Chapter One: Cardiovascu ar Probl ms Blood vessel compromise includes the following disease processes: hypertension, peripheral vascular disease, arteriosclerotic, heart disease, angina pectoris, gangrene and abdominal aortic aneurysm. 1.1 Hypertension Hypertension is a prolonged elevation of systolic and diastolic blood at or above 140 and the diastolic at or above 90 mm Hg. Primary hypertension (Essential) accounts for 90% of all cases and is thought to be caused by hormonal changes, hereditary factors, and other changes related to one’s lifestyle. Secondary hypertension is caused by another disease process, which if corrected, could correct the resulting hypertension. Blood pressure is created by the difference in the pressure of the blood as it leaves the heart and the resistance it meets flowing out to the tissues. Any factor that alters cardiac output or peripheral vascular resistance will alter blood pressure. Hypertension is a disease of the mechanisms of vascular regulation, primarily controlling the central nervous system, by the renal system (renin, angiotensin, and aldosterone) and by extracellular fluid volume. Blood pressure is elevated when the cardiac output is elevated, and the peripheral resistance is increased. Hypertension is known as the “silent killer” because of the 60 million Americans with virtually no symptoms. Risk Factors Non-modifiable risk factors are race (African American), age >30 and males. Modifiable risk factors are obesity, chronic emotional stress, elevated cholesterol levels, excessive sodium intake, tobacco, oral contraceptives and alcohol use. Associated conditions are coronary heart disease, heart failure, left ventricular hypertrophy and renal failure, peripheral vascular disease, cerebral vascular disease, stroke, nephropathy and retinopathy. Pharm cological History Use of steroids and estrogens will increase blood pressure. Signs and Symptom There are usually none; asymptomatic. Hypertension strains the heart and lungs and may result in left ventricular hypertrophy, failure, CHF or pulmonary edema.
Diagnosis Diagnosis is made by serial blood pressure readings with a systolic greater than 140 and a diastolic greater than 90. Take two or more blood pressure readings rather than relying on one single abnormal reading. Nursing Diagnosis: • Deficient knowledge related to newly diagnosed hypertension • Risk for ineffective management of therapeutic regime related to side effects of medications and required lifestyle changes • Sexual dysfunction related to effects of antihypertensive medications Nursing Interventions Teaching plan to include information about disease process, risk factors, long term complications, lifestyle modifications, and relationship of treatment to prevent complications. Teach client how to take own BP, reasons for each medication, how and when to take each medication, necessity of consistency in medication regimen and need for ongoing assessment while taking antihypertensives. Need to monitor serum electrolytes every 90-120 days for duration of the treatment. Need to monitor renal functioning, BUN and creatinine, every 90-120 days and need to monitor BP and pulse rate. • Encourage client to implement stress reduction, weight loss, smoking cessation, and exercise. • Determine if client is experiencing side effects of medications such as insomnia and impotence. • Diet should be low salt, low fat and low cholesterol. • Primary cause of a stroke in a hypertensive client is noncompliance with medication regimen. Medical Management Medical management may include diuretics (Lasix, Diazide). Diuretics block sodium and therefore, water reabsorption in the renal tubule, producing a decreased blood volume. Vasodilators (Nipride, Apresoline, Hydralazi e) Act directly on the smoothmuscle to dilate arteries and arterioles. Typically used in combination with another antihypertensive as they cause increased sodium and fluid retention and can cause reflex tachycardia (particularly during first week of therapy). Instruct about orthostatic hypertension, avoid hot baths, steam, and to take medication with meals. Advise that nasal congestion may occur. Client must report peripheral edema or constipation to the physician. Alpha-Adrenergic Blockers (Minipress, Hytrin, Regitine, Cardura)
