CARDIOVASCULAR PROBLEMS 3.

A third heart sound (S3) may be heard if ventricular wall compliance

is decreased and structures in the ventricular wall vibrate; this can
I. Anatomy and Physiology occur in conditions such as heart failure or valvular regurgitation.
A. Heart and heart wall layers However, a third heart sound may be normal in individuals younger
1. The heart is located in the mediastinum. than 30 years.
2. The heart consists of three layers. 4. A fourth heart sound (S4) may be heard on atrial systole if resistance
a. The epicardium is the outermost layer of the heart. to ventricular filling is present. Causes of this abnormal finding
b. The myocardium is the middle layer and is the actual include cardiac hypertrophy, disease, or injury to the ventricular wall.
contracting muscle of the heart. K. Heart rate
c. The endocardium is the innermost layer and lines the inner 1. The faster the heart rate, the less time the heart has for filling. At very
chambers and heart valves. fast rates the cardiac output decreases.
B. Pericardial sac 2. The normal sinus heart rate is 60 to 100 beats per minute.
1. Encases and protects the heart from trauma and infection 3. Sinus tachycardia is a rate more than 100 beats per minute.
2. Has two layers 4. Sinus bradycardia is a rate less than 60 beats per minute.
a. The parietal pericardium is the tough, fibrous outer membrane L. Autonomic nervous system
that attaches anteriorly to the lower half of the sternum, 1. Stimulation of sympathetic nerve fibers releases the neurotransmitter
posteriorly to the thoracic vertebrae, and inferiorly to the norepinephrine, producing an increased heart rate, increased
diaphragm. conduction speed through the AV node, increased atrial and
b. The visceral pericardium is the thin, inner layer that closely ventricular contractility, and peripheral vasoconstriction. Stimulation
adheres to the heart. occurs when a decrease in pressure is detected.
3. The pericardial space between the parietal and visceral layers holds 5 2. Stimulation of the parasympathetic nerve fibers releases the
to 20 mL of pericardial fluid to lubricate the pericardial surfaces and neurotransmitter acetylcholine, which decreases the heart rate and
cushion the heart. lessens atrial and ventricular contractility and conductivity.
C. There are four heart chambers. Stimulation occurs when an increase in pressure is detected.
1. The right atrium receives deoxygenated blood from the body via the M. Blood pressure (BP) control
superior and inferior vena cava. 1. Baroreceptors (specialized nerve endings affected by changes in the
2. The right ventricle receives blood from the right atrium and pumps it arterial BP), also called pressoreceptors, are located in the walls of
to the lungs via the pulmonary artery. the aortic arch and carotid sinuses.
3. The left atrium receives oxygenated blood from the lungs via four 2. Increases in arterial pressure stimulate baroreceptors, and the heart
pulmonary veins. rate and arterial pressure decrease.
4. The left ventricle is the largest and most muscular chamber; it 3. Decreases in arterial pressure reduce stimulation of the baroreceptors
receives oxygenated blood from the lungs via the left atrium and and vasoconstriction occurs, as does an increase in heart rate.
pumps blood into the systemic circulation via the aorta. 4. Stretch receptors, located in the vena cava and the right atrium,
D. There are four valves in the heart. respond to pressure changes that affect circulatory blood volume.
1. There are two atrioventricular valves, the tricuspid and the mitral, 5. When the BP decreases as a result of hypovolemia, a sympathetic
which lie between the atria and ventricles. response occurs, causing an increased heart rate and blood vessel
a. The tricuspid valve is located on the right side of the heart. constriction; when the BP increases as a result of hypervolemia, an
b. The bicuspid (mitral) valve is located on the left side of the opposite effect occurs.
heart. 6. Antidiuretic hormone (vasopressin) influences BP indirectly by
c. The atrioventricular valves close at the beginning of ventricular regulating vascular volume.
contraction and prevent blood from flowing back into the atria 7. Increases in blood volume result in decreased antidiuretic hormone
from the ventricles; these valves open when the ventricles relax. release, increasing diuresis, decreasing blood volume, and thus
2. There are two semilunar valves, the pulmonic and the aortic. decreasing BP.
a. The pulmonic semilunar valve lies between the right ventricle 8. Decreases in blood volume result in increased antidiuretic hormone
and the pulmonary artery. release; this promotes an increase in blood volume and therefore BP.
b. The aortic semilunar valve lies between the left ventricle and the 9. Renin, a potent vasoconstrictor, causes the BP to increase.
aorta. 10. Renin converts angiotensinogen to angiotensin I; angiotensin I is then
c. The semilunar valves prevent blood from flowing back into the converted to angiotensin II in the lungs.
ventricles during relaxation; they open during ventricular 11. Angiotensin II stimulates the release of aldosterone, which promotes
contraction and close when the ventricles begin to relax. water and sodium retention by the kidneys; this action increases blood
E. Sinoatrial (SA) node volume and BP.
1. The main pacemaker that initiates each heartbeat N. The vascular system
2. It is located at the junction of the superior vena cava and the right 1. Arteries are vessels through which the blood passes away from the
atrium. heart to various parts of the body; they convey highly oxygenated
3. The SA node generates electrical impulses 60 to 100 times per minute blood from the left side of heart to the tissues.
and is controlled by the sympathetic and parasympathetic nervous 2. Arterioles control the blood flow into the capillaries.
systems. 3. Capillaries allow the exchange of fluid and nutrients between the
F. Atrioventricular (AV) node blood and the interstitial spaces.
1. Located in the lower aspect of the atrial septum 4. Venules receive blood from the capillary bed and move blood into the
2. Receives electrical impulses from the SA node veins.
3. If the SA node fails, the AV node can initiate and sustain a heart rate 5. Veins transport deoxygenated blood from the tissues back to the right
of 40 to 60 beats per minute. heart and then to the lungs for oxygenation.
G. The bundle of His 6. Valves help return blood to the heart against the force of gravity.
1. A continuation of the AV node; located at the interventricular septum 7. The lymphatics drain the tissues and return the tissue fluid to the
2. It branches into the right bundle branch, which extends down the right blood.
side of the interventricular septum; and the left bundle branch, which II. Diagnostic Tests and Procedures
extends into the left ventricle. A. Cardiac markers
3. The right and left bundle branches terminate in the Purkinje fibers. 1. Troponin
H. Purkinje fibers a. Troponin is composed of three proteins— troponin C, cardiac
1. Purkinje fibers are a diffuse network of conducting strands located troponin I, and cardiac troponin T.
beneath the ventricular endocardium. b. Troponin I have a high affinity for myocardial injury; it rises
2. These fibers spread the wave of depolarization through the ventricles. within 3 hours and persists for up to 7 to 10 days.
3. Purkinje fibers can act as the pacemaker with a rate between 20 and c. Normal values are low, with troponin I being less than 0.35
40 beats per minute if the SA and AV nodes fail. ng/mL (less than 0.35 mcg/L) and troponin T being less than 0.1
I. Coronary arteries ng/mL (less than 0.1 mcg/L); thus, any rise can indicate
1. The right main coronary artery supplies the right atrium and ventricle, myocardial cell damage.
the inferior portion of the left ventricle, the posterior septal wall, and 2. High-sensitivity Troponin (hsTnT)
the SA and AV nodes. a. HsTnT assays detect troponins at much lower concentrations
2. The left main coronary artery consists of two major branches, the left and as early as 60 to 90 minutes after myocardial cell injury.
anterior descending (LAD) and the circumflex arteries. b. HsTnT speeds the triage of clients with suspected myocardial
3. The LAD artery supplies blood to the anterior wall of the left infarction.
ventricle, the anterior ventricular septum, and the apex of the left c. Normal values are low, <14 ng/L for women and <22ng/L for
ventricle. men.
4. The circumflex artery supplies blood to the left atrium and the lateral 3. CK-MB (creatine kinase, myocardial muscle)
and posterior surfaces of the left ventricle. The coronary arteries a. An elevation in value indicates myocardial damage.
supply the capillaries of the myocardium with blood. If blockage b. An elevation occurs within hours and peaks at 18 hours after
occurs in these arteries, the client is at risk for myocardial acute ischemia.
infarction (MI). c. Normal value for CK-MB (CK-2) ranges from 2 to 6 ng/mL (2
J. Heart sounds to 6 mcg/L).
1. The first heart sound (S1) is heard as the atrioventricular valves close 4. Myoglobin
and is loudest at the apex of the heart. a. Myoglobin is an oxygen-binding protein found in cardiac and
2. The second heart sound (S2) is heard when the semilunar valves close skeletal muscle.
and is loudest at the base of the heart.
 b. The level rises within 2 hours after cell death, with a rapid a. An electrocardiogram (ECG) reflects the electrical activity of
decline in the level after 7 hours; however, it is not cardiac cardiac cells and records electrical activity at a speed of 25
specific. mm/second.
B. Complete blood count b. An electrocardiographic strip consists of horizontal lines
1. The red blood cell counts decreases in rheumatic heart disease and representing seconds and vertical lines representing voltage.
infective endocarditis, and increases in conditions characterized by c. Each small square represents 0.04 second.
inadequate tissue oxygenation. d. Each large square represents 0.20 second.
2. The white blood cell counts increases in infectious and inflammatory e. The P wave represents atrial depolarization.
diseases of the heart and after MI, because large numbers of white f. The PR interval represents the time it takes an impulse to travel
blood cells are needed to dispose of the necrotic tissue resulting from from the atria through the atrioventricular node, bundle of His,
the infarction. and bundle branches to the Purkinje fibers.
3. An elevated hematocrit level can reflect vascular volume depletion. g. Normal PR interval duration ranges from 0.12 to 0.2 second.
4. Decreases in hemoglobin and hematocrit levels can indicate anemia. h. The PR interval is measured from the beginning of the P wave
C. Blood coagulation factors: An increase in coagulation factors can occur to the end of the PR segment.
during and after MI, placing the client at greater risk for thrombophlebitis i. The QRS complex represents ventricular depolarization.
and formation of clots in the coronary arteries. j. Normal QRS complex duration ranges from 0.04 to 0.1 second.
D. Serum lipids k. The Q wave appears as the first negative deflection in the QRS
1. The lipid profile measures serum cholesterol, triglyceride, and complex and reflects initial ventricular septal depolarization.
lipoprotein levels. l. The R wave is the first positive deflection in the QRS complex.
2. The lipid profile is used to assess the risk of developing coronary m. The S wave appears as the second negative deflection in the
artery disease. QRS complex.
3. Lipoprotein-a or Lp(a), a modified form of low-density lipoprotein n. The J point marks the end of the QRS complex and the
(LDL), increases atherosclerotic plaques and increases clots. beginning of the ST segment.
E. Homocysteine: Elevated levels may increase the risk of cardiovascular o. The QRS duration is measured from the end of the PR segment
disease; normal value is 4.5 to 11.9 mcmol/L (4.5 to 11.9 mcmol/L), age to the J point.
and gender dependent. p. The ST segment represents early ventricular repolarization.
F. Highly sensitive C-reactive protein (hsCRP): Detects an inflammatory q. The T wave represents ventricular repolarization and ventricular
process such as that associated with the development of atherothrombosis; a diastole.
level less than 1 mg/L is considered low risk, and a level greater than 3 r. The U wave may follow the T wave.
mg/L places the client at high risk for heart disease. s. A prominent U wave may indicate an electrolyte abnormality,
G. Microalbuminuria: A small amount of protein in the urine has been a such as hypokalemia.
marker for endothelial dysfunction in cardiovascular disease. t. The QT interval represents ventricular refractory time or the
H. Electrolytes total time required for ventricular depolarization and
1. Potassium repolarization.
a. Hypokalemia causes increased cardiac electrical instability, u. The QT interval is measured from the beginning of the QRS
ventricular dysrhythmias, and increased risk of digoxin toxicity. complex to the end of the T wave.
b. In hypokalemia, the electrocardiogram (ECG) shows flattening v. The QT interval normally lasts 0.32 to 0.4 second but varies
and inversion of the T wave, the appearance of a U wave, and with the client’s heart rate, age, and gender.
ST depression. 3. Interventions
c. Hyperkalemia causes asystole and ventricular dysrhythmias. a. Determine the client’s ability to lie still; advise the client to lie
d. In hyperkalemia, the ECG may show tall, peaked T waves, still, breathe normally, and refrain from talking during the test.
widened QRS complexes, prolonged PR intervals, or flat P b. Reassure the client that an electrical shock will not occur.
waves. c. Document any cardiac medications the client is taking.
2. Sodium Q. Holter monitoring
a. The serum sodium level decreases with the use of diuretics. 1. Description
b. The serum sodium level decreases in heart failure, indicating a. A noninvasive test; the client wears a monitor and an
water excess. electrocardiographic tracing is recorded continuously over a
I. Calcium period of 24 hours or more while the client performs activities
1. Hypocalcemia can cause ventricular dysrhythmias, prolonged ST and of daily living.
QT intervals, and cardiac arrest. b. The monitor identifies dysrhythmias if they occur and evaluates
2. Hypercalcemia can cause a shortened ST segment and widened T the effectiveness of anti-dysrhythmics or pacemaker therapy.
wave, atrioventricular block, tachycardia or bradycardia, digitalis 2. Interventions
hypersensitivity, and cardiac arrest. a. Instruct the client to resume normal daily activities and to
J. Phosphorus level: Phosphorus levels should be interpreted with calcium maintain a diary documenting activities if asked to do so and
levels, because the kidneys retain or excrete them in an inverse relationship. any symptoms that may develop for correlation with the
K. Magnesium electrocardiographic tracing.
1. A low magnesium level can cause ventricular tachycardia and b. Instruct the client using a wired monitor to avoid tub baths,
fibrillation. showers, or swimming, because they will interfere with the
2. Electrocardiographic changes that may be observed with electrocardiographic recorder device.
hypomagnesemia include tall T waves and depressed ST segments. R. Echocardiography
3. A high magnesium level can cause muscle weakness, hypotension, 1. Description
and bradycardia. a. This noninvasive procedure is based on the principles of
4. Electrocardiographic changes that may be observed with ultrasound and evaluates structural and functional changes in the
hypermagnesemia include a prolonged PR interval and widened QRS heart.
complex. Electrolyte and mineral imbalances can cause cardiac b. Used to detect valvular abnormalities, congenital heart defects,
electrical instability that can result in life-threatening wall motion, ejection fraction, and cardiac function.
dysrhythmias. c. Transesophageal echocardiography may be performed, in which
L. Blood urea nitrogen: The blood urea nitrogen level is elevated in heart the echocardiogram is done through the esophagus to view the
disorders such as heart failure and cardiogenic shock that reduce renal posterior structures of the heart; this is an invasive exam and
circulation. requires preparation and care similar to endoscopy procedures.
