CardiovascularCarePlans
PART I: Medical-Surgical Nursing
ASSESSMENT/INTERVENTIONS RATIONALES
Teachthepatienttoholdthedoseifthereisa20-bpmorgreaterchange
fromhisorhernormalrateandtonotifythehealthcareproviderifhe
orshehasomittedadosebecauseofasloworsignificantlychanged
HR.
Suchachangemaysignalthatthepatientisreceivingtoomuch
medicationandadoseadjustmentmaybenecessaryifslowingof
theHRpersists.
Explainthatserumpotassiumlevelsaremonitoredroutinely. Lowlevelsofpotassiumcanpotentiatedigoxintoxicity.
ExplainthatapicalHRandperipheralpulsesareassessedforirregularity. Irregularitymaysignalthepresenceofdysrhythmias(e.g.,heart
block),whichisassociatedwithdigoxintoxicity.
Teachthepatienttobealerttonausea,vomiting,anorexia,headache,
diarrhea,blurredvision,yellow-hazevision,andmentalconfusion.
Explaintheimportanceofreportingsignsandsymptomspromptlyto
thehealthcareproviderorstaffiftheyoccur.
Theseareotherindicatorsofdigoxintoxicitythatnecessitateprompt
medicalattentionfortimelyintervention.
Nursing Diagnosis
Deficient Knowledge
related to unfamiliarity with the purpose, precautions, and side effects of vasodilators
Desired Outcome:
Within the 24-hr period before hospital discharge, the patient verbalizes knowledge of the purpose, precautions, and side effects of vasodilators.
ASSESSMENT/INTERVENTIONS RATIONALES
Assessthepatient’shealthcareliteracy(language,reading,
comprehension).Assesscultureandculturallyspecificinformation
needs.
Thisassessmenthelpsensurethatinformationisselectedandpresented
inamannerthatisculturallyandeducationallyappropriate.
Teachthepurposeofvasodilators. SeediscussioninImpaired Gas Exchange,p.170.
Explainthataheadachecanoccurafteradministrationofa
vasodilator.
Headachecanoccurbecauseofdilationofthecranialvesselsorfrom
orthostatichypotension.
Suggestthatlyingdownwillhelpalleviatepain. Asupinepositionmayhelpalleviatethepainbyincreasingbloodflowto
theheartandhead,althoughbloodflowtotheheadmayworsenthe
headache.Painmedicationanddecreaseddosageofthevasodilator
maybenecessary.
Teachtheimportanceofassessmentforweightgainandsignsof
peripheralorsacraledema.
Apossiblesideeffectofvasodilatortherapyisadecreaseinvenousreturn
totherightsideoftheheartwithsubsequentaccumulationinthe
periphery.
Forpatientsonlong-termACEinhibitortherapy,explainthe
importanceoffollow-upmonitoringofbloodlevelsofserum
creatinine.
ACEinhibitorsmaycausekidneydamage,resultingindecreasedcreatinine
clearance.Ifthisoccurs,thepatientmayneedtobetakenoffthe
medication.
ForpatientsreceivingACEinhibitors,teachtheimportanceofusing
carewhenrisingfromasittingorrecumbentposition.
Thereispotentialforinjurycausedbyorthostatichypotension,apotential
sideeffectofACEinhibitors.
TeachthepatientreceivingACEinhibitorsthetechniqueforand
importanceofassessingBPbeforetakingthemedication.Explain
thatitispossibletopurchaseautomaticBPmachinesfromlocal
pharmaciesandifnecessarytoseekreimbursementorfunding
informationfromasocialworker.
VasodilatorscancauseanexcessivereductioninBP.Althoughpatients
shouldobtainBPparametersfromtheirhealthcareproviders,ACE
inhibitorsareusuallywithheldwhenBPislessthan110/60mmHg.
Teachthepatienttonotifythehealthcareproviderifheorshehas
omittedadosebecauseofaloworsignificantlychangedBP.
Itmaybenecessarytolowerthedoseorchangethemedication.
PART I: Medical-Surgical Nursing
discuss drug-drug, food-drug, and herb-drug interactions.
✓
Signs and symptoms that necessitate immediate medical attention: dyspnea, decreased exercise tolerance, altera-tions in pulse rate/rhythm, alteraaltera-tions in or loss of con-sciousness (caused by dysrhythmias or decreased cardiac output), oliguria, and weight gain of greater than 2-3 lb in 24 hr or 3-5 lb in 48 hr.
✓
Reinforcement that heart failure/cardiomyopathy is a chronic disease requiring lifetime treatment.
✓
Importance of abstaining from alcohol, which increases cardiac muscle deterioration.
✓
Importance of a low-sodium diet (less than 1000 mg/
day) to prevent fluid retention.
✓
Need for physical support from family and outside agen-cies as the disease progresses.
✓
Availability of community and medical support, such as:
• The American Heart Association at
www .americanheart.org• The Heart and Stroke Foundation at
www .heartandstroke.comPATIENT-FAMILY TEACHING AND DISCHARGE PLANNING
When providing patient-family teaching, focus on sensory information, avoid giving excessive information, and initiate a visiting nurse referral for necessary follow-up teaching.
Include verbal and written information about the following:
DIAGNOSES/PROBLEMS:
“Prolonged Bedrest” p. 61
“Psychosocial Support” p. 72
“Coronary Artery Disease” for Imbalanced Nutrition: More Than Body Requirements
p. 156
“Dysrhythmias and Conduction Disturbances.”