N211: Health Differences Across the Lifespan I Hyperkalemia caused by discontinuing the diuretic & continuing the supplement may cause heart block and bradycardia because potassium is a cardiac depressant and it decreases the excitability of the heart. Malignant Hypertension Malignant hypertension, also known as hypertensive crisis, is when the blood pressure elevates rapidly and extremely, the heart, kidney and brain may be damaged. Clients require immediate hospitalization. When diastolic blood pressure is 115-130 mg Hg, client will complain of a severe occipital headache, abnormal neurological signs, seizure activity, and pulmonary edema. IV drugs include vasodilators such as Nipride, Hyperstat, Tridil, and Apresoline. Adrenergic inhibitors such as Aldomet (methyldopa) and Labetalol (Normodyne) can also be used. Nifedipine, a calcium channel blocker is not used due to the severe adverse risk of causing ischemia. Once the blood pressure falls, diuretics are used to continue water and sodium excretion. Nitroprusside dilates the arteries and veins, causing severe hypotension. Patients require hemodynamic monitoring via an intra-arterial line or electronically controlled cuff every five minutes, along with frequent blood pressure and pulse readings. Monitor hourly urine output readings. Monitor for adverse effects of the medications such as headaches, tachycardia, orthostatic hypotension, ventricular dysrhythmias from potassium depletion. Provide a safe environment in case of CNS complications, such as confusion, lethargy, visual disturbances. Nursing Interventions Weight loss if body mass index is >25, limit alcohol consumption to two drinks or less daily, limit sodium intake, stop smoking, reduce saturated fats and cholesterol; reduce or eliminate caffeine intake, and teach client stress reduction techniques. DASH diet (dietary approaches to hypertension diet) to include fruits, vegetables, low fat dairy and fiber with low saturated/total fat. Drugs/Diuretics Indications Adverse Reactions Nursing Interventions Thiazide Chlorthalidone (Hygroton) Hydrochlorothiazide (Microzide, Esidrix) Indapamide (Lozol) Metolazone (Zroxolyn) Decrease fluid volume Inexpensive Effective Used for severe hypertension Taken orally Hypokalemia s/s: dry mouth, thirst, weakness, drowsiness, muscle aches and tachycardia Hyperuricemia Glucose intolerance Sexual dysfunction Observe for postural hypotension Hypokalemia increases risk of digitalis toxicity Administer potassium supplements
N211: Health Differences Across the Lifespan I Indications dverse Reactio s
Nursing Interventions Caution with clients with gout, renal failure and lithium Volume depletion and electrolyte depletion are rapid Same nursing interventions as above Watch for hyperkalemia and renal failure Increase in lithium levels Give with meals to decrease GI distress
Enhance other hypertensives Rapid action Used when thiazides fail Causes volume depletion
Furosemide (Lasix) Torsemide (Demadex) Bumetanide (Bumex) Spironolactone (Aldactone) Amiloride (Midamor) HCTZ and Triamterene (Maxidex) HCTZ and Amiloride (Moduretic) HCTZ and Spironolactone (Aldactazide)
Hypokalemia Hyperuricemia Glucose intolerance Sexual dysfunction Weakness
Potassium Sparing Volume depletion without significant potassium loss Hyperkalemia Gynecomastia Sexual dysfunction Decrease fluid volume while minimizing potassium loss Side effects of individual drug offset or minimized by its partner
Combination Loops and Potassium Sparing Do not overdo potassium foods Follow scheduling doses to avoid sleep disruption 1.2 Peripheral Vascular Disease Peripheral Vascular Disease is a chronic inadequate blood flow in the lower extremities. Circulatory problems can be due to arterial or venous pathology. The signs and symptoms and varies, depending on the source of pathology. Signs and Symptoms May include moderate edema, burning, itching, prominent superficial veins, ulcers and skin changes. Acute PVD
N211: Health Differences Across the Lifespan I Involves and embolus, which can result from atrial fibrillation. This can occur in healthy or diseased arteries and is associated with trauma, post- operative immobilization, anemia and dehydration. Predisposing Factors for arterial disease are arteriosclerosis (95% of all cases) and advanced age. Predisposing Factors for venous disease is valvular incompetence and history of deep vein thrombosis (DVT). Associated arterial diseases are Raynaud disease (nonatherosclerotic, triggered by extreme heat or cold; Buerger disease (occlusive inflammatory disease, strongly associated with smoking) diabetes and acute occlusion (emboli/thrombi). Associated venous diseases are varicose veins, thrombophlebitis and venous stasis ulcers. 