cardiac conditions

Cardiac Conditions

During pregnancy blood volume increases as much as 50% above the nonpregnant level and is accompanied byincreases in maternal heart rate and stroke volume necessitating a drop in systemic and pulmonary vascular resistance.The client with heart disease may not be able to readily accommodate the higher workload of pregnancy as a result ofdecreased cardiac reserves.

(This plan of care is to be used in conjunction with the Trimesters and The High-Risk Pregnancy.)

CLIENT ASSESSMENT DATA BASE

Activity/Rest

Inability to carry on normal activitiesNocturnal/exertion-related dyspnea; orthopnea

Circulation

Tachycardia, palpitations; severe dysrhythmia.History of congenital/organic heart disease, rheumatic fever.Upward displacement of the diaphragm and heart proportionate to uterine size.May have a continuous diastolic or presystolic murmur; cardiac enlargement; loud systolic murmur, associated with a

thrill.BP may be elevated or may be decreased with decreased vascular resistance.Clubbing of toes and fingers may be present, with symmetric cyanosis in surgically untreated tetralogy of Fallot.

Elimination

Urine output may be decreased.Nocturia.

Food/Fluid

Obesity (risk factor)May have edema of the lower extremities

Pain/Discomfort

May report chest pain with/without activity

Respiration

Cough; may or may not be productive.Hemoptysis .Respiratory rate may be increased.Dyspnea/shortness of breath, orthopnea may be reported.Rales may be present.

Safety

Repeated streptococcal infections

Teaching/Learning

Possible history of valve replacement/prosthetic device, mitral valve prolapse, Marfan’s syndrome, surgicallytreated/untreated (rare) tetralogy of Fallot

DIAGNOSTIC STUDIESWhite Blood Cell (WBC) Count: Leukocytosis indicative of generalized infection, primarily streptococcal.Hemoglobin (Hg)/Hematocrit (Hct): Reveals actual versus physiological anemia; polycythemia.Maternal Arterial Blood Gases: Provide secondary assessment of potential fetal compromise due to maternal

respiratory involvement.Sedimentation Rate: Elevated in the presence of cardiac inflammation.Maternal Electrocardiogram (ECG): Demonstrates patterns associated with specific cardiac disorders,

dysrhythmias.Echocardiography: Diagnoses mitral valve prolapse or Marfan’s syndrome.Radionuclide Cardiac Imaging: Evaluates suspected atrial or ventricular septal defects, patent ductus arteriosus, or

intracardiac shunts.Serial Ultrasonography: Detects gestational age of fetus and possible IUGR.

NURSING PRIORITIES1. Monitor degree/progression of symptoms.2. Promote client involvement in control of condition and self-care.3. Monitor fetal well-being.4. Support client/couple toward culmination of a safe delivery.

DISCHARGE GOALS

Inpatient care not required unless complications develop.

NURSING DIAGNOSIS: Cardiac Output, risk for [decompensation]

Risk Factors May Include: Increased circulating volume, dysrhythmias, altered myocardialcontractility, inotropic changes in the heart

Possibly Evidenced By: [Not applicable; presence of signs/symptoms establishes an actualdiagnosis]

DESIRED OUTCOMES/EVALUATION Identify/adopt behaviors to minimize stressors andCRITERIA—CLIENT WILL: maximize cardiac function.

Tolerate the stress of increasing blood volume as indicated by BP andpulse within individually appropriate limits.

Demonstrate adequate placental circulation, kidney function withFHR and fetal movement WNL, and individually appropriate urineoutput.

ACTIONS/INTERVENTIONS RATIONALE

Independent

Determine/monitor client’s functional Useful for identifying client needs/limitations,classification (as outlined by the New York effectiveness of therapies, and progression/Heart Association): remission of condition.

Class I: No limitation of physical activity,no discomfort during exertion

Class II: Ordinary activity may cause symptomsof palpitation, dyspnea, and angina

Class III: Less than ordinary activity causescardiac symptoms, such as fatigue,dyspnea, and angina

Class IV: Symptoms of cardiac insufficiencyoccur in the absence of physical activity,and mortality risk per Clark’s classificationsystem of risk status for pregnant women.

