastic or rubber material (fingers of rubber gloves) when wires are not attached to the pulse generator; cover with nonconductive tape.

c. Ground all electrical equipment, using a three-pronged plug.

d. Wear gloves when handling exposed wires.

e. Keep dressings dry.

E. Permanent pacemakers

1. Pulse generator is internal and surgically implanted in a subcutaneous pocket below the clavicle.

2. The leads are passed transvenously via the cephalic or subclavian vein to the endocardium on the right side of the heart; postoperatively, limitation of arm movement on the operative side is required to prevent lead wire dislodgement.

3. Permanent pacemakers may be single-chambered, in which the lead wire is placed in the chamber to be paced, or dual-chambered, with lead wires placed in both the right atrium and ventricle.

4. Biventricular pacing of the ventricles allows for synchronized depolarization and is used for moderate to severe heart failure to improve cardiac output.

5. A permanent pacemaker is programmed when inserted and can be reprogrammed if necessary by noninvasive transmission from an external programmer to the implanted generator.

6. Pacemakers may be powered by a lithium battery with an average life span of 10 years, nuclear-powered with a life span of 20 years or longer, or designed to be recharged externally.

7. Pacemaker function can be checked in the HCP’s office or clinic by a pacemaker interrogator or programmer or from home, using a special telephone transmitter device.

8. The client may be provided with a device placed over the pacemaker battery generator with an attachment to the telephone; the heart rate then can be transmitted to the clinic.

Instruct the client about the pacemaker, including the programmed rate.

Instruct the client in the signs of battery failure and when to notify the health care provider (HCP).

Instruct the client to report any fever, redness, swelling, or drainage from the insertion site.

Report signs of dizziness, weakness or fatigue, swelling of the ankles or legs, chest pain, or shortness of breath.

Keep a pacemaker identification card in the wallet and obtain and wear a Medic-Alert bracelet.

Instruct the client in how to take the pulse, to take the pulse daily, and to maintain a diary of pulse rates.

Wear loose-fitting clothing over the pulse generator site.

Avoid contact sports.

Inform all health care providers that a pacemaker has been inserted.

Instruct the client to inform airport security that he or she has a pacemaker because the pacemaker may set off the security detector.

Instruct the client that most electrical appliances can be used without any interference with the functioning of the pacemaker; however, advise the client not to operate electrical appliances directly over the pacemaker site.

Avoid transmitter towers and antitheft devices in stores.

Instruct the client that if any unusual feelings occur when near any electrical devices to move 5 to 10 feet away and check the pulse.

Instruct the client about the methods of monitoring the function of the device.

Emphasize the importance of follow-up with the HCP.

Use cell phones on the side opposite the pacemaker.

A. Description

1. Coronary artery disease is a narrowing or obstruction of one or more coronary arteries as a result of atherosclerosis, which is an accumulation of lipid-containing plaque in the arteries

2. The disease causes decreased perfusion of myocardial tissue and inadequate myocardial oxygen supply leading to hypertension, angina, dysrhythmias, MI, heart failure, and death.

3. Collateral circulation, more than one artery supplying a muscle with blood, is normally present in the coronary arteries, especially in older persons.

4. The development of collateral circulation takes time and develops when chronic ischemia occurs to meet the metabolic demands; therefore an occlusion of a coronary artery in a younger individual is more likely to be lethal than in an older individual.

5. Symptoms occur when the coronary artery is occluded to the point that inadequate blood supply to the muscle occurs, causing ischemia.

6. Coronary artery narrowing is significant if the lumen diameter of the left main artery is reduced at least 50%, or if any major branch is reduced at least 75%.

7. The goal of treatment is to alter the atherosclerotic progression.

B. Assessment

1. Possibly normal findings during asymptomatic periods

2. Chest pain

3. Palpitations

4. Dyspnea

5. Syncope

6. Cough or hemoptysis

7. Excessive fatigue

C. Diagnostic studies

1. Electrocardiography

a. When blood flow is reduced and ischemia occurs, ST-segment depression, T-wave inversion, or both is noted; the ST segment returns to normal when the blood flow returns.

b. With infarction, cell injury results in ST-segment elevation, followed by T-wave inversion and an abnormal Q wave.

2. Cardiac catheterization

a. Cardiac catheterization provides the most definitive source for diagnosis.

b. Cardiac catheterization shows the presence of atherosclerotic lesions.

3. Blood lipid levels

a. Blood lipid levels may be elevated.

b. Cholesterol-lowering medications may be prescribed to reduce the development of atherosclerotic plaques.

D. Interventions

1. Instruct the client regarding the purpose of diagnostic medical and surgical procedures and preprocedure and postprocedure expectations.

2. Assist the client to identify risk factors that can be modified.

3. Assist the client to set goals to promote lifestyle changes to reduce the impact of risk factors.

4. Assist the client to identify barriers to compliance with the therapeutic plan and to identify methods to overcome barriers.

5. Instruct the client regarding a low-calorie, low-sodium, low-cholesterol, and low-fat diet, with an increase in dietary fiber.

6. Stress to the client that dietary changes are not temporary and must be maintained for life; instruct the client regarding prescribed medications.

7. Provide community resources to the client regarding exercise, smoking cessation, and stress reduction as appropriate.

E. Surgical procedures

1. PTCA to compress the plaque against the walls of the artery and dilate the vessel

2. Laser angioplasty to vaporize the plaque

3. Atherectomy to remove the plaque from the artery

4. Vascular stent (bare metal or drug-eluting) to prevent the artery from closing and to prevent restenosis

5. Coronary artery bypass grafting to improve blood flow to the myocardial tissue at risk for ischemia or infarction because of the occluded artery

F. Medications

1. Nitrates to dilate the coronary arteries and decrease preload and afterload

2. Calcium channel blockers to dilate coronary arteries and reduce vasospasm

3. Cholesterol-lowering medications to reduce the development of atherosclerotic plaques

4. β-Blockers to reduce the BP in individuals who are hypertensive

A. Description

1. Angina is chest pain resulting from myocardial ischemia caused by inadequate myocardial blood and oxygen supply.

2. Angina is caused by an imbalance between oxygen supply and demand.

3. Causes include obstruction of coronary blood flow resulting from atherosclerosis, coronary artery spasm, or conditions increasing myocardial oxygen consumption.

The goal of treatment for angina is to provide relief from the acute attack, correct the imbalance between myocardial oxygen supply and demand, and prevent the progression of the disease and further attacks to reduce the risk of MI.

B. Patterns of angina

1. Stable angina

a. Also called exertional angina

b. Occurs with activities that involve exertion or emotional stress; relieved with rest or nitroglycerin

c. Usually has a stable pattern of onset, duration, severity, and relieving factors

2. Unstable angina

a. Also called preinfarction angina

b. Occurs with an unpredictable degree of exertion or emotion and increases in occurrence, duration, and severity over time

c. Pain may not be relieved with nitroglycerin.

3. Variant angina

a. Also called Prinzmetal’s or vasospastic angina

b. Results from coronary artery spasm

c. May occur at rest

d. Attacks may be associated with ST- segment elevation noted on the electrocardiogram (ECG).

4. Intractable angina is a chronic, incapacitating angina unresponsive to interventions.

5. Preinfarction angina

a. Associated with acute coronary insufficiency

b. Lasts longer than 15 minutes

c. Symptom of worsening cardiac ischemia

d. Characterized by chest pain that occurs days to weeks before an MI

C. Assessment

1. Pain

a. Pain can develop slowly or quickly.

b. Pain usually is described as mild or moderate.

c. Substernal, crushing, squeezing pain may occur.

d. Pain may radiate to the shoulders, arms, jaw, neck, or back.

e. Pain intensity is unaffected by inspiration and expiration.

f. Pain usually lasts less than 5 minutes; however, pain can last up to 15 to 20 minutes.

g. Pain is relieved by nitroglycerin or rest.

