care of clients with cardiovascular problems
TRANSCRIPT
Assessment of Cardiovascular Function
Overview of Anatomy and Physiology of the HeartThree layers of the heart:
EndocardiumMyocardiumEpicardium
Four chambersHeart valvesCoronary arteriesCardiac conduction systemCardiac hemodynamics
Structure of the Heart
Coronary Arteries
Cardiac Conduction System
Terms: Cardiac Action Potential Depolarization: electrical activation of a cell
caused by the influx of sodium into the cell while potassium exits the cell
Repolarization: return of the cell to the resting state caused by re-entry of potassium into the cell while sodium exits
Refractory periods:Effective refractory period: phase in which
cells are incapable of depolarizingRelative refractory period: phase in which cells
require a stronger-than-normal stimulus to depolarize
Cardiac Action Potential
Great Vessel and Heart Chamber Pressures
Terms: Cardiac Output
Stroke volume: the amount of blood ejected with each heartbeat
Cardiac output: amount of blood pumped by the ventricle in liters per minute
Preload: degree of stretch of the cardiac muscle fibers at the end of diastole
Contractility: ability of the cardiac muscle to shorten in response to an electrical impulse
Afterload: the resistance to ejection of blood from the ventricle
Ejection fraction: the percent of end-diastolic volume ejected with each heartbeat
CO= SV x HRControl of heart rate
Autonomic nervous system and baroreceptors Control of strike volume
Preload: Frank-Starling lawAfterload: affected by systemic vascular
resistance and pulmonary vascular resistanceContractility increased by catecholamines,
SNS, some medications and decreased by hypoxemia, acidosis, some medications
AssessmentHealth history
Demographic information Family/genetic historyCultural/social factors
Risk factorsSee Chart 26-2ModifiableNonmodifiable
Most Common Clinical Manifestations
Chest painDyspneaPeripheral edema and weight gainFatigueDizziness, syncope, changes in level of
consciousnessSee Chart 26-1 and Table 26-2
Assessing Chest Pain
Assessing Chest Pain
Assessing Chest Pain
Assessing Chest Pain
Assessing Chest Pain
Assessing Chest Pain
AssessmentNutritionEliminationActivity and exerciseSleep and restCognition and perceptionSelf-perception and self-conceptRoles and relationshipsSex and reproductionCoping and stress
Health Promotion, Perception, and Management Questions
Ask regarding health promotion and preventive practices.
What type of health issues do you have? Are you able to identify any family history or behaviors that put you at risk for this health problem?
What are your risk factors for heart disease? What do you do to stay healthy?
How is your health? Have you noticed any changes?
Do you have a cardiologist or primary health care provider? How often do you go for check-ups?
Do you use tobacco or alcohol?What medications do you take?
Laboratory TestsCardiac biomarkersCK and CK-MBMyoglobinTroponin T and I Lipid profileBrain (B-type) natriuretic peptideC-reactive proteinHomocysteine
Electrocardiography12-lead ECGContinuous monitoring: hardwire and
telemetrySignal-averaged ECGContinuous ambulatory monitoringTranstelephonic monitoringWireless mobile monitoringCardiac stress testing
Exercise stress testing Pharmacologic stress testing
Diagnostic TestsChest x-ray and fluoroscopyEchocardiogram and transesophageal
echocardiogramRadionuclide imagingMyocardial perfusion imagingEquilibrium radionuclide angiocardiography
(ERNA or MUGA)CT scansPET scansElectrophysiologic testing (EPS)
Cardiac CatheterizationInvasive procedure used to measure cardiac
chamber pressures and assess patency of the coronary arteries
Requires ECG and hemodynamic monitoring; emergency equipment must be available
Assessment prior to test; allergies, blood workAssessment of patient after procedure: circulation,
potential for bleeding, potential for dysrhythmias Activity restrictionsPatient education before & after procedure
See Chart 26-4
Hemodynamic MonitoringCVPPulmonary artery pressure Intra-arterial BP monitoring
Phlebostatic Level
Pulmonary Artery Catheter
Pulmonary Artery Catheter and Pressure Monitoring System
Arterial Pressure Monitoring System
Dysrhythmias
Dysrhythmias: dsiorders of the formation or conduction (or both) of the electrical impulses in the heart
These disorders can cause disturbances of:RateRhythmBoth rate and rhythm
Potentially can alter blood flow & cause hemodynamic changes
Diagnosed by analysis of ECG waveform
Relationship of ECG Complex, Lead System, and Electrical Impulse
ECG Electrode Placement
ECG Graph and Commonly Measured Components
Heart Rate Determination
Normal Sinus Rhythm
Sinus Bradycardia
Sinus Tachycardia
Sinus Arrhythmia
Premature Atrial Complexes
Atrial Flutter
Atrial Fibrillation
Multifocal PVCs-Quadrigeminy
Ventricular Tachycardia
Ventricular Fibrillation
Asystole
First-Degree AV Block
Second-Degree AV Block, Type 1
Second-Degree AV Block, Type 2
Third-Degree AV Block
Nursing Process: Patient with a Dysrhythmia: Assessment
Assess indicators of cardiac output and oxygenation, especially changes in level of consciousness.
Physical assessment includes:Rate and rhythm of apical and peripheral pulsesAssess heart sounds Blood pressure and pulse pressure Signs of fluid retention
Health history: include presence of coexisting conditions and indications of previous occurrence
Medications
Nursing Process: The Care of the Patient with a Dysrhythmia: Diagnosis
Decreased cardiac outputAnxiety Deficient knowledge
Collaborative Problems/Potential Complications
Cardiac arrestHeart failureThromboembolic event, especially with atrial
fibrillation
Nursing Process: The Care of the Patient with a Dysrhythmia: Planning
Goals may include eradicating or decreasing the occurrence of the dysrhythmia to maintain cardiac output, minimizing anxiety, and acquiring knowledge about the dysrhythmia and its treatment.