Provide information about the necessity of Minimizes cardiac stress and conserves energy.adequate rest (e.g., 8–10 hr at night and 1/2 hr Class IV clients may require bedrest for theafter each meal). duration of the pregnancy. (Refer to ND: Activity

Intolerance, risk for.)

Discuss use of left or right lateral position. The occurrence of supine hypotension possibly to thepoint of loss of consciousness can be prevented if theclient avoids the supine position and adopts thelateral recumbent resting position.

Monitor vital signs. The beginning stage of decompensation caused byintolerance of circulatory load, infection, or anxietymay first be noted by an insidious change in the vitalsign pattern, associated with increased temperature,pulse (110 bpm or greater), respiration (greater than20–34/min), and BP.

Auscultate client’s breath sounds. Congestive heart failure (CHF) may develop,especially in clients whose functional classification isclass III or IV. Conversely, clients with mitral valveprolapse may be symptom-free during pregnancy,owing to the increase in left ventricular volume, yetare at high risk for involvement related to chest pain,palpitations, and possibly death after delivery.

Evaluate FHR, daily fetal movement count, and Fetal hypoxia caused by beginning stage ofNST results as indicated. (Refer to CP: The High- maternal cardiac decompensation may be noted inRisk Pregnancy; ND: Injury, risk for fetal.) the form of tachycardia, bradycardia, or reduction

in fetal activity.

Assess for evidence of venostasis with resulting Prolonged positioning of legs and ankles belowdependent edema of extremities or generalized the level of the heart further impairs venous returnedema. Instruct client to elevate legs when sitting in an already stressed circulatory system anddown and periodically during the day. places the client at risk for PIH.

Instruct client to monitor fluid intake/output. Although intake and output should be(Refer to ND: Fluid Volume, risk for excess.) approximately the same, cardiovascular involvement

may negatively affect kidney function, resulting inoliguria/anuria.

Investigate reports of chest pain and palpitations. Clients with mitral valve prolapse may developRecommend limiting caffeine as appropriate. arrhythmias resulting in chest pain and palpitations.

Limiting caffeine may reduce frequency of episodes.

Review medication needs and reason for conversion Because of its large molecular size, heparin sodiumto heparin by warfarin (Coumadin) users. does not cross the placenta, as does warfarin; also,

heparin may prevent clot formation in the client withvalve prosthesis/atrial fibrillation.

Instruct client in self-administration of medication Involves client in therapeutic process, andsuch as heparin. Observe return demonstration of promotes self-care.procedure by client.

Assess for/review signs of ecchymosis, epistaxis, Signs of bleeding may indicate a need to reduceand so forth during anticoagulant therapy. heparin dosage.

Collaborative

Participate in/coordinate multispecialty care Provides opportunity to review management ofconference as appropriate. both pregnancy and cardiac condition, and to plan

for special needs during intrapartum and postpartumperiods.

Administer medications such as digitalis glycosides Cardiac stress brought on by increased demand(digoxin or digitoxin) or propranolol (Inderal) as for output is greatest between 28 and 32indicated. Monitor for early labor. weeks’ gestation, then levels off until delivery.

Digitalis glycosides maximize ventricularcontractions, but increased plasma volumemay lower circulating levels of the drug,necessitating increased or more frequentdoses. Digitalis has a direct effect on themyometrium, often causing early labor aswell as shortening the length of labor. Propranololmay be used to control dysrhythmias associatedwith mitral valve prolapse. Note: Althoughthese drugs cross the placenta and have noreported teratogenic effects, studies have notyet clearly established their safety in pregnancy.In addition, ACE inhibitors are contraindicatedbecause of the risk of fetal death or intractableneonatal renal failure.

Administer loading dose of heparin. Warfarin users should have their anticoagulantconverted to heparin. Initial dose may beadministered intravenously by healthcareprovider.