2. Dyspnea

3. Pallor

4. Sweating

5. Palpitations and tachycardia

6. Dizziness and syncope

7. Hypertension

8. Digestive disturbances

D. Diagnostic studies

1. Electrocardiography: Readings are normal during rest, with ST depression, or T-wave inversion during an episode of pain.

2. Stress testing: Chest pain or changes in the electrocardiogram or vital signs during testing may indicate ischemia.

3. Cardiac enzyme and troponin levels: Findings are normal in angina.

4. Cardiac catheterization: Catheterization provides a definitive diagnosis by providing information about the patency of the coronary arteries.

E. Interventions

1. Immediate management

a. Assess pain; institute pain relief measures.

b. Administer oxygen by nasal cannula as prescribed.

c. Assess vital signs and provide continuous cardiac monitoring and nitroglycerin as prescribed to dilate the coronary arteries, reduce the oxygen requirements of the myocardium, and relieve the chest pain.

d. Ensure bed rest is maintained, place the client in semi-Fowler’s position, and stay with the

client.

e. Obtain a 12-lead ECG.

f. Establish an IV access route.

2. Following the acute episode

a. Instruct the client regarding the purpose of diagnostic medical and surgical procedures and the preprocedure and postprocedure expectations.

b. Assist the client to identify angina-precipitating events.

c. Instruct the client to stop activity and rest if chest pain occurs and to take nitroglycerin as prescribed.

d. Instruct the client to seek medical attention if pain persists.

e. Instruct the client regarding prescribed medications.

f. Provide diet instructions to the client, stressing that dietary changes are not temporary and must be maintained for life.

g. Assist the client to identify risk factors that can be modified.

h. Assist the client to set goals that will promote changes in lifestyle to reduce the impact of risk factors.

i. Assist the client to identify barriers to compliance with the therapeutic plan and to identify methods to overcome barriers.

j. Provide community resources to the client regarding exercise, smoking cessation, and stress reduction.

F. Surgical procedures: See Section VII, Coronary Artery Disease.

G. Medications

1. See Section VII, Coronary Artery Disease.

2. Antiplatelet therapy may be prescribed; it inhibits platelet aggregation and reduces the risk of developing an acute MI.

A. Description

1. Myocardial infarction occurs when myocardial tissue is abruptly and severely deprived of oxygen.

2. Ischemia can lead to necrosis of myocardial tissue if blood flow is not restored.

3. Infarction does not occur instantly but evolves over several hours.

4. Obvious physical changes do not occur in the heart until 6 hours after the infarction, when the infarcted area appears blue and swollen.

5. After 48 hours, the infarct turns gray, with yellow streaks developing as neutrophils invade the tissue.

6. By 8 to 10 days after infarction, granulation tissue forms.

7. Over 2 to 3 months, the necrotic area develops into a scar; scar tissue permanently changes the size and shape of the entire left ventricle.

8. Not all clients experience the classic symptoms of an MI.

9. Women may experience atypical discomfort, shortness of breath, or fatigue and often present with NSTEMI (non–ST-elevation myocardial infarction) or T-wave inversion.

10. An older client may experience shortness of breath, pulmonary edema, dizziness, altered mental status, or a dysrhythmia.

B. Location of MI (see Fig. 60-1)

1. Obstruction of the left anterior descending artery results in anterior wall or septal MI, or both.

2. Obstruction of the circumflex artery results in posterior wall MI or lateral wall MI.

3. Obstruction of the right coronary artery results in inferior wall MI.

C. Risk factors

1. Atherosclerosis

2. Coronary artery disease

3. Elevated cholesterol levels

4. Smoking

5. Hypertension

6. Obesity

7. Physical inactivity

8. Impaired glucose tolerance

9. Stress

D. Diagnostic studies

1. Troponin level

a. Level rises within 3 hours.

b. Level remains elevated for up to 7 to 10 days.

2. Total creatine kinase level

a. Level rises within 6 hours after the onset of chest pain.

b. Level peaks within 18 hours after damage and death of cardiac tissue.

3. CK-MB isoenzyme

a. Peak elevation occurs 18 hours after the onset of chest pain.

b. Level returns to normal 48 to 72 hours later.

4. Myoglobin: Level rises within 2 hours after cell death, with a rapid decline in the level after 7 hours.

5. White blood cell count: An elevated white blood cell count up to 20,000 cells/mm3 appears on the second day following the MI and lasts up to 1 week.

6. Electrocardiogram

a. Electrocardiogram shows either ST-elevation MI (STEMI), T-wave inversion, or non–STelevation MI (NSTEMI); an abnormal Q wave may also present.

b. Hours to days after the MI, ST- and T-wave changes will return to normal but the Q-wave changes usually remain permanently.

7. Diagnostic tests following the acute stage

a. Exercise tolerance test or stress test may be prescribed to assess for electrocardiographic changes and ischemia and to evaluate for medical therapy or identify clients who may need invasive therapy.

b. Thallium scans may be prescribed to assess for ischemia or necrotic muscle tissue.

c. Multigated cardiac blood pool imaging scans may be used to evaluate left ventricular function.

d. Cardiac catheterization is performed to determine the extent and location of obstructions of the coronary arteries.

E. Assessment

1. Pain

a. Client may experience crushing substernal pain.

b. Pain may radiate to the jaw, back, and left arm.

c. Pain may occur without cause, primarily early in the morning.

d. Pain is unrelieved by rest or nitroglycerin and is relieved only by opioids.

e. Pain lasts 30 minutes or longer.

2. Nausea and vomiting

3. Diaphoresis

4. Dyspnea

5. Dysrhythmias

6. Feelings of fear and anxiety

7. Pallor, cyanosis, coolness of extremities

G. Interventions, acute stage

Pain relief increases oxygen supply to the myocardium; administer morphine as a priority in managing pain in the client having an MI.

1. Obtain a description of the chest discomfort.

2. Administer oxygen by nasal cannula as prescribed and institute pain relief measures (morphine, nitroglycerin as prescribed).

3. Assess vital signs and cardiovascular status and maintain cardiac monitoring.

4. Ensure bed rest and place the client in a semi-Fowler’s position to enhance comfort and tissue oxygenation; stay with the client.

5. Establish an IV access route.

6. Obtain a 12-lead ECG.

7. Administer antidysrhythmics as prescribed.

8. Administer thrombolytic therapy, which may be prescribed within the first 6 hours of the coronary event.

9. Monitor for signs of bleeding if the client is receiving thrombolytic therapy.

10. Monitor laboratory values as prescribed.

11. Administer β-blockers as prescribed to slow the heart rate and increase myocardial perfusion while reducing the force of myocardial contraction.

12. Monitor for complications related to the MI.

13. Monitor for cardiac dysrhythmias because tachycardia and PVCs frequently occur in the first few hours after MI.

14. Assess distal peripheral pulses and skin temperature because poor cardiac output may be identified by cool diaphoretic skin and diminished or absent pulses.

15. Monitor intake and output.

16. Assess respiratory rate and breath sounds for signs of heart failure, as indicated by the presence of crackles or wheezes or dependent edema.

17. Monitor the BP closely after the administration of medications; if the systolic pressure is lower than 100 mm Hg or 25 mm Hg lower than the previous reading, lower the head of the bed and notify the HCP.

18. Provide reassurance to the client and family.

H. Interventions following the acute episode

1. Maintain bed rest for the first 24 to 36 hours as prescribed.

2. Allow the client to stand to void or use a bedside commode if prescribed.

3. Provide range-of-motion exercises to prevent thrombus formation and maintain muscle strength.

4. Progress to dangling legs at the side of the bed or out of bed to the chair for 30 minutes three times a day as prescribed.

5. Progress to ambulation in the client’s room and to the bathroom and then in the hallway three times a day.

6. Monitor for complications.

7. Encourage the client to verbalize feelings regarding the MI.

I. Cardiac rehabilitation: Process of actively assisting the client with cardiac disease to achieve and maintain a vital and productive life within the limitations of the heart disease.

