Cardiology with Pharmacology for NursesCompiled from ati review modules, kaplan

study guides, and other sources.

Assembled by Tentance

Vascular System OverviewStructure

Arteries - originate in the aorta or its branches; transport blood to the systemic circulation Aorta - assists the flow of blood to the arteries or acts as a reservoir for blood during

ejection of the ventricles Pulmonary artery - originates in the right ventricle and transports deoxygenated

blood from the circulation to the lungs to be oxygenated (only artery carrying deoxygenated blood)

Gerontologic considerations—loss of arterial elasticity, blood vessel lumen narrows

Veins Carry deoxygenated blood and body waste from the systemic circulation to the right

atrium by way of the inferior and superior vena cava Superior vena cava and inferior vena cava—largest veins in the body; bring

deoxygenated blood from the upper and lower body to the right atrium Pulmonary veins—return oxygenated blood from the lungs to the left atrium (only

vein carrying oxygenated blood)

Veins have valves to ensure unidirectional blood flow

Capillaries Arterioles—smallest arteries Venules—smallest veins

Layers Tunica intima—smooth lining of blood vessel Tunica media—muscle layer Tunica adventitia—connective tissue binds vessels to adjacent structures

Vascular System Function

Oxygenated blood leaves left ventricle, travels though aorta and arterioles (smaller branches)

Deoxygenated blood returns to the right side of heart by inferior and superior venae cavae

Coronary circulation - circulation to the myocardium

Peripheral circulation - circulation through the periphery (extremities) Delivers oxygen, nutrients, hormones, and antibodies to organs, tissues, and cells Removes end products of metabolism from tissues and cells

Vascular System Mechanics1. Autonomic nervous system—regulates heart rate, influences arteriolar constriction

and blood pressure a. Neural reflexes are controlled via vasomotor center in the medulla oblongata b. Stimulation and inhibition of the circulatory system

i. Pressoreceptors (baroreceptors)—specialized nerve endings affected by changes in pressure of blood in arteries

ii. Chemoreceptors—located in the aortic arch and carotid bodies; sensitive to lack of oxygen, increased blood CO2, and decreased pH

iii. Medullary ischemic reflex—produces vasoconstriction of small blood vessels in response to stimulation of the vasoconstrictor center by excess CO2 and lack of oxygen

c. Sympathetic branch (“fight or flight”) 1) Increases blood pressure, heart rate, respiratory rate, blood glucose, and

blood flow to the muscles of the legs 2) Inhibits blood flow to the GI tract

d. Parasympathetic branch (“rest and relax”) 1) Counterbalances the sympathetic branch to maintain blood pressure, heart

rate, and respiratory rate within normal limits 2) Stimulates blood flow to the GI tract

Peripheral Vascular DiseaseIntermittent claudication - severe pain in calf muscle that occurs with walking and is caused by ischemia and a buildup of lactic acid; pain often described as cramping

Exercise increases metabolic needs of tissuesDamaged arteries are unable to dilate and supply tissues with oxygen

Rest pain - sudden blockage of a vessel by a thrombus reduces blood supply to tissues and produces ischemic pain; pain relieved by dependent position

Coldness and pallor of extremities during elevation

Cyanosis of the tissues - occurs when blood contains too little oxygen

Dependent rubor - tissues of the extremities are reddish blue in colorIndicative of peripheral vessel damage where vessels remain permanently dilatedDevelops after prolonged anoxia or exposure to severe cold

Trophic changes - adverse changes in the skin and nails of the extremities result from prolonged ischemia of tissues (loss of lower extremity hair)

Leg ulcers and cellulitisVenous stasis is a consequence of venous insufficiencyVenous stasis provides a medium for bacterial growth, which results in ulcerations

Gangrenous changes—death and decay of tissues of the extremities result from severe and prolonged ischemia

The nurse cares for the client diagnosed with an abdominal aortic aneurysm (AAA). Which postoperative intervention should the nurse include in the client's plan of care?

1. Performing circulation checks distal to the graft.

2. Elevating extremities during rest periods.

3. Instructing the client on application of warm soaks to the lower extremities.

4. Placing the client on a high protein and low carbohydrate diet.

The nurse cares for the client diagnosed with an abdominal aortic aneurysm (AAA). Which postoperative intervention should the nurse include in the client's plan of care?1. Correct: Performing circulation checks distal to the graft.Due to the nature of the aortic repair, distal pulses should be marked preoperatively. Postoperatively, hourly circulation checks should be performed to document the rate, rhythm, and character of distal pulses. Abdominal aortic aneurysm is the localized enlargement of the abdominal aorta's wall; may be asymptomatic or client may complain of abdominal and low back pain; other symptoms include pulsating mass in periumbilical area, bruit over aorta, and blood pressure may be lower in legs than arms; nursing considerations include monitoring blood pressure frequently, monitoring renal function, CBC, and instructing client to avoid bending lifting, and constipation.2. Incorrect: Elevating extremities during rest periods.The client should remain flat in bed without flexion of extremities to avoid compression of lower extremity arteries.3. Incorrect: Instructing the client on application of warm soaks to the lower extremities.Warm soaks are not indicated. The nurse should prevent thrombophlebitis by applying elastic or sequential compression stocking.4. Incorrect: Placing the client on a high protein and low carbohydrate diet.A low cholesterol, low fat diet is indicated for this client postoperatively

ThrombophlebitisThe inflammation of a vessel wall caused by the attachment of a blood clot to that wall

with consequential partial occlusion of the vessel.

Superficial venous thrombosis involving the saphenous or surface veins.

Deep vein thrombosis (DVT) involving the deep venous system and can extend from the foot to the iliofemoral region.

Thrombophlebitis can lead to a pulmonary embolism

Nursing interventions for thrombophlebitisProviding client education and encouragement pertaining to measures for

prevention of thrombophlebitis.Early and frequent ambulation. Avoiding prolonged periods of standing, sitting, or immobility. Elevating legs when sitting. Avoiding crossing legs, which will reduce the circulation and exacerbate venous

stasis.Facilitate bed rest and elevation of the client’s extremity above the level of the heart

(avoid using a knee gatch or pillow under knees).Maintaining fluid intake of 2,500 mL per day to prevent dehydration, which causes

circulation to be sluggish. Discontinuing smoking, which is known to be a risk factor. Measuring lower extremities for fitted elastic support hose/TED (thromboembolic

disorder) hose to lower extremities.

Deep Vein ThrombosisThe most common complication following trauma, surgery, or disability related to

immobilityApply pneumatic compression stockings and/or elastic stockings.Reposition the client every 2 hr and ambulate early and regularly.Administer low-level anticoagulants as prescribed.Monitor the client’s extremities for calf pain, warmth, erythema, and edemaFacilitate bed rest and elevation of the client’s extremity above the level of the heart

(avoid using a knee gatch or pillow under knees).Administer intermittent or continuous warm moist compresses. Do NOT massage the affected limb to prevent thrombus from dislodging and

becoming an embolus.Monitor the client’s leg circumferences. Administer analgesics (nonsteroidal anti-inflammatory agents).

Nursing interventions for deep venous thrombosisAdministering anticoagulants as prescribed.

Initially, intravenous heparin is administered by continuous infusion for 5 to 7 days with doses adjusted according to coagulation studies. Protamine sulfate, the heparin antidote, should be readily available to counteract the development of heparin-induced antiplatelet antibodies.

Warfarin (Coumadin) is then administered orally and is continued by the client for approximately 3 months. Vitamin K, the warfarin antidote, should be readily available for prolonged clotting times.

Elevating the affected extremity during bedrest. Administering analgesia. Encouraging TED hose use when the client is being permitted to ambulate.

Heparin sodium Subcutaneously every 12 hr, continuous or intermittent IV infusionMonitor activated partial thromboplastin time (aPTT). Keep value at 1.5 to 2

times the baseline. Stop heparin if platelet count is less than 100,000/mm3.For toxicity, administer protamine sulfate

Enoxaparin, dalteparin sodium, tinzaparin: Subcutaneously every 12 hr for 2 to 8 days

No monitoring required so may be used at home with appropriate teaching.Stop enoxaparin if platelet count is less than 100,000/mm3.

Fondaparinux sodium: Subcutaneously every 12 hr for 5 to 9 days

Client teaching for anticoagulants. Watch for bleeding from the gums or nose Increased vaginal bleeding Blood in the urine Bruising easilyAvoid taking aspirin or ibuprofen (increases bleeding tendencies). Use an electric razor for shaving. Avoid alcohol use (inhibits warfarin). Brush teeth gently. Avoid rubbing or massaging legs. Avoid periods of prolonged sitting or crossing legs.

The home health nurse visits the client who had a hip fracture repaired. In assessing the client, the nurse is especially aware of the complications of long-term immobility. The nurse should assess for which sign?