M. Blood glucose: An acute cardiac episode can elevate the blood glucose 2. Interventions: Advise the client to lie still, breathe normally, and
level. refrain from talking during the test.
N. B-type natriuretic peptide (BNP) S. Exercise electrocardiography testing (stress test)
1. BNP is released in response to atrial and ventricular stretch; it serves 1. Description
as a marker for heart failure. a. This noninvasive test studies the heart during activity to detect
2. BNP levels should be less than 100 ng/mL (less than 100 mcg/L); the and evaluate coronary artery disease.
higher the level, the more severe the heart failure. b. Treadmill testing is the most commonly used mode of stress
O. Chest x-ray testing.
1. Description: Radiography of the chest is done to determine c. If the client is unable to tolerate exercise, an intravenous (IV)
anatomical changes such as the size, silhouette, and position of the infusion of dipyridamole or dobutamine hydrochloride is given
heart. to dilate the coronary arteries and simulate the effect of exercise;
2. Interventions the client may need to be NPO (nothing by mouth) for 3 to 6
a. Prepare the client, explaining the purpose and procedure. hours preprocedure.
b. Remove jewelry. 2. Preprocedure interventions
c. Ensure that the client is not pregnant. a. Ensure that an informed consent is obtained if required.
P. Electrocardiography b. Encourage adequate rest the night before the procedure.
1. Description: This common noninvasive diagnostic test records the c. Instruct the client having a noninvasive test to eat a light meal 1
electrical activity of the heart and is useful for detecting cardiac to 2 hours before the procedure.
dysrhythmias, the location and extent of MI, and cardiac hypertrophy, d. Instruct the client to avoid smoking, alcohol, and caffeine before
and for evaluation of the effectiveness of cardiac medications. the procedure.
2. Basics of Electrocardiography e. Instruct the client to ask the primary health care provider
(PHCP) or cardiologist about taking prescribed medication on
 the day of the procedure; theophylline products are usually c. Monitor peripheral pulses and the color, warmth, and sensation
withheld 12 hours before the test, and calcium channel blockers of the extremity distal to the insertion site at least every 30
and beta blockers are usually withheld on the day of the test to minutes for 2 hours initially.
allow the heart rate to increase during the stress portion of the d. Notify the PHCP if the client reports numbness and tingling; if
test. the extremity becomes cool, pale, or cyanotic; or if loss of the
f. Instruct the client to wear nonconstrictive, comfortable clothing peripheral pulses occurs. This could indicate clot formation and
and supportive rubbersoled shoes for the exercise stress test. is an emergency.
g. Instruct the client to notify the PHCP if any chest pain, e. Apply a sandbag or compression device (if prescribed) to the
dizziness, or shortness of breath occurs during the procedure. insertion site to provide additional pressure if required.
3. Postprocedure interventions: Instruct the client to avoid taking a hot f. Monitor for bleeding; if bleeding occurs, apply manual pressure
bath or shower for at least 1 to 2 hours. immediately and notify the PHCP.
T. Myocardial nuclear perfusion imaging (MNPI) g. Monitor for hematoma; if a hematoma develops, notify the
1. Description PHCP.
a. Nuclear cardiology involves the use of radionuclide techniques h. If the PHCP uses a vascular closure device to seal the arterial
and scanning for cardiovascular assessment. puncture site, there is no need for prolonged compression or bed
b. The most common tests include technetium pyrophosphate rest, and clients may be out of bed in 1 to 2 hours according to
scanning, thallium imaging, and multigated cardiac blood pool manufacturing recommendations for the product used.
imaging; these tests can evaluate cardiac motion and calculate i. If no vascular closure device was inserted, keep the extremity
the ejection fraction. extended for 4 to 6 hours, as prescribed, to prevent arterial
2. Preprocedure interventions occlusion. Maintain strict bed rest for 6 to 12 hours, as
a. Ensure that an informed consent is obtained. prescribed; however, the client may turn from side to side. Do
b. Inform the client that a small amount of radioisotope will be not elevate the head of the bed more than 15 degrees. If the
injected and that the radiation exposure and risks are minimal. antecubital vessel was used, immobilize the arm with an
3. Postprocedure interventions armboard.
a. Assess vital signs. j. Encourage fluid intake, if not contraindicated, to promote renal
b. Assess injection site for bleeding or discomfort. excretion of the dye and to replace fluid loss caused by the
c. Inform the client that fatigue is possible. osmotic diuretic effect of the dye.
U. Magnetic resonance imaging (MRI) k. Monitor for nausea, vomiting, rash, or other signs of
1. Description hypersensitivity to the dye.
a. This is a noninvasive diagnostic test that produces an image of Y. Intravascular ultrasonography (IVUS): A catheter with a transducer is
the heart or great vessels through the interaction of magnetic used as an alternative to injecting a dye into the coronary arteries and
fields, radio waves, and atomic nuclei. detects plaque distribution and composition; it also detects arterial
b. It provides information on chamber size and thickness, valve dissection and the degree of stenosis of an occluded artery.
and ventricular function, and blood flow through the great III. Therapeutic Management
vessels and coronary arteries. A. Percutaneous transluminal coronary angioplasty (PTCA)
2. Preprocedure interventions 1. Description
a. Evaluate the client for the presence of a pacemaker or other a. An invasive, nonsurgical technique in which one or more
implanted items that present a contraindication to the test. coronary arteries are dilated with a balloon catheter to open the
b. Ensure that the client has removed all metallic objects such as a vessel lumen and improve arterial blood flow
watch, jewelry, clothing with metal fasteners, and metal hair b. PTCA may be used for clients with an evolving MI, alone or in
fasteners. combination with medications, to achieve reperfusion.
c. Inform the client they may experience claustrophobia while in c. The client can experience reocclusion after the procedure; thus,
the scanner. the procedure may need to be repeated.
V. Electrophysiological studies: An invasive procedure in which a d. Complications can include arterial dissection or rupture,
programmed electrical stimulation of the heart is induced to cause embolization of plaque fragments, spasm, and acute MI.
dysrhythmias and conduction defects; assists in finding an accurate e. Firm commitment is needed on the client’s part to stop smoking,
diagnosis and aids in determining treatment adhere to diet restrictions, lose weight, alter the exercise pattern,
W. Electron-beam computed tomography (EBCT) scan: Determines and stop any behaviors that lead to progressive artery occlusion.
whether calcications are present in the arteries; a coronary artery calcium 2. Preprocedure interventions
(CAC) score is provided (a score higher than 300 indicates high risk of a. Similar to preprocedure interventions for cardiac catheterization
myocardial infarction and requires intensive preventive treatment). b. The PHCP may prescribe preprocedure medications, including
X. Cardiac catheterization acetylsalicylic acid.
1. Description c. Instruct the client that chest pain may occur during balloon
a. An invasive test involving insertion of a catheter into the heart inflation and to report it if it does occur.
and surrounding vessels 3. Postprocedure interventions
b. Obtains information about the structure and performance of the a. Similar to postprocedure intervention following cardiac
heart chambers and valves and the coronary circulation catheterization
2. Preprocedure interventions b. Administer anticoagulants and antiplatelets as prescribed to
a. Ensure that informed consent has been obtained. prevent thrombus formation.
b. Assess for allergies to seafood, iodine, or radiopaque dyes; if c. IV nitroglycerin may be prescribed to prevent coronary artery
allergic, the client may be premedicated with antihistamines and vasospasm.
corticosteroids to prevent a reaction. d. Encourage fluids, if not contraindicated, to enhance renal
c. Withhold solid food for 6 to 8 hours and liquids for 4 hours as excretion of dye.
prescribed to prevent vomiting and aspiration during the e. Instruct the client in the administration of prescribed
procedure. medications; daily acetylsalicylic acid (aspirin) may be
d. Document the client’s height and weight, because these data will prescribed.
be needed to determine the amount of dye to be administered. f. Assist the client with planning lifestyle modifications.
e. Document baseline vital signs and note the quality and presence B. Laser-assisted angioplasty
of peripheral pulses for postprocedure comparison. 1. Description
f. Inform the client that a local anesthetic will be administered a. A laser probe is advanced through a cannula similar to that used
before catheter insertion. for PTCA.
g. Inform the client that they may feel a fluttery feeling as the b. Used for clients with small occlusions in the coronary arteries,
catheter passes through the heart, a flushed and warm feeling also the distal superficial femoral, proximal popliteal and
when the dye is injected, a desire to cough, and palpitations common iliac arteries
caused by heart irritability. c. Heat from the laser vaporizes the plaque to open the occluded
h. The insertion site is prepared by shaving or clipping the hair and artery.
cleaning with an antiseptic solution. 2. Preprocedure and postprocedure interventions
i. Administer preprocedure medications such as sedatives if a. Care is similar to that for PTCA.
prescribed. b. Monitor for complications of coronary dissection, acute
j. Insert an IV line if prescribed. If a client taking metformin is occlusion, perforation, embolism, and MI.
scheduled to undergo a procedure requiring the C. Coronary artery stents
administration of iodine dye, the metformin is withheld for 1. Description
24 hours prior to the procedure because of the risk of lactic a. Coronary artery stents are used with PTCA to provide a
acidosis. The medication is not resumed until prescribed by supportive scaffold to eliminate the risk of acute coronary vessel
the PHCP (usually 48 hours after the procedure or after closure and to improve long-term patency of the vessel.
renal function studies are done and the results are b. A balloon catheter bearing the stent is inserted into the coronary
evaluated). artery and positioned at the site of occlusion; balloon inflation
3. Postprocedure interventions deploys the stent.
a. Monitor vital signs and cardiac rhythm for dysrhythmias at least c. When placed in the coronary artery, the stent reopens the
every 30 minutes for 2 hours initially. blocked artery.
b. Assess for chest pain. If dysrhythmias or chest pain occurs, 2. Preprocedure and postprocedure interventions
notify the PHCP. a. Care is similar to that for PTCA.
 b. Acute thrombosis is a major concern following the procedure; i. The client is monitored for signs of cardiac tamponade, which
the client is placed on antiplatelet therapy such as clopidogrel include sudden cessation of previously heavy mediastinal
and acetylsalicylic acid (aspirin) for several months following drainage, jugular vein distention with clear lung sounds,
the procedure. The length of time for antiplatelet therapy is equalization of right atrial (RA) pressure and pulmonary artery
determined by the type of stent (metal or medication-coated). wedge pressure, and pulsus paradoxus.
c. Monitor for complications of the procedure such as stent j. Pain is monitored, differentiating sternotomy pain from anginal
migration or occlusion, coronary artery dissection, and bleeding pain, which would indicate graft failure.
resulting from anticoagulation. 4. Transfer of the client from the cardiac surgical unit
D. Atherectomy a. Monitor vital signs, level of consciousness, and peripheral
1. Description perfusion.
a. Atherectomy removes plaque from a coronary artery by the use b. Monitor for dysrhythmias.
of a cutting chamber on the inserted catheter or a rotating blade c. Auscultate lungs and assess respiratory status.
that pulverizes the plaque. d. Encourage the client to splint the incision, cough, deep-breathe,
b. Atherectomy is also used to improve blood flow to ischemic and use the incentive spirometer to raise secretions and prevent
limbs in individuals with peripheral arterial disease. atelectasis.
2. Preprocedure and postprocedure interventions e. Monitor temperature and white blood cell count, which, if
a. Care is similar to that for PTCA. elevated after 3 to 4 days, indicate infection.
b. Monitor for complications of perforation, embolus, and f. Provide adequate fluids and hydration as prescribed to liquefy
reocclusion. secretions.
E. Transmyocardial revascularization g. Assess suture line and chest tube insertion sites for redness,
1. May be used for clients with widespread atherosclerosis involving purulent discharge, and signs of infection.
vessels that are too small and numerous for replacement or balloon h. Assess sternal suture line for instability, which may indicate
catheterization; performed through a small chest incision infection.
2. Transmyocardial revascularization uses a high-powered laser that i. Guide the client to gradually resume activity.
creates 20 to 24 channels through the muscle of the left ventricle; j. Assess the client for tachycardia, postural (orthostatic)
blood enters these small channels, providing the affected region of the hypotension, and fatigue before, during, and after activity.
heart with oxygenated blood. k. Discontinue activities if the BP drops more than 10 to 20 mm
3. The opening on the surface of the heart heals; however, the main Hg or if the pulse increases more than 10 beats per minute.
channels remain and perfuse the myocardium. l. Monitor episodes of pain closely.