■ Dysrhythmias

■ Heart failure

■ Pulmonary edema

■ Cardiogenic shock

■ Thrombophlebitis

■ Pericarditis

■ Mitral valve insufficiency

■ Postinfarction angina

■ Ventricular rupture

■ Dressler’s syndrome (a combination of pericarditis, pericardial effusion, and pleural effusion, which can occur several weeks to months following a myocardial infarction)

1. Place the client in a high Fowler’s position.

2. Administer oxygen.

3. Assess the client quickly, including assessing lung sounds.

4. Ensure an intravenous access device is in place.

5. Prepare for the administration of a diuretic and morphine sulfate.

6. Insert a Foley catheter as prescribed.

7. Prepare for intubation and ventilator support, if required.

8. Document the event, actions taken, and the client’s response.

Pulmonary edema is a life-threatening event that can result from severe heart failure. In pulmonary edema, the left ventricle fails to eject sufficient blood, and pressure increases in the lungs because of the accumulated blood. The client is immediately placed in a high Fowler’s position, with the legs in a dependent position, to reduce pulmonary congestion and relieve edema. Oxygen is always prescribed, usually in high concentrations by mask or cannula to improve gas exchange and pulmonary function; the goal is to keep the oxygen saturation above 90%. The client is then assessed quickly, including checking the lung sounds. Next it is important to ensure that an intravenous (IV) access device is in place for the administration of a diuretic and morphine sulfate. Furosemide, a rapid-acting diuretic, will eliminate accumulated fluid. Morphine sulfate reduces venous return (preload), decreases anxiety, and also reduces the work of breathing. A Foley catheter is inserted to measure output accurately. The nurse then prepares for intubation and ventilator support, if required. The nurse stays with the client and provides reassurance. Vital signs are monitored and a cardiac monitor is used to monitor the heart rate and for dysrhythmias. The lung sounds are monitored for crackles, decreased breath sounds, and for a response to treatment. A weight measurement will also determine a response to treatment. Other interventions may include the administration of digoxin to increase ventricular contractility and improve cardiac output, bronchodilators for severe bronchospasm or bronchoconstriction, medications to facilitate myocardial contractility and enhance stroke volume, and vasodilators to reduce afterload, increase the capacity of the systemic venous bed, and decrease venous return to the heart. The nurse finally documents the event, actions taken, and the client’s response.

A. Description

1. Heart failure is the inability of the heart to maintain adequate cardiac output to meet the metabolic needs of the body because of impaired pumping ability.

2. Diminished cardiac output results in inadequate peripheral tissue perfusion.

3. Congestion of the lungs and periphery may occur; the client can develop acute pulmonary edema.

B. Classification

1. Acute heart failure occurs suddenly.

2. Chronic heart failure develops over time; however, a client with chronic heart failure can develop an acute episode.

C. Types of heart failure

1. Right ventricular failure, left ventricular failure

a. Because the two ventricles of the heart represent two separate pumping systems, it is possible for one to fail alone for a short period.

b. Most heart failure begins with left ventricular failure and progresses to failure of both ventricles.

c. Acute pulmonary edema, a medical emergency, results from left ventricular failure.

d. If pulmonary edema is not treated, death will occur from suffocation because the client literally drowns in his or her own fluids.

2. Forward failure, backward failure

a. In forward failure, an inadequate output of the affected ventricle causes decreased perfusion to vital organs.

b. In backward failure, blood backs up behind the affected ventricle, causing increased pressure in the atrium behind the affected ventricle.

3. Low output, high output

a. In low-output failure, not enough cardiac output is available to meet the demands of the body.

b. High-output failure occurs when a condition causes the heart to work harder to meet the demands of the body.

4. Systolic failure, diastolic failure

a. Systolic failure leads to problems with contraction and ejection of blood.

b. Diastolic failure leads to problems with the heart relaxing and filling with blood.

D. Compensatory mechanisms

1. Compensatory mechanisms act to restore cardiac output to near-normal levels.

2. Initially, these mechanisms increase cardiac output; however, they eventually have a damaging effect on pump action.

3. Compensatory mechanisms contribute to an increase in myocardial oxygen consumption; when this occurs, myocardial reserve is exhausted and clinical manifestations of heart failure develop.

4. Compensatory mechanisms include increased heart rate, improved stroke volume, arterial vasoconstriction, sodium and water retention, and myocardial hypertrophy.

E. Assessment

1. Right- and left-sided heart failure

Signs of left ventricular failure are evident in the pulmonary system. Signs of right ventricular failure are evident in the systemic circulation.

2. Acute pulmonary edema

a. Severe dyspnea and orthopnea

b. Pallor

c. Tachycardia

d. Expectoration of large amounts of blood-tinged, frothy sputum

e. Wheezing and crackles on auscultation

f. Gurgling respirations

g. Acute anxiety, apprehension, restlessness

h. Profuse sweating

i. Cold, clammy skin

j. Cyanosis

k. Nasal flaring

l. Use of accessory breathing muscles

m. Tachypnea

n. Hypocapnia, evidenced by muscle cramps, weakness, dizziness, and paresthesias

G. Following the acute episode

1. Encourage the client to verbalize feelings about the lifestyle changes required as a result of the heart failure.

2. Assist the client to identify precipitating risk factors of heart failure and methods of eliminating these risk factors.

3. Instruct the client in the prescribed medication regimen, which may include digoxin, a diuretic, angiotensin-converting enzyme (ACE) inhibitors, low-dose β-blockers, and vasodilators.

4. Advise the client to notify the HCP if side effects occur from the medications.

5. Advise the client to avoid over-the-counter medications.

6. Instruct the client to contact the HCP if he or she is unable to take medications because of illness.

7. Instruct the client to avoid large amounts of caffeine, found in coffee, tea, cocoa, chocolate, and some carbonated beverages.

8. Instruct the client about the prescribed low-sodium, low-fat, and low-cholesterol diet.

9. Provide the client with a list of potassium-rich foods because diuretics can cause hypokalemia (except for potassium-retaining diuretics).

10. Instruct the client regarding fluid restriction, if prescribed, advising the client to spread the fluid out during the day and to suck on hard candy to reduce thirst.

11. Instruct the client to balance periods of activity and rest.

12. Advise the client to avoid isometric activities, which increase pressure in the heart.

13. Instruct the client to monitor daily weight.

14. Instruct the client to report signs of fluid retention such as edema or weight gain.

A. Description

1. Cardiogenic shock is failure of the heart to pump adequately, thereby reducing cardiac output and compromising tissue perfusion.

2. Necrosis of more than 40% of the left ventricle occurs, usually as a result of occlusion of major coronary vessels.

3. The goal of treatment is to maintain tissue oxygenation and perfusion and improve the pumping ability of the heart.

B. Assessment

1. Hypotension: BP lower than 90 mm Hg systolic or 30 mm Hg lower than the client’s baseline

2. Urine output lower than 30 mL/hour

3. Cold, clammy skin

4. Poor peripheral pulses

5. Tachycardia

6. Pulmonary congestion

7. Tachypnea

8. Disorientation, restlessness, and confusion

9. Continuing chest discomfort

C. Interventions

1. Administer morphine sulfate intravenously as prescribed to decrease pulmonary congestion and relieve pain.

2. Administer oxygen as prescribed.

3. Prepare for intubation and mechanical ventilation.

4. Administer diuretics and nitrates as prescribed while monitoring the BP constantly.

5. Administer vasopressors and positive inotropes as prescribed to maintain organ perfusion.

6. Prepare the client for insertion of an intraaortic balloon pump, if prescribed, to improve coronary artery perfusion and improve cardiac output.

7. Prepare the client for immediate reperfusion procedures such as PTCA or coronary artery bypass graft.

8. Monitor arterial blood gas levels and prepare to treat imbalances.

9. Monitor urinary output.

10. Assist with the insertion of a pulmonary artery (Swan-Ganz) catheter to assess degree of heart failure; readings obtained from the catheter correlating to cardiogenic shock include an increased pulmonary capillary wedge pressure (PCWP) and a decreased cardiac output

11. Monitor distal pulses and maintain the transducer at the level of the right atrium if the client has a pulmonary artery (Swan-Ganz) catheter.