Decreased Cardiac Output
MonitoringECG monitoringAssessment of signs and symptoms
Administration of medications and assessment of medication effects
Adjunct therapy: cardioversion, defibrillation, pacemakers
Other InterventionsAnxiety
Use a calm, reassuring manner.Measures to maximize patient control to make
episodes less threateningCommunication and teaching
Teaching self-careInclude family in teaching
PacemakersAn electronic device that provides electrical
stimuli to the heart muscleTypes:
PermanentTemporary
NASPE-BPEG code for pacemaker function
Implanted Transvenous Pacemaker
Transcutaneous Pacemaker
ECG On-Demand Pacing
Complications of Pacemaker UseInfectionBleeding or hematoma formationDislocation of the leadSkeletal muscle or phrenic nerve stimulationCardiac tamponadePacemaker malfunction
See Table 27-2
Nursing Process: The Care of the Patient with an Implanted Cardiac Device: Assessment
Device function; ECGCardiac output and hemodynamic stabilityIncision siteCopingPatient and family knowledge
Nursing Process: The Care of the Patient with an Implanted Cardiac Device: Diagnosis
Risk for infectionRisk for ineffective copingKnowledge deficiency
Nursing Process: The Care of the Patient with an Implanted Cardiac Device- Planning
Goals include absence of infection, adherence to self-care program, effective coping, and maintenance of device function.
InterventionsRisk for ineffective coping
Support of patient and family copingSetting of realistic goalsAllow patient to talk, share feeling and
experiences Support groups or referralStress reduction techniques
Knowledge deficiencyPatient and family teaching
See Chart 27-3
Cardioversion and DefibrillationTreat tachydysrhythmias by delivering an
electrical current that depolarizes a critical mass of myocardial cells. When cells repolarize, the sinus node is usually able to recapture its role as heart pacemaker.
In cardioversion, the current delivery is synchronized with the patient’s ECG.
In defibrillation, the current delivery is unsynchronized.
Safety Measures Ensure good contact between skin and pads or
paddles. Use a conductive medium and 20-25 pounds of pressure.
Place paddles so that they do not touch bedding or clothing and are not near medication patches or oxygen flow.
If cardioverting, turn the synchronizer on. If defibrillating, turn the synchronizer off. Do not charge the device until ready to shock. Call “clear” three times; follow checks
required for clear and ensure that no one is in contact with the patient, bed, or equipment.
Paddle Placement for Defibrillation
Implantable Cardioverter Defibrillator (ICD)A device that detects and terminates life-
threatening episodes of tachycardia or fibrillation
NASPE-BPEG codeAntitachycardia pacing
ICD
Invasive Methods to Diagnose and Treat Recurrent Dysrhythmias
Electrophysiologic studiesCardiac conduction surgery
Maze procedureCatheter ablation therapy
Coronary Atherosclerosis
Atherosclerosis is the abnormal accumulation of lipid deposits and fibrous tissue within arterial walls and lumen.
In coronary atherosclerosis, blockages and narrowing of the coronary vessels reduce blood flow to the myocardium.
Cardiovascular disease is the leading cause of death in the United States for men and women of all racial and ethnic groups.
CAD (coronary artery disease) is the most prevalent cardiovascular disease in adults.
Pathophysiology of Atherosclerosis
Coronary Arteries
Clinical Manifestations
Symptoms are due to myocardial ischemia.Symptoms and complications are related to
the location and degree of vessel obstruction.Angina pectoris Myocardial infarctionHeart failureSudden cardiac death
The most common symptom of myocardial ischemia is chest pain; however, some individuals may be asymptomatic or have atypical symptoms such as weakness, dyspnea, and nausea.
Atypical symptoms are more common in women and in persons who are older or who have a history of heart failure or diabetes.
Angina Pectoris
A syndrome characterized by episodes of paroxysmal pain or pressure in the anterior chest caused by insufficient coronary blood flow
Physical exertion or emotional stress increases myocardial oxygen demand, and the coronary vessels are unable to supply sufficient blood flow to meet the oxygen demand.
Types of anginaSee Chart 28-3
Anginal pain varies from mild to severeMay be described as tightness, choking, or a
heavy sensationIt is frequently retrosternal and may radiate to
neck, jaw, shoulders, back, or arms (usually left).
Anxiety frequently accompanies the pain.Other symptoms may occur: dyspnea/shortness
of breath, dizziness, nausea, and vomiting.The pain of typical angina subsides with rest or
NTG. Unstable angina is characterized by increased
frequency and severity and is not relieved by rest and NTG. Requires medical intervention!
TreatmentTreatment seeks to decrease myocardial
oxygen demand and increase oxygen supply.MedicationsOxygenReduce and control risk factors.Reperfusion therapy may also be done.
MedicationsNitroglycerin
See Chart 28-5Beta-adrenergic blocking agentsCalcium channel blocking agentsAntiplatelet and anticoagulant medicationsAspirinClopidogrel and ticlopidineHeparinGlycoprotein IIB/IIIa agents
Nursing Process: The Care of the Patient with Angina Pectoris: AssessmentSymptoms and activities, especially those
that precede and precipitate attacksSee Chart 28-6Risk factors, lifestyle, and health promotion
activities Patient and family knowledgeAdherence to the plan of care
Collaborative ProblemsAcute pulmonary edemaHeart failureCardiogenic shockDysrhythmias and cardiac arrestMyocardial infarction
Nursing Process: The Care of the Patient with Angina Pectoris: DiagnosisIneffective cardiac tissue perfusionDeath anxietyDeficient knowledgeNoncompliance, ineffective management of
therapeutic regimen
Nursing Process: The Care of the Patient with Angina Pectoris: PlanningGoals include the immediate and appropriate
treatment of angina, prevention of angina, reduction of anxiety, awareness of the disease process, understanding of prescribed care, adherence to the self-care program, and absence of complications.