1. Homan's sign.2. Kernig's sign.3. Brudzinski's sign.4. Chadwick's sign.

The home health nurse visits the client who had a hip fracture repaired. In assessing the client, the nurse is especially aware of the complications of long-term immobility. The nurse should assess for which sign?

X 1. Homan's sign.A positive Homan's sign is pain in the calf on dorsiflexion of ankle. It suggests possible development of deep vein thrombosis, a

complication of immobility. Deep vein thrombosis is an aggregate of platelets attached to a vein wall; risk factors include pregnancy, immediate postpartum period, prolonged immobility, use of oral contraceptives, sepsis, smoking, dehydration, CHF, and trauma; indications include calf pain, localized edema of one extremity, possible warm skin over the affected leg, possible fever, chills, and perspiration; treatment includes bed rest, elevating extremity, anticoagulants, possible thrombolytic drugs, and possible surgery; nursing care includes maintaining bed rest, raising extremity, elastic stockings after acute stage, and administering prescribed analgesics. Hazards of immobility include pressure ulcers, osteoporosis, hypercalcemia, negative nitrogen balance, increased cardiac workload, orthostatic hypotension, stasis of respiratory secretions, boredom, and depression; nursing considerations include turning frequently, providing good skin care, giving high protein diet with small frequent feedings, having the client rise from bed slowly, turn, cough, and breathe deeply.

2. Kernig's sign.A positive Kernig's sign is the inability of a supine client to completely extend his leg when the

thigh is flexed on his abdomen. It is seen in meningitis.3. Brudzinski's sign.A positive Brudzinski's sign is when flexion of the hips and knees is produced when a supine

client's neck is flexed. It is seen in meningitis.4. Chadwick's sign.Chadwick's sign is the blue tinge a cervix has in early pregnancy.

Vena cava filter

Insertion of a filter in the vena cava to prevent further emboli from reaching the pulmonary vasculature

Nursing actions Prepare clients for the procedure (NPO status, informed consent).Monitor postoperatively (vital signs, SaO2, incision drainage, pain management).

A postpartum nurse is caring for a client who has deep vein thrombosis. Which of the following are risk factors for development of this disorder? (Select all that apply.)

Smoking Multiparity Diabetes mellitus Polyhydramnios Maternal age greater than 35

A postpartum nurse is caring for a client who has deep vein thrombosis. Which of the following are risk factors for development of this disorder? (Select all that apply.)

X Smoking X Multiparity X Diabetes mellitus

Polyhydramnios X Maternal age greater than 35

Risk factors for the development of deep vein thrombosis include pregnancy, immobility, obesity, smoking, cesarean birth, multiparity, previous thromboembolism, diabetes mellitus, and maternal age greater than 35 years. Polyhydramnios is not a risk factor associated with deep vein thrombosis.

Blood pressure

The pressure exerted by the blood against the walls of vessels Systolic blood pressure - maximum pressure of blood exerted against the arterial

wall when the heart is contracting

Diastolic blood pressure - lowest pressure of blood exerted against the wall of the artery when the heart is at rest

Pulse pressure - difference between systolic and diastolic blood pressure

Arterial Lines

Arterial lines are placed in the radial (most common), brachial, or femoral artery, and provide continuous information about changes in blood pressure, and permit the withdrawal of samples of arterial blood. Intra-arterial pressures can differ from cuff pressures.

The integrity of the arterial waveform should be assessed to verify the accuracy ofblood pressure readings.Monitor circulation in the limb with the arterial line (capillary refill, temperature,color).Arterial lines are not to be used for intravenous fluid infusion.

Pulmonary Artery CathetersPulmonary artery (PA) catheters have multiple ports and components that enable a variety of hemodynamic measurements, the collection of blood samples, and the infusion of intravenous fluids.The PA catheter is inserted into a large vein (internal jugular, femoral, subclavian, brachial) and threaded through the right atria and ventricle into a branch of the pulmonary artery.Pulmonary artery catheters have multiple lumens.

Proximal lumen can be used to measure right atrial pressure (CVP), infuse intravenous fluids, and to obtain venous blood samples.

Distal lumen can be used to measure pulmonary artery pressures (PA systolic, PA diastolic, mean pulmonary artery pressure, and pulmonary artery wedge pressure). This lumen is not to be used for intravenous fluid infusion.

Balloon inflation port is intermittently used for PAWP measurements. When not in use, it should be left deflated and in the ‘locked’ position.

Thermistor measures temperature differences between the right atrium and the pulmonary artery in order to determine cardiac output.

☐Additional infusion ports may be indicated, depending on the brand.

Preprocedure Nursing Actions for Line InsertionEnsure the client’s understanding of the procedure prior to obtaining consent.Assemble the pressure monitoring system.Purge all air from system.Maintain sterility of connections.Place the client in supine or Trendelenburg position.Administer sedation and pain medications as prescribed.Level transducer with phlebostatic axis (4th intercostal space, mid-axillary line).Zero system with atmospheric pressure.Hemodynamic pressure lines must be calibrated to read atmospheric pressure as zero, and the transducer should be positioned at the right atrium (phlebostatic axis).Obtain initial readings as prescribed.Compare arterial blood pressure to non-invasive cuff pressure (NIBP).Document the client’s response.

Postprocedure Nursing ActionsObtain chest x-ray following the procedure to confirm catheter placement.Continually monitor respiratory and cardiac status (vital signs, heart rhythm, SaO2).Observe respiratory pattern and effort.Compare NIBP to arterial blood pressure.Maintain line placement and integrity.Observe and document waveforms. Report changes in waveforms to the provider, as this can indicate catheter migration or displacement.Document catheter placement each shift and as needed (after movement for transport).Monitor and secure connections between pressure tubing, transducers, and catheter ports.Obtain readings from hemodynamic catheter as prescribed.Place the client in supine position prior to recording hemodynamic values. Head of bed can be elevated 15° to 30°.Level the transducer at the phlebostatic axis before readings and with all position changes.Zero system to atmospheric pressure.

Which of the following actions are necessary to obtain an accurate hemodynamic reading? (Select all that apply.)

Place the client in high-Fowler’s position, with the head elevated no more than 30°.Level transducer to phlebostatic axis.Zero transducer to room air.Record readings.Compare readings to physical assessment.

Which of the following actions are necessary to obtain an accurate hemodynamic reading? (Select all that apply.)

Place the client in high-Fowler’s position, with the head elevated no more than 30°.

X Level transducer to phlebostatic axis.X Zero transducer to room air.X Record readings.X Compare readings to physical assessment.

Normal Values of Hemodynamic Monitoring

Central Venous Pressure (CVP) 1-8 mm Hg Measures Preload in Right HeartPulmonary Artery Systolic (PAS) 15-26 mm HgPulmonary Artery Diastolic (PAD) 5-15 mm HgPulmonary Artery Wedge Pressure (PAWP) 4-12 mm Hg Measures Preload in Left HeartCardiac Output (CO) 4-6 L/minMixed Venous Oxygen Saturation (SvO2) 60% to 80%

Afterload Pulmonary Vascular Resistance - Right HeartSystemic Vascular Resistance - Left Heart

A nurse has just obtained the following hemodynamic readings for a client:PAS 34 mm HgPAD 21 mm HgPAWP 16 mm HgCVP 12 mm HgWhich of the following conditions support these hemodynamic values? (Select all that

apply.)Heart failureCor pulmonaleHypovolemic shockPulmonary hypertension

A nurse has just obtained the following hemodynamic readings for a client:PAS 34 mm HgPAD 21 mm HgPAWP 16 mm HgCVP 12 mm HgWhich of the following conditions support these hemodynamic values? (Select all

that apply.)X Heart failureX Cor pulmonale

Hypovolemic shockX Pulmonary hypertensionThese elevated hemodynamic measurements are consistent with left

ventricular failure andpulmonary problems. Hypovolemic shock is characterized by low

hemodynamic values.

