❖ Endocarditis
Description◆Endocarditis is an infection of the lining of the endocardium, heart valves, or a cardiac prosthesis resulting from bacterial (particularly streptococci, staphylococci, or enterococci) or fungal invasion
◆Conditions that increase the risk of endocarditis are having a prosthetic heart valve or having a dam- aged heart valve—for example, from rheumatic fever, syphilis, a congenital heart or heart valve defect, mitral valve prolapse with a murmur, hypertrophic cardiomyopathy, Marfan syndrome, or I.V. drug abuse
Signs and symptoms
◆Nonspecifi c signs and symptoms include chills, diaphoresis, fatigue, weakness, anorexia, weight loss, pleuritic pain, and arthralgia (intermittent fever and night sweats may recur for weeks)
◆The classic physical sign of endocarditis is a loud, regurgitant heart murmur, or sudden change in an existing murmur, or the discovery of a new murmur along with fever
◆Other signs include petechiae of the skin and mucous membranes and splinter hemorrhages under the nails
◆Rarely, endocarditis produces Osler’s nodes (tender, raised subcutaneous lesions on the fi ngers or toes), Roth’s spots (hemorrhagic areas with white centers on the retina), and Janeway lesions (purplish macules on the palms or soles)
◆Embolization from vegetating lesions or diseased valve tissues may produce specifi c signs and symp- toms of infarction of splenic, renal, cerebral, pulmonary, or peripheral vascular infarction
Diagnosis and treatment
◆Diagnostic tests may include echocardiogram and ECG
◆Laboratory tests may include white blood cell count (WBC), erythrocyte sedimentation rate, and serum rheumatoid factor
◆Three or more blood cultures in a 24- to 48-hour period identify the causative organism
◆An antibiotic is prescribed, based on the infecting organism; an I.V. antibiotic lasting 4 to 6 weeks is usually prescribed, followed by a course of oral antibiotics
◆Surgery may be necessary to repair or replace a defective heart valve Nursing interventions
◆Make sure the patient maintains bed rest to reduce myocardial oxygen demands
◆Encourage adequate fl uid intake
◆Watch for signs and symptoms of embolization (such as hematuria, fl ank pain, pleuritic chest pain, dyspnea, left upper quadrant pain, neurologic defi cits, and numbness and tingling of the extremities)
◆Assess the patient for signs and symptoms of heart failure, such as dyspnea, tachycardia, tachypnea, crackles, neck vein distention, edema, and weight gain
◆Suggest quiet diversionary activities to prevent excessive physical exertion
◆Teach the patient about the need for prophylactic antibiotics when undergoing invasive procedures, such as dental work; genitourinary, GI, or gynecologic procedures; or childbirth
◆Tell the patient about signs and symptoms of endocarditis that should immediately be reported to the practitioner
Preoperative care Intraoperative procedure Postoperative care
grimaces and other physiologic mea- sures.) Bloody drainage in the chest tube is normal, as is feeling the need to void while the urinary catheter is in place. The tubes and lines may restrict patient movement, but the nurse should help the patient to pre- vent injury.
● Ask the patient if he has an advanced directive in place.
The internal mammary artery may also be rerouted to bypass an occlusion.
● After the procedure is completed, the blood in the bypass machine is slowly warmed, and the patient’s body temperature is returned to nor- mal. While the incisions are closed, epicardial pacing wires are placed and grounded, and chest tubes are inserted.
● Maintain adequate renal circulation.
Postoperative renal insuffi ciency is caused by complications of extracorporeal circulation during surgery and can lead to the need for hemodialysis if permanent damage occurs.
● Document daily weight and fl uid intake and output. Monitor serum elec- trolytes frequently.
● Make the patient as comfortable as possible; for example, by administering an opioid analgesic or positioning for comfort.
● Organize activities so that the patient can rest frequently. A structured program of early, progressive ambulation and activity can be helpful, but must allow for individual differences.
● Provide a program of cardiac risk modifi cation. Encourage participation in a cardiac rehabilitation program.