1. Central venous pressure (CVP)

a. The CVP is the pressure within the superior vena cava; it reflects the pressure under which blood is returned to the superior vena cava and right atrium.

b. The CVP is measured with a central venous line in the superior vena cava.

c. Normal CVP pressure is about 3 to 8 mm Hg.

d. An elevated CVP indicates an increase in blood volume as a result of sodium and water retention, excessive IV fluids, alterations in fluid balance, or kidney failure.

e. A decreased CVP indicates a decrease in circulating blood volume and may be a result of fluid imbalances, hemorrhage, or severe vasodilation, with pooling of blood in the extremities that limits venous return.

2. Measuring CVP

a. The right atrium is located at the mid-axillary line at the fourth intercostal space; the zero point on the transducer needs to be at the level of the right atrium.

b. The client needs to be supine, with the head of the bed at 45 degrees.

c. The client needs to be relaxed; note that activity that increases intrathoracic pressure, such as coughing or straining, will cause false increases in the readings.

d. If the client is on a ventilator, the reading should be taken at the point of end-expiration.

e. To maintain patency of the line, a constant small amount of fluid is delivered under pressure.

3. Pulmonary artery pressures

a. A pulmonary artery catheter is used to measure right heart and indirect left heart pressures.

b. Pulmonary artery wedge pressure (PAWP) is also known as pulmonary artery occlusive pressure (PAOP) and as pulmonary capillary wedge pressure (PCWP).

c. The measurement is obtained during momentary balloon inflation of the pulmonary artery catheter and is reflective of left ventricular end-diastolic pressure.

d. Pulmonary artery wedge pressure (PAWP) normally ranges between 4 and 12 mm Hg; elevations may indicate left ventricular failure, hypervolemia, mitral regurgitation, or intracardiac shunt whereas decreases may indicate hypovolemia or afterload reduction.

e. Normal right atrial (RA) pressure ranges from 1 to 8 mm Hg; increases occur with right ventricular failure, whereas decreases may indicate hypovolemia.

f. Normal pulmonary artery pressure (PAP) ranges from 15 to 26 mm Hg systolic/5 to 15 mm Hg diastolic.

4. Mean arterial pressure (MAP)

a. An approximation of the average pressure in the systemic circulation throughout the cardiac cycle; used in hemodynamic monitoring.

b. MAP must be between 60 and 70 mm Hg for adequate organ perfusion.

1. Description

a. Pericarditis is an acute or chronic inflammation of the pericardium.

b. Chronic pericarditis, a chronic inflammatory thickening of the pericardium, constricts the heart, causing compression.

c. The pericardial sac becomes inflamed.

d. Pericarditis can result in loss of pericardial elasticity or an accumulation of fluid within the

sac.

e. Heart failure or cardiac tamponade may result.

2. Assessment

a. Precordial pain in the anterior chest that radiates to the left side of the neck, shoulder, or back

b. Pain is grating and is aggravated by breathing (particularly inspiration), coughing, and swallowing

c. Pain is worse when in the supine position and may be relieved by leaning forward.

d. Pericardial friction rub (scratchy, high-pitched sound) is heard on auscultation and is

produced by the rubbing of the inflamed pericardial layers.

e. Fever and chills

f. Fatigue and malaise

g. Elevated white blood cell count

h. Electrocardiographic changes with acute pericarditis; ST-segment elevation with the onset of inflammation; atrial fibrillation is common.

i. Signs of right ventricular failure in clients with chronic constrictive pericarditis

3. Interventions

a. Assess the nature of the pain.

b. Position the client in a high Fowler’s position, or upright and leaning forward.

c. Administer analgesics, nonsteroidal antiinflammatory drugs, or corticosteroids for pain as prescribed.

d. Auscultate for a pericardial friction rub.

e. Check results of blood culture to identify causative organism.

f. Administer antibiotics for bacterial infection as prescribed.

g. Administer diuretics and digoxin as prescribed to the client with chronic constrictive pericarditis; surgical incision of the pericardium (pericardiectomy) may be necessary.

h. Monitor for signs of cardiac tamponade, including pulsus paradoxus, jugular vein distention with clear lung sounds, muffled heart sounds, narrowed pulse pressure, tachycardia, and decreased cardiac output.

i. Notify the HCP if signs of cardiac tamponade occur.

1. Description: Acute or chronic inflammation of the myocardium as a result of pericarditis, systemic infection, or allergic response

2. Assessment

a. Fever

b. Pericardial friction rub

c. Gallop rhythm

d. Murmur that sounds like fluid passing an obstruction

e. Pulsus alternans

f. Signs of heart failure

g. Fatigue

h. Dyspnea

i. Tachycardia

j. Chest pain

3. Interventions

a. Assist the client to a position of comfort, such as sitting up and leaning forward.

b. Administer analgesics, salicylates, and nonsteroidal antiinflammatory drugs as prescribed to reduce fever and pain.

c. Administer oxygen as prescribed.

d. Provide adequate rest periods.

e. Limit activities to avoid overexertion and decrease the workload of the heart.

f. Administer digoxin as prescribed, and monitor for signs of digoxin toxicity.

g. Administer antidysrhythmics as prescribed.

h. Administer antibiotics as prescribed to treat the causative organism.

i. Monitor for complications, which can include thrombus, heart failure, and cardiomyopathy.

1. Description

a. Endocarditis is an inflammation of the inner lining of the heart and valves.

b. Occurs primarily in clients who are IV drug abusers, have had valve replacements or repair of valves with prosthetic materials, or other structural cardiac defects

c. Ports of entry for the infecting organism include the oral cavity (especially if the client has had a dental procedure in the previous 3 to 6 months), infections (cutaneous, genitourinary, gastrointestinal, and systemic) and surgery or invasive procedures, including IV line

placement.

2. Assessment

a. Fever

b. Anorexia

c. Weight loss

d. Fatigue

e. Cardiac murmurs

f. Heart failure

g. Embolic complications from vegetation fragments traveling through the circulation

h. Petechiae

i. Splinter hemorrhages in the nail beds

j. Osler’s nodes (reddish tender lesions) on the pads of the fingers, hands, and toes

k. Janeway lesions (nontender hemorrhagic lesions) on the fingers, toes, nose, or earlobes

l. Splenomegaly

m. Clubbing of the fingers

3. Interventions

a. Provide adequate rest balanced with activity to prevent thrombus formation.

b. Maintain antiembolism stockings.

c. Monitor cardiovascular status.

d. Monitor for signs of heart failure.

e. Monitor for signs of emboli.

f. Monitor for splenic emboli, as evidenced by sudden abdominal pain radiating to the left shoulder and the presence of rebound abdominal tenderness on palpation.

g. Monitor for renal emboli, as evidenced by flank pain radiating to the groin, hematuria, and pyuria.

h. Monitor for confusion, aphasia, or dysphasia, which may indicate central nervous system emboli.

i. Monitor for pulmonary emboli as evidenced by pleuritic chest pain, dyspnea, and cough.

j. Assess skin, mucous membranes, and conjunctiva for petechiae.

k. Assess nail beds for splinter hemorrhages.

l. Assess for Osler’s nodes on the pads of the fingers, hands, and toes.

m. Assess for Janeway lesions on the fingers, toes, nose, or earlobes.

n. Assess for clubbing of the fingers.

o. Evaluate blood culture results.

p. Administer antibiotics intravenously as prescribed.

q. Plan and arrange for discharge, providing resources required for the continued administration of IV antibiotics.

4. Client education

Teach the client to maintain aseptic technique during setup and administration of intravenous antibiotics.

Instruct the client to administer intravenous antibiotics at scheduled times to maintain the blood level.

Instruct the client to monitor intravenous catheter sites for signs of infection and report this immediately to the health care provider (HCP).

Instruct the client to record the temperature daily for up to 6 weeks and report fever.