Factors affecting cardiovascular performance1. Cardiac output

a. Preload–ventricular end-diastolic pressure (VEDP) 1) Venous return–increased return increases VEDP 2) End-systolic volume– increased volume increases VEDP 3) Frank-Starling law of the heart–within a physiologic range of muscle

contraction, increased preload will increase cardiac output; excessive preload will decrease cardiac output b. Afterload–resistance to ejection of blood from the left ventricle; correlates with

aortic systolic pressure; increased afterload increases myocardial oxygen demand c. Myocardial contractility–determined by preload, sympathetic nervous stimulation,

myocardial oxygen supply d. Heart rate–tachycardia or bradycardia decrease cardiac output

ElectrocardiographyUses an electrocardiograph to record the electrical activity of the heart over time. The electrocardiograph is connected by wires (leads) to skin electrodes placed on various areas of the body.Nursing ActionsPosition the client in a supine position with the chest exposed.Wash the client’s skin to remove oils.Attach one electrode to each extremity by applying electrodes to flat surfaces above the wrists and ankles and the other six electrodes to the chest, avoiding chest hair. (On male clients, chest hair may need to be shaved.)Check for changes on serial ECGs.Angina – ST depression and/or T-wave inversion (ischemia)MI – T-wave inversion (ischemia), ST-segment elevation (injury), and an abnormal Q wave (necrosis)

Cardiac cycle - one complete heartbeatTwo parts

1) Systole - contraction of (ejection of blood from) both atria and then both ventricles; initiated by release of impulse by SA node

2) Diastole - relaxation and filling of both atria and then both ventricles Cardiac output is stroke volume × heart rate

1) Stroke volume - the amount of blood ejected with each beat 2) Heart rate - the number of beats per minute

Cardiac output depends upon 1) Preload and Afterload 2) Contractility 3) Age—decreased beta receptor responsiveness with age; altered autonomic

nervous system control

Cardiac enzymes Released into the bloodstream when the heart muscle suffers ischemia.

Creatine kinase Mb isoenzyme (CK-Mb) - more sensitive to myocardium0% of total CK Initial: 4 to 6 hours, Duration: 3 daysTroponin T < 0.2 ng/l Initial: 3 to 5 hours, Duration: 14 to 21 daysTroponin I < 0.03 ng/l Initial: 3 hours, Duration: 7 to 10 daysMyoglobin < 90 mcg/l 2 Initial: 2 hours, Duration: 24 hr

Lipid Studies

Cholesterol - Screening test for heart disease(total) < 200 mg/dl

Hdl - “good” cholesterol produced by the liver Females – 35 to 80 mg/dl

Males – 35 to 65 mg/dlLDL - “bad” cholesterol can be up to 70% of total cholesterol

< 130 mg/dlTriglycerides - evaluating test for atherosclerosis

< 150 mg/dl

Echocardiogram

Ultrasound of the heart, used to diagnose valve disorders and cardiomyopathy.Indications - Cardiomyopathy, Heart failure

Nursing Actions - Explain the reason for the test to the client. The test is pain free and takes up to 1 hour.

Intraprocedure Nursing Actions Instruct the client to lie on left side and remain still.

Post procedure Nursing Actions Inform the client that the results of the test and a plan for follow-up care will be provided by the provider. There is no specific post procedure instructions that need to be followed.

Thallium ScansRadioisotopes cannot reach areas with decreased or absent perfusion and they appear as “cold spots.”

Nursing Actions

Instruct the client to avoid smoking and consuming caffeinated beverages for 4 hours prior to the procedure. These can affect the test.

Stress TestingPatient walks on a treadmill, working the heart. Once the client’s heart rate reaches a certain rate, the test is discontinued.Indications - Angina, Heart Failure, Myocardial Infarction, Dysrhythmia

Preprocedure Nursing Actions - Ensure that informed consent has been obtained.Explain to the client that he will be walking on a treadmill, and comfortableshoes and clothing are recommended.If the client is disabled or unable to be physically challenged, the provider canorder the test be a pharmacological stress test, where a drug, such as adenosine(Adenocard), is given to stress the heart instead of walking on the treadmill.The client is instructed to fast 2 to 4 hours before the procedure according toagency policy and to avoid tobacco, alcohol, and caffeine before the test.

Intraprocedure Nursing Actions - Remind the client that once the heart reaches a certain rate, the test will be discontinued.

Postprocedure Nursing Actions - The client is monitored by ECG and his blood pressure is checked frequently until he is stable.The provider will discuss findings with client. There are no specific postprocedureconsiderations for this test.

AngiographyCardiac catheterization, is an invasive diagnostic procedure used to evaluate the presence and degree of coronary artery blockage. It can be done on the lower extremities to determine blood flow and areas of blockage. Angiography involves the insertion of a catheter into a femoral (sometimes brachial) vessel and threading it into the right or left side of the heart. Coronary artery narrowings and/or occlusions are identified by the injection of contrast media under fluoroscopy.

Preprocedure Nursing ActionsEnsure that the consent form is signed.Maintain the client on NPO status for at least 8 hr (risk for aspiration when lyingflat for the procedure).Assess that the client and family understand the procedure.Smoking can change the test results, ensure the client refrains from smoking.

Assess for iodine/shellfish allergy (contrast media).Assess renal function prior to introduction of contrast dye.Administer premedication as prescribed [methylprednisone (Solu-Medrol), diphenhydramine (Benadryl)].Client Education

Instruct the client that he can be awake and sedated during procedure. A localanesthetic should be used. A small incision is made, often in the groin to insertthe catheter. The client can feel warmth and flushed when the dye is inserted.After the procedure, the client must keep the affected leg straight. Pressure (asandbag) can be placed on the incision to prevent bleeding.

Intraprocedure Nursing ActionsAdminister sedatives and analgesia as prescribed.Continually monitor vital signs and heart rhythm.

Be prepared to intervene for dysrhythmias.Have resuscitation equipment and emergency medications readily available.

Postprocedure Nursing ActionsAssess vital signs every 15 min x 4, every 30 min x 2, every hour x 4, and then every 4 hr (follow hospital protocol).Assess the groin site at the same intervals for:

Bleeding and hematoma formationThrombosis; document pedal pulse, color, temperatureMaintain bed rest in supine position with extremity straight for prescribed time.A vascular closure device may be used to hasten hemostasis following catheter

removal.

Older adult clients can have arthritis, which can make lying in bed for 4-6 hr after the procedure painful. The provider can be notified for prescribed medication.

A nurse is caring for a client following an angioplasty that was inserted through the femoral artery. While turning the client, the nurse discovers blood underneath the client’s lower back. The nurse should suspect

A. retroperitoneal bleeding.B. cardiac tamponade.C. bleeding from the incisional site.D. heart failure

A nurse is caring for a client following an angioplasty that was inserted through the femoral artery. While turning the client, the nurse discovers blood underneath the client’s lower back. The nurse should suspect

A. retroperitoneal bleeding.B. cardiac tamponade.X C. bleeding from the incisional site.D. heart failure

The incisional site is most likely leaking blood that is seeping under the client. The nurseshould assess the incision for drainage, apply pressure, monitor blood pressure and heartrate, and notify the surgeon. Retroperitoneal bleeding, cardiac tamponade, and heart failure would not be indicative of these findings.

Coronary Artery Bypass SurgeryTo increase blood flow to heart muscle in patients with severe angina. Saphenous vein is used for graft; as many as five arteries are bypassed Preoperative Nursing Care: Education and psychological preparation Postoperative Nursing Care

Provide intensive evaluation of organ systems Provide chest drainage Pain relief Be alert to psychological state of disorientation or depression Provide activity as tolerated with progress as ordered from foot dangling over side of

bed, to sitting in chair, to walking in room by third day Provide guidance concerning long-term care and follow-up

HypertensionPersistent elevation of the systolic blood pressure above 140 mmHg and of diastolic

blood pressure above 90 mmHg Assessment

There may be no symptoms, or there could be: headache, dizziness; facial flushing, anginal pain (insufficient blood flow through coronary arteries to the myocardium), intermittent claudication (decreased adequacy of blood supply to the legs during periods of activity), retinal hemorrhages and exudates (damage to arterioles that supply the retina), severe occipital headaches associated with nausea, vomiting, drowsiness, giddiness, anxiety, and mental impairment due to vessel damage within the brain, polyuria, nocturia, protein, and RBCs in urine, and diminished ability of kidneys to concentrate urine (hardening of arterioles within the kidney causing arteriolar nephrosclerosis), dyspnea upon exertion from left-sided heart failure, edema of the extremities from right-sided heart failure

Patient’s history should include Age of onset (all ages, but more common with increasing age) Family history History of renal or cardiovascular disease Recent complaints of dyspnea, fatigue, weakness, anginal-type pain, swelling of

feet, or nocturia Sudden gain or loss of weight Recent severe headaches or drenching sweats Personality type Activity level Alcohol intake Diet, including sodium intake

Physical Examination for Hypertension

a. Blood pressure reading on both arms in supine and erect positions and on one leg: readings should be taken every one to two hours over an eight-hour period for one to two days (a single blood pressure reading is almost always inaccurate) b. Ophthalmoscopic examination for evidence of vascular changes c. Examination of the heart and aorta by means of auscultation, EKG readings, and aortography d. Palpation of the arteries in the neck, wrists, femoral areas, and feet for evidence of coarctation of the aorta (decreased amplitude of pulses and lower blood pressure in the legs than in the arm) e. Neurological examination for signs of cerebral thrombosis or hemorrhage f. Gerontologic considerations - high incidence of hypertension; parameters are the same as for younger adults; increased systolic blood pressure common; treatment goal is <140/90 mm Hg or <130/80 mmHg in diabetic clients; consider effects of antihypertensive medications