F. Coronary artery bypass grafting m. Home Care Instructions for the Client After Cardiac Surgery.
1. Description 1) Progressive return to activities at home
a. The occluded coronary arteries are bypassed with the client’s 2) Limiting of pushing or pulling activities for 6 weeks
own venous or arterial blood vessels. following discharge
b. The saphenous vein, internal mammary artery, or other arteries 3) Maintenance of incisional care and recording signs of
may be used to bypass lesions in the coronary arteries. redness, swelling, or drainage
c. Coronary artery bypass grafting is performed when the client 4) Sternotomy incision heals in about 6 to 8 weeks
does not respond to medical management of coronary artery 5) Avoidance of crossing legs; wearing elastic hose as
disease or when vessels are severely occluded. prescribed until edema subsides, and elevating the surgical
d. A minimally invasive direct coronary artery bypass (MIDCAB) limb (if used to obtain the graft) when sitting in a chair
may be an option for some clients who have a lesion in the LAD 6) Use of prescribed medications
artery; a sternal incision is not required (usually a 2-inch [5-cm] 7) Dietary measures, including the avoidance of saturated fats
left thoracotomy incision is done), and cardiopulmonary bypass and cholesterol and the use of salt
is not required in this procedure 8) Resumption of sexual intercourse on the advice of the
2. Preoperative interventions primary health care provider or cardiologist after exercise
a. Familiarize the client and family with the cardiac surgical tolerance is assessed (usually, if the client can walk 1
critical care unit. block or climb 2 flights of stairs without symptoms, it is
b. Inform the client to expect a sternal incision, possible arm or leg safe to resume sexual activity)
incision(s), one or two chest tubes, a Foley catheter, and several G. Heart transplantation
IV fluid catheters. 1. A donor heart from an individual with a comparable body weight and
c. Inform the client that an endotracheal tube will be in place for a ABO compatibility is transplanted into a recipient within less than 6
short period of time and that they will be unable to speak. hours of procurement.
d. Advise the client they will be on mechanical ventilation and to 2. The surgeon removes the diseased heart, leaving the posterior portion
breathe with the ventilator and not fight it. of the atria to serve as an anchor for the new heart.
e. Instruct the client that postoperative pain is expected and that 3. Because a remnant of the client’s atria remains, two unrelated P
pain medication will be available. waves are noted on the ECG.
f. Instruct the client in how to splint the chest incision, cough and 4. The transplanted heart is denervated and unresponsive to vagal
deep breathe, use the incentive spirometer, and perform arm and stimulation; because the heart is denervated, clients do not experience
leg exercises. angina.
g. Encourage the client and family to discuss anxieties and fears 5. Symptoms of heart rejection include hypotension, dysrhythmias,
related to surgery. weakness, fatigue, and dizziness.
h. Note that prescribed medications may be discontinued 6. Endomyocardial biopsies are performed at regularly scheduled
preoperatively (usually, diuretics 2 to 3 days before surgery, intervals and whenever rejection is suspected.
digoxin 12 hours before surgery, and aspirin and anticoagulants 7. The client requires lifetime immunosuppressive therapy.
1 week before surgery). 8. Strict aseptic technique and vigilant handwashing must be maintained
i. Administer medications as prescribed, which may include when caring for the post transplantation client because of increased
potassium chloride, antihypertensives, antidysrhythmics, and risk for infection from immunosuppression.
antibiotics. 9. The heart rate approximates 100 beats per minute and responds
3. Cardiac surgical unit postoperative interventions slowly to exercise or stress with regard to increases in heart rate,
a. Mechanical ventilation may continue for 6 to 24 hours. contractility, and cardiac output
b. Heart rate and rhythm, pulmonary artery and arterial pressures, IV. Cardiac Dysrhythmias
urinary output, and neurological status are monitored closely. A. Normal sinus rhythm
c. Mediastinal and pleural chest tubes to the water seal drainage 1. Rhythm originates from the SA node.
system with prescribed suction are present; drainage exceeding 2. Description
100 to 150 mL/hr is reported to the PHCP. a. Atrial and ventricular rhythms are regular.
d. Epicardial pacing wires are covered with sterile caps or b. Atrial and ventricular rates are 60 to 100 beats per minute.
connected to a temporary pacemaker generator; all equipment in c. PR interval and QRS width are within normal limits.
use must be properly grounded to prevent microshock. B. Sinus bradycardia
e. Fluid and electrolyte balance is monitored closely; fluids are 1. Description
usually restricted to 1500 to 2000 mL because of postoperative a. Atrial and ventricular rhythms are regular.
edema. b. Atrial and ventricular rates are less than 60 beats per minute.
f. The blood pressure is monitored closely, because hypotension c. PR interval and QRS width are within normal limits.
can cause collapse of a vein graft; hypertension can cause d. Treatment may be necessary if the client is symptomatic (signs
increased pressure, promoting leakage from the suture line, of decreased cardiac output).
causing bleeding. e. A low heart rate may be normal for some individuals, such as
g. Temperature is monitored and rewarming procedures are athletes.
initiated using warm or thermal blankets if the temperature 2. Interventions
drops below 96.8° F (36.0° C); rewarm the client no faster than a. Attempt to determine the cause of sinus bradycardia; withhold
1.8 degrees/hr to prevent shivering, and discontinue rewarming medication suspected of causing the bradycardia and notify the
procedures when the temperature approaches 98.6° F (37.0° C). PHCP.
h. Potassium is administered intravenously as prescribed to b. Administer oxygen as prescribed for the symptomatic client.
maintain the potassium level between 4 and 5 mEq/L (4 to 5 c. Administer atropine sulfate as prescribed to increase the heart
mmol/L) to prevent dysrhythmias. rate to 60 beats per minute.
 d. Be prepared to apply a noninvasive (transcutaneous) pacemaker d. Administer oxygen as prescribed.
initially if the atropine sulfate does not increase the heart rate e. Administer antidysrhythmic therapy as prescribed.
sufficiently. H. Guidelines for performing adult CPR
e. Avoid additional doses of atropine sulfate, because this will 1. Follow CAB (compressions, airway, breathing) guidelines. If a victim
induce tachycardia. is noted to be not breathing or only gasping, activate the emergency
f. Monitor for hypotension, and administer fluids intravenously as response system and obtain an automated external defibrillator (AED)
prescribed. or monophasic or biphasic defibrillator, depending on the setting and
g. Depending on the cause of the bradycardia, the client may need equipment available.
a permanent pacemaker. 2. For updated information, refer to the American Heart Association.
C. Sinus tachycardia The latest update for adult CPR can be located at American Heart
1. Description Association (2020). Highlights of the 2020 American Heart
a. Atrial and ventricular rates are 100 to 180 beats per minute. Association Guidelines for CPR and ECC. p. 11 at
b. Atrial and ventricular rhythms are regular. https://professional.heart.org/en/scien ce-news/2020-aha-guidelines-
c. PR interval and QRS width are within normal limits. for-cpr-and-ecc
2. Interventions V. Management of Dysrhythmias
a. Identify the cause of the tachycardia. A. Vagal maneuvers
b. Decrease the heart rate to normal by treating the underlying 1. Description: Vagal maneuvers induce vagal stimulation of the cardiac
cause. conduction system and are used to terminate supraventricular
D. Atrial fibrillation (Fig. 53.7) tachydysrhythmias.
1. Description 2. Carotid sinus massage
a. Multiple rapid impulses from many foci depolarize in the atria a. The client turns the head away from the side to be massaged.
in a totally disorganized manner at a rate of 350 to 600 times per b. The PHCP massages over one carotid artery for a few seconds
minute. to determine whether a change in cardiac rhythm occurs.
b. The atria quiver, which can lead to the formation of thrombi. c. The client must be on a cardiac monitor; an electrocardiographic
c. Usually no definitive P wave can be observed, only fibrillatory rhythm strip before, during, and after the procedure should be
waves before each QRS. documented on the chart.
2. Interventions d. Have a defibrillator and resuscitative equipment available.
a. Administer oxygen. e. Monitor vital signs, cardiac rhythm, and level of consciousness
b. Administer anticoagulants as prescribed because of the risk of following the procedure.
emboli. 3. Valsalva maneuver
c. Administer cardiac medications as prescribed to control the a. The PHCP instructs the client to bear down or induces the
ventricular rhythm and assist in the maintenance of cardiac client’s gag reflex to stimulate a vagal response.
output. b. Monitor the heart rate, rhythm, and BP.
d. Prepare the client for cardioversion as prescribed. c. Observe the cardiac monitor for a change in rhythm.
e. Instruct the client in the use of medications as prescribed to d. Record an electrocardiographic rhythm strip before, during, and
control the dysrhythmia. after the procedure.
E. Premature ventricular contractions e. Provide an emesis basin if the gag reflex is stimulated, and
1. Description initiate precautions to prevent aspiration.
a. Early ventricular contractions result from increased irritability f. Have a defibrillator and resuscitative equipment available.
of the ventricles. B. Cardioversion
b. PVCs frequently occur in repetitive patterns such as bigeminy, 1. Description
trigeminy, and quadrigeminy. a. Cardioversion is synchronized countershock to convert an
c. The QRS complexes may be unifocal or multifocal. undesirable rhythm to a stable rhythm.
2. Interventions b. Cardioversion can be an elective procedure performed by the
a. Identify the cause and treat on the basis of the cause. PHCP for stable tachydysrhythmias resistant to medical
b. Evaluate oxygen saturation to assess for hypoxemia, which can therapies or an emergent procedure for hemodynamically
cause PVCs. unstable ventricular or supraventricular tachydysrhythmias.
c. Evaluate electrolytes, particularly the potassium level, because c. A lower amount of energy is used than with defibrillation.
hypokalemia can cause PVCs. d. The defibrillator is synchronized to the client’s R wave to avoid
d. Oxygen and medication may be prescribed in the case of acute discharging the shock during the vulnerable period (T wave).
myocardial ischemia or MI. For the client experiencing PVCs, e. If the defibrillator is not synchronized, it could discharge on the
notify the PHCP or cardiologist if the client complains of T wave and cause VF.
chest pain or if the PVCs increase in frequency, are 2. Preprocedure interventions
multifocal, occur on the T wave (R-on-T), or occur in runs of a. If an elective procedure, ensure that informed consent is
ventricular tachycardia. obtained.
F. Ventricular tachycardia b. Administer sedation as prescribed.
1. Description c. If an elective procedure, hold digoxin for 48 hours preprocedure
a. VT occurs because of a repetitive firing of an irritable as prescribed to prevent postcardioversion ventricular
ventricular ectopic focus at a rate of 140 to 250 beats per minute irritability.
or more. d. If an elective procedure for atrial fibrillation or atrial flutter, the
b. VT may present as a paroxysm of three self-limiting beats or client should receive anticoagulant therapy for 4 to 6 weeks
more, or may be a sustained rhythm. preprocedure, and a transesophageal echocardiogram (TEE)
c. VT can lead to cardiac arrest. should be performed to rule out clots in the atria prior to the
2. Stable client with sustained VT (with pulse and no signs or symptoms procedure.
of decreased cardiac output) 3. During the procedure
a. Administer oxygen as prescribed. a. Ensure that the skin is clean and dry in the area where the
b. Administer antidysrhythmics as prescribed. electrode pads/hands-off pads will be placed.
3. Unstable client with VT (with pulse and signs and symptoms of b. Stop the oxygen during the procedure to avoid a fire hazard.
decreased cardiac output) c. Be sure that no one is touching the bed or the client when
a. Administer oxygen and antidysrhythmic therapy as prescribed. delivering the countershock (check the entire length of the client
b. Prepare for synchronized cardioversion if the client is unstable. 3 times).
c. The PHCP may attempt cough cardiopulmonary resuscitation 4. Postprocedure interventions
(CPR) by asking the client to cough hard every 1 to 3 seconds. a. Priority assessment includes ability of the client to maintain the
4. Pulseless client with VT: Defibrillation and CPR airway and breathing.
G. Ventricular fibrillation b. Resume oxygen administration as prescribed.
1. Description c. Assess vital signs.
a. Impulses from many irritable foci in the ventricles fire in a d. Assess level of consciousness.
totally disorganized manner. e. Monitor cardiac rhythm.
b. VF is a chaotic rapid rhythm in which the ventricles quiver and f. Monitor for indications of successful response, such as
there is no cardiac output. conversion to sinus rhythm, strong peripheral pulses, an
c. VF is fatal if not successfully resolved within 3 to 5 minutes. adequate BP, and adequate urine output.
d. Client is unconscious with no pulse, BP, respirations, or heart g. Assess the skin on the chest for evidence of burns from the
sounds. edges of the pads.
2. Interventions C. Defibrillation
a. Initiate CPR until a defibrillator is available. 1. Defibrillation is an asynchronous countershock used to terminate
b. The client is defibrillated immediately with 120 to 200 joules pulseless VT or VF.
(biphasic defibrillator) or 360 joules (monophasic defibrillator); 2. The defibrillator is charged to 120 to 200 joules (biphasic) or 360
check the entire length of the client 3 times to make sure no one joules (monophasic) for 1 countershock from the defibrillator, and
is touching the client or the bed; when clear, proceed with then CPR is resumed immediately and continued for five cycles or
defibrillation. about 2 minutes.
c. CPR is continued for 2 minutes, and the cardiac rhythm is
reassessed to determine the need for further countershock.
