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, alterations 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, 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
.com181
Pulmonary Arterial Hypertension 23
OVERVIEW/PATHOPHYSIOLOGY
Pulmonary blood vessels exchange the primary gases CO
2and O
2at 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, pulmonary 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 common presenting symptoms), eventually progressing to dyspnea at rest. Syncope, precordial chest pain, and palpita- tions can occur because of low cardiac output or hypoxia.
Chronic indicators:
Signs of right or left ventricular failure as a result of right ventricular enlargement and eventual fluid overload.
Right (diastolic) ventricular failure:
Peripheral edema, increased venous pressure and pulsations, liver engorgement, distended neck veins.
Left (systolic) ventricular failure:
Dyspnea; shortness of breath, particularly on exertion; decreased blood pressure (BP); oliguria; orthopnea; anorexia.
Physical assessment:
Pale, cool skin with peripheral cya- nosis due to decreased cardiac output, systemic vasoconstric- tion and ventilation-perfusion mismatch, systolic murmur caused by tricuspid regurgitation or pulmonary stenosis, dia- stolic murmur caused by pulmonary valvular incompetence, accentuated S
2heart sound, possible S
3or S
4heart sound, distended neck veins, and a parasternal heave caused by right ventricular enlargement.
DIAGNOSTIC TESTS
Chest x-ray examination:
Demonstrates enlargement of the pulmonary artery and right atrium and ventricle. Pulmonary vasculature may appear engorged.
Echocardiography:
Valuable for showing increased right ventricular dimension, thickened right ventricular wall, and possible tricuspid or pulmonary valve dysfunction. This test indirectly measures pulmonary artery systolic pressure.
Radionuclide imaging:
Equilibrium-gated blood pool imaging and thallium imaging assess function of the right ventricle.
Computerized tomography (CT) scan:
Evaluates diameter of the main pulmonary arteries, which is helpful in evaluating severity of disease. High-resolution CT can confirm the pres- ence of interstitial lung disease. Spiral CT is more specific in evaluating pulmonary embolus.
Right heart catheterization:
Gold standard for diagnosing PAH. It also provides helpful information regarding severity of the disease and establishing prognosis. Pulmonary vascular resistance will be very high, and pulmonary artery and right ventricular pressures can approach or equal systemic arterial pressures. Vasodilator challenge is often performed to assess reactivity and guide treatment. Adenosine, epoprostenol, and nitric oxide typically are used.
Pulmonary perfusion scintigraphy (perfusion scan):
A non- invasive way to assess pulmonary blood flow. This study involves intravenous (IV) injection of serum albumin tagged with trace amounts of a radioisotope, most often technetium.
The particles pass through the circulation and lodge in the
pulmonary vascular bed. Subsequent scanning reveals concen-
trations of particles in areas of adequate pulmonary blood flow.
PART I: Medical-Surgical Nursing
Pa
CO2with decreased gas exchange.
Oximetry:
May show decreased O
2saturation (92% or less).
Blood tests to rule out secondary causes of PAH:
Anti-nuclear antibody, rheumatoid arthritis, erythrocyte sedimentation rate (tests for collagen vascular disorders), HIV, and thyroid-stimulating hormone (thyroid abnormalities commonly coexist with PAH).
Complete blood count (CBC):
Polycythemia can occur in the presence of chronic hypoxemia as a result of compensation.
Liver function tests:
May be abnormal if venous congestion is significant. Examples include increased aspartate amino- transferase (AST), alanine aminotransferase (ALT), and bilirubin.
Electrocardiogram (ECG) results:
Will show evidence of right atrial enlargement and right ventricular enlargement (evidenced by right axis deviation, right bundle branch block, tall and peaked P waves, and large R waves in V
1) secondary to the increased pressure needed to force blood through the hypertensive pulmonary vascular bed.
Pulmonary function test:
Results are usually normal, although some individuals will have increased residual volume, reduced maximum voluntary ventilation, and decreased vital capacity.
Sleep study:
Confirms diagnosis of obstructive sleep apnea as etiology for associated PAH.
Exercise testing:
Symptom-limited stress test or 6-min walk test can help assess severity of symptoms and guide response to treatment.
Nursing Diagnosis:
Impaired Gas Exchange
related to altered blood flow occurring with pulmonary capillary constriction
Desired Outcome:
The patient has improved gas exchange by at least 24 hr before hospital discharge, as evidenced by O
2saturation greater than 92% (90% or greater for patients with COPD) and Pa
O280 mm Hg or higher.
ASSESSMENT/INTERVENTIONS RATIONALES
Assess O2 saturation; report O2 saturation 92% or less to the health care provider.
Low O2 saturation may signal the need for oxygen supplementation.
Monitor ABG results. Report significant findings to the health care provider.
ABG results can reveal signs of hypoventilation (decreased PaO2, increased PaCO2, and decreased pH), which can signal respiratory failure, or hyperventilation (low PaCO2 and high pH), which can occur with anxiety or respiratory distress. Hypoxemia is the key gas deficit seen with pulmonary vascular vasoconstriction. Blood flow through the lungs is impaired, making it difficult to exchange O2 for CO2. O2 becomes low (hypoxemia) and CO2 becomes high (hypercarbia). Hypercarbia causes a change in pH to the acid side. Although initially respiratory in origin, hypoxemia eventually results in metabolic acidosis because of lactic acid production. Values outside of normal or acceptable range should be reported promptly for timely intervention.
Assess all lung fields for breath sounds q4-8h or more frequently as indicated.
Adventitious sounds (especially rales) can occur with fluid overload;
diminished breath sounds are congruent with disease severity.
Assess respiratory rate (RR), pattern, and depth; chest excursion; and use of accessory muscles of respiration q4h.
Increased RR, abdominal breathing, use of accessory muscles, and nasal flaring are signals of hypoxia and respiratory distress.
Inspect skin and mucous membranes for cyanosis or skin color change.
These color changes are significant and later signs of decreased gas exchange.
Assess mental status and report significant changes. Changes in mental acuity or level of consciousness (LOC) may be indications of hypoxemia or acid-base imbalance.
Assist the patient into high Fowler’s position (head of bed [HOB] up 90 degrees), if possible.
This position reduces work of breathing and maximizes chest excursion.