Laboratory Studies to determine Hypertension

Urinalysis and urine cultures to determine the presence of protein, RBCs, pus cells, and casts (all indicative of renal disease) Blood count and sedimentation rate Serum sodium, potassium, chloride, and carbon dioxide (all indicative of primary aldosteronism) Urinary catecholamine metabolites (indicative of pheochromocytoma) Urine 17-ketosteroids and blood corticoids (both indicative of Cushing’s disease) Intravenous pyelogram, urine cultures, radioisotope renogram, renal arteriography, intravenous urograms (all tests for renal disease) BUN and creatinine

If clinical workup indicates no evidence of coarctation of the aorta, adrenal disease, or primary renal disease, then the condition is diagnosed as essential hypertension

Primary (essential or idiopathic)—constitutes 90% of all cases; may be benign (gradual onset and prolonged course) or malignant (abrupt onset and short dramatic course, which is rapidly fatal unless treated)

Secondary—develops as a result of another primary disease of the cardiovascular system, renal system, adrenal glands, or neurological system

Plan/Implementation for Hypertension

1. Medications 2. Nursing management

a. Provide a restful, quiet hospital environment b. Provide complete explanations of all procedures and diagnostic studies c. Listen to the patient’s fears and worries and offer reassurance d. Completely explain dietary restrictions (i.e., salt restriction, low fat) e. Document patient’s blood pressure both standing and lying down f. Encourage weight loss if patient is obese g. Provide moderate salt-restricted diet h. Plan program of regular physical exercise

i. Encourage changes in job or domestic settings for patients who live or work under considerable stress j. Educate patient regarding drug therapy

1) Lie down immediately if faintness, weakness, nausea, or vomiting occurs 2) Avoid hot baths, excessive amounts of alcohol, and immobility following exercise 3) Always rise slowly from a lying to a sitting position and from sitting to standing to

allow the vascular system to adjust to positional changes 4) Avoid standing motionless, especially within the first hour or two after receiving

medication (standing causes leg vessels to relax, allowing blood to pool within lower extremities)

5) Use caution when driving an automobile or when operating heavy or dangerous machinery, especially with medications causing sedation

6) Avoid constipation because it may cause either an increased or irregular absorption of hypotensive drugs, which can result in critical hypotensive reactions

7) Should hypotensive crises occur frequently, wrap legs firmly with elastic bandages when ambulating to promote venous return

8) Never take a larger dose of drug than prescribed without consulting the doctor

9) Always take medication on time and do not skip a dose (noncompliance is common)

10) Never suddenly discontinue a drug without the doctor’s permission to avoid severe rebound hypertensive reaction

11) Always report side effects to the physician; impotence problems warrant change of therapy

12) Consult with health care provider before taking any prescription or over-the-counter medications

Gerontologic considerations for Hypertension

Blood pressure assessment—inflate cuff pressure to level above disappearance of brachial or radial pulse

Assess for orthostatic blood pressure changesElderly may not tolerate systolic blood pressure <120 mm Hg

Elderly may have significant drop in blood pressure immediately after meals Polypharmacy - interaction between NSAIDs and antihypertensive medications

Medications for HypertensionBeta Blockers

Atenolol (Tenormin) Bradycardia Hypotension Bronchospasm Once-a-day dose increases compliance, Check apical pulse; if <60 bpm, hold drug

and call physician, Don’t discontinue abruptly, Masks signs of shock and hypoglycemiaMetoprolol (Lopressor) Bradycardia Hypotension Heart failure Depression Give with meals, Teach patient to check pulse before each dose; take apical pulse

before administration; withhold if pulse is <60 bpmNadolol (Corgard) Bradycardia Hypotension Heart failureTeach client to check pulse before each dose; check apical pulse before

administering, Withhold if pulse <60 bpm, Don’t discontinue abruptlyPropranolol (Inderal) Weakness Hypotension Bronchospasm Bradycardia

Depression Blocks Sympathetic Innervation of HeartClient should take pulse at home before each dose, Dosage should be reduced

gradually before discontinued

Alpha BlockersPrazosin (Minipress) Drowsiness, dizziness Weakness Palpitations Nausea Blocks a-mediated vasoconstriction Assess for first-dose syncope, Orthostatic hypotension precautionsAlpha-2 AgonistsMethyldopa (Aldomet) Drowsiness, Dizziness, Bradycardia, Hemolytic Anemia, Fever, Orthostatic Hypotension, Prevents reuptake of norepinephrine Monitor CBC and liver function, Take at hs to minimize daytime drowsiness, Change position slowlyClonidine (Catapres) Drowsiness, Dizziness, Dry mouth, Headache, Dermatitis, Severe rebound hypertension Don’t discontinue abruptly, Apply patch to non-hairy area (upper outer arm, anterior chest), Take orthostatic hypotension precautions, older adults are at a higher risk orthostatic hypotension and CNS adverse effects

POTASSIUM-SPARING DIURETICSSpironolactone Hyperkalemia GI upset Weigh regularly, Monitor for symptoms of hyperkalemiaTHIAZIDE DIURETICSHydrochlorothiazide Hypokalemia Dehydration Postural hypotensionWeigh regularly, Monitor for symptoms of hypokalemia, take postural hypotension precautionsVasodilatorsHydralazine (Apresoline) Headache, Palpitations, Edema, Tachycardia, Lupus erythematosus-like syndrome, Dilates arteriolar smooth muscleGive with meals, observe mental status, check for weight gain, edemaMorphine sulfate Hypotension, Respiratory depression, Decreased mental alertness, Constipation, Reduces cardiac workload/preload/afterload pressures, Relieves pain, reduces anxiety

ACE InhibitorsCaptopril (Capoten) Enalapril (Vasotec) Dizziness, Orthostatic hypotension, Persistent cough, Hyperkalemia, Blocks conversion of Angiotensin I to Angiotensin II Report swelling of face, lightheadedness. Report persistent cough.Angiotensin II Receptor Blocker (ARB)Losartan (Cozaar) Less likely to cause persistent cough and hyperkalemia than are ACE inhibitors, Prevents binding of angiotensin II with tissue receptor sites Maximal effects require 3 to 6 weeks, Can be used in combination with a diuretic for better BP controlCalcium Channel BlockersNifedipine (Procardia) Verapamil (Calan) Diltiazem (Cardizem) Amlodipine (Norvasc) Hypotension, Dizziness, GI distress, Liver dysfunction, Jitteriness, Reduces workload of left ventricle, Coronary vasodilatorMonitor blood pressure during dosage adjustments, assist patient with ambulation at start of therapy. Nifedipine - high risk hypotension and constipation in older adults

Acute Hypertensive CrisisOften occurs with noncompliance.

Nursing Actions Thorough Assessment - Severe headache, Extremely high blood pressure

(generally, systolic blood pressure greater than 240 mm Hg, diastolic greater than 120 mm Hg), Blurred vision, dizziness, and disorientation, Epistaxis

Administer IV antihypertensive therapies, such as nitroprusside (Nipride), nicardipine (Cardene IV), and labetalol (Normodyne).

Before, during, and after administration of IV antihypertensive, closely monitor blood pressure every 5 to 15 min as prescribed.

Assess the client’s neurological status such as pupils, level of consciousness, and muscle strength, frequently to monitor for cerebrovascular change.

Monitor the ECG to assess the client’s cardiac status.

A nurse is caring for a client who is admitted to the emergency department with a blood pressure of 266/147 mm Hg. The client reports a headache and states that she is seeing double. The client states that she ran out of her diltiazem (Cardizem) 3 days ago, and she has not been able to purchase more. Which of the following nursing interventions should the nurse expect to perform first?

A. Administer acetaminophen for headache. B. Provide teaching in regard to the importance of not abruptly stopping an

antihypertensive. C. Obtain IV access and prepare to administer an IV antihypertensive. D. Call social services for a referral for financial assistance in obtaining

prescribed medication

A nurse is caring for a client who is admitted to the emergency department with a blood pressure of 266/147 mm Hg. The client reports a headache and states that she is seeing double. The client states that she ran out of her diltiazem (Cardizem) 3 days ago, and she has not been able to purchase more. Which of the following nursing interventions should the nurse expect to perform first?

A. Administer acetaminophen for headache. B. Provide teaching in regard to the importance of not abruptly stopping an

antihypertensive. X C. Obtain IV access and prepare to administer an IV antihypertensive.

D. Call social services for a referral for financial assistance in obtaining prescribed medication

The greatest risk to the client is injury due to a blood pressure of 266/147 mm Hg, which can be life-threatening. The highest priority is to decrease the client’s blood pressure as quickly as possible. An IV should be started for IV access. Medications given by the IV route will be absorbed and distributed much faster than by the oral route. Administering acetaminophen for headache, providing teaching regarding medication administration, and obtaining financial assistance is important, but not the priority at this time.

