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MEDICAL-SURGICALNURSING:Cardiovascular Care Plans DeficientKnowledge Heart Failure 177

Dalam dokumen How to Use This Book (Halaman 193-197)

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.com

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:

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.

Importance of abstaining from smoking and excessive salt and alcohol intake, which increase blood pressure.

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

The Heart and Stroke Foundation at www.heartandstroke

.com

181

Pulmonary Arterial Hypertension 23

OVERVIEW/PATHOPHYSIOLOGY

Pulmonary blood vessels exchange the primary gases CO

2

and O

2

at the arteriole level. In healthy individuals, this exchange occurs with each respiration. However, the pulmonary vascu-lature’s ability to provide adequate gas exchange may be altered in the presence of lung and heart disease. When pul-monary pressures rise, pulpul-monary arterial hypertension (PAH) results.

PAH may be idiopathic (rare), which has a poor prognosis and affects primarily young and middle-age women; or it can be secondary (most common), which often responds to therapy and may be present in a variety of medical conditions. The cause of idiopathic pulmonary arterial hypertension (IPAH) is unknown. It may be familial and has been linked to the bone morphogenetic protein receptor 2 (BMPR2). Often the etiology of secondary PAH is chronic hypoxia, which can result from increased pulmonary blood flow from a ventricular or atrial shunt, left ventricular failure, chronic obstructive pulmonary disease (COPD) or obstructive sleep apnea (OSA), pulmonary embolus, interstitial lung disease, human immuno-deficiency virus (HIV) infection, collagen vascular disorders such as scleroderma or lupus, portal hypertension due to liver disease, or any physiologic occurrence that increases pulmo-nary vascular resistance or constriction of the vessels in the pulmonary tree.

HEALTH CARE SETTING

Primary care with possible hospitalization in a cardiac or medical-surgical unit resulting from complications or in a special center for heart-lung transplantation

ASSESSMENT

Acute indicators: Exertional dyspnea and fatigue (the most

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