 3. Reassess the rhythm after 2 minutes, and if VF or pulseless VT 1. When a pacing stimulus is delivered to the heart, a spike (straight
continues, the defibrillator is charged to give a second shock at the vertical line) is seen on the monitor or ECG strip.
same energy level previously used. 2. Spikes precede the chamber being paced; a spike preceding a P wave
4. Resume CPR after the shock, and continue with the life support indicates that the atrium is paced, and a spike preceding the QRS
protocol. Before defibrillating a client, be sure that the oxygen is complex indicates that the ventricle is being paced.
shut off to avoid the hazard of fire, and be sure that no one is 3. An atrial spike followed by a P wave indicates atrial depolarization,
touching the bed or the client. and a ventricular spike followed by a QRS complex represents
D. Use of pad electrodes ventricular depolarization; this is referred to as capture.
1. One pad is placed at the third intercostal space to the right of the D. Temporary pacemakers
sternum; the other is placed at the fifth intercostal space on the left 1. Noninvasive transcutaneous pacing
midaxillary line. a. Noninvasive transcutaneous pacing is used as a temporary
2. Avoid placing pads directly over breast tissue, medication patches, or emergency measure in the profoundly bradycardic or asystolic
an implanted device. client until invasive pacing can be initiated.
3. Pads for hands-off biphasic defibrillation may be applied in an b. Large electrode pads are placed on the client’s chest and back
anterior-posterior position or apex-posterior position. and connected to an external pulse generator.
4. Apply firm pressure of at least 25 lb to each of the pads. c. Wash the skin with soap and water before applying electrodes.
5. Be sure that no one is touching the bed or the client when delivering d. It is not necessary to shave the hair or apply alcohol or tinctures
the countershock. to the skin.
E. Automated external defibrillator (AED) e. Place the posterior electrode between the spine and left scapula
1. An AED is used for prehospital cardiac arrest. behind the heart, avoiding placement over bone.
2. Place the client on a firm, dry surface. f. Place the anterior electrode between V2 and V5 positions over
3. Turn on the AED and follow the voice prompts. the heart.
4. Place the electrode patches in the correct position on the client’s g. Do not place the anterior electrode over breast tissue; rather,
chest. displace the breast tissue and place the electrode under the
5. Stop CPR. breast.
6. Ensure that no one is touching the client to avoid motion artifact h. Do not take the pulse or BP on the left side; the results will not
during rhythm analysis. be accurate because of the muscle twitching and electrical
7. The machine will advise whether a shock is necessary. current.
8. Shocks are recommended for pulseless VT or VF only (usually three i. Ensure that electrodes are in good contact with the skin.
shocks are delivered). j. Set pacing rate as prescribed; establish stimulation threshold to
9. If unsuccessful, CPR is continued for 1 minute and then another series ensure capture.
of shocks is delivered. k. If loss of capture occurs, assess the skin contact of the electrodes
F. Automated implantable cardioverter-defibrillator (AICD) and increase the current until capture is regained.
1. Description l. Evaluate the client for discomfort from cutaneous and muscle
a. An AICD monitors cardiac rhythm and detects and terminates stimulation; administer analgesics as needed.
episodes of VT and VF by delivering 25 to 30 joules up to 4 2. Invasive transvenous pacing
times, if necessary. a. Pacing lead wire is placed through the antecubital, femoral,
b. An AICD is used in clients with episodes of spontaneous jugular, or subclavian vein into the right atrium or right ventricle
sustained VT or VF unrelated to an MI or in clients whose so that it is in direct contact with the endocardium.
medication therapy has been unsuccessful in controlling life- b. Monitor the pacemaker insertion site.
threatening dysrhythmias. c. Restrict client movement to prevent lead wire displacement.
c. Transvenous electrode leads are placed in the right atrium and 3. Invasive epicardial pacing—applied by using a transthoracic
ventricle in contact with the endocardium; leads are used for approach; the lead wires are threaded loosely on the epicardial surface
sensing, pacing, and delivery of cardioversion or defibrillation. of the heart after cardiac surgery.
d. The generator is most commonly implanted in the left pectoral 4. Reducing the risk of microshock
region. a. Use only inspected and approved equipment.
2. Client education b. Insulate the exposed portion of wires with plastic or rubber
a. Instruct the client in the basic functions of the AICD. material (fingers of rubber gloves) when wires are not attached
b. Know the rate cutoff of the AICD and the number of to the pulse generator; cover with nonconductive tape.
consecutive shocks that it will deliver. c. Ground all electrical equipment, using a three-pronged plug.
c. Wear loose-fitting clothing over the AICD generator site. d. Wear gloves when handling exposed wires.
d. Instruct the client on activities to avoid, including contact sports, e. Keep dressings dry. Vital signs are monitored and cardiac
to prevent trauma to the AICD generator and lead wires. monitoring is done continuously for the client with a
e. Report any fever, redness, swelling, or drainage from the temporary pacemaker.
insertion site. E. Permanent pacemakers
f. Report symptoms of fainting, nausea, weakness, blackouts, and 1. Pulse generator is internal and surgically implanted in a subcutaneous
rapid pulse rates to the PHCP. pocket below the clavicle.
g. During shock discharge, the client may feel faint or short of 2. The leads are passed transvenously via the cephalic or subclavian vein
breath. to the endocardium on the right side of the heart; postoperatively,
h. Instruct the client to sit or lie down if a shock is felt and to limitation of arm movement on the operative side is required to
notify the PHCP. prevent lead wire dislodgment.
i. Advise the client to maintain a log of the date, time, and activity 3. Permanent pacemakers may be single-chambered, in which the lead
preceding the shock; the symptoms preceding the shock; and wire is placed in the chamber to be paced; or dual-chambered, with
post-shock sensations. lead wires placed in both the right atrium and the right ventricle.
j. Instruct the client and family in how to access the emergency 4. Biventricular pacing of the ventricles allows for synchronized
medical system. depolarization and is used for moderate to severe heart failure to
k. Encourage the family to learn CPR. improve cardiac output.
l. Instruct the client to avoid electromagnetic fields directly over 5. A permanent pacemaker is programmed when inserted and can be
the AICD, because they can inactivate the device. reprogrammed, if necessary, by noninvasive transmission from an
m. Instruct the client to move away from the magnetic field external programmer to the implanted generator.
immediately if beeping tones are heard, and to notify the PHCP. 6. Pacemakers may be powered by a lithium battery with an average life
n. Keep an AICD identification card in the wallet, and obtain and span of 10 years, nuclear-powered with a life span of 20 years or
wear a MedicAlert bracelet. longer, or designed to be recharged externally.
o. Inform all PHCPs that an AICD has been inserted; certain 7. Pacemaker function can be checked in the PHCP’s office or clinic by
diagnostic tests, such as MRI, and procedures using diathermy a pacemaker interrogator or programmer or from home, using a
or electrocautery interfere with AICD function. special telephone transmitter device.
VI. Pacemakers 8. Client teaching.
A. Description: Temporary or permanent device that provides electrical a. Instruct the client about the pacemaker, including the
stimulation and maintains the heart rate when the client’s intrinsic programmed rate.
pacemaker fails to provide an adequate rate b. Instruct the client in the signs of battery failure and when to
B. Settings notify the PHCP or cardiologist.
1. A synchronous (demand) pacemaker senses the client’s rhythm and c. Instruct the client to report any fever, redness, swelling, or
paces only if the client’s intrinsic rate falls below the set pacemaker drainage from the insertion site.
rate for stimulating depolarization. d. Report signs of dizziness, weakness or fatigue, swelling of the
2. An asynchronous (fixed rate) pacemaker paces at a preset rate ankles or legs, chest pain, or shortness of breath.
regardless of the client’s intrinsic rhythm and is used when the client e. Keep a pacemaker identification card in the wallet, and obtain
is asystolic or profoundly bradycardic. and wear a MedicAlert bracelet.
3. Overdrive pacing suppresses the underlying rhythm in f. Instruct the client in how to take the pulse, to take the pulse
tachydysrhythmias so that the sinus node will regain control of the daily, and to maintain a diary of pulse rates.
heart. g. Wear loose-fitting clothing over the pulse generator site.
C. Spikes h. Avoid contact sports.
i. Inform all PHCPs that a pacemaker has been inserted.
 j. Instruct the client to inform airport security that they have a a. Also called exertional angina
pacemaker, because the pacemaker may set off the security b. Occurs with activities that involve exertion or emotional stress;
detector. relieved with rest or nitroglycerin
k. Instruct the client that most electrical appliances can be used c. Usually has a stable pattern of onset, duration, severity, and
without any interference with the functioning of the pacemaker; relieving factors
however, advise the client not to operate electrical appliances 2. Unstable angina
directly over the pacemaker site. a. Also called pre-infarction angina
l. Avoid transmitter towers and antitheft devices in stores. b. Associated with worsening cardiac ischemia
m. Instruct the client that if any unusual feelings occur when near c. Occurs with an unpredictable degree of exertion or emotion and
any electrical devices, to move 5 to 10. increases in occurrence, duration, and severity over time
VII. Coronary Artery Disease d. Lasts longer than 15 minutes
A. Description e. Pain may not be relieved with nitroglycerin.
1. Coronary artery disease is a narrowing or obstruction of one or more 3. Variant angina
coronary arteries as a result of atherosclerosis, which is an a. Also called Prinzmetal’s or vasospastic angina
accumulation of lipid-containing plaque in the arteries. b. Results from coronary artery spasm
2. The disease causes decreased perfusion of myocardial tissue and c. May occur at rest d. Attacks may be associated with ST-segment
inadequate myocardial oxygen supply, leading to hypertension, elevation noted on the ECG.
angina, dysrhythmias, MI, heart failure, and death. 4. Intractable angina is a chronic, incapacitating angina unresponsive to
3. Collateral circulation (more than one artery supplying a muscle with interventions.
blood) develops over time in response to chronic ischemia; therefore, C. Assessment
an occlusion of a coronary artery in a younger individual is more 1. Pain
likely to be lethal than one in an older individual.
4. Symptoms of ischemia occur when the coronary artery is occluded to Characteristics of Pain: Angina and Myocardial Infarction
the point of inadequate blood supply to the cardiac muscle. Angina Myocardial Infarction
5. Coronary artery narrowing is significant if the lumen diameter of the Can develop slowly or quickly Occurs without cause, primarily early in
left main artery is reduced by at least 50% or if any major branch is Usually described as mild or moderate the morning
reduced at least 75%. pain Crushing substernal pain
6. The goal of treatment is to alter the atherosclerotic progression. Substernal, crushing, squeezing pain May radiate to the jaw, back, and left
May radiate to the shoulders, arms, jaw, arm
B. Assessment
neck, and back Last 30 minutes or longer
1. Possibly normal findings during asymptomatic periods Usually lasts less than 5 minutes; Is unrelieved by rest or nitroglycerin,
2. Chest pain however, can last up to 15 to 20 and relieved only by opioids
3. Palpitations minutes
4. Dyspnea Relieve by nitroglycerine or rest
5. Syncope a. Pain can develop slowly or quickly.
6. Cough or hemoptysis b. Pain usually is described as mild or moderate.
7. Excessive fatigue c. Substernal, crushing, squeezing pain may occur.
C. Diagnostic studies d. Pain may radiate to the shoulders, arms, jaw, neck, or back.
1. Electrocardiography e. Pain intensity is unaffected by inspiration and expiration.
a. When blood flow is reduced and ischemia occurs, ST-segment f. Pain usually lasts less than 5 minutes but may last 15 to 20
depression, T-wave inversion, or both are noted; the ST segment minutes.
returns to normal when the blood ow returns. g. Pain is relieved by nitroglycerin or rest.
b. With infarction, cell injury results in ST-segment elevation, 2. Dyspnea
followed by T-wave inversion and an abnormal Q wave. 3. Pallor
2. Cardiac catheterization: Cardiac catheterization shows the presence 4. Sweating
and extent of atherosclerotic lesions. 5. Palpitations and tachycardia
3. Blood lipid levels 6. Dizziness and syncope
a. Blood lipid levels may be elevated. 7. Hypertension
b. Cholesterol-lowering medications may be prescribed to reduce 8. Digestive disturbances
the development of atherosclerotic plaques. D. Diagnostic studies
D. Interventions 1. Electrocardiography: Readings are normal during rest, with ST
1. Assist the client to identify modifiable risk factors and to set goals to depression or T-wave inversion during an episode of pain.
promote healthy lifestyle changes. 2. Stress testing: Chest pain or changes in the ECG or vital signs during
2. Assist the client to identify barriers to adherence with the therapeutic testing may indicate ischemia.
plan and to identify methods to overcome barriers. 3. Troponin and cardiac enzyme levels: Findings are normal in angina.
3. Instruct the client regarding a low-calorie, low-sodium, low- 4. Cardiac catheterization: Provides a definitive diagnosis by providing
cholesterol, and low-fat diet, with an increase in dietary fiber. information about the patency of the coronary arteries.
4. Stress that dietary changes should be incorporated for the rest of the E. Interventions
client’s life; instruct the client regarding prescribed medications. 1. Immediate management
5. Provide community resources to the client regarding exercise, a. Assess pain; institute pain relief measures.
smoking cessation, and stress reduction as appropriate. b. Administer oxygen by nasal cannula as prescribed.
E. Surgical procedures c. Assess vital signs and provide continuous cardiac monitoring
1. PTCA to compress the plaque against the walls of the artery and and nitroglycerin as prescribed to dilate the coronary arteries,
dilate the vessel reduce the oxygen requirements of the myocardium, and relieve
2. Laser angioplasty to vaporize the plaque the chest pain.
3. Atherectomy to remove the plaque from the artery d. Ensure that bed rest is maintained, place the client in semi-
4. Vascular stent to prevent the artery from closing and to prevent Fowler’s position, and stay with the client.
restenosis e. Obtain a 12-lead ECG.