CardiomyopathyImpaired cardiac function leading to heart failure.

Blood circulation is impaired to the lungs or body when the cardiac pump is compromised.Of the three types (dilated cardiomyopathy, hypertrophic cardiomyopathy, and restrictive cardiomyopathy), dilated cardiomyopathy is the most common.

Dilated – decreased contractility and increased ventricular filling pressures. This can be a result of:

Coronary artery diseaseInfection or inflammation of the heart muscleVarious cancer treatments Prolonged alcohol abuseActivity intolerance may be a symptom of dilated cardiomyopathy related to

worsening failure

Heart Failure

Failure of the cardiac muscle to pump sufficient blood to meet the body’s metabolic needs

Class I: Client exhibits no symptoms with activity (chest pain, SOB).Class II: Client has symptoms with ordinary exertion.Class III: Client displays symptoms with minimal exertion.Class IV: Client has symptoms at rest.

Conditions that predispose heart to gradual failure

Inflow of blood to the heart is reduced due to hemorrhage or dehydration Inflow of blood to the heart is increased due to excessive IV fluids or sodium and water retention Outflow of blood from the heart is obstructed due to damaged valves and narrowed arteries The heart muscle is damaged from ischemia or inflammatory processes The metabolic needs of the body are increased as a result of fever or pregnancy

Some disease processes that may lead to heart failure include: Hypertensive disease, Arteriosclerosis, Valvular heart disease, Rheumatic heart disease, Ischemic heart disease, Constrictive pericarditis, Circulatory overload, Pulmonary disease, Tachydysrhythmias

Compensatory Mechanisms of a failing heart

Ventricular dilation - increase in the length of muscle fibers, creating an increase in the volume of the heart chambers

1) Starling’s law - a stretched muscle contracts more forcefully; therefore, dilation causes an increased systolic output within limits

2) This compensatory mechanism is limited because if stretched beyond a certain point, muscle fibers cease to increase contractile power of the heart and because a greatly dilated heart requires more oxygen to meet its metabolic needs, resulting, in time, in hypoxia of the heart muscle

Ventricular hypertrophy - increase in diameter of muscle fibers creating a thickening of the walls of the chambers and a corresponding increase in the weight of the heart

1) Generally follows persistent dilation, further increasing the contractile power of muscle fibers

2) Limited compensatory mechanism because in time increased muscle mass of heart outgrows coronary blood supply and becomes hypoxic

Tachycardia - least effective compensatory mechanism because when heart rate becomes too rapid, the ventricles are unable to fill adequately, with resultant hypotension and shock

Cardiac decompensation occurs when the heart is unable to cope with the work demands placed upon it and thus expends most of its reserve

AssessmentPresence of characteristic symptoms of left or

right heart failureMuffled heart soundsAbnormal heart sounds (S3) Rales (crackles) at the base of the lungsHazy lung fields and prominent, distended

pulmonary veins on x-ray Elevated venous pressure Distended neck veinsProlonged circulation timeReduction in cardiac outputPresence of albuminuriaElevated BUN

Gerontologic considerations - may see change in grooming habits, change in personality, dizziness or lightheadedness, decreased appetite, gait and balance alterations, malaise, chronic cough, nocturia; manifestations are worse during exacerbation of heart failure

Human B-type natriuretic peptides (hBNP): Elevated in heart failure. Usedto differentiate dyspnea related to heart failure versus respiratory problemand to monitor the need for and the effectiveness of aggressive heart failureintervention.

A level below 100 pg/mL indicates no heart failure.Levels between 100 to 300 pg/mL suggest heart failure is present.A level above 300 pg/mL indicates mild heart failure.A level above 600 pg/mL indicates moderate heart failure.A level above 900 pg/mL indicates severe heart failure.

Nursing Management

Medications - primarily Digitalis and diureticsDiet

Restricted sodium dietNormal intake: 6–15 g/d No table salt: 1.6–2.8 g/d No salt: 1.2–1.4 g/dStrict low-sodium diet: 0.2–1 g/d

Low calorie, supplemented with vitamins - promotes weight loss, reducing the workload of the heart Bland, low residue—avoids discomfort from gastric distention and heartburn Small, frequent feedings to avoid gastric distention, flatulence, and heartburn

Record intake and output Weigh dailyGood skin careOxygen therapyEncourage bedrest and energy conservation until stablePlace in high Fowler’s position to support breathingTeaching about disease process and medications

A nurse is caring for a client who has a diagnosis of heart failure and asks how to limit fluid intake to 2,000 mL/day. Which of the following responses should the nurse give to the client?

A. “Pour the amount of fluid you drink into an empty 2 liter bottle to keep track of how much you drink.”

B. “Each glass contains 8 ounces. There are 30 milliliters per ounce, so you can have a total of 8 glasses or cups of fluid each day.”

C. “This is the same as 2 quarts, or about the same as two pots of coffee.”D. “Take sips of water or ice chips so you will not take in too much fluid.”

A nurse is caring for a client who has a diagnosis of heart failure and asks how to limit fluid intake to 2,000 mL/day. Which of the following responses should the nurse give to the client?X A. “Pour the amount of fluid you drink into an empty 2 liter bottle to keep track of how much you drink.”

B. “Each glass contains 8 ounces. There are 30 milliliters per ounce, so you can have a total of 8 glasses or cups of fluid each day.”

C. “This is the same as 2 quarts, or about the same as two pots of coffee.”D. “Take sips of water or ice chips so you will not take in too much fluid.”Pouring the amount of fluid consumed into an empty 2 L bottle will give the client a

visual guide to how much fluid is consumed and how much is left. Glasses and cups vary in size. Providing frames of reference for the amount of fluid in 2 L or suggesting that the client take sips of water or ice chips are not concrete methods to determine intake.

Identify which of the following food selections are high in sodium (mark with an S) and which are high in potassium (mark with a P).

Cheese (cheddar and cottage cheese)CantaloupeMilkSoy sauceCured meats (pork)White potatoesAvocadoBananaRaisinsMeats (beef, pork, chicken, and veal)Codfish, salmon, and tuna

Identify which of the following food selections are high in sodium (mark with an S) and which are high in potassium (mark with a P).

S Cheese (cheddar and cottage cheese)P CantaloupeS MilkS Soy sauceSP Cured meats (pork)P White potatoesP AvocadoP BananaP RaisinsP Meats (beef, pork, chicken, and veal)P Codfish, salmon, and tuna

Interdisciplinary CareCardiology and pulmonary services should be consulted to manage heart failure.Respiratory services should be consulted for inhalers, breathing treatments, andsuctioning for airway management.Cardiac rehabilitation services can be consulted if the client has prolonged weaknessand needs assistance with increasing level of activity.Nutritional services can be consulted for diet modification to promote low sodium,and low-saturated fat food choices.

Ventricular assist device (VAD)A VAD is a mechanical pump that assists a heart that is too weak to pump blood through the body. A VAD is used in clients who are eligible for heart transplants or who have severe end-stage heart failure and are not candidates for heart transplants. Heart transplantation is the treatment of choice for clients who have severe dilated cardiomyopathy.

Nursing ActionsPrepare the client for the procedure (NPO status and informed consent).Monitor postoperatively (vital signs, SaO2, incision drainage, and pain management).

Heart Transplantation

A possible option for clients who have end-stage heart failure. Lifelong immunosuppressant therapy is required posttransplantation to prevent rejection.

Nursing ActionsPrepare the client for the procedure (NPO status and informed consent).Monitor postoperatively (vital signs, SaO2, incision drainage, and pain

management).