Treatment of Anginal Pain
Treatment of anginal pain is a priority nursing concern.
Patient is to stop all activity and sit or rest in bed.
Assess the patient while performing other necessary interventions. Assessment includes VS, observation for respiratory distress, and assessment of pain. In the hospital setting, the ECG is assessed or obtained.
Administer oxygen.Administer medications as ordered or by
protocol, usually NTG.
AnxietyUse a calm mannerStress-reduction techniquesPatient teachingAddressing patient spiritual needs may assist
in allaying anxietiesAddress both patient and family needs
Patient TeachingLifestyle changes and reduction of risk factors Explore, recognize, and adapt behaviors to
avoid to reduce the incidence of episodes of ischemia.
Teaching regarding disease processMedicationsStress reductionWhen to seek emergency careSee Chart 28-7
Myocardial InfarctionMyocardium is permanently destroyed.Caused by reduced blood flow in a coronary
artery due to rupture of an atherosclerotic plaque and subsequent occlusion of the artery by a thrombus.
In unstable angina, the plaque ruptures but the artery is not completely occluded.
Unstable angina and acute myocardial infarction are considered the same process but at different point on the continuum.
The term “acute coronary syndrome” includes unstable angina and myocardial infarction.
Effects of Ischemia, Injury, and Infarction on ECG
Clinical Manifestations and DiagnosisChest pain, other symptoms
See Chart 28-8ECGLaboratory tests--biomarkers
See Table 28-3CK-MBMyoglobinTroponin T or I
Treatment of Acute MI (See Chart 28-9)Obtain diagnostic tests including ECG within
10 minutes of admission to the ED.OxygenAspirin, nitroglycerin, morphine, beta-blockersAngiotensin-converting enzyme inhibitor within
24 hoursEvaluate for percutaneous coronary
intervention or thrombolytic therapy.As indicated; IV heparin or LMWH, clopidogrel
or ticlopidine, glycoprotein IIb/IIIa inhibitorBed rest
Nursing Process: The Care of the Patient with ACS: AssessmentA vital component of nursing care!See Chart 28-8.Assess all symptoms carefully and compare to
previous and baseline data to detect any changes or complications.
Assess IVs.Monitor ECG.
Nursing Process: The Care of the Patient with ACS: DiagnosisIneffective cardiac tissue perfusionRisk for fluid imbalanceRisk for ineffective peripheral tissue
perfusionDeath anxietyDeficient knowledge
Collaborative ProblemsAcute pulmonary edemaHeart failureCardiogenic shockDysrhythmias and cardiac arrestPericardial effusion and cardiac tamponade
Nursing Process: The Care of the Patient with ACS: Planning
Goalsrelief of pain or ischemic signs and symptoms, prevention of further myocardial damage, absence of respiratory dysfunction, maintenance of or attainment of adequate
tissue perfusion, reduced anxiety, adherence to the self-care program, absence or early recognition of complications.
Percutaneous Coronary Intervention
Coronary Artery Bypass Grafts
Greater and lesser saphenous veins are commonly used for bypass graft procedures.
Cardiopulmonary Bypass System
Postoperative Care of the Cardiac Surgical Patient
Valvular DisordersRegurgitation: the valve does not close
properly and blood backflows through the valve
Stenosis: the valve does not open completely and blood flow through the valve is reduced
Valve prolapse: the stretching of an atrioventricular valve leaflet into the atrium during diastole
Specific Valvular DisordersMitral valve prolapseMitral regurgitationMitral stenosisAortic regurgitationAortic stenosis
Pathophysiology: Left Heart Failure as a Result of Aortic and Mitral Valvular Heart Disease
Valve Repair and Replacement ProceduresValvuloplasty
Commissurotomy: open or closedBalloon valvuloplasty: open or closedAnnuloplastyLeaflet repairChordoplasty
Valve replacement
Balloon Valvuloplasty
Annuloplasty Ring Insertion
Valve Leaflet Resection and Repair with Ring Annuloplasty
Valve Replacement
Types of Replacement ValvesMechanical valves
Do not deteriorate or become infected as easily, but are thrombogenic and require life-long anticoagulation therapy.
Tissue (biologic) valvesXenograft (heterograft): pig or cow valveHomograft (allograft): human valveAutograft: patient’s own valve
Mechanical Valves
CardiomyopathyCardiomyopathy is a series of progressive
events that culminates in impaired cardiac output and can lead to heart failure, sudden death, or dysrhythmias.
Types: Dilated cardiomyopathyHypertrophic cardiomyopathyRestrictive cardiomyopathyArrhythmogenic cardiomyopathyUnclassified cardiomyopathies
Types of Cardiomyopathy
Infectious Diseases of the HeartAny of the layers of the heart may be affected
by an infectious process.Diseases are named by the layer of the heart
that is affected.Diagnosis is made by patient symptoms and
echocardiogram.Blood cultures may be used to identify the
infectious agent and to monitor therapy.Treatment is with appropriate antimicrobial
therapy. Patients need to be instructed to complete the course of appropriate antimicrobial therapy, and require teaching about infection prevention and health promotion.
Rheumatic EndocarditisOccurs most often in school-age children, after
group A beta-hemolytic streptococcal pharyngitisInjury to heart tissue is caused by inflammatory
or sensitivity reaction to the streptococci.Myocardial and pericardial tissue is also
affected, but endocarditis results in permanent changes in the valves.