1.3 Arterial Disease Arterial Disease signs and symptoms: Smooth and shiny skin, loss of hair, thickened nails, pallor on elevation, rubor when dependent, cool temperature, decreased or absent pulses. Pain is sharp, increases with walking and elevation, intermittent claudication (classic presenting symptom occurs in skeletal muscles during exercise and is relieved by rest). Pain occurs when elevation of extremities are horizontal; may be relieved by dependent position. Ulcers are very painful, occur on lateral lower legs, toes, heels; demarcated edges, necrotic and non-edematous. 1.4 Venous Disease Venous Disease signs and symptoms: brown pigment around ankles, cyanotic when dependent, normal pulses. Persistent, aching, full feeling and dull sensation. Relieved when client is horizontal, elevate legs and use compression stockings. Ulcers are slightly painful, occur in medial legs, ankles; uneven edges, superficial and marked edema. Nursing Diagnosis • Ineffective tissue perfusion related to decreased oxygen supply • Activity intolerance related to complexity of management regimen • Impaired skin integrity related to… • Risk for infection related to… • Acute pain related to… Non-invasive treatment for arterial disease is elimination of smoking, topical antibiotic, bedrest, saline dressing and fibrinolytics agents if clots are present. Non-invasive treatment for venous disease is systemic antibiotics, snug dressing or alginate dressing if ulcerated; limb elevation, fibrinolytics agents and anticoagulants.
N211: Health Differences Across the Lifespan I Surgical interventions for arterial disease are embolectomy (removal of clot); endarterectomy (removal of clot and stripping of plaque); arterial bypass (Teflon or Dacron graft or autograft); percutaneous transluminal angioplasty (PTA), compression of plaque; amputation (removal of extremity). Surgical interventions for venous disease are vein ligation, thrombectomy or debridement. Treatment is aimed at vasodilation, pain relief, and maintaining skin integrity. Do NOT use a heating pad to keep extremities warm. Medical management includes antiplatelet (aspirin), vasodilators (Trental), anticoagulants (Coumadin), Lipid reducers (Questran, Mevacor). Nursing Interventions include encourage walking and other leg exercise, watch for signs of decreased peripheral circulation. Avoid temperature extremes, prolonged standing, constrictive clothing or crossing the legs at the knee when seated. Provide instruction about foot care and exercise programs. Develop a plan for smoking cessation. Monitor extremities for color, temperature, sensation and pulse quality. Schedule client activities within the client’s tolerance level. Encourage client to keep extremities elevated (if venous) when sitting and to change position frequently. Teach client to wear support hose or antiembolic stockings, wear shoes when ambulating. Decreased blood flow results in diminished sensation in the lower extremities. Any heat source can cause severe burns before the client realizes the damage is being done.
Page 13 Assess PT, Hgb, Hct, platelets Given orally Avoid foods high in vitamin K Nursing Implications Assess PTT, Hgb, Hct, platelets Assess stools for occult blood Avoid IM injections Antagonist: Protamine Sulfate of 148
Administered parenterally (SQ or IV) as an antagonist to thrombin and to prevent the conversion of fibrinogen to fibrin Blocks the formation of Prothrombin from vitamin K
N211: Health Differences Across the Lifespan I Indications Adverse Reactions
Nursing Implications Antagonist: Vitamin K Give after or with food to decrease gastric irritation (Ticlid) Advise not to take antacids within two hours of taking Ticlid Monitor CBC every 2 weeks for 3 months and thereafter if signs of infection develop Monitor for signs of bleeding Give one hour before meals (Persantine); no regard to meals (Plavix)
Neutropenian Thrombocytopenia Agranulocytosis Leukopenia Hemorrhage GI irritation, bleeding Pancytopenia Hemorrhage GI irritation, bleeding thrombocytopenia
Short term use after cardiac procedures Reduce risk for thrombolytic stroke Prevention of thrombolytic disorders