Left-Sided Heart Failuredevelops as a result of left ventricular dysfunction, which causes blood to back up

through the left atrium and into the pulmonary veinsDyspnea - results from pulmonary congestion due to pulmonary engorgement; poor gas exchange because of fluid in the alveoliOrthopnea - shortness of breath occurring when the patient is in a recumbent position Paroxysmal nocturnal dyspneaCheyne-Stokes respirations - exact cause in HF unknown; believed that they occur as a result of prolonged circulation time between the pulmonary circulation and the central nervous system, which in turn affects the respiratory center Pleural effusion and pulmonary edema - from severe pulmonary congestion, causing distended capillaries, which leak fluid into the interstitial and alveolar spaces of the lungs Cough and cardiac asthma - cough productive of large amounts of frothy, blood-tinged sputum results from edema fluid trapped within the pulmonary tree, irritating the delicate mucosa of the lungs

Cerebral anoxia - develops because of the decrease in cardiac output to the brain, which causes irritability, restlessness, and a shortened attention span Fatigue and muscular weakness - decreased cardiac output diminishes oxygen to tissues and decreases the speed with which metabolic wastes are swept up into the circulation for excretion, thereby creating profound exhaustionS3 gallopB -type natriuretic peptide levels increased Microalbuminuria

CVP/right atrial pressure (normal = 1 to 8 mm Hg): Normal or elevatedPAP (normal = 15 to 26 mm Hg/5 to 15 mm Hg): ElevatedPAWP (normal = 4 to 12 mm Hg): ElevatedCO (normal = 4 to 7 L/min): Decreased

The elderly may have atypical manifestations like falls, delirium, chronic cough, or weight loss

Decreased renal function, edema, and weight gain - kidney function is adversely affected by the development of HF, resulting in sodium and water retention

1) Decreased cardiac output results in decreased arterial pressure in the kidneys, reducing glomerular filtration and output of sodium chloride and water2) Reduced circulating blood volume triggers an increase in aldosterone secretion by the adrenal cortex, thereby increasing the rate of reabsorption of sodium by renal tubules 3) Increased sodium reabsorption results in increased concentration of extracellular fluid 4) Increased osmotic pressure causes an increase in the release of antidiuretic hormone (ADH) from the neurosecretory cells of the hypothalamus, resulting in increased tubular reabsorption of water

Right Sided Heart FailureDevelops from a diseased right ventricle that causes backward flow to right atrium and

venous circulation; usually caused by left-sided failureLiver enlargement and abdominal pain - as the liver becomes congested with venous blood, it enlarges; stretching of the capsule surrounding the liver causes severe discomfort in the right upper quadrant Anorexia, nausea, and bloating - secondary to venous congestion of the gastrointestinal tract (anorexia and nausea may also result from digitalis toxicity, a common problem because digitalis is a major drug in treating heart failure) Dependent edema - early signs of right-sided heart failure include edema of ankles and lower extremities, resulting from venous congestion of kidneys producing compensatory vasoconstriction that decreases renal blood flow, impairing sodium excretionCoolness of extremities - venous congestion throughout the body reduces peripheral blood flow, often causing coolness of extremities and cyanosis of nail beds Weight gainCVP/right atrial pressure (normal = 1 to 8 mm Hg): Elevated

Advanced Heart FailureWeight loss and cachexia—low cardiac output and venous congestion create malnutrition of tissues, although patient may appear puffy and bloated due to edemaShock syndrome—typical clinical picture of shock usually appears during terminal stages of HF

Stupor PallorRapid, thready pulseCold sweatsRestlessnessProfound hypotension

Medications for Heart FailureCardiac GlycosidesDigoxin (Lanoxin) Anorexia, Nausea, Bradycardia, Visual disturbances, Confusion, Abdominal painTake apical pulse for 1 full minute before administering, Notify physician if apical pulse is less than 60 (adult), less than 90-110 (infants and young children), less than 70 (older children) . Loading dose 0.5-1 mg IV or PO in divided doses over 24 h, Maintenance dose 0.125-0.5 mg IV or PO (average is 0.25 mg). Teach patient to check pulse rate and discuss side effects. Low K+ increases risk of digitalis toxicity. Take at the same time each day. Take 2 hours apart from antacids.If toxicity occurs (>2.0 nanograms/mL) - Discontinue the drug and potassium-wasting diuretics. Monitor serum potassium. Administer antidysrhythmic drug as needed. For severe toxicity: Fab body fragments (Digibind) administered, Cholestyramine and activated charcoal orally to suppress absorption.

A nurse is caring for four clients, each taking digoxin (Lanoxin). Which of the following clients is at risk for digoxin toxicity? A client who is taking

A. procainamide (Pronestyl) for premature ventricular contractions. B. ranitidine (Zantac) for peptic ulcer disease. C. phenytoin (Dilantin) for a seizure disorder. D. furosemide (Lasix) for congestive heart failure.

A nurse is caring for four clients, each taking digoxin (Lanoxin). Which of the following clients is at risk for digoxin toxicity? A client who is taking

A. procainamide (Pronestyl) for premature ventricular contractions. B. ranitidine (Zantac) for peptic ulcer disease. C. phenytoin (Dilantin) for a seizure disorder. D. furosemide (Lasix) for congestive heart failure.

Loop diuretics cause potassium to be excreted from the kidneys. Hypokalemia increases the risk for digoxin toxicity. Concurrent use with Procainamide, ranitidine or phenytoin does not increase the risk of digoxin toxicity.

Which of the following client findings suggests digitalis toxicity or a risk for developing digitalis toxicity? (Select all that apply.)

Serum potassium level of 3.2 mEq/LApical heart rate of 54/minBlurred visionDysrhythmiaWeight gain of 2 lb in 1 dayLeg crampsSlurred speechShortness of breathAnorexiaAltered mental status

Which of the following client findings suggests digitalis toxicity or a risk for developing digitalis toxicity? (Select all that apply.)

X Serum potassium level of 3.2 mEq/LX Apical heart rate of 54/minX Blurred visionX Dysrhythmia

Weight gain of 2 lb in 1 dayX Leg cramps

Slurred speechShortness of breath

X AnorexiaX Altered mental status

Hypokalemia increases the risk of digitalis toxicity. Leg cramps are a possible sign of hypokalemia. Slowed pulse, blurred vision, dysrhythmias, anorexia, and altered mental status are signs of digitalis toxicity. Weight gain and shortness of breath are signs of heart failure. Slurred speech could be a sign of a cerebrovascular accident.

Thiazide diuretics Inhibits reabsorption of sodium and chloride in distal renal tubuleHydrochlorothiazide (Hydrodiuril) Chlorothiazide (Diuril) Hypokalemia, Hyperglycemia, Blurred vision, Loss of Sodium, Dry mouth, HypotensionMonitor electrolytes, especially potassium. I and O. Monitor BUN and creatinine. Don’t give at night. Weigh patient daily. Encourage potassium-containing foodsPotassium sparing blocks effect of aldosterone on renal tubules, causing loss of sodium and water and retention of potassium.Spironolactone (Aldactone) Hyperkalemia, Hyponatremia, Hepatic and renal damage, Tinnitus, RashGive with meals. Avoid salt substitutes, containing potassium. Monitor I and O.

Human B-type natriuretic peptides (hBNP)Nesiritide (Natrecor) Hypotension, dysrhythmias like ventricular tachycardia and bradycardia. Causes natriuresis (loss of sodium and vasodilation)BNP levels will increase while on this medication. ECG, blood pressure, and other parameters must be closely monitored. Change position slowly.

Loop diuretics Inhibits reabsorption of sodium and chloride in loop of Henle and distal renal tubulesFurosemide (Lasix) Ethacrynic acid (Edecrin) Hypotension, Hypokalemia, Hyperglycemia, GI upset, WeaknessMonitor BP, pulse rate, I and O. Monitor potassium. Give IV dose over 1-2 minutes → diuresis in 5-10 min. After the PO dose diuresis is in about 30 minutes. Weigh the patient daily. Don’t give at night. Encourage potassium-containing foods.Bumetanide (Bumex) Potassium depletion, Electrolyte imbalance, Hypovolemia, Ototoxicity Supervise ambulation. Monitor blood pressure and pulse. Observe for signs of electrolyte imbalance.

Osmotic diuretic Pulls fluid from tissues due to hypertonic effectMannitol Dry mouth, ThirstI and O must be measured. Monitor vital signs. Monitor for electrolyte imbalance.

Other diureticsChlorthalidone (Hygroton, Thalitone) Dizziness, Aplastic anemia, Orthostatic hypotension, Acts like a thiazide diuretic, Acts in 2-3 h, peak 2-6 h, lasts 2-3 days. Administer in morning, Monitor output, weight, BP, electrolytes. Increase K+ in diet. Monitor glucose levels in diabetic patients. Change position slowly.

Which of the following actions should a nurse include when planning discharge teaching for a client who has heart failure? (Select all that apply.)

Conserve energy; the client should schedule rest periods between activities.Adhere to medication regimen.Weigh self weekly and notify the provider if there is a weight gain of 5 lb in 2

weeks.Get influenza vaccine yearlyIf prescribed digoxin (Lanoxin), take pulse for 1 min, and notify the provider if

the pulse is below the set limit.Take diuretics in the early morning and early afternoon (if prescribed twice

daily) to allow for uninterrupted sleep.Notify the provider of increased dyspnea, orthopnea, and inability to wear rings

or shoes.

Which of the following actions should a nurse include when planning discharge teaching for a client who has heart failure? (Select all that apply.)

X Conserve energy; the client should schedule rest periods between activities.X Adhere to medication regimen.