Treat underlying infections as necessary, e.g., Cardiac decompensation may develop/isrespiratory, and provide prophylaxis as necessary. worsened by superimposed upper respiratory(Refer to ND: Infection, risk for maternal.) infection, which is usually associated with

coughing and increased secretions, and whichmay mask deterioration of cardiac function.Prophylactic antibiotics help preventbacterial endocarditis in client with diseasedheart valves.

Using sequential serum/urine estriol levels and Reduced cardiac function may negatively affectCST/NST, assess placental functioning. (Refer to CP: placental functioning.The High-Risk Pregnancy; ND: Injury, risk forfetal.)

Obtain/review sequential ECGs. May demonstrate pathological pattern ifdecompensation is present; may identify type ofdysrhythmia.

Monitor laboratory studies, such as clotting times Prolonged clotting times may indicate need toand electrolyte levels. adjust heparin dosage. Hyponatremia/

hypokalemia may occur, owing to reduced sodiumintake or diuretic therapy with imbalancespotentiating-development/aggravation ofdysrhythmias.

Encourage use of antithrombotic stockings. Promotes venous return; limits venous stasis.

Prepare client for hospitalization as warranted Clients with a functional classification of class IIby her condition. through class IV are usually hospitalized 2 wk before

expected delivery, because likelihood ofdecompensation is greatest during the latter part ofthe third trimester. Clients with class IV function maybe hospitalized earlier in the pregnancy, dependingon fetal status/developing complications.

Monitor hemodynamic pressures using arterial CVP lines measure venous return/circulatingand central venous pressure (CVP) lines or Swan- volume; the Swan-Ganz catheter may be requiredGanz catheter to monitor pulmonary artery wedge to monitor pulmonary pressures and, indirectly,pressure as indicated. left-sided heart function in client hospitalized for

progressive CHF.

NURSING DIAGNOSIS: Fluid Volume risk for excess

Risk Factors May Include: Increasing circulating volume, changes in renal function, dietaryindiscretion


DESIRED OUTCOMES/EVALUATION Demonstrate stable fluid balance with vital signs

CRITERIA—CLIENT WILL: WNL, appropriate weight gain, absence of edema.

Verbalize understanding of restrictions/therapy needs.

List signs that require notification of care provider.


Independent

Obtain baseline weight. Instruct client to monitor Weight gain exceeding the normal 2–21/2 lb/wkher weight at home periodically as indicated. may indicate accumulating fluid and potential

CHF. If weight gain is sudden, rule out toxemia.

Review dietary intake, noting factors that may Improper diet, specifically a deficiency of proteincontribute to excessive fluid retention; provide and excess of sodium, contributes to fluidinformation as needed. retention.

Instruct client to monitor amount and color Decreased output, dark amber urine; increasing(concentration) of urine. Measure specific gravity as specific gravity may reflect impaired renalappropriate during home/office visit. perfusion associated with developing CHF.

Assess for/review signs of CHF with client (e.g., Indicates developing failure and need fordyspnea, distended neck veins, crackles, hemoptysis, immediate treatment. The normal increase of 1300and so forth). ml in circulatory volume that occurs in pregnancy

can put stress on the cardiac system. Further increaseof fluid can be especially dangerous for the clientwith existing cardiac problems.

Investigate unexplained cough. Cough unrelated to respiratory problems mayindicate developing CHF.

Collaborative

Restrict fluids and sodium in presence of CHF. Minimizes risk of fluid retention/overload.

Administer diuretics, e.g., chlorothiazide (Diuril), Helps rid body of excess fluid resistant tohydrochlorothiazide (HCTZ), furosemide (Lasix), conservative treatment of rest and decreasedas appropriate. sodium intake.

NURSING DIAGNOSIS: Tissue Perfusion, risk for altered: uteroplacental

Risk Factors May Include: Changes in circulating volume, right-to-left shunt


DESIRED OUTCOMES/EVALUATION Display BP, pulse, ABGs, and WBC count WNL.CRITERIA—CLIENT WILL: Demonstrate adequate placental perfusion as

indicated by reactive fetus with heart rate ranging from 120–160 bpmand size appropriate for gestational age.