Nursing care of the cardiac surgical patient requiring CABG(continued)
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Heart failure ❍ 113
❖ Heart failure
Description◆Heart failure is a condition in which the heart can no longer pump enough blood to meet the body’s demands
◆Left-sided heart failure may be caused by anterior MI, ventricular septal defect, cardiomyopathy, car- diac tamponade, constrictive pericarditis, increased circulating blood volume, aortic stenosis and insuf- fi ciency, or mitral stenosis and insuffi ciency
◆Right-sided heart failure may be caused by left-sided heart failure, a right ventricular MI, atrial septal defect, fl uid overload and sodium retention, mitral stenosis, pulmonary embolism, pulmonary outfl ow stenosis, chronic obstructive pulmonary disease, pulmonary hypertension (cor pulmonale), or thyro- toxicosis
◆With left-sided heart failure, the diseased left ventricle can’t pump effectively because of decreased cardiac output, decreased contractility, increased volume, and increased left ventricular pressure
◗ The left atrium can’t empty into the left ventricle, causing increased pressure in the left atrium; this pressure increase affects the lungs, causing pulmonary congestion that leads to decreased oxygenation
◗ Increased pressure in the lungs causes increased right-sided heart pressure; the right ventricle can’t relieve the pressure by emptying into the lungs, which impairs venous return to the right side of the heart
◗ As systemic pressure builds, body organs become congested with venous blood
◆Heart failure may also be classifi ed as systolic or diastolic dysfunction
◗ With systolic dysfunction, poor ventricular contraction results in inadequate emptying of the ventricle
◗ With diastolic dysfunction, reduced ventricular compliance results in increased resistance to ventricular fi lling
◆High-output failure may occur in high-output states, such as anemia, pregnancy, thyrotoxicosis, beri- beri, and arteriovenous fi stula
◗ High-output failure results in high cardiac output and leads to ventricular dysfunction
◗ Despite increased cardiac output, the heart is unable to meet the body’s increased metabolic needs Signs and symptoms
◆Both right- and left-sided heart failure may cause chest discomfort, shortness of breath, paroxysmal nocturnal dyspnea, bloating, edema in the extremities, jugular venous distention, and decreased urine output
◆Left-sided heart failure also may produce anxiety, orthopnea, dyspnea on exertion and at night, Cheyne-Stokes respirations, cough with frothy sputum, diaphoresis, crackles, rhonchi, cyanosis of extremities, respiratory acidosis, hypoxia, increased pulmonary artery pressures (determined with a pulmonary artery catheter), mental confusion, abnormal heart sounds (S3 and S4), fatigue, lethargy, mitral insuffi ciency murmur, oliguria, edema, anoxia, and nausea
◆Right-sided heart failure also may produce hepatomegaly, anorexia, nausea, splenomegaly, depen- dent edema, hepatojugular refl ex, bounding peripheral pulses, oliguria, arrhythmias, increased right- and left-sided heart pressures (determined with a pulmonary artery catheter), Kussmaul’s respirations, abnormal heart sounds (S3 and S4), fatigue, lethargy, abdominal pain, and weight gain
Diagnosis and treatment
◆Diagnostic tests may include ECG, chest X-ray, echocardiography, pulmonary artery catheter insertion, and arterial blood gas studies
◆Laboratory tests may include a CBC; liver function tests; serum creatinine, BUN, electrolyte, glucose;
albumin levels (patients with atrial fi brillation should have thyroid function tests performed); and B-type natriuretic peptide
◆The goals of treatment are to decrease cardiac workload, increase cardiac output and contractility, decrease fl uid and sodium retention, and decrease venous congestion
◆Activity is restricted to decrease cardiac workload
◆Oxygen may be administered to counteract desaturation
◆Drug therapy includes an ACE inhibitor (the cornerstone of therapy) to decrease afterload; a diuretic to decrease preload and afterload; digoxin to increase contractility and cardiac effi ciency and decrease heart rate; and a beta-adrenergic blocker to reduce heart rate and myocardial oxygen consumption
◗ Diuretics and vasodilators should be avoided in patients with diastolic dysfunction because they may not be able to tolerate reduced blood pressure or reduced volume
◗ Other drugs that may be useful in treating heart failure include vasodilators (such as hydralazine) combined with a nitrate (such as isosorbide), angiotensin II receptor blockers in patients who can’t tolerate ACE inhibitors, or nesiritide (a human B-type natriuretic peptide) to augment diuresis and decrease afterload
◗ Patients with acute pulmonary edema may also be treated with nitroglycerin I.V., morphine sulfate, oxygen, and mechanical ventilation
◆If the patient has high-output failure, correct the underlying cause Nursing interventions