Need to promptly recognize and treat “strep” throat to prevent rheumatic fever. See Chart 29-1.
Infective EndocarditisA microbial infection of the endothelial surface
of the heart. Vegetative growths occur and may embolize to tissues throughout the body.
Usually develops in people with prosthetic heart valves or structural cardiac defects. Also occurs in patients who are IV drug abusers and in those with debilitating diseases, indwelling catheters, or prolonged IV therapy. See Chart 29-2.
Types:Acute Subacute
PericarditisInflammation of the pericardiumMany causes
See Chart 29-3Nursing diagnosis: pain Potential complications
Pericardial effusionCardiac tamponade
Antibiotic ProphylaxisMechanical valve replacements including annuloplasty
or other prosthetic materialValvular defects including mitral click and murmur or
mitral regurgitation, mitral stenosis, aortic stenosis, and aortic regurgitation
A history of rheumatic heart disease, endocarditis, or myocarditis
Antibiotic prophylaxis is required for dental procedures and surgical interventions, including GU and GI procedures, to prevent endocarditis.
Heart FailureThe inability of the heart to pump sufficient blood to
meet the needs of the tissues for oxygen and nutrientsA syndrome characterized by fluid overload or
inadequate tissue perfusionThe term HF indicates myocardial disease, in which
there is a problem with the contraction of the heart (systolic failure) or filling of the heart (diastolic failure).
Some cases are reversible.Most HF is a progressive, lifelong disorder managed
with lifestyle changes and medications.
Pathophysiology of HF
Clinical Manifestations (See Chart 30-1)Right-sided failure
RV cannot eject sufficient amounts of blood, and blood backs up in the venous system. This resuts in perpheral edema, hepatomegaly, ascites, anorexia, nausea, weakness, and weight gain.
Left-sided failureLV cannot pump blood effectively to the systemic
circulation. Pulmonary venous pressures increase, resulting in pulmonary congestion with dyspnea, cough, crackles, and impaired oxygen exchange.
Chronic HF is frequently biventricular.
Classification of Heart FailureNYHA classification of HF
Classification I, II, III, IVACC/AHA classification of HF
Stages A, B, C, DTreatment guidelines are in place for each
stage.
Medical Management of HFEliminate or reduce etiologic or contributory
factors.Reduce the workload of the heart by reducing
afterload and preload.Optimize all therapeutic regimens.Prevent exacerbations of HF.Medications are routinely prescribed for HF.
MedicationsAngiotensin-converting enzyme inhibitorsAngiotensin II receptor blockersBeta-blockersDiureticsDigitalisOther medications
Nursing Process: The Care of the Patient with HF: AssessmentHealth historySleep and activityKnowledge and coping Physical exam
Mental statusLung sounds: crackles and wheezesHeart sounds: S3Fluid status/signs of fluid overload
Daily weight and I&OAssess responses to medications
Nursing Process: The Care of the Patient with HF: DiagnosisActivity intolerance and fatigueExcess fluid volumeAnxietyPowerlessnessNoncompliance
Collaborative Problems/Potential ComplicationsCardiogenic shockDysrhythmiasThromboembolismPericardial effusion and cardiac tamponade
Nursing Process: The Care of the Patient with HF: PlanningGoals may include promoting activity and
reducing fatigue, relieving fluid overload symptoms, decreasing anxiety or increasing the patient’s ability to manage anxiety, encouraging the patient to make decisions and influence outcomes, teaching the patient about the self-care program.
Activity IntoleranceBed rest for acute exacerbationsEncourage regular physical activity; 30-45 minutes daily Exercise training Pacing of activitiesWait 2 hours after eating before doing physical activity. Avoid activities in extremely hot, cold, or humid weather. Modify activities to conserve energy.Positioning; elevation of HOB to facilitate breathing and
rest, support of arms
Fluid Volume ExcessAssessment for symptoms of fluid overload Daily weightI&O Diuretic therapy; timing of medsFluid intake; fluid restrictionMaintenance of sodium restriction
See Chart 30-4
Patient TeachingMedicationsDiet: low-sodium diet and fluid restrictionMonitoring for signs of excess fluid, hypotension, and
symptoms of disease exacerbation, including daily weight
Exercise and activity programStress managementPrevention of infectionKnow how and when to contact health care providerInclude family in teaching
Pulmonary EdemaAcute event in which the LV cannot handle an overload of
blood volume. Pressure increases in the pulmonary vasculature, causing fluid to move out of the pulmonary capillaries and into the interstitial space of the lungs and alveoli.
Results in hypoxemiaClinical manifestations: restlessness, anxiety, dyspnea, cool
and clammy skin, cyanosis, weak and rapid pulse, cough, lung congestion (moist, noisy respirations), increased sputum production (sputum may be frothy and blood-tinged), decreased level of consciousness
Management of Pulmonary EdemaPreventionEarly recognition: monitor lung sounds and for
signs of decreased activity tolerance and increased fluid retention
Place patient upright and dangle legs.Minimize exertion and stress. OxygenMedications
MorphineDiuretic (furosemide)
Cardiogenic ShockA life-threatening condition with a high
mortality rateDecreased CO leads to inadequate tissue
perfusion and initiation of shock syndrome.Clinical manifestations: symptoms of HF,
shock state, and hypoxia
Pathophysiology of Cardiogenic Shock
Management of Cardiogenic ShockCorrect underlying problemMedications
Diuretics Positive inotropic agents and vasopressors
Circulatory assist devicesIntra-aortic balloon pump (IABP)
Intra-Aortic Balloon Pump
ThromboembolismDecreased mobility and decreased circulation
increase the risk for thromboembolism in patients with cardiac disorders, including those with HF.