Independent

Note individual risk factors and pregravid state. Any preexisting cardiac problems complicated byincreased circulatory needs during pregnancy mayresult in impaired tissue oxygenation. Note: Suchproblems are greater in the older client with obesityand long-standing cardiac involvement.

Assess BP and pulse. Note behavior changes, Tachycardia (heart rate greater than 110 bpm) at rest,cyanosis of mucous membranes and nail beds, increasing BP, and behavior changes may indicateactivity intolerance, and signs of decompensation early cardiac failure or hypoxia. A fall in peripheral(i.e., excessive weight gain, unexplained cough, vascular resistance may result in a worsening of right-crackles/wheezes, hemoptysis, and increased to-left shunting and cyanosis. Presence of cyanosis, apulse and respiratory rate). late sign of hypoxia, reflects severe problems and

indicates severity of tissue damage and cardiaccompromise.

Provide information about use of modified upright Eases respiratory rate by reducing pressure of theposition for sleeping and resting. enlarging uterus on the diaphragm and helps

increase vertical diameter for lung expansion. Helpsprevent venous stasis in lower extremities.

Collaborative

Monitor laboratory studies as indicated:

Pulse oximetry/ABGs; Reflects adequacy of ventilation and oxygenation.Hb/Hct; Anemia further reduces oxygen-carrying capacity of

blood and may require treatment.WBC count, culture of upper/lower respiratory Any respiratory involvement reduces intake of oxygen.

secretions. Infection increases metabolic rates and oxygen needsand may have a negative impact on tissue oxygenation.

Assess uterine/fetal blood flow using NST/CST; Uterine/placental hypoxia reduces fetal activitycheck estriol levels and FHR. (Refer to CP: The High- and FHR, and presents as late decelerations onRisk Pregnancy; ND: Injury, risk for fetal.) CST. Hypoxia may result in placental deterioration

and falling estriol levels.

NURSING DIAGNOSIS: Infection, risk for maternal

Risk Factors May Include: Inadequate primary/secondary defenses, chronic disease/condition,insufficient information to avoid exposure to pathogens


DESIRED OUTCOMES/EVALUATION Identify/adopt behaviors to reduce individual risk.CRITERIA—CLIENT WILL:

Remain free of bacterial infection.

Demonstrate appropriate use of antimicrobial agents, as indicated.


Independent

Assess for individual risk factors and history of There is increased risk of bacterial endocarditis inrheumatic fever. the prenatal client with underlying heart disease,

such as valvular damage caused by rheumatic orcongenital processes, mitral valve prolapse,ventricular septal defect, tetralogy of Fallot,pulmonic stenosis, coarctation of the aorta, orprosthetic valve.

Provide information about risk of bacterial The client with a prosthetic valve is at high risk forendocarditis during specific medical-surgical bacterial endocarditis and emboli, even in anprocedures. uncomplicated vaginal delivery. Transient

bacteremia may occur following invasiveprocedures, including dental work. (About 60%–90% of clients develop bacteremia after dentalextraction).

Review signs/symptoms suggestive of infectious Prompt recognition of problem facilitates timelyprocesses requiring notification of healthcare intervention.provider, e.g., fever, malaise, cough, cloudy/odiferous urine.

Collaborative

Assess urine periodically, note pH, and presence Bacturia may be asymptomatic and lead toof bacteria. bacteremia if untreated.

Obtain cultures as indicated. Useful in identifying infecting agent/appropriatetherapy.

Administer penicillin PO or IM, when indicated. Prophylactic antibiotics may be recommended forprevention of streptococal infection duringpregnancy, especially in the client with history ofrheumatic fever.

NURSING DIAGNOSIS: Activity Intolerance, risk for

Risk Factors May Include: Presence of circulatory problems, previous episodes of intolerance,deconditioned status


DESIRED OUTCOMES/EVALUATION Demonstrate self-responsibility for monitoringCRITERIA—CLIENT WILL: activity tolerance/intolerance.