Low Molecular Weight Heparin (Lovenox) Monitor for signs of bleeding Given SQ Monitor CBC Use soft toothbrush Avoid cuts 1.5 Arteriosclerosis Obliterans Arteriosclerosis obliterans is a sclerosis of arterioles, thickening of the walls and occlusion. 1.6 Abdominal Aortic Aneurysm (AAA) Abdominal aortic aneurysm (AAA) is the dilation of the abdominal aorta caused by an alteration in the integrity of its wall. The most common cause of AAA is atherosclerosis. AAA is a late manifestation of syphilis. AAA is often asymptomatic. The most common symptoms are abdominal pain or low back pain, with the complaint that the client can feel his/her heart beating. Without treatment, rupture and death will occur. Prevention of thrombolytic formation
N211: Health Differences Across the Lifespan I Three types of AAA: Ascending (most common and deadly), Descending or Transverse. Nursing Assessment: signs and symptoms are severe ripping, boring pain of the shoulder, neck, lower back or abdomen. Bradycardia, pericardial friction rub, pulse intensity disparity. A bruit, swooshing sound heard over a constricted artery, when auscultated is heard over the abdominal aorta, pulsation in the upper abdomen. Abdominal radiograph (aortogram, angiogram, abdominal ultrasound) is used to confirm diagnosis if aneurysm is calcified. Symptoms of rupture include hypovolemic or cardiogenic shock with sudden, severe abdominal pain. Nursing Diagnosis • Altered tissue perfusion related to enlargement and weakening of the aorta • Pain related to pressure of nerves and tissues created by enlarged vessel and tissue trauma Nursing Interventions and Plans Assess all peripheral pulses and vital signs regularly. Peripheral pulses are radial, femoral, popliteal, posterior tibial and dorsalis pedis. Observe for signs of occlusion after graft; change in pulses, severe pain, cool to cold extremities below graft and white to blue extremities. Observe renal functioning for signs of kidney damage (artery is clamped during surgery may result in kidney damage). Urine output of less than 30ml/hr, amber urine and elevated BUN and creatinine (early signs of renal failure). Observe for post-operative ileus by checking bowel sounds every shift and maintaining nasogastric tube to low continuous suction for 1 to 2 days post operatively. During abdominal aneurysm repair the large arteries are clamped for a period of time, and kidney damage can result. Normal BUN is 10-20 mg/dl and normal creatinine is 0.6-1.2mg/dl. The ratio of BUN and creatinine is 20:1. If the ratio of BUN and creatinine increases or decreases, suspect renal problems. The procedure involves the surgical removal of a portion of weakened arterial wall with an end-to-end anastomosis to a prosthetic graft. Gangrene is a lack of oxygen supply that leads to thrombosis and tissue necrosis and localized edema. The signs and symptoms are severe localized pain, discoloration and swelling that usually occurs within 72 hours of surgery or trauma. Tachycardia, tachypnea and hypotension related to toxemia and hypovolemia is also seen. 1.7 Arteriosclerotic Heart Disease
Cardiac catheterization: detects arterial blockage. Nursing Diagnosis • Acute pain related to myocardial ischemia •
Altered tissue perfusion, cardiac, related to occlusion of coronary arteries Nursing Interventions: monitor medications and instruct in proper administration of medications. Determine factors precipitating pain and assist client and family in adjusting lifestyle to decrease these factors. Teach risk factors and identify clients own risk factors. During an angina attack: provide immediate rest, take vital signs, record an EKG, administer no more than three nitroglycerine tablets, 5 minutes apart. Seek emergency treatment is no relief has occurred after taking nitroglycerine. Teach avoidance of isometric activity; implement an exercise program. Sexual activity can be resumed after exercise is tolerated, usually when able to climb two flights of stairs without exertion. Nitroglycerin can be taken prophylactically before intercourse. Diet modification of fat (saturated) and sodium. Antilipemic medications may be ordered to lower cholesterol levels. Medical Interventions Percutaneous transluminal coronary angioplasty (PTCA) is when a balloon catheter is repeatedly inflated to split or fracture plaque, and the arterial wall is stretched, enlarging the diameter of the vessel. A rotoblade is used then to pulverize plaque. Arthrectomy is when a catheter with a collect chamber is used to remove plaque that is trapped in the chamber. Other interventions include Coronary artery bypass graft (CABG), coronary artery laser therapy and coronary artery stents. Medications include Nitroglycerine, Isosorbide dinitrate, and Propranolol to cause vasodilation. These medications increase the available oxygen supply by increasing blood flow. Beta-adrenergic blockers, such as Propranolol and Lopressor, and calcium channel blockers Verapamil, Cardizem, Procardia may also be used. The aim is to decrease oxygen demand or increase myocardial oxygen supply. Nitroglycerine must be stored in a dark, glass, securely capped vial, and kept fresh enough that it tingles when you place it under your tongue. When using paste do not rub it in and always rotate sites. Proper patient teaching would always include keeping nitroglycerine available, use at the first sign of pain and stop and rest until pain subsides. Seek medical attention if pain lasts more than 20