Pulmonary embolism: blood clot from the legs moves to obstruct the pulmonary vesselsThe most common thromboembolic problem with
HFPreventionTreatmentAnticoagulant therapy
Pulmonary Emboli
Pericardial Effusion and Cardiac TamponadePericardial effusion is the accumulation of fluid in the pericardial sac.Cardiac tamponade is the restriction of heart function due to this fluid, resulting in decreased venous return and decreased CO.Clinical manifestations: ill-defined chest pain or fullness, pulsus parodoxus, engorged neck veins, labile or low BP, shortness of breath Cardinal signs of cardiac tamponade: falling systolic BP, narrowing pulse pressure, rising venous pressure, distant heart soundsSee Chart 30-6
Assessing for Cardiac Tamponade
Medical ManagementPericardiocentesisPericardiotomy
Sudden Cardiac Death/Cardiac ArrestEmergency management: cardiopulmonary
resuscitationA- airwayB- breathingC- circulationD- defibrillation for VT and VF
Vascular SystemArteries and arteriolesCapillariesVeins and venulesLymphatic vesselsFunction of the vascular system
Systemic and Pulmonary Circulation
Peripheral Blood FlowFlow rate = ΔP/RMovement of fluid across the capillary wall;
hydrostatic and osmotic forceHemodynamic resistance
Blood viscosityVessel diameter
Regulation of peripheral vascular resistance
Assessment Characteristics of arterial and venous
insufficiencySee Table 31-1
Intermittent claudicationRest painChanges in skin and appearancePulsesAging changes
Assessing Peripheral Pulses
Peroneal, Dorsalis Pedis, and Posterior Tibial Pulse Sites
Continuous-wave Doppler ultrasound detects blood flow, combined with computation of ankle or arm pressures; this diagnostic technique helps characterize the nature of peripheral vascular disease.
Color Flow Duplex Image
Nursing Process: The Care of the Patient with Peripheral Arterial Insufficiency: AssessmentHealth history Medications Risk factorsSigns and symptoms of arterial insufficiencyClaudication and rest painColor changesWeak or absent pulsesSkin changes and skin breakdown
Nursing Process: The Care of the Patient with Peripheral Arterial Insufficiency: DiagnosisAltered peripheral tissue perfusionChronic painRisk for impaired skin integrityKnowledge deficiency
Nursing Process: The Care of the Patient with Peripheral Arterial Insufficiency: PlanningMajor goals include increased arterial blood
supply, promotion of vasodilatation, prevention of vascular compression, relief of pain, attainment or maintenance of tissue integrity, and adherence to self-care program.
Improving Peripheral Arterial CirculationExercises and activities: walking, graded
isometric exercises. Consult primary health care provider before prescribing an exercise routine.
Positioning strategiesTemperature; effects of heat and coldSmoking cessationStress reduction
Maintaining Tissue IntegrityProtection of extremities and avoidance of
traumaRegular inspection of extremities with
referral for treatment and follow-up for any evidence of infection or inflammation
Good nutrition, low-fat dietWeight reduction as necessary
Progression of Atherosclerosis
Common Sites of Atherosclerotic Obstruction
Risk Factors for Atherosclerosis and PVD Modifiable NonmodifiableNicotineDietHypertensionDiabetesObesity StressSedentary lifestyleC-reactive proteinHyperhomcysteinemia
Age GenderFamilial
predisposition/genetics
Medical ManagementPreventionExercise programMedicationsPentoxifylline (Trental) and cilostazol (Pletal) Use of antiplatelet agentsSurgical management
Buerger’s Disease: Thromboangiitis ObliteransRecurring inflammatory process of the small and
intermediate vessels of (usually) the lower extremities; probably an autoimmune disorder
Most often occurs in men ages 20-35Risk or aggravating factor: tobacco Progressive occlusion of vessels results in pain,
ischemic changes, ulcerations, and gangrene.
Raynaud's DiseaseIntermittent arterial vaso-occlusion, usually of the fingertips or toesRaynaud's phenomenon is associated with other underlying disease, such as scleroderma.Manifestations: sudden vasoconstriction results in color changes, numbness, tingling, and burning painEpisodes are usually brought on by a trigger such as cold or stress.Occurs most frequently in young womenProtect from cold/other triggers. Avoid injury to hands/fingers.
Other DisordersAortoiliac diseaseAneurysms
Thoracic aortic aneurysmAbdominal aortic aneurysm
Aortic dissection
Aortoiliac Endarterectomy
Characteristics of Arterial Aneurysms
Repair of an Ascending Aortic Aneurysm
AneuRx Endograft Repair of Abdominal Aortic Aneurysm
Venous ThrombusPathophysiologyRisk factors
See Chart 31-6Endothelial damageVenous stasisAltered coagulation
ManifestationsDeep veinsSuperficial veins
Blood flow and function of valves in veins. Note impaired blood return due to incompetent valve.
Preventive MeasuresElastic hosePneumatic compression devicesSubcutaneous heparin or LMWH, warfarin
(Coumadin) for extended therapy Positioning: periodic elevation of lower
extremitiesExercises: active and passive limb exercises,
deep-breathing exercisesEarly ambulationAvoid sitting/standing for prolonged periods;
walk 10 minutes every 1-2 hours.
Nursing Process: The Care of the Patient with Leg Ulcers: AssessmentHistory of the conditionTreatment depends upon the type of ulcer.Assess for presence of infection.Assess nutrition.
Arterial Ulcer, Gangrene Due to Arterial Insufficiency, and Ulcer Due to Venous Stasis
Medical ManagementAnti-infective therapy is dependent upon
infecting agent.Oral antibiotics are usually prescribed.