Encourage oral hygiene at least twice a day with a soft toothbrush and rinse well with water after brushing.

Client should avoid use of oral irrigation devices and flossing to avoid bacteremia.

Teach the client to cleanse any skin lacerations thoroughly and apply an antibiotic ointment as prescribed.

Client should inform all HCPs of history of endocarditis and ask about the use of prophylactic antibiotics prior to invasive respiratory procedures and dentistry.

Teach the client to observe for signs and symptoms of embolic conditions and heart failure.

A. Description

1. A pericardial effusion occurs when the space between the parietal and visceral layers of the pericardium fills with fluid.

2. Pericardial effusion places the client at risk for cardiac tamponade, an accumulation of fluid in the pericardial cavity.

3. Tamponade restricts ventricular filling, and cardiac output drops. Acute cardiac tamponade can occur when small volumes (20 to 50 mL) of fluid accumulate rapidly in the pericardium.

B. Assessment

1. Pulsus paradoxus

2. Increased CVP

3. Jugular venous distention with clear lungs

4. Distant, muffled heart sounds

5. Decreased cardiac output

6. Narrowing pulse pressure

C. Interventions

1. The client needs to be placed in a critical care unit for hemodynamic monitoring.

2. Administer fluids intravenously as prescribed to manage decreased cardiac output.

3. Prepare the client for chest x-ray or echocardiography.

4. Prepare the client for pericardiocentesis to withdraw pericardial fluid if prescribed.

5. Monitor for recurrence of tamponade following pericardiocentesis.

6. If the client experiences recurrent tamponade or recurrent effusions or develops adhesions from chronic pericarditis, a portion (pericardial window) or all of the pericardium (pericardiectomy) may be removed to allow adequate ventricular filling and contraction.

A. Description

1. Valvular heart disease occurs when the heart valves cannot fully open (stenosis) or close completely (insufficiency or regurgitation).

2. Valvular heart disease prevents efficient blood flow through the heart.

B. Types

1. Mitral stenosis: Valvular tissue thickens and narrows the valve opening, preventing blood from flowing from the left atrium to the left ventricle.

2. Mitral insufficiency, regurgitation: Valve is incompetent, preventing complete valve closure during systole.

3. Mitral valve prolapse: Valve leaflets protrude into the left atrium during systole.

4. Aortic stenosis: Valvular tissue thickens and narrows the valve opening, preventing blood from flowing from the left ventricle into the aorta.

5. Aortic insufficiency: Valve is incompetent, preventing complete valve closure during diastole.

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C. Repair procedures

1. Balloon valvuloplasty

a. Balloon valvuloplasty is an invasive nonsurgical procedure.

b. A balloon catheter is passed from the femoral vein through the atrial septum to the mitral valve or through the femoral artery to the aortic valve.

c. The balloon is inflated to enlarge the orifice.

d. Institute precautions for arterial puncture if appropriate.

e. Monitor for bleeding from the catheter insertion site.

f. Monitor for signs of systemic emboli.

g. Monitor for signs of a regurgitant valve by monitoring cardiac rhythm, heart sounds, and cardiac output.

2. Mitral annuloplasty: Tightening and suturing the malfunctioning valve annulus to eliminate or greatly reduce regurgitation

3. Commissurotomy, valvotomy

a. The procedure is accomplished with cardiopulmonary bypass during open heart surgery.

b. The valve is visualized, thrombi are removed from the atria, fused leaflets are incised, and calcium is debrided from the leaflets, thus widening the orifice.

D. Valve replacement procedures

1. Mechanical prosthetic valves: These prosthetic valves are durable. Thromboembolism is a problem following valve replacement with a mechanical prosthetic valve, and lifetime anticoagulant therapy is required.

2. Bioprosthetic valves

a. Biological grafts are xenografts (valves from other species)—porcine valves (pig), bovine valves (cow), or homografts (human cadavers).

b. The risk of clot formation is small; therefore long-term anticoagulation may not be indicated.

3. Preoperative interventions: Consult with the HCP regarding discontinuing anticoagulants 72 hours before surgery.

4. Postoperative interventions

a. Monitor closely for signs of bleeding.

b. Monitor cardiac output and for signs of heart failure.

c. Administer digoxin as prescribed to maintain cardiac output and prevent atrial fibrillation.

d. Client education 

Adequate rest is important, and fatigue is usual. Anticoagulant therapy is necessary if a mechanical prosthetic valve has been inserted. Instruct the client concerning hazards related to anticoagulant therapy and to notify the health care provider (HCP) if bleeding or excessive bruising occurs. Instruct the client concerning the importance of good oral hygiene to reduce the risk of infective endocarditis. Brush teeth twice daily with a soft toothbrush, followed by oral rinses. Avoid irrigation devices, electric toothbrushes, and flossing because these activities can cause the gums to bleed, allowing bacteria to enter the mucous membranes and bloodstream. Monitor incision and report any drainage or redness. Avoid any dental procedures for 6 months. Heavy lifting (more than 10 lb) is to be avoided, and exercise caution when in an automobile to prevent injury to the sternal incision. If a prosthetic valve was inserted, a soft, audible, clicking sound may be heard. Instruct the client concerning the importance of prophylactic antibiotics before any invasive procedure and the importance of informing all HCPs of history of valve replacement or repair. Obtain and wear a Medic-Alert bracelet.

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A. Description

1. Cardiomyopathy is a subacute or chronic disorder of the heart muscle.

2. Treatment is palliative, not curative, and the client needs to deal with numerous lifestyle changes and a shortened life span.

1. Description

a. Thrombus can be associated with an inflammatory process.

b. When a thrombus develops, inflammation occurs, thickening the vein wall and leading to embolization.

2. Types

a. Thrombophlebitis: Thrombus associated with inflammation

b. Phlebothrombosis: Thrombus without inflammation

c. Phlebitis: Vein inflammation associated with invasive procedures, such as IV lines

d. Deep vein thrombophlebitis: More serious than a superficial thrombophlebitis because of the risk for pulmonary embolism

3. Risk factors for thrombus formation

a. Venous stasis from varicose veins, heart failure, immobility

b. Hypercoagulability disorders

c. Injury to the venous wall from IV injections; administration of vessel irritants (chemotherapy, hypertonic solutions)

d. Following surgery, particularly orthopedic and abdominal surgery

e. Pregnancy

f. Ulcerative colitis

g. Use of oral contraceptives

h. Certain malignancies

i. Fractures or other injuries of the pelvis or lower extremities

1. Assessment

a. Red, warm area radiating up the vein and extremity

b. Pain and soreness

c. Swelling

2. Interventions

a. Apply warm, moist soaks as prescribed to dilate the vein and promote circulation (assess temperature of soak before applying).

b. Assess for signs of complications such as tissue necrosis, infection, or pulmonary embolus

1. Assessment

a. Calf or groin tenderness or pain with or without swelling

b. Positive Homans’ sign may be noted; however, false-positive results are common, so this is not a reliable assessment measure.

c. Warm skin that is tender to touch

2. Interventions

a. Provide bed rest as prescribed.

b. Elevate the affected extremity above the level of the heart as prescribed.

c. Avoid using the knee gatch or a pillow under the knees.

d. Do not massage the extremity.

e. Provide thigh-high or knee-high antiembolism stockings as prescribed to reduce venous stasis and assist in the venous return of blood to the heart; teach how to apply and remove stockings.

f. Administer intermittent or continuous warm, moist compresses as prescribed.

g. Palpate the site gently, monitoring for warmth and edema.

h. Measure and record the circumferences of the thighs and calves.

i. Monitor for shortness of breath and chest pain, which can indicate pulmonary emboli.

j. Administer thrombolytic therapy (tissue plasminogen activator) if prescribed, which must be initiated within 5 days after the onset of symptoms.

k. Administer heparin therapy as prescribed to prevent enlargement of the existing clot and prevent the formation of new clots.

l. Monitor activated partial thromboplastin time during heparin therapy.

m. Administer warfarin (Coumadin) as prescribed following heparin therapy when the symptoms of deep vein thrombophlebitis have resolved.

n. Monitor prothrombin time and international normalized ratio during warfarin (Coumadin) therapy.

o. Monitor for the hazards and side effects associated with anticoagulant therapy.

p. Administer analgesics as prescribed to reduce pain.

q. Administer diuretics as prescribed to reduce lower extremity edema.

r. Client education

Instruct the client concerning the hazards of anticoagulation therapy.