Weigh self weekly and notify the provider if there is a weight gain of 5 lb in 2 weeks.X Get influenza vaccine yearlyX If prescribed digoxin (Lanoxin), take pulse for 1 min, and notify the provider if the pulse is below the set limit.X Take diuretics in the early morning and early afternoon (if prescribed twice daily) to allow for uninterrupted sleep.X Notify the provider of increased dyspnea, orthopnea, and inability to wear rings or shoes.The client who has heart failure should take medications as prescribed. If prescribed digoxin, the client should take her pulse for 1 min, and notify the provider if her pulse rate is below the set limit. The client should take diuretics early in the morning and early in the afternoon to prevent interruptions in sleep. The client should also get vaccinations (pneumococcal and yearly influenza vaccines), maintain fluid and sodium restrictions (dietary consult can be useful), weigh herself at the same time daily, and notify the provider of a weight gain of 2 lb in 24 hr or 5 lb in 1 week

Acute Pulmonary EdemaA life-threatening medical emergency.

Symptoms include anxiety, tachycardia, acute respiratory distress, dyspnea at rest,change in level of consciousness, and an ascending fluid level within the lungs(crackles, cough productive of frothy, blood-tinged sputum).

Nursing ActionsAdminister prescribed medications to improve cardiac output.Teach the client about measures to improve tolerance to activity, such asalternating periods of activity with periods of rest.

Prompt response for pulmonary edema includes:Positioning the client in high-Fowler’s position.Administration of oxygen, positive airway pressure, and/or intubation and

mechanical ventilation.IV morphine (to decrease anxiety, respiratory distress, and decrease venous return).IV administration of rapid-acting loop diuretics, such as furosemide (Lasix).Effective intervention should result in diuresis (carefully monitor output), reduction in

respiratory distress, improved lung sounds, and adequate oxygenation.

Cardiac TamponadeCan result from fluid accumulation in the pericardial sac. Signs include hypotension, jugular venous distention, muffled heart sounds, and paradoxical pulse (variance of 10 mm Hg or more in systolic blood pressure between expiration and inspiration). Hemodynamic monitoring will reveal intracardiac and pulmonary artery pressures similar and elevated (plateau pressures).

Nursing Actions:Notify the provider immediately.Administer IV fluids to combat hypotension as prescribed.Obtain a chest x-ray or echocardiogram to confirm diagnosis.Prepare the client for pericardiocentesis (informed consent, gather materials, administer medications as appropriate).Monitor hemodynamic pressures as they normalize. Monitor heart rhythm; changes indicate improper positioning of the needle. Monitor for recurrence of signs after the procedure.

Coronary Artery DiseaseCaused by an imbalance between myocardial oxygen supply and demand.

An increased risk of coronary artery disease exists for older adult clients who arephysically inactive, have one or more chronic diseases (hypertension, heart failure,and diabetes mellitus), or have lifestyle (smoking and diet) habits that contribute toatherosclerosis.The incidence of cardiac disease increases with age, especially in the presence ofhypertension, diabetes mellitus, hypercholesterolemia, elevated homocysteine, andhighly sensitive C-reactive protein (HS-CRP).Atherosclerotic changes related to aging predispose the heart to poor blood perfusionand oxygen delivery.

Nonmodifiable Risk Factors for Coronary Artery Disease

Increasing age Family history of coronary artery disease

Men are more likely to develop heart disease than are premenopausal women even if they are the same age

Race (higher incidence in African Americans than whites)

Modifiable Risk Factors for Coronary Artery DIsease

Elevated serum cholesterolCigarette smoking

HypertensionDiabetes mellitusPhysical inactivity

ObesityStress

Oral contraceptive use or hormone replacement therapyHyperthyroidism

Methamphetamine or Cocaine Use

Nursing management for Coronary Artery Disease

Health Promotion Do not smoke Follow balanced diet that limits intake of fat and sodium Check blood pressure and cholesterol regularlyEngage in regular physical activity - the goal is reduction of blood pressure and

pulse rate upon exertion

A client who has angina reports that he is not able to make all of the lifestyle changes recommended. Which of the following changes should the nurse suggest that the client work on first?

A. Diet modificationB. Relaxation exercisesC. Smoking cessationD. Taking omega-3 capsules

A client who has angina reports that he is not able to make all of the lifestyle changes recommended. Which of the following changes should the nurse suggest that the client work on first?

A. Diet modificationB. Relaxation exercisesC. Smoking cessationD. Taking omega-3 capsules

According to the airway, breathing, and circulation (ABC) priority setting framework, ensuring that the client has adequate oxygen should be the nurse’s first priority. Nicotine causes vasoconstriction, elevates blood pressure, and narrows coronary arteries; therefore, the nurse should suggest that the client first work on a smoking cessation program.

AnginaAngina pectoris is a warning sign of an impending acute MI. Relieved by rest or nitroglycerin. Precipitated by exertion or stress. Symptoms last less than 15 minutes. Not associated with nausea, epigastric distress, dyspnea, anxiety, or diaphoresis.

Stable angina (exertional angina) occurs with exercise or emotional stress and is relieved by rest or nitroglycerin (Nitrostat).

Unstable angina (preinfarction angina) occurs with exercise or emotional stress, but it increases in occurrence, severity, and duration over time.

Variant angina (Prinzmetal’s angina) is due to a coronary artery spasm, often occurring during periods of rest.

Pain unrelieved by rest or nitroglycerin and lasting for more than 15 min differentiates an MI from angina.

Assessment for Angina

Pallor and cool, clammy skinTachycardia

Heart palpitationsDiaphoresis

VomitingDecreased level of consciousness

Antianginal Medications

Vasodilators

Nitroglycerin (Nitro-Bid, Nitrostat, Transderm-Nitro) Flushing, Hypotension, Headache, Tachycardia, Dizziness, Blurred vision Prevents coronary artery vasospasm and reduces preload and afterload, decreasing myocardial oxygen demand.Avoid alcoholic beverages. Sublingual dose may be repeated every 5 min for 3 doses, If pain is unrelieved, then seek immediate further medical care. Protect drug from light. Should wet tablet with saliva and place under tongue. Lie down when taking sublingual nitroglycerin. Headache most common side effect.

Isosorbide (Isordil, Sorbitrate) Headache, Orthostatic hypotensionChange position slowly. Take between meals. Don’t discontinue abruptly.

Calcium channel blockersAmlodipine (Norvasc) Diltiazem (Cardizem) Verapamil (Calan) Hypotension Contraindicated in second- or third-degree heart block, cardiogenic shock, severe bradycardia, heart failure, or hypotension. Use cautiously with renal or hepatic impairment. Can potentiate the action of digoxin.

Angiotensin converting enzyme inhibitorsCaptopril (Capoten) Dry annoying cough, Hypotension, Hyperkalemia Diuretics increase effect. Avoid high-potassium foods.

Beta blockersPropranolol (Inderal) Metoprolol (Lopressor) Atenolol (Tenormin) Carvedilol (Coreg) Bradycardia, Hypotension, Bronchoconstriction Should not be given to clients with known or suspected coronary artery spasms. Clients who continue to smoke have reduced effectiveness of therapy. Clients with asthma may experience bronchospasms. Should be used with caution in clients with diabetes mellitus (may mask signs of hypoglycemia). Should be discontinued gradually to prevent rebound angina. Hold the medication if the client’s apical pulse is less than 60/min and notify the provider.

Aspirin (Ecotrin) and Clopidogrel (Plavix) GI Bleeds, Tinnitus can be a sign of aspirin toxicity. Prevents platelets from forming together, which can produce arterial clotting.■Remind the client of the risk for bruising and bleeding while on this medication. Encourage the client to use aspirin tablets with enteric coating and to take with food. Ask the client if she is experiencing ringing in the ears.

Glycoprotein IIB/IIIA inhibitorsEptifibatide (Integrilin) Bleeding. Used to prevent the binding of fibrogen, in turn blocking platelet aggregation. In combination with aspirin therapy, IIB/IIA inhibitors are standard therapy.Instruct the client to report signs of bleeding during medication therapy.

A client asks a nurse why her provider prescribed 1 aspirin per day. Which of the following responses should the nurse give?

A. “Aspirin reduces the formation of blood clots that could cause a heart attack.”

B. “Aspirin decreases any pain due to myocardial ischemia.”C. “Aspirin dissolves any clots that are forming in your coronary arteries.”D. “Aspirin relieves any headaches that are caused by other medications.”

A client asks a nurse why her provider prescribed 1 aspirin per day. Which of the following responses should the nurse give?

X A. “Aspirin reduces the formation of blood clots that could cause a heart attack.”

B. “Aspirin decreases any pain due to myocardial ischemia.”C. “Aspirin dissolves any clots that are forming in your coronary arteries.”D. “Aspirin relieves any headaches that are caused by other medications.”