Compression therapyDébridement of woundDressingsOther
Nursing Process: The Care of the Patient with Leg Ulcers: DiagnosisImpaired skin integrityImpaired physical mobilityImbalanced nutrition
Collaborative Problems/Potential ComplicationsInfection Gangrene
Nursing Process: The Care of the Patient with Leg Ulcers: PlanningMajor goals include restoration of skin
integrity, improved physical mobility, adequate nutrition, and absence of complications.
MobilityWith leg ulcers, activity is usually initially
restricted to promote healing.Gradual progression of activityActivity to promote blood flow; encourage
patient to move about in bed and exercise upper extremities.
Diversional activitiesPain medication prior to activities
Other InterventionsSkin integrity
Skin care/hygiene and wound carePositioning of legs to promote circulationAvoidance of trauma
NutritionMeasures to ensure adequate nutritionAdequate protein, vitamins C and A, iron, and zinc
are especially important for wound healing.Include cultural considerations and patient
teaching in the dietary plan.
Cellulitis and Lymphatic DisordersCellulitis: infection and swelling of skin tissues Lymphangitis: inflammation/infection of the
lymphatic channelsLymphadenitis: inflammation/infection of the
lymph nodes Lymphedema: tissue swelling related to
obstruction of lymphatic flowPrimary: congenitalSecondary: acquired obstruction
Blood Pressure = Cardiac Output x Peripheral Resistance
Cardiac Output = Heart Rate x Stroke Volume
Hypertension AKA High blood pressureDefined by the Seventh Report of the Joint National
Commission on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) as a systolic pressure greater than 140 mm Hg and a diastolic pressure greater than 90 mm Hg, based on the average of two or more accurate blood pressure measurements taken during two or more contacts with a health care provider (Chobanian, Bakris, Black, et al., 2003).
Classification of Blood Pressure for Adults Age 18 and Older
Incidence of Hypertension- “The Silent Killer”Primary hypertensionSecondary hypertension28-31% of the adult population of the U.S.
have hypertension. 90-95% of this population with hypertension
have primary hypertension.Incidence is greater in southeastern U.S. and
among African-Americans.
Factors Involved in the Control of Blood Pressure
Factors that Influence the Development of Hypertension Increased sympathetic nervous system
activityIncreased reabsorption of sodium, chloride
and water by the kidneysIncreased activity of the renin-angiotensin
systemDecreased vasodilatationInsulin resistance
Manifestations of HypertensionUsually NO symptoms other than elevated
blood pressureSymptoms seen related to organ damage are
seen late and are serious: Retinal and other eye changesRenal damage Myocardial infarctionCardiac hypertrophyStroke
Major Risk Factors HypertensionSmokingObesityPhysical inactivityDyslipidemiaDiabetes mellitusMicroalbuminuria or GFR <60Older ageFamily history
Patient AssessmentHistory and PhysicalLaboratory tests
UrinalysisBlood chemistryCholesterol levels
ECG
Recommendations for Follow-up Based on Initial Blood Pressure Readings
Persons with diabetes mellitus or chronic renal disease as evidenced by a reduced GFR or an elevated serum creatinine have a lower goal pressure of 130/80 (JNC 7).
JNC 7 Treatment Algorithm
Lifestyle ModificationsWeight lossReduced alcohol intakeReduced sodium intakeRegular physical activityDiet: high in fruits, vegetables, and low-fat
dairyDASH diet
DASH Diet
Medication TreatmentUsually initial medication treatment is a diuretic,
a beta blocker, or both.Low doses are initiated and the medication
dosage is increased gradually if blood pressure does not reach target goal.
Additional medications are added if needed.Multiple medications may be needed to control
blood pressure.Lifestyle changes initiated to control BP must be
maintained.
Medication Therapy for HypertensionDiuretic and related drugs
Thiazide diureticsLoop diureticsPotassium-sparing diureticsAldosterone receptor blockers
Central Alpha2-Agonists and other centrally acting drugs
Beta blockersBeta blockers with intrinsic sympathomimetic
activityAlpha and beta blockers
Medication Therapy for Hypertension (continued)VasodilatorsAngiotensin-converting enzyme (ACE)
inhibitorsAngiotensin II antagonistsCalcium channel blockers
NondihydropyridinesDihydropyridines
Nursing History and AssessmentHistory and risk factorsAssess potential symptoms of target organ
damageAngina, shortness of breath, altered speech, altered
vision, nosebleeds, headaches, dizziness, balance problems, nocturia
Cardiovascular assessment: apical and peripheral pulses
Personal, social, and financial factors that will influence the condition or its treatment
Goals:Patient understanding of disease process.Patient understanding of treatment regimen.Patient participation in self-care.Absence of complications.
Nursing DiagnosesKnowledge deficit regarding the relation of
the treatment regimen and control of the disease process.
Noncompliance with therapeutic regimen related to side effects of prescribed therapy.
InterventionsPatient teachingSupport adherence to the treatment regimenConsultation/collaboration Follow-up careEmphasize control rather than cure Reinforce and support lifestyle changesA lifelong process
Gerontologic ConsiderationsNoncomplianceInclude familyUnderstanding of therapeutic regimen
Reading instructionsMonotherapy
Hypertensive CrisesHypertensive emergency
Blood pressure >180/120 and must be lowered immediately to prevent damage to target organs.
Hypertensive urgency Blood pressure is very high but no evidence of
immediate or progressive target organ damage.