Recognize the signs and symptoms of bleeding.

Avoid prolonged sitting or standing, constrictive clothing, or crossing legs when seated.

Elevate the legs for 10 to 20 minutes every few hours each day.

Plan a progressive walking program.

Inspect the legs for edema, and measure the circumference of the legs.

Wear antiembolism stockings as prescribed.

Avoid smoking.

Avoid any medications unless prescribed by the health care provider (HCP).

Instruct the client concerning the importance of follow-up HCP visits and laboratory studies.

Obtain and wear a Medic-Alert bracelet.

1. Description

a. Venous insufficiency results from prolonged venous hypertension, which stretches the veins and damages the valves.

b. The resultant edema and venous stasis cause venous stasis ulcers, swelling, and cellulitis.

c. Treatment focuses on decreasing edema and promoting venous return from the affected extremity.

d. Treatment for venous stasis ulcers focuses on healing the ulcer and preventing stasis and ulcer recurrence.

2. Assessment

a. Stasis dermatitis or brown discoloration along the ankles, extending up to the calf

b. Edema

c. Ulcer formation: Edges are uneven, ulcer bed is pink, and granulation is present.

3. Interventions

For venous insufficiency, leg elevation is usually prescribed to assist with the return of blood to the heart.

a. Instruct the client to wear elastic or compression stockings during the day and evening as prescribed (instruct the client to put on elastic stockings on awakening, before getting out of bed).

b. Advise the client to put on a clean pair of elastic stockings each day; it may be necessary to wear the stockings for the remainder of life.

c. Instruct the client to avoid prolonged sitting or standing, constrictive clothing, or crossing legs when seated.

d. Instruct the client to elevate the legs for 10 to 20 minutes every few hours each day.

e. Instruct the client to elevate the legs above the level of the heart when in bed.

f. Instruct the client in the use of an intermittent sequential pneumatic compression system, if prescribed; instruct the client to apply the compression system twice daily for 1 hour in the morning and evening.

g. Advise the client with an open ulcer that the compression system is applied over a dressing.

1. Description

a. Distended, protruding veins that appear darkened and tortuous are evident.

b. Vein walls weaken and dilate, and valves become incompetent.

2. Assessment

a. Pain in the legs with dull aching after standing

b. A feeling of fullness in the legs

c. Ankle edema

3. Trendelenburg’s test

a. Place the client in a supine position with the legs elevated.

b. When the client sits up, if varicosities are present, veins fill from the proximal end; veins normally fill from the distal end.

4. Interventions

a. Assist with Trendelenburg’s test.

b. Emphasize the importance of antiembolism stockings as prescribed.

c. Instruct the client to elevate the legs as much as possible.

d. Instruct the client to avoid constrictive clothing and pressure on the legs.

e. Prepare the client for sclerotherapy or vein stripping as prescribed.

5. Sclerotherapy

a. A solution is injected into the vein, followed by the application of a pressure dressing.

b. Incision and drainage of the trapped blood in the sclerosed vein is performed 14 to 21 days after the injection, followed by the application of a pressure dressing for 12 to 18 hours.

6. Laser therapy: A laser fiber is used to heat and close the main vessel contributing to the varicosity.

7. Vein stripping

a. Varicose veins may be removed if they are larger than 4 mm in diameter or if they are in clusters; other treatments are usually tried before vein stripping

b. Preoperatively assist the HCP with vein marking.

c. Evaluate pulses as a baseline for comparison postoperatively.

d. Maintain elastic (Ace) bandages on the client’s legs postoperatively.

e. Monitor the groin and leg for bleeding through the elastic bandages.

f. Monitor the extremity for edema, warmth, color, and pulses.

g. Assess for paresthesias, which could include saphenous nerve damage.

h. Elevate the legs above the level of the heart postoperatively.

i. Encourage range-of-motion exercises of the legs.

j. Instruct the client to avoid leg dangling or chair sitting.

k. Instruct the client to elevate the legs when sitting.

l. Emphasize the importance of wearing elastic stockings after bandage removal.

1. Description

a. Chronic disorder in which partial or total arterial occlusion deprives the lower extremities of oxygen and nutrients

b. Tissue damage occurs below the level of the arterial occlusion.

c. Atherosclerosis is the most common cause of peripheral arterial disease.

2. Assessment

a. Intermittent claudication (pain in the muscles resulting from an inadequate blood supply)

b. Rest pain, characterized by numbness, burning, or aching in the distal portion of the lower extremities, which awakens the client at night and is relieved by placing the extremity in a dependent position

c. Lower back or buttock discomfort

d. Loss of hair and dry scaly skin on the lower extremities

e. Thickened toenails

f. Cold and gray-blue color of skin in the lower extremities

g. Elevational pallor and dependent rubor in the lower extremities

h. Decreased or absent peripheral pulses

i. Signs of arterial ulcer formation occurring on or between the toes or on the upper aspect of the foot that are characterized as painful

j. BP measurements at the thigh, calf, and ankle are lower than the brachial pressure (normally, BP readings in the thigh and calf are higher than those in the upper extremities).

3. Interventions

Because swelling in the extremities prevents arterial blood flow, the client with peripheral arterial disease is instructed to elevate the feet at rest but to refrain from elevating them above the level of the heart because extreme elevation slows arterial blood flow to the feet. In severe cases of peripheral arterial disease, clients with edema may sleep with the affected limb hanging from the bed or they may sit upright (without leg elevation) in a chair for comfort.

a. Assess pain.

b. Monitor the extremities for color, motion and sensation, and pulses.

c. Obtain BP measurements.

d. Assess for signs of ulcer formation or signs of gangrene.

e. Assist in developing an individualized exercise program, which is initiated gradually and slowly increased.

f. Encourage prescribed exercise, which will improve arterial flow through the development of collateral circulation.

g. Instruct the client to walk to the point of claudication, stop and rest, and then walk a little farther.

h. Instruct the client with peripheral arterial disease to avoid crossing the legs, which interferes with blood flow.

i. Instruct the client to avoid exposure to cold (causes vasoconstriction) to the extremities and to wear socks or insulated shoes for warmth at all times.

j. Instruct the client never to apply direct heat to the limb, such as with a heating pad or hot water, because the decreased sensitivity in the limb will cause burning.

k. Instruct the client to inspect the skin on the extremities daily and to report any signs of skin breakdown.

l. Instruct the client to avoid tobacco and caffeine because of their vasoconstrictive effects.

m. Instruct the client in the use of hemorheological and antiplatelet medications as prescribed.

n. Inform the client of the importance of taking all medications prescribed by the HCP.

4. Procedures to improve arterial blood flow

a. Percutaneous transluminal angioplasty, with or without intravascular stent

b. Laser-assisted angioplasty

c. Atherectomy

d. Bypass surgery: Inflow procedures bypass the occlusion above the superficial femoral arteries and include aortoiliac, aortofemoral, and axillofemoral bypasses; outflow procedures bypass the occlusion at or below the superficial femoral arteries and include femoropopliteal and femorotibial bypass

1. Description

a. Raynaud’s disease is vasospasm of the arterioles and arteries of the upper and lower

extremities.

b. Vasospasm causes constriction of the cutaneous vessels.

c. Attacks are intermittent and occur with exposure to cold or stress.

d. Affects primarily fingers, toes, ears, and cheeks

2. Assessment

a. Blanching of the extremity, followed by cyanosis during vasoconstriction

b. Reddened tissue when the vasospasm is relieved

c. Numbness, tingling, swelling, and a cold temperature at the affected body part

3. Interventions

a. Monitor pulses.

b. Administer vasodilators as prescribed.

c. Instruct the client regarding medication therapy.

d. Assist the client to identify and avoid precipitating factors such as cold and stress.

e. Instruct the client to avoid smoking.

f. Instruct the client to wear warm clothing, socks, and gloves in cold weather.

g. Advise the client to avoid injuries to fingers and hands. 