◆Monitor the patient for common signs and symptoms of heart failure, such as chest discomfort, short- ness of breath, and paroxysmal nocturnal dyspnea
◆Also watch for signs and symptoms of left-sided heart failure, such as anxiety, orthopnea, and abnormal breath sounds
◆Monitor for signs and symptoms of right-sided heart failure, such as jugular venous distension, hep- atomegaly, splenomegaly, peripheral edema, and bounding peripheral pulses
◆Encourage bed rest in semi-Fowler’s position for ease of breathing
◆Provide rest intervals between periods of activity
◆Restrict fl uids as prescribed
◆Administer medications as prescribed, and monitor for their therapeutic and adverse effects (see Nursing implications in clinical pharmacology, page 364)
◆Monitor fl uid intake and output
◆Administer oxygen as prescribed
◆Monitor vital signs carefully, especially when administering vasoactive drugs
◆Check the patient’s weight daily
◆Frequently assess for cardiac and respiratory signs of heart failure
◆Note changes that suggest worsening of heart failure or fl uid imbalance
◆Explain procedures and provide reassurance to decrease patient and family anxiety
◆Teach the patient and family about medications and the importance of careful management of fl uids, sodium intake, and weight
❖ Hypertension
Description◆Hypertension is persistent high blood pressure, usually defi ned as a systolic pressure above 140 mm Hg or a diastolic pressure above 90 mm Hg based on two or more consecutive readings over a 2-week period (see Classifying blood pressure readings)
◆Three types of hypertension exist: essential or idiopathic (elevated blood pressure of unknown cause); secondary (elevated blood pressure of known cause, such as renovascular disease, pregnancy, and coarctation of the aorta); and malignant (severe, fulminant form with a diastolic pressure
above 140 mm Hg)
◆Hypertension may result from renovascular disease, toxemia of pregnancy, pheochromocytoma, pituitary tumor, coarctation of the aorta, adrenocortical hyperfunction, Cushing’s syndrome, polycythe- mia, atherosclerosis, and some medications; a genetic predisposition, smoking, diabetes, stress, seden- tary lifestyle, and obesity increase the risk of developing hypertension
Signs and symptoms
◆The cardinal sign is consistently elevated blood pressure although there may be no other symptoms or physical fi ndings
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Hypertension ❍ 115
◆Related signs and symptoms may include headache (usually in the morning), dizziness, bruits, fl ushed face, epistaxis, blurred vision, retinopathy, retinal hemorrhages, restlessness, crackles, and dyspnea (if the lungs are involved)
Diagnosis and treatment
◆Diagnostic tests depend on the suspected cause or effects of hypertension
◗ For example, kidney function tests, such as urinalysis and creatinine and BUN levels, may be per- formed because renal damage can cause hypertension
◗ ECG, chest X-ray, and echocardiography may be done to determine if hypertension has affected cardiac function
◗ Ophthalmic examination may refl ect retinal damage
◆Diet, exercise, and lifestyle modifi cations (such as smoking cessation, reducing alcohol intake, stress management, and weight reduction) are recommended fi rst
◆If nonpharmacologic measures fail to maintain blood pressure within normal limits, antihyperten- sives, such as diuretics, ACE inhibitors, beta-adrenergic blockers, calcium channel blockers, angiotensin II receptor blockers, alpha-adrenergic blockers, and combined alpha- and beta-adrenergic blockers, are prescribed
Nursing interventions
◆Monitor the patient’s blood pressure regularly, and assess for other signs and symptoms of hyperten- sion, such as headache and retinal hemorrhages
◆Provide a calm, quiet environment
◆Teach the patient and family about weight control, stress reduction, and smoking cessation
◆Discuss the importance of a low-sodium diet; include the dietitian in teaching low-sodium recipes and recipe modifi cation for the patient and the person who does the cooking
◆Teach the patient how to take his blood pressure
In 2003, the National Institutes of Health issued the Seventh Report of the Joint National Committee on Prevention, Detec- tion, Evaluation, and Treatment of High Blood Pressure. Categories now are normal, prehypertension, and stages 1 and 2 hypertension.
The revised categories are based on the average of two or more readings taken on separate visits after an initial screen- ing. They apply to adults age 18 and older. (If the systolic and diastolic pressures fall into different categories, use the higher of the two readings to classify the readings.)
Patients with prehypertension are at increased risk of developing hypertension and should follow health-promoting life- style modifi cations to prevent cardiovascular disease.
Category Systolic Diastolic
Normal < 120 mm Hg and < 80 mm Hg
Prehypertension 120 to 139 mm Hg or 80 to 89 mm Hg
Hypertension
Stage 1 140 to 159 mm Hg or 90 to 99 mm Hg
Stage 2 ≥160 mm Hg or ≥100 mm Hg