Hypertensive EmergencyReduce BP 25% in first hourReduce to 160/100 over 6 hoursThen gradual reduction to normal over a period
of daysExceptions are ischemic stroke and aortic
dissectionMedications
IV vasodilators: sodium nitroprusside, nicardipine, fenoldopam mesylate, enalaprilat, nitroglycerin
Need very frequent monitoring of BP and cardiovascular status
Hypertensive UrgencyPatient requires close monitoring of blood
pressure and cardiovascular status.Assess for potential evidence of target organ
damage. Medications
Fast-acting oral agents: beta-adrenergic blocker- labetalol; angiotensin-converting enzyme inhibitors: captopril or alpha2-agonists-clonidine
Hematologic SystemThe blood and the blood forming sites, including the
bone marrow and the reticuloendothelial system
Blood
Plasma
Blood cells
Hematopoiesis
Blood Cells Erythrocyte: RBCLeukocyte: WBC
NeutrophilMonocyteEosinophil Basophil Lymphocyte: T lymphocyte and B lymphocyte
Thrombocyte: platelet
Blood Smear
Hematopoiesis
Hemostasis
AnemiasLower-than-normal hemoglobin and fewer-than-normal
circulating erythrocytes are signs of an underlying disorderHypoproliferative: defect in production of RBCs
Due to iron, vitamin B12 or folate deficiency, decreased erythropoietin production, and cancer
Hemolytic: excess destruction of RBCs Due to altered erythropoiesis, or other causes such as
hypersplenism, drug-induced or autoimmune processes, mechanical heart valves
May also be due to blood loss
ManifestationsDepend upon the rapidity of the development of the
anemia, duration of the anemia, metabolic requirements of the patient, concurrent problems, and concomitant features
Fatigue, weakness, and malaisePallor and jaundice Cardiac and respiratory symptomsTongue changesNail changes Angular cheilosis Pica
Medical ManagementCorrect or control the causeProvide transfusion of packed RBCsTreatment is specific to the type of anemia:
Dietary therapy Iron or vitamin supplementation: iron, folate, B12 BMT or PBSCT Immunosuppressive therapy Other
Nursing Process—Assessment of the Patient With Anemia
Health history and physical examLaboratory dataPresence of symptoms and impact of those
symptoms on the patient’s life: fatigue, weakness, malaise, pain
Nutritional assessment MedicationsCardiac and GI assessments Blood loss: menses and potential GI lossNeurologic assessment
Nursing Process—Diagnosing the Patient With Anemia
Fatigue
Altered nutrition
Altered tissue perfusion
Noncompliance with prescribed therapy
Collaborative Problems/Potential Complications
Heart failure
Angina
Paresthesias
Confusion
Nursing Process—Planning the Care of the Patient With Anemia
Major goals include decreased fatigue, attainment or maintenance of adequate nutrition, maintenance of adequate tissue perfusion, compliance with prescribed therapy, and absence of complications
InterventionsBalance physical activity, exercise, and rest
Maintain adequate nutrition
Provide patient education to promote compliance with medications and nutrition
Monitor VS and pulse oximetry and provide supplemental oxygen as needed
Monitor for potential complications
Leukemia Hematopoietic malignancy with unregulated
proliferation of leukocytes
Types:
Acute myeloid leukemia
Chronic myeloid leukemia
Acute lymphocytic leukemia
Chronic lymphocytic leukemia
Acute Myeloid Leukemia (AML)Defect in the stem cells that differentiate into all myeloid
cells: monocytes, granulocytes, erythrocytes, and platelets
Most common nonlymphocytic leukemiaAffects all ages with peak incidence at age 60Prognosis is variableManifestations: fever and infection, weakness and
fatigue, bleeding tendencies, pain from enlarged liver or spleen, hyperplasia of gums, and bone pain
Treatment is aggressive chemotherapy: induction therapy, BMT, and PBSCT
Chronic Myeloid Leukemia (CML) Mutation in myeloid stem cell with uncontrolled proliferation of
cells: Philadelphia chromosome Stages: chronic phase, transformational phase, blast crisis Uncommon in people under 20; incidence increases with age;
mean age is 55 to 60 years Life expectancy is 3 to 5 years Manifestations (initially may be asymptomatic): malaise; anorexia;
weight loss; confusion or shortness of breath due to leukostasis; enlarged, tender spleen; enlarged liver
Treatment: imatinib mesylate (Gleevec) blocks signals in leukemic cells that express BCR-ABL protein; chemotherapy, BMT, and PBSCT
Acute Lymphocytic LeukemiaUncontrolled proliferation of immature cells from lymphoid
stem cellMost common in young children, boys more often than girlsPrognosis is good for children; 80% event-free after 5 years,
but survival drops with increased ageManifestations: leukemic cell infiltration is more common
with this leukemia with symptoms of meningeal involvement and liver, spleen, and bone marrow pain
Treatment: chemotherapy, imatinib mesylate (if Philadelphia chromosome positive), BMT or PBSCT, and monoclonal antibody therapy
Chronic Lymphocytic LeukemiaMalignant B lymphocytes, most of which are
mature, may escape apoptosis, resulting in excessive accumulation of cells
Most common form of leukemiaMore common in older adults and affects men
more oftenSurvival varies from 2 to 14 years depending
upon stage
Chronic Lymphocytic Leukemia (cont.)
Manifestations: lymphadenopathy, hepatomegaly, splenomegaly; in later stages, anemias and thrombocytopenia; autoimmune complications with RES destroying RBCs and platelets may occur; B symptoms include fever, sweats, and weight loss
Treatment: early stage may require no treatment, chemotherapy, or monoclonal antibody therapy
Nursing Process—Assessment of the Patient With Leukemia
Health historyAssess for symptoms of leukemia and complications
of anemia, infection, and bleeding Weakness and fatigue See Charts 33-8 and 33-9
Laboratory tests Leukocyte count, ANC, hematocrit, platelets,
electrolytes, and cultures reports
Nursing Process—Diagnosis of the Patient With Leukemia
Risk for bleedingRisk for impaired skin integrityImpaired gas exchangeImpaired mucous membraneImbalanced nutritionAcute painHyperthermiaFatigue and activity intoleranceImpaired physical mobility
Nursing Process—Diagnosis of the Patient With Leukemia (cont.)