5. Coronary artery bypass grafting past the occluded artery to improve f. Establish an IV access route.
blood flow to the myocardial tissue at risk for ischemia or infarction 2. Following the acute episode
F. Medications a. See section VII, D (Coronary Artery Disease, Interventions)
1. Nitrates to dilate the coronary arteries and decrease preload and b. Assist the client to identify angina-precipitating events.
afterload c. Instruct the client to stop activity and rest if chest pain occurs,
2. Calcium channel blockers to dilate coronary arteries and reduce and to sit down and take nitroglycerin as prescribed. The client
vasospasm is usually instructed to call emergency medical services if the
3. Cholesterol-lowering medications to reduce the development of nitroglycerin does not relieve the pain, and many PHCPs
atherosclerotic plaques recommend that the client also chew an aspirin.
4. Beta blockers to control hypertension F. Surgical procedures: See section VII, E (Coronary Artery Disease, Surgical
III. Angina procedures)
A. Description G. Medications
1. Angina is chest pain resulting from myocardial ischemia caused by 1. See section VII, F (Coronary Artery Disease, Medications)
inadequate myocardial blood and oxygen supply. 2. Antiplatelet therapy may be prescribed to inhibit platelet aggregation
2. Angina is caused by an imbalance between oxygen supply and and reduce the risk of developing an acute MI.
demand. IX. Myocardial Infarction
3. Causes include obstruction of coronary blood flow resulting from A. Description
atherosclerosis, coronary artery spasm, or conditions increasing 1. MI occurs when myocardial tissue is abruptly and/or severely
myocardial oxygen consumption. The goal of treatment for angina deprived of oxygen.
is to provide relief from the acute attack, correct the imbalance 2. Ischemia can lead to necrosis of myocardial tissue if blood flow is not
between myocardial oxygen supply and demand, and prevent the restored.
progression of the disease and further attacks to reduce the risk 3. Infarction does not occur instantly but evolves over several hours.
of MI. 4. Obvious physical changes do not occur in the heart until 6 hours after
B. Patterns of angina the infarction, when the infarcted area appears blue and swollen.
1. Stable angina
 5. After 48 hours, the infarct turns gray, with yellow streaks developing 3. Assess vital signs and cardiovascular status, and maintain cardiac
as neutrophils invade the tissue. monitoring.
6. By 8 to 10 days after infarction, granulation tissue forms. 4. Assess respiratory rate and breath sounds for signs of heart failure, as
7. Over 2 to 3 months, the necrotic area develops into a scar; scar tissue indicated by the presence of crackles or wheezes or dependent edema.
permanently changes the size and shape of the ventricle. 5. Place the client in a semi-Fowler’s position to enhance comfort and
B. Location of MI tissue oxygenation; ensure bed rest and stay with the client.
1. Obstruction of the LAD artery results in anterior wall or septal MI, or 6. Establish an IV access route.
both. 7. Obtain a 12-lead ECG.
2. Obstruction of the circumflex artery results in posterior wall MI or 8. Monitor laboratory values.
lateral wall MI. 9. Monitor for cardiac dysrhythmias, because tachycardia and PVCs
3. Obstruction of the right coronary artery results in inferior wall MI. frequently occur in the first few hours after MI; administer
C. Risk factors antidysrhythmics as prescribed.
1. Atherosclerosis 10. Administer thrombolytic therapy, which may be prescribed within the
2. Coronary artery disease first 6 hours of the coronary event if cardiac catheterization is not to
3. Elevated cholesterol levels be done emergently; monitor for signs of bleeding if the client is
4. Smoking receiving thrombolytic therapy.
5. Hypertension 11. Assess for poor cardiac output, which may appear as cool diaphoretic
6. Obesity skin and diminished or absent pulses.
7. Physical inactivity 12. Monitor the BP closely after administering medications; if the systolic
8. Impaired glucose tolerance pressure is lower than 100 mm Hg or 25 mm Hg lower than the
9. Stress previous reading, lower the head of the bed and notify the PHCP.
D. Diagnostic studies 13. Administer beta blockers as prescribed to slow the heart rate and
1. Troponin level: Level rises within 3 hours and remains elevated for up increase myocardial perfusion while reducing the force of myocardial
to 7 to 10 days. contraction.
2. Total CK level: Level rises within 6 hours after the onset of chest pain 14. Provide reassurance to the client and family.
and peaks within 18 hours after damage and death of cardiac tissue. H. Interventions following the acute episode
3. CK-MB isoenzyme: Peak elevation occurs 18 hours after the onset of 1. Maintain bed rest as prescribed.
chest pain and returns to normal 48 to 72 hours later. 2. Allow the client to stand to void or use a bedside commode if
4. Myoglobin: Level rises within 2 hours after cell death, with a rapid prescribed.
decline in the level after 7 hours. 3. Provide range-of-motion exercises to prevent thrombus formation and
5. White blood cell count: An elevated white blood cell count appears on maintain muscle strength.
the second day following the MI and lasts up to 1 week. 4. Progress to dangling legs at the side of the bed or out of bed to the
6. Electrocardiogram chair for 30 minutes 3 times a day as prescribed.
a. ECG shows either ST segment elevation MI (STEMI), T-wave 5. Progress to ambulation in the client’s room and to the bathroom and
inversion, or NSTEMI; an abnormal Q wave may also present. then in the hallway 3 times a day.
b. Hours to days after the MI, ST- and T-wave changes will return 6. Monitor for complications.
to normal, but the Q-wave changes usually remain permanently. 7. Administer angiotensin-converting enzyme (ACE) inhibitors,
7. Cardiac catheterization may be done emergently to determine the angiotensin-II receptor blockers (ARBs), calcium channel blockers,
extent and location of obstructions of the coronary arteries; this aspirin, thienopyridines (clopidogrel), and lipid-lowering agents as
allows for use of PTCA and restoration of blood flow to the prescribed.
myocardium. 8. Encourage the client to verbalize feelings regarding the MI.
8. Diagnostic tests following the acute stage I. Cardiac rehabilitation: Process of actively assisting the client with cardiac
a. Exercise tolerance test or stress test to assess for disease to achieve and maintain a vital and productive life within the
electrocardiographic changes and ischemia and to evaluate for limitations of the heart disease; also refer to section VII, D (Coronary
medical therapy or identify clients who may need invasive Artery Disease, Interventions)
therapy X. Heart Failure
b. Thallium scans to assess for ischemia or necrotic muscle tissue A. Description
c. Multigated cardiac blood pool imaging scans may be used to 1. Heart failure is the inability of the heart to maintain adequate cardiac
evaluate left ventricular function. output to meet the metabolic needs of the body because of impaired
d. If not done urgently, cardiac catheterization to determine the pumping ability.
coronary artery obstructions will be done after the client is 2. Diminished cardiac output results in inadequate peripheral tissue
stabilized. perfusion.
E. Assessment 3. Congestion of the lungs and periphery may occur; the client can
1. Pain develop acute pulmonary edema.
a. Client may experience crushing substernal pain. B. Classification
b. Pain may radiate to the jaw, back, and left arm. 1. Acute heart failure occurs suddenly.
c. Pain may occur without cause, primarily early in the morning. 2. Chronic heart failure develops over time; however, a client with
d. Pain is unrelieved by rest or nitroglycerin and is relieved only chronic heart failure can develop an acute episode.
by opioids. C. Types of heart failure
e. Pain lasts 30 minutes or longer. 1. Right ventricular failure, left ventricular failure
2. Nausea and vomiting a. Because the two ventricles of the heart represent two separate
3. Diaphoresis pumping systems, it is possible for one to fail alone for a short
4. Dyspnea period.
5. Dysrhythmias b. Most heart failure begins with left ventricular failure and
6. Feelings of fear and anxiety, impending doom progresses to failure of both ventricles.
7. Pallor, cyanosis, coolness of extremities c. Acute pulmonary edema, a medical emergency, results from left
8. Women may experience atypical discomfort, shortness of breath, or ventricular failure.
fatigue and often present with non–ST-elevation myocardial d. If pulmonary edema is not treated, death will occur from
infarction (NSTEMI) or T-wave inversion. suffocation because the client literally drowns in their own
9. An older client may experience shortness of breath, pulmonary fluids.
edema, dizziness, or altered mental status. 2. Forward failure, backward failure
F. Complications of MI a. In forward failure, an inadequate output of the affected ventricle
1. Dysrhythmias causes decreased perfusion to vital organs.
2. Heart failure b. In backward failure, blood backs up behind the affected
3. Pulmonary edema ventricle, causing increased pressure in the atrium behind the
4. Cardiogenic shock affected ventricle.
5. Thrombophlebitis 3. Low output, high output
6. Pericarditis a. In low-output failure, not enough cardiac output is available to
7. Mitral valve insufficiency meet the demands of the body.
8. Postinfarction angina b. High-output failure occurs when a condition causes the heart to
9. Ventricular rupture work harder to meet the demands of the body.
10. Dressler’s syndrome (a combination of pericarditis, pericardial 4. Systolic failure, diastolic failure
effusion, and pleural effusion, which can occur several weeks to a. Systolic failure, also known as heart failure with reduced
months following a myocardial infarction) ejection fraction (HFrEF), is a problem with contraction and
G. Interventions, acute stage ejection of blood.
Pain relief increases oxygen supply to the myocardium; b. Diastolic failure, also known as heart failure with preserved
administer morphine as a priority in managing pain in the ejection fraction (HFpEF), is a problem with the heart relaxing
client having an MI. and filling with blood.
1. Obtain a description of the chest discomfort. D. Compensatory mechanisms
2. Administer oxygen and institute pain relief measures (morphine, 1. Compensatory mechanisms act to restore cardiac output, but they
nitroglycerin as prescribed). eventually have a damaging effect on pump action.
 2. Compensatory mechanisms increase myocardial oxygen consumption; 1. Description
when myocardial reserve is exhausted, clinical manifestations of heart a. Pericarditis is an acute or chronic inflammation of the
failure develop. pericardium.
3. Compensatory mechanisms include increased heart rate and stroke b. Chronic pericarditis, a chronic inflammatory thickening of the
volume, arterial vasoconstriction, sodium and water retention, and pericardium, constricts the heart, causing compression.
myocardial hypertrophy. c. The pericardial sac becomes inflamed.
E. Assessment d. Pericarditis can result in loss of pericardial elasticity or an
accumulation of fluid within the sac.
Clinical Manifestation of Right-Sided and Left-Sided Heart Failure e. Heart failure or cardiac tamponade may result.
Right-Sided Heart Failure Left-Sided Heart Failure 2. Assessment
Dependent edema (legs and sacrum) Signs of pulmonary congestion a. Pain in the anterior chest that radiates to the left side of the neck,
Jugular venous distention Dyspnea shoulder, or back
Abdominal distention Tachypnea b. Pain is grating and is aggravated by breathing (particularly
Hepatomegaly Crackles in the lungs inspiration), coughing, and swallowing.
Splenomegaly Dry, hacking cough c. Pain is worse when in the supine position and may be relieved
Anorexia and nausea Paroxysmal nocturnal dyspnea by leaning forward.
Weight gain Increased BP (from fluid volume d. Pericardial friction rub (scratchy, high-pitched sound) on
excess) or decreased BP (from pump auscultation is produced by the rubbing of the inflamed
failure)
pericardial layers.
Nocturnal diuresis
e. Fever and chills
Swelling of the fingers and hands
f. Fatigue and malaise
Increased BP (from fluid volume
g. Elevated white blood cell count
excess) or decreased BP (from pump
failure) h. Electrocardiographic changes with acute pericarditis; ST-
1. Right- and left-sided heart failure segment elevation with the onset of inflammation; atrial
2. Acute pulmonary edema fibrillation is common.
a. Severe dyspnea i. Signs of right ventricular failure in clients with chronic
b. Tachycardia, tachypnea constrictive pericarditis
c. Nasal flaring; use of accessory breathing muscles 3. Interventions
d. Wheezing and crackles on auscultation; gurgling respirations a. Assess the nature of the pain.
e. Expectoration of large amounts of blood-tinged, frothy sputum b. Place the client in a high-Fowler’s position, or upright and
f. Acute anxiety, apprehension, restlessness leaning forward.
g. Profuse sweating c. Administer oxygen.
h. Cold, clammy skin d. Administer analgesics, nonsteroidal anti-inflammatory drugs
i. Cyanosis (NSAIDs), or corticosteroids for pain as prescribed.
e. Auscultate for a pericardial friction rub.
Signs of left ventricular failure are evident in the pulmonary f. Check results of blood culture to identify the causative
system. Signs of right ventricular failure are evident in the organism.
systemic circulation. g. Administer antibiotics for bacterial infection as prescribed.
h. Administer diuretics and digoxin as prescribed to the client with
F. Immediate management of acute pulmonary edema chronic constrictive pericarditis; surgical incision of the
1. The nurse is monitoring a hospitalized client who is being treated for pericardium (pericardial window) or pericardiectomy may be
a diagnosis of heart failure. The client is on a cardiac monitor and necessary.
oxygen at 2 L/minute via nasal cannula. The client calls the nurse and i. Monitor for signs of cardiac tamponade.
reports severe dyspnea. On assessment the nurse notes that the client’s j. Notify the PHCP if signs of cardiac tamponade occur.
heart rate is 128 beats per minute and respirations are 24 breaths per B. Myocarditis
minute. The client is anxious and restless, is sweating profusely, and 1. Description: Acute or chronic inflammation of the myocardium as a
the client’s skin is cool and clammy. Wheezing and crackles are heard result of pericarditis, systemic infection, or allergic response
on auscultation of the lungs, and the client is expectorating blood- 2. Assessment
tinged frothy sputum. Pulse oximetry reading is 89%. The nurse takes a. Fever
the following actions: b. Dyspnea
a. Places the client in a high-Fowler’s position. c. Tachycardia
b. Stays with the client and asks another person to contact the d. Chest pain
primary health care provider. e. Pericardial friction rub
c. Ensures oxygen administration and increases flow rate or f. Gallop rhythm
method of administration as prescribed. g. Murmur
d. Ensures that an intravenous (IV) access device is in place. h. Pulsus alternans
e. Prepares for the administration of a diuretic and morphine i. Signs of heart failure
sulfate. 3. Interventions
f. Inserts a Foley catheter as prescribed. a. Position for comfort, such as sitting up and leaning forward.
g. Prepares for intubation and ventilator support, if required. b. Administer oxygen as prescribed.
h. Documents the event, actions taken, and the client’s response. c. Administer analgesics, salicylates, and NSAIDs as prescribed to
G. Following the acute episode reduce fever and pain.
1. Assist the client to identify precipitating risk factors of heart failure d. Administer digoxin as prescribed.
and methods of eliminating these risk factors. e. Administer antidysrhythmics as prescribed.