1. Description

a. Buerger’s disease is an occlusive disease of the median and small arteries and veins.

b. The distal upper and lower limbs are affected most commonly.

2. Assessment

a. Intermittent claudication

b. Ischemic pain occurring in the digits while at rest

c. Aching pain that is more severe at night

d. Cool, numb, or tingling sensation

e. Diminished pulses in the distal extremities

f. Extremities that are cool and red in the dependent position

g. Development of ulcerations in the extremities

3. Interventions

a. Instruct the client to stop smoking.

b. Monitor pulses.

c. Instruct the client to avoid injury to the upper and lower extremities.

d. Administer vasodilators as prescribed.

e. Instruct the client regarding medication therapy. 

A. Description

1. An aortic aneurysm is an abnormal dilation of the arterial wall caused by localized weakness and stretching in the medial layer or wall of the aorta.

2. The aneurysm can be located anywhere along the abdominal aorta.

3. The goal of treatment is to limit the progression of the disease by modifying risk factors, controlling the BP to prevent strain on the aneurysm, recognizing symptoms early, and preventing rupture.

B. Types of aortic aneurysm

1. Fusiform: Diffuse dilation that involves the entire circumference of the arterial segment

2. Saccular: Distinct localized outpouching of the artery wall

3. Dissecting: Created when blood separates the layers of the artery wall, forming a cavity between them

4. False (pseudoaneurysm)

a. Pseudoaneurysm occurs when the clot and connective tissue are outside the arterial wall.

b. Pseudoaneurysm occurs as a result of vessel injury or trauma to all three layers of the arterial wall.

C. Assessment

1. Thoracic aneurysm

a. Pain extending to neck, shoulders, lower back, or abdomen

b. Syncope

c. Dyspnea

d. Increased pulse

e. Cyanosis

f. Weakness

g. Hoarseness, difficulty swallowing because of pressure from the aneurysm

2. Abdominal aneurysm

a. Prominent, pulsating mass in abdomen, at or above the umbilicus

b. Systolic bruit over the aorta

c. Tenderness on deep palpation

d. Abdominal or lower back pain

3. Rupturing aneurysm

a. Severe abdominal or back pain

b. Lumbar pain radiating to the flank and groin

c. Hypotension

d. Increased pulse rate

e. Signs of shock

f. Hematoma at flank area

4. Diagnostic tests

a. Diagnostic tests are done to confirm the presence, size, and location of the aneurysm.

b. Tests include abdominal ultrasound, computed tomography scan, and arteriography.

5. Interventions

a. Monitor vital signs.

b. Assess risk factors for the arterial disease process.

c. Obtain information regarding back or abdominal pain.

d. Question the client regarding the sensation of pulsation in the abdomen.

e. Inspect the skin for the presence of vascular disease or breakdown.

f. Check peripheral circulation, including pulses, temperature, and color.

g. Observe for signs of rupture.

h. Note any tenderness over the abdomen.

i. Monitor for abdominal distention.

6. Nonsurgical interventions

a. Modify risk factors.

b. Instruct the client regarding the procedure for monitoring BP.

c. Instruct the client on the importance of regular HCP visits to follow the size of the aneurysm.

d. Instruct the client that if severe back or abdominal pain or fullness, soreness over the umbilicus, sudden development of discoloration in the extremities, or a persistent elevation of BP occurs to notify the HCP immediately. Instruct the client with an aortic aneurysm to report immediately the occurrence of chest or back pain, shortness of breath, difficulty swallowing, or hoarseness.

D. Pharmacological interventions

1. Administer antihypertensives to maintain the BP within normal limits and to prevent strain on the aneurysm.

2. Instruct the client about the purpose of the medications.

3. Instruct the client about the side effects and schedule of the medication.

E. Abdominal aortic aneurysm resection

1. Description: Surgical resection or excision of the aneurysm; the excised section is replaced with a graft that is sewn end to end

2. Preoperative interventions

a. Assess all peripheral pulses as a baseline for postoperative comparison.

b. Instruct the client in coughing and deep-breathing exercises.

c. Administer bowel preparation as prescribed.

3. Postoperative interventions

a. Monitor vital signs.

b. Monitor peripheral pulses distal to the graft site.

c. Monitor for signs of graft occlusion, including changes in pulses, cool to cold extremities below the graft, white or blue extremities or flanks, severe pain, or abdominal distention.

d. Limit elevation of the head of the bed to 45 degrees to prevent flexion of the graft.

e. Monitor for hypovolemia and kidney failure resulting from significant blood loss during surgery.

f. Monitor urine output hourly, and notify the HCP if it is lower than 30 to 50 mL/hour.

g. Monitor serum creatinine and blood urea nitrogen levels daily.

h. Monitor respiratory status and auscultate breath sounds to identify respiratory complications.

i. Encourage turning, coughing and deep breathing, and splinting the incision.

j. Ambulate as prescribed.

k. Maintain nasogastric tube to low suction until bowel sounds return.

l. Assess for bowel sounds and report their return to the HCP.

m. Monitor for pain and administer medication as prescribed.

n. Assess incision site for bleeding or signs of infection.

o. Prepare the client for discharge by providing instructions regarding pain management, wound care, and activity restrictions.

p. Instruct the client not to lift objects heavier than 15 to 20 lb for 6 to 12 weeks.

q. Advise the client to avoid activities requiring pushing, pulling, or straining.

r. Instruct the client not to drive a vehicle until approved by the HCP.

1. Description

a. A thoracotomy or median sternotomy approach is used to enter the thoracic cavity.

b. The aneurysm is exposed and excised, and a graft or prosthesis is sewn onto the aorta.

c. Total cardiopulmonary bypass is necessary for excision of aneurysms in the ascending aorta.

d. Partial cardiopulmonary bypass is used for clients with an aneurysm in the descending aorta.

2. Postoperative interventions

a. Monitor vital signs and neurological and renal status.

b. Monitor for signs of hemorrhage, such as a drop in BP and increased pulse rate and respirations, and report to the HCP immediately.

c. Monitor chest tubes for an increase in chest drainage, which may indicate bleeding or separation at the graft site.

d. Assess sensation and motion of all extremities and notify the HCP if deficits are noted, which can occur because of a lack of blood supply to the spinal cord during surgery.

e. Monitor respiratory status and auscultate breath sounds to identify respiratory complications.

f. Encourage turning, coughing, and deep breathing while splinting the incision.

g. Monitor cardiac status for dysrhythmias.

h. Monitor for pain and administer medication as prescribed.

i. Assess the incision site for bleeding or signs of infection.

j. Prepare the client for discharge by providing instructions regarding pain management, wound care, and activity restrictions.

k. Instruct the client not to lift objects heavier than 15 to 20 lb for 6 to 12 weeks.

l. Advise the client to avoid activities requiring pushing, pulling, or straining.

m. Instruct the client not to drive a vehicle until approved by the HCP.

A. Description

1. Embolectomy is removal of an embolus from an artery, using a catheter.

2. A patch graft may be required to close the artery.

B. Preoperative interventions

1. Obtain a baseline vascular assessment.

2. Administer anticoagulants as prescribed.

3. Administer thrombolytics as prescribed.

4. Place a bed cradle on the bed.

5. Avoid bumping or jarring the bed.

6. Maintain the extremity in a slightly dependent position.

C. Postoperative interventions

1. Assess cardiac, respiratory, and neurological status.

2. Monitor affected extremity for color, temperature, and pulse.

3. Assess sensory and motor function of the affected extremity.

4. Monitor for signs and symptoms of new thrombi or emboli.

5. Administer oxygen as prescribed.

6. Monitor pulse oximetry.

7. Monitor for complications caused by reperfusion of the artery, such as spasms and swelling of the skeletal muscles.

8. Monitor for signs of swollen skeletal muscles such as edema, pain on passive movement, poor capillary refill, numbness, and muscle tenseness.