Aspirin decreases platelet aggregation. One aspirin a day is not sufficient to alleviate ischemic pain. Aspirin does not dissolve clots. Other medications can cause headaches, but one aspirin per day is not administered as an analgesic

Heparin Can produce hemorrhage from any body site (10%) ,Tissue irritation/pain at injection site, Anemia ,Thrombocytopenia, Fever Monitor therapeutic PTT at 1.5–2.5 times the control without signs of hemorrhage. Lower limit of normal 20–25 sec; upper limit of normal 32–39 sec. For IV administration: use infusion pump, peak 5 minutes, duration 2–6 hours For injection: give deep SQ; never IM (danger of hematoma), onset 20–60 minutes, duration 8–12 hours Antidote: protamine sulfate within 30 minutes Can be allergenicEnoxaparin low-molecular weight heparin (Lovenox) Same as heparin Less allergenic than heparin, Must be given deep SQ, never IV or IM. Does not require lab test monitoringWarfarin (Coumadin) Hemorrhage, Diarrhea, Rash, FeverMonitor therapeutic PT at 1.5–2.5 times the control, or monitor international normalized ratio (INR) Normal PT 9.5–12 sec; normal INR 2.0–3.5. Onset: 12–24 hours, peak 1.5–3 days, duration: 3–5 days. Antidotes: vitamin K, whole blood, plasma. Teach measures to avoid venous stasis. Emphasize importance of regular lab testing. Patient should avoid foods high in vitamin K: many green vegetables, pork, rice, yogurt, cheeses, fish, milk.

AnalgesicsMorphine sulfate respiratory depression,euphoria, sedation, and a decrease in GI motility.Use cautiously with clients who have asthma or emphysema due to the risk ofrespiratory depression.For the client having chest pain, assess the client’s pain every 5 to 15 min. Watch the client for signs of respiratory depression, especially older adults. If the respirations are 12/min or less, stop the medication and notify the provider immediately. Monitor the client’s vital signs closely for signs of hypotension and decreased respirations. Observe the client for nausea and vomiting.

Myocardial Infarction

Can occur without cause, often in the morning, after rest. Relieved only by opioids. Symptoms last more than 30 minutes. Associated with nausea, epigastric distress, dyspnea, anxiety, diaphoresis

Cardiac enzymes released with cardiac muscle injuryMyoglobin – Levels no longer evident after 24 hrCreatine kinase-MB – Levels no longer evident after 3 daysTroponin I – Levels no longer evident after 7 daysTroponin T – Levels no longer evident after 14 to 21 days

A client who has a diagnosis of an MI reports that dyspnea began 2 weeks ago. Which of the following cardiac enzymes should the nurse assess to determine if the infarction occurred 14 days ago?

A. CK-MBB. Troponin IC. Troponin TD. Myoglobin

A client who has a diagnosis of an MI reports that dyspnea began 2 weeks ago. Which of the following cardiac enzymes should the nurse assess to determine if the infarction occurred 14 days ago?

A. CK-MBB. Troponin I

X C. Troponin TD. MyoglobinThe Troponin T level will still be evident 14 to 21 days following an MI. Troponin

I levelsare no longer evident after 7 days, myoglobin levels are no longer evident after

24 hr, andcreatine kinase-MB levels are no longer evident after 3 days.

Interdisciplinary Care for Myocardial Infarction

Pain management services can be consulted if pain persists and/or is uncontrolled.

Cardiac rehabilitation care can be consulted if the client has prolonged weakness andneeds assistance with increasing level of activity.

Nutritional services can be consulted for diet modification to promote low-sodiumand low-saturated fat food choices.

Medications for Myocardial InfarctionThrombolyticsReteplase (Retavase) Alteplase (Activase) Tissue plasminogen activator (t-PA) Bleeding t-PA is a naturally occurring enzyme Low allergenic risk but high cost

Anistreplase (Eminase) Streptokinase (Streptase [SK]) Bleeding Because streptokinase is made from a bacterium, patient can have an allergic reaction. Not used if patient had recent Streptococcus infection or received Streptase in past year

Retavase and Activase break down plasminogen into plasmin, which dissolves the fibrin network of a clot. Eminase and Streptase bind with plasminogen to form a complex that digests fibrin.Indications - MIs within the first 6 hours after symptoms, limited arterial thrombosis, thrombotic strokes, occluded shunts Nursing considerations - Check for signs of bleeding; minimize number of punctures for inserting IVs; avoid IM injections; apply pressure at least twice as long as usual after any puncture.

Which of the following findings will help a nurse distinguish angina from an MI?A. Angina can be relieved with rest and nitroglycerin.B. An MI will be relieved with nitroglycerin.C. An MI will have cardiac enzyme levels within the expected reference range.D. Angina can occur for longer than 30 min.

Which of the following findings will help a nurse distinguish angina from an MI?X A. Angina can be relieved with rest and nitroglycerin.

B. An MI will be relieved with nitroglycerin.C. An MI will have cardiac enzyme levels within the expected reference range.D. Angina can occur for longer than 30 min.

Angina can be relieved with rest and nitroglycerin. An MI will need to be relieved using

opioids. Cardiac enzymes are abnormal with an MI. Angina usually occurs for 15 min or less

Cardiogenic ShockInjury to the left ventricle can lead to decreased cardiac output and heart failure. A serious complication of pump failure, commonly following an MI of 40% blockage.Assessment - Tachycardia, hypotension, inadequate urinary output, decreased level of consciousness, respiratory distress, cool, clammy skin, decreased peripheral pulses, and chest pain.

Nursing ActionsAdministration of oxygen; possible intubation and ventilation may be required.IV administration of morphine, diuretics, and/or nitroglycerin to decrease preload;

and IV administration of vasopressors and/or positive inotropes to increase cardiac output and to maintain organ perfusion.

Maintain continuous hemodynamic monitoring.

Ischemic mitral regurgitation

Ischemia can be evidenced by the development of a new cardiac murmur.

Nursing ActionsAdminister oxygen to the client.Notify the provider immediately.

Ventricular aneurysms/rupture

Necrosis due to an MIChest pain, dysrhythmias, and severe hypotension.

Nursing ActionsAdminister oxygen to the client.Notify the provider immediately.

Dysrhythmias

An inferior wall MI may lead to an injury to the AV node resulting in bradycardia and second-degree AV heart block. An anterior wall MI may lead to an injury to the ventricle resulting in premature ventricular contractions, bundle branch, or a complete heart block.

Nursing ActionsMonitor ECG and vital signs.Administer oxygen.Administer antidysrhythmic medications as indicated.Prepare for cardiac pacemaker if needed.

Atrial FibrillationThe atria fibrillate, or quiver, due to diseased heart tissue of the sinus electrical conduction system. Frequently accompanied by a rapid ventricular response.

Treated with calcium channel blockers depress depolarization and decrease oxygen demand of the heart.Verapamil (Calan) Diltiazem (Cardizem) Decrease force of contraction, Decrease heart rate, Slow rate of conduction through the AV node. Can cause Bradycardia and hypotension. Severe hypotension may be reversed with calcium chloride.

A client presents to the emergency room with severe hypotension. The family states the client is taking verapamil (Calan) for atrial fibrillation. The emergency room nurse should prepare to give which of the following?

A. Calcium chloride B. Epinephrine sodium chloride C. Potassium chloride D. Magnesium sulfate

A client presents to the emergency room with severe hypotension. The family states the client is taking verapamil (Calan) for atrial fibrillation. The emergency room nurse should prepare to give which of the following?

X A. Calcium chloride B. Epinephrine sodium chloride C. Potassium chloride D. Magnesium sulfate

Verapamil is a calcium channel blocker used to treat atrial fibrillation, atrial flutter and paroxysmal ventricular tachycardia. Severe hypotension may be reversed with calcium chloride given slowly, IV. The other medications will not reverse the hypotension

Which of the following clients are at risk for the development of dysrhythmias? (Select all that apply.)

Metabolic alkalosisA client who has a serum potassium level of 4.3 mEq/LA client who has an SaO2 of 96%A client who has COPDA client who is 3 hr post MI

Which of the following clients are at risk for the development of dysrhythmias? (Select all that apply.)

X Metabolic alkalosisA client who has a serum potassium level of 4.3 mEq/LA client who has an SaO2 of 96%X A client who has COPDX A client who is 3 hr post MI

These ABG results, COPD, and a recent MI are risk factors for developing a dysrhythmia. A potassium level of 4.3 mEq/L (expected reference range) and an oxygen saturation of 96% (expected reference range) do not increase the risk for developing dysrhythmias.

EndocarditisBacterial endocarditis or subacute bacterial endocarditis - infection of the valves or lining of the heart.

Bacterial endocarditis prophylaxisReceiving prophylactic antibiotic therapy prior to dental and surgical

procedures (dental extractions, endodontic surgery, surgical procedures that involve the respiratory or gastrointestinal mucosa).

Causative organisms include Streptococcus viridans and Staphylococcus aureus.

Nursing ActionsAdminister antibiotics parenterally for approximately 8 weeks.