2. Encourage the client to verbalize feelings about the lifestyle changes f. Administer antibiotics as prescribed to treat the causative
required as a result of the heart failure. organism.
3. Instruct the client in the prescribed medication regimen, which may g. Monitor for complications including thrombus, heart failure, and
include digoxin, a diuretic, ACE inhibitors, low-dose beta blockers, cardiomyopathy.
and vasodilators. C. Endocarditis
4. Advise the client to notify the PHCP if side effects occur from the 1. Description
medications. a. Endocarditis is an inflammation of the inner lining of the heart
5. Advise the client to avoid over-the-counter medications. and valves.
6. Instruct the client to contact the PHCP if unable to take medications b. Occurs primarily in clients who are IV drug users, have had
because of illness. valve replacements or repair of valves with prosthetic materials,
7. Instruct the client to avoid large amounts of caffeine, found in coffee, or have other structural cardiac defects
tea, cocoa, chocolate, and some carbonated beverages. c. Ports of entry for the infecting organism include the oral cavity
8. Instruct the client about the prescribed low-sodium, low-fat, and low- (especially if the client has had a dental procedure in the
cholesterol diet. previous 3 to 6 months), infections (cutaneous, genito-urinary,
9. Provide the client with a list of potassium-rich foods, because gastrointestinal, and systemic), and surgery or invasive
diuretics (except for potassium-sparing diuretics) can cause procedures, including IV line placement.
hypokalemia. 2. Assessment
10. Instruct the client regarding fluid restriction, if prescribed, advising a. Fever
the client to spread the fluid out during the day and to suck on hard b. Anorexia, weight loss
candy to reduce thirst. c. Fatigue
11. Instruct the client to balance periods of activity and rest. d. Cardiac murmurs
12. Advise the client to avoid isometric activities, which increase pressure e. Heart failure
in the heart. f. Embolic complications from vegetation fragments traveling
13. Instruct the client to monitor daily weight. through the arterial circulation
14. Instruct the client to report signs of fluid retention such as edema or g. Petechiae
weight gain. h. Splinter hemorrhages in the nail beds
XI. Inflammatory Diseases of the Heart i. Osler’s nodes (reddish, tender lesions) on the pads of the
A. Pericarditis fingers, hands, and toes
 j. Janeway lesions (nontender hemorrhagic lesions) on the fingers, 4. Aortic stenosis: Valvular tissue thickens and narrows the valve
toes, nose, or earlobes opening, preventing blood from flowing from the left ventricle into
k. Splenomegaly the aorta.
l. Clubbing of the fingers 5. Aortic insufficiency: Valve is incompetent, preventing complete valve
3. Interventions closure during diastole.
a. Provide adequate rest balanced with activity to prevent 6. For aortic disorders
thrombus formation.
b. Monitor for signs of heart failure. Aortic Stenosis Aortic Insufficientcy
c. Monitor for splenic emboli, as evidenced by sudden abdominal Symptoms
pain radiating to the left shoulder and rebound abdominal Dyspnea on exertion Dyspnea
tenderness on palpation. Angina Angina
d. Monitor for renal emboli, as evidenced by flank pain radiating Syncope on exertion Tachycardia
to the groin, hematuria, and pyuria. Fatigue Fatigue
Orthopnea Orthopnea
e. Monitor for confusion, aphasia, or dysphasia, which may
Paroxysmal nocturnal dyspnea Paroxysmal nocturnal dyspnea
indicate central nervous system emboli. Harsh systolic crescendo-decrescendo Blowing decrescendo diastolic murmur
f. Monitor for pulmonary emboli as evidenced by pleuritic chest murmur
pain, dyspnea, and cough. Interventions
g. Assess skin, mucous membranes, and conjunctiva for petechiae. Refer to the section on repair procedures.
h. Assess nail beds for splinter hemorrhages. Prepare the client for value replacement as indicated.
i. Assess for Osler’s nodes on the pads of the fingers, hands, and
toes. 7. For tricuspid disorders
j. Assess for Janeway lesions on the fingers, toes, nose, or
earlobes. Tricuspid Valve Disorders
k. Assess for clubbing of the fingers. Tricuspid Stenosis Tricuspid Insufficiency
l. Evaluate blood culture results. Symptoms
m. Administer antibiotics intravenously as prescribed. Easily fatigue with minimal effort Asymptomatic in mild situations
n. Plan and arrange for discharge, providing resources required for Reports fluttering sensations in the neck Signs of right ventricular failure,
the continued administration of IV antibiotics. (obstructed venous flow) including ascites, hepatomegaly,
4. Client education peripheral edema
a. Home Care Instructions for the Client with Infective Cyanosis Pleural effusion
Endocarditis Rumbling diastolic murmur Systolic murmur heard at the left sternal
1) Teach the client to maintain aseptic technique during setup boarder, fourth intercostal space
and administration of intravenous (IV) antibiotics. Signs of right ventricular failure,
2) Instruct the client to administer IV antibiotics at scheduled including ascites, hepatomegaly,
peripheral edema, jugular vein
times to maintain the blood level.
distention with clear lung fields
3) Instruct the client to monitor IV catheter sites and report
Symptoms of decreased cardiac output
signs of infection immediately to the PHCP or
cardiologist.
Interventions
4) Instruct the client to record the temperature daily for up to Refer to the section on repair procedures.
6 weeks and to report fever. Prepare the client for valve replacement as indicated.
5) Encourage oral hygiene at least twice a day with a soft
toothbrush and thorough rinsing. 8. For pulmonary valve disorders:
6) Teach the client to cleanse any skin lacerations thoroughly
and apply an antibiotic ointment as prescribed. Pulmonary Valve Disorders
7) Client should inform all PHCPs of history of endocarditis Pulmonary Stenosis Pulmonary Insufficiency
and ask about the use of prophylactic antibiotics prior to Symptoms
invasive respiratory procedures and dentistry. Asymptomatic in a mild condition Asymptomatic in a mild condition
8) Teach the client to observe for signs and symptoms of Dyspnea Dyspnea
embolic conditions and heart failure. Fatigue Fatigue
XII. Cardiac Tamponade Syncope Syncope
A. Description Signs of right ventricular failure, Signs of right ventricular failure,
1. A pericardial effusion occurs when the space between the parietal and including ascites, hepatomegaly, including ascites, hepatomegaly,
visceral layers of the pericardium fills with fluid. peripheral edema peripheral edema
2. Pericardial effusion places the client at risk for cardiac tamponade, an Systolic thrill heard at left sternal Systolic thrill heard at left sternal
accumulation of fluid in the pericardial cavity. border border
3. Tamponade restricts ventricular filling, and cardiac output drops. Interventions
Acute cardiac tamponade can occur when small volumes (20 to 50 Refer to the section on repair Refer to the section on repair
mL) of fluid accumulate rapidly in the pericardium. procedures. procedures.
B. Assessment Prepare the client for pulmonary valve Prepare the client for pulmonary valve
commissurotomy as indicated. replacement as indicated.
1. Pulsus paradoxus
C. Repair procedures
2. Increased CVP
1. Percutaneous balloon valvuloplasty
3. Jugular venous distention with clear lungs
a. A balloon catheter is passed from the femoral vein through the
4. Distant, muffled heart sounds
atrial septum to the mitral valve or through the femoral artery to
5. Decreased cardiac output
the aortic valve.
6. Narrowing pulse pressure
b. The balloon is inflated to enlarge the orifice.
C. Interventions
c. Monitor for bleeding from the catheter insertion site.
1. The client needs to be placed in a critical care unit for hemodynamic
d. Institute precautions for arterial puncture if appropriate; site care
monitoring.
and monitoring is similar to that after cardiac catheterization.
2. Administer fluids intravenously as prescribed to manage decreased
e. Monitor for signs of systemic emboli.
cardiac output.
f. Monitor for signs of a regurgitant valve by monitoring cardiac
3. Prepare the client for chest x-ray or echocardiography.
rhythm, heart sounds, and cardiac output.
4. Prepare the client for pericardiocentesis to withdraw pericardial fluid
2. Mitral annuloplasty: Tightening and suturing the malfunctioning
if prescribed.
valve annulus to eliminate or greatly reduce regurgitation;
5. Monitor for recurrence of tamponade following pericardiocentesis.
percutaneous or open surgical approach
6. If the client experiences recurrent tamponade or recurrent effusions or
3. Commissurotomy, valvotomy
develops adhesions from chronic pericarditis, a portion (pericardial
a. Thrombi are removed and calcium deposits are debrided; the
window) or all of the pericardium (pericardiectomy) may be removed
valve is incised and widened.
to allow adequate ventricular filling and contraction.
b. Percutaneous route or open-heart surgical approach
III. Valvular Heart Disease
D. Valve replacement procedures
A. Description
1. Mechanical prosthetic valves are durable.
1. Valvular heart disease occurs when the heart valves cannot open fully
2. Risk of clot formation is high as the body reacts to the artificial
(stenosis) or close completely (insufficiency or regurgitation).
materials; anticoagulation is required. Thromboembolism can be a
2. Valvular heart disease prevents efficient blood flow through the heart.
complication following valve replacement with a mechanical
B. Types
prosthetic valve, and lifetime anticoagulant therapy is required.
1. Mitral stenosis: Valvular tissue thickens and narrows the valve
3. Bioprosthetic valves
opening, preventing blood from flowing from the left atrium to the
a. Biological grafts are xenografts (valves from other species, such
left ventricle.
as porcine valves [pig] or bovine valves [cow]) or homografts
2. Mitral insufficiency, regurgitation: Valve is incompetent, preventing
(from human cadavers). These valves are less durable than
complete valve closure during systole.
mechanical prosthetic valves.
3. Mitral valve prolapse: Valve leaflets protrude into the left atrium
b. The risk of clot formation is small; therefore, long-term
during systole.
anticoagulation may not be indicated.
4. Open heart surgical approach
 5. Preoperative interventions: Consult with the PHCP regarding b. When a thrombus develops, inflammation occurs, thickening the
discontinuing anticoagulants 72 hours before surgery. vein wall and leading to embolization.
6. Postoperative interventions 2. Types
a. Monitor closely for signs of bleeding. a. Thrombophlebitis: Thrombus associated with vein inflammation
b. Monitor cardiac output and for signs of heart failure. b. Phlebothrombosis: Thrombus without vein inflammation
c. Client education (Box 53.8) c. Phlebitis: Vein inflammation associated with invasive
1) Adequate rest is important; fatigue is common. procedures, such as IV lines
2) Anticoagulant therapy is necessary if a mechanical d. Deep vein thrombophlebitis: More serious than a superficial
prosthetic valve has been inserted. thrombophlebitis because of the risk for pulmonary embolism
3) Instruct the client concerning hazards related to 3. Risk factors for thrombus formation
anticoagulant therapy and to notify the PHCP or a. Venous stasis from varicose veins, heart failure, immobility
cardiologist of any bleeding or excessive bruising. b. Hypercoagulability disorders
4) Monitor incision and report any drainage or redness. c. Injury to the venous wall from IV injections; administration of
5) Instruct the client concerning the importance of good oral vessel irritants (chemotherapy, hypertonic solutions)
hygiene to reduce the risk of infective endocarditis. d. Following surgery, particularly orthopedic and abdominal
6) Brush teeth twice daily with a soft toothbrush, followed by surgery
oral rinses. e. Pregnancy
7) Avoid irrigation devices, electric toothbrushes, and f. Ulcerative colitis
flossing, because these activities can cause the gums to g. Use of oral contraceptives
bleed, allowing bacteria to enter the mucous membranes h. Certain malignancies
and bloodstream. i. Fractures or other injuries of the pelvis or lower extremities
8) Avoid any dental procedures for 6 months. B. Phlebitis
9) Avoid heavy lifting (more than 10 lb [4.5kg] or as 1. Assessment
prescribed), and exercise caution when in an automobile to a. Red, warm area radiating up the vein and extremity
prevent injury to the sternal incision. b. Pain
10) If a mechanical valve was inserted, a soft, audible clicking c. Swelling
sound may be heard. 2. Interventions
11) Instruct the client concerning the importance of a. Apply warm, moist soaks as prescribed to dilate the vein and
prophylactic antibiotics before any invasive procedure and promote circulation (assess temperature of soak before
the importance of informing all PHCPs of history of valve applying).
replacement or repair. b. Assess for signs of complications such as tissue necrosis,
12) Obtain and wear a MedicAlert bracelet. infection, or pulmonary embolus.
IV. Cardiomyopathy C. Deep vein thrombophlebitis
A. Description 1. Assessment
1. Cardiomyopathy is a subacute or chronic disorder of the heart muscle. a. Calf or groin tenderness or pain with or without swelling
2. Treatment is palliative, not curative, and the client needs to deal with b. Positive Homans’ sign may be noted; however, false-positive
numerous lifestyle changes and a shortened life span. results are common, so this is not a reliable assessment measure.