9. Maintain bed rest initially, with the client in a semi-Fowler’s position.

10. Place a bed cradle on the bed.

11. Check the incision site for bleeding or hematoma.

12. Administer anticoagulants as prescribed.

13. Monitor laboratory values related to anticoagulant therapy.

14. Instruct the client to recognize the signs and symptoms of infection and edema.

15. Instruct the client to avoid prolonged sitting or crossing the legs when sitting.

16. Instruct the client to elevate the legs when sitting.

17. Instruct the client to wear antiembolism stockings as prescribed and how to remove and reapply the stockings.

18. Instruct the client to ambulate daily.

19. Instruct the client about anticoagulant therapy and the hazards associated with anticoagulants.

A. Vena caval filter: Insertion of an intracaval filter (umbrella) that partially occludes the inferior vena cava and traps emboli to prevent pulmonary emboli

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B. Ligation: Suturing or placing clips on the inferior vena cava to prevent pulmonary emboli; done via abdominal laparotomy

C. Preoperative interventions: If the client has been taking an anticoagulant, consult with the HCP regarding discontinuation of the medication to prevent hemorrhage.

D. Postoperative interventions

1. Monitor vital signs.

2. Assess cardiac, respiratory, neurological, and renal status.

3. Administer oxygen as prescribed.

4. Monitor pulse oximetry.

5. Maintain a semi-Fowler’s position.

6. Avoid hip flexion.

7. Provide activity as prescribed.

8. Check the insertion site for bleeding or hematoma and signs or symptoms of infection.

9. Assess for peripheral edema.

10. Maintain antiembolism stockings as prescribed.

11. Monitor laboratory values related to anticoagulant therapy.

12. Instruct the client to recognize the signs and symptoms of infection and edema.

13. Instruct the client to avoid prolonged sitting or crossing the legs when sitting.

14. Instruct the client to elevate the legs when sitting.

15. Instruct the client to wear antiembolism stockings as prescribed and how to remove and reapply the stockings.

16. Instruct the client to ambulate daily.

17. Instruct the client about anticoagulant therapy and the hazards associated with anticoagulants.

A. Description

1. For an adult (ages 18 and older), a normal BP is a systolic BP below 120 mm Hg and a diastolic below 80 mm Hg.

2. An individual classified with prehypertension has a systolic BP between 120 and 139 mm Hg or a diastolic pressure between 80 and 89 mm Hg.

3. Stage 1 hypertension can be classified as a systolic BP between 140 and 159 mm Hg or a diastolic pressure between 90 and 99 mm Hg.

4. Stage 2 hypertension can be classified as a systolic BP equal to or greater than 160 mm Hg or a diastolic pressure equal to or greater than 100 mm Hg.

5. Hypertension is a major risk factor for coronary, cerebral, renal, and peripheral vascular disease.

6. The disease is initially asymptomatic.

7. The goals of treatment include reduction of the BP and preventing or lessening the extent of organ damage.

8. Nonpharmacological approaches, such as lifestyle changes, may be prescribed initially; if the BP cannot be decreased after a reasonable time period (1 to 3 months), the client may require pharmacological treatment.

B. Primary or essential hypertension

1. No known cause

2. Risk factors

a. Aging

b. Family history

c. African-American race

d. Obesity

e. Smoking

f. Stress

g. Excessive alcohol

h. Hyperlipidemia

i. Increased intake of salt or caffeine

C. Secondary hypertension

1. Treatment depends on the cause and the organs involved.

2. Secondary hypertension occurs as a result of other disorders or conditions.

3. Precipitating disorders or conditions

a. Cardiovascular disorders

b. Renal disorders

c. Endocrine system disorders

d. Pregnancy

e. Medications (e.g., estrogens, glucocorticoids, mineralocorticoids)

D. Assessment

1. May be asymptomatic

2. Headache

3. Visual disturbances

4. Dizziness

5. Chest pain

6. Tinnitus

7. Flushed face

8. Epistaxis

E. Interventions

1. Goals

a. One treatment goal is to reduce the BP.

b. Another treatment goal is to prevent or lessen the extent of organ damage.

2. Question the client regarding the signs and symptoms indicative of hypertension.

3. Obtain the BP two or more times on both arms, with the client supine and standing.

4. Compare the BP with prior documentation.

5. Determine family history of hypertension.

6. Identify current medication therapy.

7. Obtain weight.

8. Evaluate dietary patterns and sodium intake.

9. Assess for visual changes or retinal damage.

10. Assess for cardiovascular changes such as distended neck veins, increased heart rate, and dysrhythmias.

11. Evaluate chest x-ray for heart enlargement.

12. Assess the neurological system.

13. Evaluate renal function.

14. Evaluate results of diagnostic and laboratory studies.

F. Nonpharmacological interventions

1. Weight reduction, if necessary, or maintenance of ideal weight

2. Dietary sodium restriction to 2 g daily as prescribed

3. Moderate intake of alcohol and caffeine-containing products

4. Initiation of a regular exercise program

5. Avoidance of smoking

6. Relaxation techniques and biofeedback therapy

7. Elimination of unnecessary medications that may contribute to the hypertension

Describe the importance of compliance with the treatment plan.

Describe the disease process, explaining that symptoms usually do not develop until organs have suffered damage.

Initiate and assist the client in planning a regular exercise program, avoiding heavy weight-lifting and isometric exercises.

Emphasize the importance of beginning the exercise program gradually.

Encourage the client to express feelings about daily stress.

Assist the client to identify ways to reduce stress.

Teach relaxation techniques.

Instruct the client in how to incorporate relaxation techniques into the daily living pattern.

Instruct the client and family in the technique for monitoring blood pressure.

Instruct the client to maintain a diary of blood pressure readings.

Emphasize the importance of lifelong medication and the need for follow-up treatment.

Instruct the client and family about dietary restrictions, which may include sodium, fat, calories, and cholesterol.

Instruct the client in how to shop for and prepare low-sodium meals.

Provide a list of products that contain sodium.

Instruct the client to read labels of products to determine sodium content, focusing on substances listed as sodium, NaCl, or MSG (monosodium glutamate).

Instruct the client to bake, roast, or boil foods, avoid salt in preparation of foods, and avoid using salt at the table.

Instruct the client that fresh foods are best to consume and to avoid canned foods.

Instruct the client about the actions, side effects, and scheduling of medications.

Advise the client that if uncomfortable side effects occur to contact the health care provider and not to stop the medication.

Instruct the client to avoid over-the-counter medications.

Stress the importance of follow-up care.

A. Description

1. A hypertensive crisis is any clinical condition requiring immediate reduction in BP.

2. A hypertensive crisis is an acute and life-threatening condition.

3. The accelerated hypertension requires emergency treatment because target organ damage (brain, heart, kidneys, retina of the eye) can occur quickly.

4. Death can be caused by stroke, kidney failure, or cardiac disease.

B. Assessment

1. An extremely high BP; usually the diastolic pressure is higher than 120 mm Hg

2. Headache

3. Drowsiness and confusion

4. Blurred vision

5. Changes in neurological status

6. Tachycardia and tachypnea

7. Dyspnea

8. Cyanosis

9. Seizures

C. Interventions

1. Maintain a patent airway.

2. Administer antihypertensive medications intravenously as prescribed.

3. Monitor vital signs, assessing the BP every 5 minutes.

4. Maintain bed rest, with the head of the bed elevated at 45 degrees.

5. Assess for hypotension during the administration of antihypertensives; place the client in a

supine position if hypotension occurs.

6. Have emergency medications and resuscitation equipment readily available.

7. Monitor IV therapy, assessing for fluid overload.

8. Monitor intake and output.

9. Insert a Foley catheter as prescribed.

10. Monitor urinary output; if oliguria or anuria occurs, notify the HCP.