Risk for excess fluid volume
DiarrheaRisk for deficient fluid
volumeSelf-care deficitAnxietyDisturbed body imagePotential for spiritual
distressGrieving diagnosesDeficient knowledge
Collaborative Problems/Potential Complications
InfectionBleedingRenal dysfunctionTumor lysis syndromeNutritional depletionMucositisDepression
Nursing Process—Planning the Care of the
Patient With LeukemiaMajor goals include absence of complications,
attainment and maintenance of adequate nutrition, activity tolerance, ability for self-care and to cope with the diagnosis and prognosis, positive body image, and an understanding of the disease process and its treatment
InterventionsSee Charts 33-8 and 33-9 for interventions
related to risk of infection and bleedingMucositis
Frequent, gentle oral hygieneSoft toothbrush, or if counts are low, sponge-
tipped applicatorsRinse only with NS, NS and baking soda, or
prescribed solutions Perineal and rectal care
Improving NutritionProvide oral care before and after meals
Administer analgesics before meals
Provide appropriate treatment of nausea
Provide small, frequent feedings with soft foods that are moderate in temperature
Provide a low-microbial diet
Provide nutritional supplements
LymphomaNeoplasm of lymph origin
Hodgkin’s lymphoma
Non-Hodgkin’s lymphoma
Hodgkin’s DiseaseUnicentric originReed–Sternberg cell Suspected viral etiology; familial pattern; incidence
occurs in early 20s and again after age 50Excellent cure rate with treatmentManifestations: painless lymph node enlargement;
pruritus; B symptoms such as fever, sweats, and weight loss
Treatment is determined by stage of the disease and may include chemotherapy and/or radiation therapy
Non-Hodgkin's Lymphoma (NHL)Lymphoid tissues become infiltrated with malignant
cells that spread unpredictably; localized disease is rare
Incidence increases with age; the average age of onset is 50 to 60
Prognosis varies with the type of NHLTreatment is determined by type and stage of disease
and may include interferon, chemotherapy, and/or radiation therapy
Multiple MyelomaMalignant disease of plasma cells in the bone marrow with
destruction of boneM protein and Bence-Jones proteinMedian survival is 3 to 5 years; there is no cureManifestations: bone pain, osteoporosis, fractures,
elevated serum protein hypocalcemia, renal damage, renal failure, symptoms of anemia, fatigue, weakness, increased serum viscosity, and increased risk for bleeding and infection
Treatment may include chemotherapy, corticosteroids, radiation therapy, and biphosphonates
Bleeding DisordersPrimary thrombocythemiaThrombocytopeniaIdiopathic thrombocytopenia purpura (ITP)HemophiliaAcquired coagulation disorders: liver disease,
anticoagulants, and vitamin K deficiencyDisseminated intravascular coagulation (DIC)Bleeding precautions
See Chart 33-9
Disseminated Intravascular CoagulationNot a disease but a sign of an underlying disorderSeverity is variable; may be life-threatening Triggers may include sepsis, trauma, shock, cancer abruptio
placentae, toxins, and allergic reactionsAltered hemostasis mechanism causes massive clotting in
microcirculation; as clotting factors are consumed, bleeding occurs; symptoms are related to tissue ischemia and bleeding
Laboratory tests; see Table 33-5 Treatment: treat underlying cause, correct tissue ischemia,
replace fluids and electrolytes, maintain blood pressure, replace coagulation factors, and use heparin
Nursing Process—Assessment of the Patient With DIC
Be aware of patients who are at risk for DIC and assess for signs and symptoms of the condition
Assess for signs and symptoms and progression of thrombi and bleeding
See Chart 33-13
Nursing Process—Diagnosis of the Patient With DIC
Risk for fluid volume deficiency
Risk for impaired skin integrity
Risk for imbalanced fluid volume
Ineffective tissue perfusion
Death anxiety
Collaborative Problems/Potential Complications
Renal failure
Gangrene
Pulmonary embolism or hemorrhage
Acute respiratory distress syndrome
Stroke
Nursing Process--Planning the Care of the Patient With DIC
Major goals include maintenance of hemodynamic status, maintenance of intact skin and oral mucosa, maintenance of fluid balance, maintenance of tissue perfusion, enhanced coping, and absence of complications
InterventionsAssessment and interventions should target
potential sites of organ damage
Monitor and assess carefully
Avoid trauma and procedures that increase the risk of bleeding, including activities that increase intracranial pressure
See Chart 33-14
Therapies for Blood DisordersAnticoagulant therapy
Splenectomy
Therapeutic apheresis
Therapeutic phlebotomy
Blood component therapy
Blood Transfusion AdministrationSee Charts 33-17 and 33-18Review patient history including history of
transfusions and transfusion reactions; note concurrent health problems and obtain baseline assessment and VS
Perform patient teaching and obtain consentEquipment: IV (20 gauge or greater for PRBCs),
appropriate tubing, and normal saline solutionProcedure to identify patient and blood productMonitoring of patient and VS Postprocedure careNursing management of adverse reactions
ComplicationsFebrile nonhemolytic reactionAcute hemolytic reactionAllergic reactionCirculatory overloadBacterial contaminationTransfusion-related acute lung injuryDelayed hemolytic reactionDisease acquisitionComplications of long-term transfusion therapy