B. Types, signs and symptoms, and treatment c. Warm skin that is tender to touch
2. Interventions
Pathophysiology, Signs and Symptoms, and Treatment of Cardiomyopathies a. Provide bed rest if prescribed.
Dilated Hypertrophic Cardiomyopathy Restrictive b. Elevate the affected extremity above the level of the heart as
Cardiomyopathy Nonobstructed Obstructed Cardiomyopathy prescribed.
Pathophysiology c. Avoid using the knee gatch or a pillow under the knees.
Fibrosis of  Hypertrophy of Same as for  Mimics d. Do not massage the extremity.
myocardium the walls nonobstructed constrictive e. Provide thigh-high or knee-high antiembolism stockings as
and  Hypertrophied except for pericarditis prescribed to reduce venous stasis and assist in the venous return
endocardium septum obstruction of  Fibrosed walls of blood to the heart; teach how to apply and remove stockings.
Dilated chambers  Relatively small left ventricular cannot expand f. Administer intermittent or continuous warm, moist compresses
Mural wall chamber size outflow tract or contract
associated with as prescribed.
thrombi  Chambers
the g. Palpate the site gently, monitoring for warmth and edema.
prevalent narrowed;
hypertrophied emboli h. Measure and record the circumferences of the thighs and calves.
septum and common i. Monitor for shortness of breath and chest pain, which can
mitral valve indicate pulmonary emboli.
incompetence j. Administer thrombolytic therapy (tissue plasminogen activator)
Signs and Symptoms if prescribed, which must be initiated within 5 days after the
Fatigue and  Dyspnea  Same as  Dyspnea and onset of symptoms.
weakness  Angina for fatigue k. Administer heparin therapy as prescribed to prevent
Heart failure (left  Fatigue, nonobstru  Heart failure enlargement of the existing clot and prevent the formation of
side) syncope, cted (right side) new clots.
Dysrhythmias or palpitations except  Mild to l. Monitor activated partial thromboplastin time during heparin
heart block  Mild with mitral moderate therapy.
Systemic or cardiomegal regurgitati cardiomegaly m. Administer warfarin as prescribed following heparin therapy
pulmonary y on  S3 and S4 when the symptoms of deep vein thrombophlebitis have
emboli  S4 gallop murmur gallops resolved.
S3 and S4 gallops  Ventricular  Atrial  Heart block
fibrillation  n. Monitor prothrombin time and international normalized ratio
Moderate to severe dysrhythmia Emboli during warfarin therapy.
cardiomegaly s
o. Monitor for the adverse effects associated with anticoagulant
 Sudden
therapy.
death
common p. Client education
 Hearth 1) Instruct the client concerning the hazards of
failure anticoagulation therapy.
Treatment 2) Recognize the signs and symptoms of bleeding.
Symptomatic For both nonobstructed and  Supportive 3) Avoid prolonged sitting or standing, constrictive clothing,
treatment of obstructed: treatment of or crossing the legs when seated.
heart failure  Symptomatic treatment symptoms 4) Elevate the legs for 10 to 20 minutes every few hours each
Vasodilators  Beta blockers  Treatment of day.
Control of  Conversion of atrial fibrillation hypertension 5) Plan a progressive walking program.
dysrhythmias  Surgery: Ventriculomyotomy or  Conversion 6) Inspect the legs for edema, and measure the circumference
Surgery: Heart muscle resection with mitral from of the legs.
transplant valve replacement dysrhythmias 7) Wear antiembolism stockings as prescribed.
 Digoxin, nitrates, and other  Exercise 8) Avoid smoking.
vasodilators contraindicated with restrictions 9) Avoid any medications unless prescribed by the PHCP or
the obstructed form  Emergency cardiologist.
treatment of 10) Instruct the client concerning the importance of follow-up
acute PHCP visits and laboratory studies.
pulmonary 11) Obtain and wear a MedicAlert bracelet.
edema
D. Venous insufficiency
1. Description
XV. Vascular Disorders
a. Venous insufficiency results from prolonged venous
A. Venous thrombosis
hypertension, which stretches the veins and damages the valves.
1. Description
b. The resultant edema and venous stasis cause venous stasis
a. Thrombus can be associated with an inflammatory process.
ulcers, swelling, and cellulitis.
 c. Treatment focuses on decreasing edema and promoting venous a. Intermittent claudication (pain in the muscles during exercise,
return from the affected extremity. resulting from an inadequate blood supply)
d. Treatment for venous stasis ulcers focuses on healing the ulcer b. Rest pain, characterized by numbness, burning, or aching in the
and preventing stasis and ulcer recurrence. distal portion of the lower extremities, which awakens the client
2. Assessment at night and is relieved by placing the extremity in a dependent
a. Stasis dermatitis or brown discoloration along the ankles and position
lower calf c. Lower back or buttock discomfort
b. Edema d. Dry, scaly skin and loss of hair on the legs
c. Ulcer formation: Edges are uneven, ulcer bed is pink, and e. Thickened toenails
granulation is present; usually located on the lateral malleolus. f. Cold and gray-blue color of skin in the lower extremities
3. Interventions g. Elevational pallor and dependent rubor in the lower extremities
For venous insufficiency, leg elevation is h. Decreased or absent peripheral pulses
usually prescribed to assist with the return of i. Painful arterial ulcer formation on or between the toes or on the
blood to the heart. upper aspect of the foot
a. Instruct the client to wear elastic or compression stockings j. BP measurements at the thigh, calf, and ankle are lower than the
during the day and evening if prescribed (instruct the client to brachial pressure (normally, BP readings in the thigh and calf
put on elastic stockings on awakening, before getting out of are higher than those in the upper extremities).
bed); stockings may be necessary for the remainder of the 3. Interventions Because swelling in the extremities prevents arterial
client’s life. blood flow, the client with peripheral arterial disease is instructed
b. Instruct the client to avoid prolonged sitting or standing, to elevate the feet at rest but to refrain from elevating them above
constrictive clothing, or crossing the legs when seated. the level of the heart, because extreme elevation slows arterial
c. Instruct the client to elevate the legs above the level of the heart blood flow to the feet. In severe cases of peripheral arterial
for 10 to 20 minutes every few hours each day. disease, clients with edema may sleep with the affected limb
d. Instruct the client in the use of an intermittent sequential hanging from the bed, or they may sit upright (without leg
pneumatic compression system, if prescribed (used twice daily elevation) in a chair for comfort.
for 1 hour in the morning and evening). a. Assess pain.
e. Advise the client with an open ulcer to apply the compression b. Monitor the extremities for color, motion and sensation, and
system over a dressing. pulses.
4. Wound care c. Obtain distal extremity BP measurements.
a. Provide care to the wound as prescribed. d. Assess for signs of ulcer formation or signs of gangrene.
b. Assess the client’s ability to care for the wound, and initiate e. Assist in developing an individualized exercise program, which
home care resources as necessary. is increased slowly to improve arterial flow through the
c. If an Unna boot (dressing constructed of gauze moistened with development of collateral circulation.
zinc oxide) is prescribed, the PHCP will change it weekly. f. Instruct the client to walk to the point of claudication pain, stop
d. The wound is cleansed with normal saline before application of and rest, and then walk a little farther.
the Unna boot; povidoneiodine and hydrogen peroxide are not g. Instruct the client with peripheral arterial disease to avoid
used, because they destroy granulation tissue. crossing the legs, which interferes with blood flow.
e. The Unna boot is covered with an elastic wrap that hardens to h. Instruct the client to avoid exposing extremities to cold (causes
promote venous return and prevent stasis. vasoconstriction) and to wear socks or insulated shoes for
f. Monitor for signs of arterial occlusion from an Unna boot that warmth at all times.
may be too tight. i. Instruct the client never to apply direct heat to the limb, such as
g. Keep tape off the client’s skin. with a heating pad or hot water, because the decreased
h. Occlusive dressings such as polyethylene film or a hydrocolloid sensitivity in the limb can cause burns.
dressing may be used to cover the ulcer. j. Instruct the client to inspect the skin on the extremities daily and
5. Medications to report any signs of skin breakdown.
a. Apply topical agents to the wound as prescribed to debride the k. Instruct the client to avoid tobacco and caffeine because of their
ulcer, eliminate necrotic tissue, and promote healing. vasoconstrictive effects.
b. When applying topical debriding agents, apply an oil-based l. Instruct the client in the use of hemorheological and antiplatelet
agent such as petroleum jelly on surrounding skin to protect medications as prescribed.
healthy tissue. 4. Procedures to improve arterial blood flow
c. Administer antibiotics as prescribed if infection or cellulitis a. Percutaneous transluminal angioplasty, with or without
occurs. intravascular stent
E. Varicose veins b. Laser-assisted angioplasty
1. Description c. Atherectomy
a. Distended, protruding veins that appear darkened and tortuous. d. Peripheral arterial bypass surgery: Graft material is sutured
b. Vein walls weaken and dilate, and valves become incompetent. above and below the occlusion to facilitate blood flow around
2. Assessment the occlusion. Inflow procedures bypass the occlusion above the
a. Pain in the legs with dull aching after standing superficial femoral arteries and include aortoiliac, aortofemoral,
b. A feeling of fullness in the legs and axillofemoral bypasses; outflow procedures bypass the
c. Ankle edema occlusion at or below the superficial femoral arteries and
3. Trendelenburg’s test include femoropopliteal and femorotibial bypass.
a. Place the client in a supine position with the legs elevated. 5. Preoperative interventions
b. When the client sits up, if varicosities are present, veins fill from a. Assess baseline vital signs and peripheral pulses.
the proximal end; veins normally fill from the distal end. b. Insert an IV line and urinary catheter as prescribed.
4. Interventions c. Maintain a central venous catheter and/or arterial line if inserted.
a. Emphasize wearing antiembolism stockings as prescribed. 6. Postoperative interventions
b. Instruct the client to elevate the legs as much as possible. a. Assess vital signs and notify the PHCP if changes occur.
c. Instruct the client to avoid constrictive clothing and pressure on b. Monitor for hypotension, which may indicate hypovolemia.
the legs. c. Monitor for hypertension, which may place stress on the graft
d. Prepare the client for sclerotherapy or vein stripping as and cause clot formation.
prescribed. d. Maintain bed rest for 24 hours as prescribed.
5. Sclerotherapy e. Instruct the client to keep the affected extremity straight, limit
a. A solution is injected into the vein, followed by the application movement, and avoid bending the knee and hip.
of a pressure dressing. f. Monitor for warmth, redness, and edema, which often are
b. Incision and drainage of the trapped blood in the sclerosed vein expected outcomes because of increased blood flow.
is performed 14 to 21 days after the injection, followed by the g. Monitor for vessel or graft occlusion, which often occurs within
application of a pressure dressing for 12 to 18 hours. the first 24 hours.
6. Laser therapy: A laser fiber is used to heat and close the main vessel h. Assess peripheral pulses and assess for adverse changes in color
contributing to the varicosity. and temperature of the extremity.
7. Vein stripping: Varicose veins may be removed if they are larger than i. Assess the incision for drainage, warmth, or swelling.
4 mm in diameter or if they are in clusters; other treatments are j. Monitor for excessive bleeding (a small amount of bloody
usually tried before vein stripping. drainage is expected).
VI. Arterial Disorders k. Monitor the area over the graft for hardness, tenderness, and
A. Peripheral arterial disease warmth, which may indicate infection; if this occurs, notify the
1. Description PHCP immediately.
a. Chronic disorder in which partial or total arterial occlusion l. Instruct the client about proper foot care and measures to
deprives the lower extremities of oxygen and nutrients prevent ulcer formation.
b. Tissue damage occurs below the level of the arterial occlusion. m. Assist the client in modifying lifestyle to prevent further plaque
c. Atherosclerosis is the most common cause of peripheral arterial formation.
disease. n. Following arterial revascularization, monitor for a sharp
2. Assessment increase in pain, because pain is frequently the first indicator of
 postoperative graft occlusion. If signs of graft occlusion occur, e. Check peripheral circulation, including pulses, temperature, and
notify the PHCP immediately. color.
B. Raynaud’s disease f. Observe for signs of rupture (back pain, abdominal pain,
1. Description changes in vital signs, signs of shock).
a. Raynaud’s disease is vasospasm of the arterioles and arteries of 6. Nonsurgical interventions
the upper and lower extremities. a. Modify risk factors.
b. Vasospasm causes constriction of the cutaneous vessels. b. Instruct the client regarding the procedure for monitoring BP.
c. Attacks occur with exposure to cold or stress. c. Instruct the client on the importance of regular PHCP visits to
d. Affects primarily fingers, toes, ears, and cheeks monitor the size of the aneurysm.
2. Assessment d. Instruct the client to notify the PHCP immediately if they
a. Blanching of the extremity, followed by cyanosis from experience severe back or abdominal pain or fullness, soreness
vasoconstriction over the umbilicus, sudden development of discoloration in the
b. Reddened tissue when the vasospasm is relieved extremities, or a persistent elevation of BP. Instruct the client
c. Numbness, tingling, swelling, and a cold temperature at the with an aortic aneurysm to report immediately the
affected body part occurrence of chest or back pain, shortness of breath,
3. Interventions difficulty swallowing, or hoarseness.
a. Monitor pulses. D. Pharmacological interventions
b. Administer vasodilators as prescribed. 1. Administer antihypertensives to maintain the BP within normal limits
c. Instruct the client regarding medication therapy. and to prevent strain on the aneurysm.
d. Assist the client to identify and avoid precipitating factors such 2. Instruct the client about the purpose, side effects, and schedule of the
as cold and stress. medications.
e. Instruct the client to avoid smoking. E. Abdominal aortic aneurysm resection
f. Instruct the client to wear warm clothing, socks, and gloves in 1. Description: Surgical resection or excision of the aneurysm; the
cold weather. excised section is replaced with a graft that is sewn end to end.
g. Advise the client to avoid injuries to fingers and hands. 2. Preoperative interventions
C. Buerger’s disease (thromboangiitis obliterans) a. Assess all peripheral pulses as a baseline for postoperative
1. Description comparison.
a. Buerger’s disease is an occlusive disease of the median and b. Instruct the client in coughing and deepbreathing exercises.
small arteries and veins. 3. Postoperative interventions
b. The distal upper and lower limbs are affected most commonly. a. Monitor vital signs.