Patients with HF may require an ICD.
p. 164
179
Hypertension 22
OVERVIEW/PATHOPHYSIOLOGY
Hypertension affects more than one of three adults in the United States, with more than 60% of individuals older than 65 years diagnosed with hypertension (AHA, 2013). Hyper-tension occurs when cardiac output and peripheral vascular resistance are altered. Most commonly, endothelial changes of peripheral arterioles cause restriction of blood flow, raising arterial pressure.
Risk factors include age, heredity, ethnicity (incidence is higher in African Americans), renal disease, obesity, hyperlipidemia, smoking, and some endocrine disorders (e.g., Cushing’s disease, thyroid disease, primary aldosteronism, pheochromocytoma).
Complications of hypertension include increased inci-dence of transient ischemic attack/stroke, retinopathy, car-diovascular disease, heart failure, aortic aneurysm, and renal failure.
Hypertension is defined by the Joint National Committee on Prevention, Detection, Evaluation and Treatment of Hypertension (JNC 7) (based on the average of two or more
properly measured readings at each of two or more visits after an initial screen) as:
• Normal blood pressure: systolic blood pressure (SBP) less than 120 mm Hg and diastolic blood pressure (DBP) less than 80 mm Hg
• Prehypertension: SBP 120-139 mm Hg or DBP 80-89 mm Hg
• Hypertension
• Stage 1: SBP 140-159 mm Hg or DBP 90-99 mm Hg
• Stage 2: SBP 160 mm Hg or greater or DBP 100 mm Hg or greater
• Treatment goals of hypertension in persons 60 yr of age and older is to achieve blood pressure of less than 150/90 (JNC 8). In persons less than 60 yr of age, or those with chronic kidney disease or diabetes, the treatment goal is less than 140/90 (JNC 8).
HEALTH CARE SETTING
Primary care or cardiology clinic setting most commonly;
patients with severe hypertension may require acute hospitalization.
Nursing Diagnosis:
Deficient Knowledge
related to unfamiliarity with the need for frequent blood pressure (BP) checks, adherence to antihypertensive therapy, and lifestyle changes
Desired Outcome:
Following teaching, the patient verbalizes knowledge of the importance of frequent BP checks and adhering to antihypertensive therapy and lifestyle changes.
ASSESSMENT/INTERVENTIONS RATIONALES
Assess the patient’s health care literacy (language, reading, comprehension). Assess culture and culturally specific information needs.
This assessment helps ensure that information is selected and presented in a manner that is culturally and educationally appropriate.
Teach the importance of assessing BP at frequent intervals and adhering to the prescribed medication therapy.
Frequent assessment provides feedback on response to therapy and may help improve adherence to therapy. Self-assessment is also helpful for evaluating “white coat hypertension,” the phenomenon of increased BP when assessed by a health care provider.
continued
PART I: Medical-Surgical Nursing
Provide teaching guidelines on the importance of exercise, stress reduction, weight loss (if appropriate), decreased alcohol intake, and a less than 2 g/day sodium diet. Review how to read food labels and choose low sodium foods. Refer to a nutritionist and exercise program, if appropriate.
Primary treatment for this disease includes promotion of lifestyle modification, which can lower BP significantly when adhered to.
Teach medication actions, administration times, side effects, adverse effects, and the importance of taking as prescribed. Include drug-drug, food-drug, and herb-drug interactions.
Knowledge about and adherence to the prescribed regimen can lower morbidity and mortality risk and improve patient outcomes.
Teach the importance of seeking medical evaluation if BP reading is greater than 200/100 mm Hg or less than 90/60 mm Hg, or if headache, dizziness, lightheadedness, or blurred vision occurs.
Severe hypertension or hypotension can be life threatening, compromising perfusion to vital organs.
ADDITIONAL NURSING DIAGNOSES/PROBLEMS:
“Psychosocial Support” p. 72
“Coronary Artery Disease” for Imbalanced Nutrition: More Than Body Requirements
p. 156
Deficient Knowledge (purpose, precautions, and side effects of beta-blockers)
p. 157
Deficient Knowledge (relaxation technique effective for stress reduction)
p. 159
PATIENT-FAMILY TEACHING AND DISCHARGE PLANNING
When providing patient-family teaching, focus on sensory information, avoid giving excessive information, and initiate a visiting nurse referral for necessary follow-up teaching.
Include verbal and written information about the following:
✓
Signs and symptoms that necessitate immediate medical attention: elevated or decreased BP readings (greater than 200/100 mm Hg or less than 90/60 mm Hg), head-ache, dizziness, lightheadedness, blurred vision, chest pain, dyspnea, or syncope.
✓
Self blood pressure evaluation when indicated. Moni-toring machines are available in local stores and phar-macies and on-line. Remind the patient that evaluation of BP should be done while seated, after resting for 5 min, and recorded. Taking 3 readings 1 min apart in the morning and evening is recommended by the Amer-ican Society for Hypertension (ASH). Appropriate cuff size must be selected (AHA guidelines). Measurement of standing BP can be obtained when indicated, i.e., in diabetic autonomic neuropathy, when orthostatic symp-toms are present, or when a dose increase in antihyper-tensive therapy has been made (ASH).
✓
Medications, including name, purpose, dosage, sched-ule, precautions, and potential side effects. Discuss drug-drug, food-drug-drug, and herb-drug interactions.
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Importance of abstaining from smoking and excessive salt and alcohol intake, which increase blood pressure.
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Reinforcement that hypertension is a chronic disease requiring lifetime treatment.
✓
Need for physical support from the family and outside agencies.
✓
Availability of community and medical support such as the American Heart Association at
www .americanheart.org✓