Adopt behaviors to maximize tolerance.

Take appropriate actions if cardiac/respiratory symptoms arise.


Independent

Assess for development of subjective/objective Indicates a worsening of the cardiac condition,symptoms (e.g., lessening of tolerance to ordinary evidenced by a decrease in the client’s functionalphysical activity, fatigue, cyanosis, inability to carry capacity.on normal daily activities, increasing dyspnea withor without physical activity, nocturnal dyspnea,change in pulse rate, development of respiratorysymptoms).

Review signs/symptoms with the client and Promotes self-care and timely medicalsignificant other(s). interventions.

Assist client in setting priorities and restructuring Circulatory/respiratory impairment may interferedaily routine to include needed rest/sleep periods. with ability to perform activities of daily livingDetermine expectations of client and partner. (ADLs) and may result in fatigue. Activity isExplore conflicts/differences. limited in relation to the extent of cardiac

impairment. Clients with class I or II limitation mayonly need to include midmorning andmidafternoon rest periods, whereas class III orclass IV clients may need bedrest for much orall of the day.

Identify energy conserving methods to accomplish May enable client to manage activities morenecessary ADLs. effectively.

Ascertain effectiveness of household assistance and May be needed to maximize rest, limit fatigue, andavailable resources. preserve cardiac function.

Collaborative

Refer to home care agency, community resources Can provide additional assistance when necessary.as indicated.

Refer to occupational therapist (OT), physical May be helpful in identifying assistivetherapist (PT), as appropriate. techniques/devices to conserve energy and

accomplish desired ADLs.

NURSING DIAGNOSIS: Knowledge deficit [Learning Need], regarding condition,prognosis, and treatment needs

May Be Related To: Lack of exposure to and/or misinterpretation of information

Possibly Evidenced By: Request for information, statement of misconception, inaccuratefollow-through of instructions

DESIRED OUTCOMES/EVALUATION Verbalize understanding of individual conditionCRITERIA—CLIENT WILL: and treatment needs.

Identify symptoms indicating deterioration ofcardiac functioning.

Intervene and/or notify healthcare provider appropriately.


Independent

Assess understanding of pathology/complications Establishes data base for health teaching.regarding cardiac condition and pregnancy. Increasingly severe cardiac symptoms mayReview history, incidence of complications, indicate client’s need for more information and/orand so forth. assistance to manage necessary self-care.

Discuss necessity for frequent monitoring; i.e., every Provides for early detection of problems and2 wk during first 20 wk, then every week prompt intervention.until delivery.

Provide information about symptoms indicative Symptoms associated with decompensationof cardiac involvement, such as shortness of breath, should be differentiated from symptomscough, palpitations, unusual or rapid weight gain associated with PIH. (Refer to CP: Pregnancy-(i.e., 2.2–4.4 lb or 1–2 kg in a 2-day period), edema, Induced Hypertension; ND: Fluid Volume deficit.)or anorexia.

Provide information as appropriate regarding Enhances informed decision making, helps reducediet, rest/sleep, exercise, and relaxation. likelihood of complications. The impact of pregnancy

superimposed on an existing cardiac problem maynecessitate changes in lifestyle. An understanding oftechniques designed to lessen cardiac stress mayrequire the acquisition of new knowledge.

Review need/techniques to avoid infection. Resistance may be lowered because of generalcondition.

Review side effects of both prescription and Determines client’s level of knowledge andOTC drugs. provides current information.

Discuss special considerations, such as need to Such foods counteract/alter anticoagulant drugavoid foods high in vitamin K (raw, deep-green effect.leafy vegetables) when on anticoagulants.

Include healthcare team in teaching/planning. Provides continuity and completeness of care.

Provide appropriate information for protocol of May foster self-responsibility and reduce anxiety.care in home/community/hospital setting.

Identify support groups, community resources. May serve as role model for necessary adaptations,enhance coping ability, and provide encouragementfor a successful outcome.

cardiac conditions

Documents