2. Assessment b. Monitor peripheral pulses distal to the graft site.
a. Intermittent claudication c. Monitor for signs of graft occlusion, including changes in
b. Ischemic pain occurring in the digits while at rest pulses, cool to cold extremities below the graft, white or blue
c. Aching pain that is more severe at night extremities or flanks, severe pain, or abdominal distention.
d. Cool, numb, or tingling sensation d. Limit elevation of the head of the bed to 45 degrees to prevent
e. Diminished pulses in the distal extremities flexion of the graft.
f. Extremities that are cool and red in the dependent position e. Maintain nasogastric tube to low suction until bowel sounds
g. Development of ulcerations in the extremities return; monitor for bowel sounds.
3. Interventions: See Raynaud’s disease f. Monitor for hypovolemia and kidney failure resulting from
VII. Aortic Aneurysms significant blood loss during surgery.
A. Description g. Monitor urine output hourly, and notify the PHCP if it is lower
1. An aortic aneurysm is an abnormal dilation of the arterial wall caused than 30 to 50 mL/hr.
by localized weakness and stretching in the medial layer or wall of the h. Monitor serum creatinine and blood urea nitrogen levels daily.
aorta. i. Monitor respiratory status, and auscultate breath sounds to
2. The aneurysm can be located anywhere along the abdominal aorta. identify respiratory complications.
3. The goal of treatment is to limit the progression of the disease by j. Encourage turning, coughing and deep breathing, and splinting
modifying risk factors, controlling the BP to prevent strain on the the incision.
aneurysm, recognizing symptoms early, and preventing rupture. k. Monitor incision site for bleeding and signs of infection.
B. Types of aortic aneurysm l. Monitor pain level, and administer pain medication as
1. Fusiform: Diffuse dilation that involves the entire circumference of prescribed.
the arterial segment m. Ambulate as prescribed.
2. Saccular: Distinct localized outpouching of the artery wall n. Prepare the client for discharge by providing instructions
3. Dissecting: Created when blood separates the layers of the artery regarding pain management, wound care, and activity
wall, forming a cavity between them restrictions.
4. False (pseudoaneurysm): Occurs when the clot and connective o. Instruct the client not to lift objects heavier than 15 to 20 lb for 6
tissue are outside the arterial wall as a result of vessel injury or trauma to 12 weeks.
to all three layers of the arterial wall. p. Advise the client to avoid activities requiring pushing, pulling,
C. Assessment or straining.
1. Thoracic aneurysm q. Instruct the client not to drive a vehicle until approved by the
a. Pain extending to neck, shoulders, lower back, or abdomen PHCP.
b. Syncope r. Endovascular aneurysm grafting involves insertion of a graft
c. Dyspnea using a vascular catheter; it does not require an abdominal
d. Increased pulse incision. The preoperative and postoperative care is similar to
e. Cyanosis that of a surgical abdominal aneurysm repair.
f. Hoarseness, difficulty swallowing because of pressure from the F. Thoracic aneurysm repair
aneurysm 1. Description
2. Abdominal aneurysm a. A thoracotomy or median sternotomy approach is used to enter
a. Prominent, pulsating abdominal mass at or above the umbilicus the thoracic cavity.
b. Systolic bruit over the aorta b. The aneurysm is exposed and excised, and a graft or prosthesis
c. Abdominal distention is sewn onto the aorta.
d. Tenderness on deep palpation c. Total cardiopulmonary bypass is necessary for excision of
e. Abdominal or lower back pain aneurysms in the ascending aorta.
3. Rupturing aneurysm d. Partial cardiopulmonary bypass is used for clients with an
a. Severe abdominal or back pain aneurysm in the descending aorta.
b. Lumbar pain radiating to the flank and groin 2. Postoperative interventions
c. Hypotension a. Monitor vital signs and neurological and renal status.
d. Increased pulse rate b. Monitor for signs of hemorrhage, such as a drop in BP and
e. Signs of shock increased pulse rate and respirations, and report them to the
f. Hematoma at flank area PHCP immediately.
4. Diagnostic tests c. Monitor chest tubes for an increase in chest drainage, which
a. Diagnostic tests are done to confirm the presence, size, and may indicate bleeding or separation at the graft site.
location of the aneurysm. d. Assess sensation and motion of all extremities and notify the
b. Tests include abdominal ultrasound, computed tomography PHCP if deficits are noted, which can occur because of a lack of
scan, and arteriography. blood supply to the spinal cord during surgery.
5. Interventions e. Monitor respiratory status and auscultate breath sounds to
a. Monitor vital signs. identify respiratory complications.
b. Assess for back or abdominal pain. f. Encourage turning, coughing, and deep breathing while
c. Question the client regarding the sensation of pulsation in the splinting the incision.
abdomen. g. Prepare the client for discharge by providing instructions
d. Avoid palpating the abdomen if an abdominal aneurysm is regarding pain management, wound care, and activity
suspected. restrictions.
 h. Instruct the client not to lift objects heavier than 15 lb for 6 to 12 b. Renal disorders
weeks. c. Endocrine system disorders
i. Advise the client to avoid activities requiring pushing, pulling, d. Pregnancy
or straining. e. Medications (e.g., estrogens, glucocorticoids,
j. Instruct the client not to drive a vehicle until approved by the mineralocorticoids)
PHCP. D. Assessment
III. Embolectomy 1. May be asymptomatic
A. Description 2. Headache
1. Embolectomy is removal of an embolus from an artery, using a 3. Visual disturbances
catheter. 4. Dizziness
2. A patch graft may be required to close the artery. 5. Chest pain
B. Preoperative interventions 6. Tinnitus
1. Obtain a baseline assessment of peripheral pulses. 7. Flushed face
2. Administer anticoagulants as prescribed. 8. Epistaxis
3. Administer thrombolytics as prescribed. E. Interventions
4. Place a bed cradle on the bed to keep the weight of linens from 1. Goals: To reduce the BP and to prevent or lessen the extent of organ
causing pain and pressure. damage
5. Avoid bumping or jarring the bed. 2. Question the client regarding the signs and symptoms of
6. Maintain the extremity in a slightly dependent position. hypertension.
C. Postoperative interventions 3. Obtain the BP two or more times on both arms, with the client supine
1. Assess cardiac, respiratory, and neurological status. and standing.
2. Monitor affected extremity for color, temperature, and pulse. 4. Compare the BP with prior documentation.
3. Assess sensory and motor function of the affected extremity. 5. Determine family history of hypertension.
4. Monitor for signs and symptoms of new thrombi or emboli. 6. Identify current medication therapy.
5. Administer oxygen as prescribed. 7. Obtain weight.
6. Monitor pulse oximetry. 8. Evaluate dietary patterns and sodium intake.
7. Monitor for complications caused by reperfusion of the artery, such as 9. Assess for visual changes or retinal damage.
spasms and swelling of the skeletal muscles. 10. Assess for cardiovascular changes such as distended neck veins,
8. Monitor for signs of swollen skeletal muscles such as edema, pain on increased heart rate, and dysrhythmias.
passive movement, poor capillary refill, numbness, and muscle 11. Evaluate chest x-ray for heart enlargement.
tenseness. 12. Assess the neurological system.
9. Maintain bed rest initially, with the client in a semi-Fowler’s position. 13. Evaluate renal function.
10. Place a bed cradle on the bed. 14. Evaluate results of diagnostic and laboratory studies.
11. Check the incision site for bleeding or hematoma. F. Nonpharmacological interventions
12. Administer anticoagulants as prescribed. 1. Weight reduction, if necessary, or maintenance of ideal weight
13. Monitor laboratory values related to anticoagulant therapy. 2. Dietary sodium restriction to 2 g daily as prescribed
14. Instruct the client to recognize the signs and symptoms of infection 3. Moderate intake of alcohol and caffeinecontaining products
and edema. 4. Initiation of a regular exercise program
15. Instruct the client to avoid prolonged sitting or crossing the legs when 5. Avoidance of smoking
sitting. 6. Relaxation techniques and biofeedback therapy
16. Instruct the client to elevate the legs when sitting. 7. Elimination of unnecessary medications that may contribute to the
17. Instruct the client to wear antiembolism stockings as prescribed and hypertension
how to remove and reapply the stockings. G. Pharmacological interventions
18. Instruct the client to ambulate daily. 1. Medication therapy is individualized for each client, and the selection
19. Instruct the client about anticoagulant therapy and the hazards of the medication is based on such factors as the client’s age,
associated with anticoagulants. preferences, coexisting conditions, and hypertension severity.
IX. Vena Cava Filter H. Education for the Client with Hypertension
A. Vena cava filter: Insertion of an intracaval filter (umbrella) that partially 1. Describe the importance of adherence with the treatment plan.
occludes the inferior vena cava and traps emboli to prevent pulmonary 2. Describe the disease process, explaining that symptoms usually do not
emboli develop until organs have suffered damage.
B. The filter is placed through a catheter placed in a large vein in the neck or 3. Assist the client in planning a gradual regular exercise program,
groin and advanced to the inferior vena cava. avoiding heavy weight-lifting and isometric exercises.
C. Preoperative interventions: If the client has been taking an anticoagulant, 4. Encourage the client to express feelings about daily stresses.
consult with the PHCP regarding discontinuation of the medication 5. Assist the client to identify ways to reduce stress.
preoperatively to prevent hemorrhage. 6. Teach relaxation techniques and encourage the client to incorporate
D. Postoperative interventions: Similar to care after embolectomy. them into the day.
XX. Hypertension 7. Instruct the client and family in the technique for monitoring blood
A. Description pressure (BP).
1. For an adult (ages 18 years and older), a normal BP is a systolic BP 8. Instruct the client to maintain a diary of BP readings.
below 120 mm Hg and a diastolic pressure below 80 mm Hg. 9. Emphasize the importance of lifelong medication.
2. Elevated blood pressure is defined as a systolic BP between 120 and 10. Instruct the client and family about dietary restrictions, which may
129 mm Hg and a diastolic BP below 80 mm Hg. include sodium, fat, calories, and cholesterol.
3. Hypertension (Stage 1) is defined as an SBP between 130 and 139 11. Instruct the client in how to shop for and prepare low sodium meals.
mm Hg or a diastolic BP between 80 and 89 mm Hg. 12. Provide a list of products that contain sodium.
4. Hypertension (Stage 2) is defined as a SBP at least 140 mm Hg or a 13. Instruct the client to read labels of products to determine sodium
diastolic BP at least 90 mm Hg. content, focusing on substances listed as sodium, NaCl, or MSG
5. If either the SBP or DBP is outside of a range, the higher (monosodium glutamate).
measurement determines the classification. 14. Instruct the client to bake, roast, or boil foods; to avoid salt in the
6. Hypertension is a major risk factor for coronary, cerebral, renal, and preparation of foods; and to avoid the use of salt at the table.
peripheral vascular disease. 15. Instruct the client to consume fresh foods and to avoid canned foods.
7. The disease is initially asymptomatic. 16. Instruct the client about the actions, side effects, and scheduling of
8. The goals of treatment include reduction of the BP and preventing or medications.
lessening the extent of organ damage. 17. Advise the client that if uncomfortable side effects occur, to contact
9. Nonpharmacological approaches, such as lifestyle changes, may be the primary health care provider or cardiologist and not to stop the
prescribed initially; if the BP cannot be decreased after 1 to 3 months, medication.
the client may require pharmacological treatment. 18. Instruct the client to avoid over-the-counter medications.
B. Primary or essential hypertension 19. Stress the importance of follow-up care.
1. Risk factors XXI. Hypertensive Crisis
a. Aging A. Description
b. Family history 1. A hypertensive crisis is an acute and life-threatening condition
c. Obesity requiring immediate reduction in BP.
d. Smoking 2. Emergency treatment is required, because target organ damage (brain,
e. Stress heart, kidneys, retina of the eye) can occur quickly.
f. Excessive alcohol 3. Death can be caused by stroke, kidney failure, or cardiac disease.
g. Hyperlipidemia B. Assessment
h. Increased intake of salt or caffeine 1. An extremely high BP; systolic over 180 mm Hg and/or diastolic over
C. Secondary hypertension 120 mm Hg
1. Secondary hypertension occurs as a result of other disorders or 2. Headache
conditions. 3. Drowsiness and confusion
2. Treatment depends on the cause and the organs involved. 4. Blurred vision
3. Precipitating disorders or conditions 5. Changes in neurological status
a. Cardiovascular disorders 6. Tachycardia and tachypnea
 7. Dyspnea
8. Cyanosis
9. Seizures
C. Interventions
1. Maintain a patent airway.
2. Administer antihypertensive medications intravenously as prescribed.
3. Monitor vital signs, assessing the BP every 5 minutes.
4. Monitor neurological status.
5. Maintain bed rest, with the head of the bed elevated at 45 degrees.
6. Assess for hypotension during the administration of
antihypertensives; place the client in a supine position if hypotension
occurs.
7. Have emergency medications and resuscitation equipment readily
available.
8. Monitor IV therapy, assessing for fluid overload.
9. Insert a Foley catheter as prescribed.
10. Monitor intake and urinary output; if oliguria or anuria occurs, notify
the PHCP.