N211: Health Differences Across the Lifespan I minutes. Instruct the patient about risk factors for myocardial infarction. Common activities that lead to anginal pain are exposure to cold, emotional upset or excitement, exertion, smoking, heavy meals, and rushing about as well as decongestants, diet pills, caffeine and nicotine. Prevention is the best treatment and includes reducing risk factors, reducing calories, fats, salt and getting regular exercise. Complications include arrhythmias, CHF, and MI. Nitrates open (dilate) the arteries to the heart. This increases blood flow to the heart, relieving chest pain or discomfort. Nitrates also dilate veins throughout the body so that they can hold more blood. This reduces the amount of blood going back to the heart, reducing the heart's workload. Calcium channel blockers are prescribed to treat angina (chest pain) and high blood pressure. Calcium channel blockers affect the movement of calcium in the cells of the heart and blood vessels. As a result, calcium channel blockers relax blood vessels and increase the supply of blood and oxygen to the heart, while reducing its workload. Calcium channel blockers may be used to treat heart failure caused by high blood pressure when other medications to lower blood pressure do not work. Beta-blockers are a class of drugs used to control symptoms of heart failure that are made worse by certain hormones called catecholamines. The body releases these hormones as part of its response to heart failure. Beta-blockers have a variety of effects throughout the body. They are used to treat heart disease that causes chest pain, high blood pressure, heart attacks, and cardiomyopathy and irregular, rapid heartbeats (arrhythmias). Beta-blockers are also used to prevent migraine headaches, treat tremors, and control anxiety. Beta-blockers may work by slowing the heart rate, which allows the left ventricle (the main pumping chamber of the heart) to fill more completely. Some of these medicines may also help open or widen blood vessels in the body.
Monitor apical heart rate Assess for decreased BP Do not stop medication abruptly
Calcium Channel Blockers Assess for decreased BP Monitor serum potassium Swallow pills whole Store at room temperature Do not stop abruptly Take one hour before meals and two hours after meals 1.9 Cardiac Failure Cardiac Failure (Heart Failure) is when the heart cannot pump enough blood to meet the body’s metabolic needs or tissue’s oxygen demands. Primary underlying conditions that cause heart failure are ischemic heart disease, myocardial insufficiency, cardiomyopathy, valvular heart disease and hypertension. Verapamil (Calan) Nifedipine HCL (Procardia) Diltiazem HCL (Norvasc, Cardizem) Anginal problems Inhibits influx of calcium ions
N211: Health Differences Across the Lifespan I Nursing Assessment: left sided heart failure or pulmonary edema (left ventricular failure) results in pulmonary congestion due to the inability of the left ventricle to pump blood to the periphery. Signs and symptoms include SOB, dyspnea, and a moist cough, crackles, and gallop rhythm: S3 and S4. Clients will also have fatigue, tachycardia, anxiety, restlessness and confusion. Right-sided heart failure also known as Cor Pulmonale, causes peripheral edema (right sided ventricular failure). This results in peripheral congestion due to the inability of the right ventricle to pump blood out to the lungs. This often results from left sided failure or pulmonary disease. Symptoms include peripheral edema, swelling, dependent edema, jugular vein distention, hepatomegaly and weight gain. Causes include atherosclerosis, conduction defects, COPD, fluid overload, hypertension, MI, pulmonary hypertension, valvular insufficiency or stenosis. Enlargement of the ventricles is demonstrated on chest x-ray. Chest x-ray shows increased pulmonary congestion and left ventricular hypertrophy. Right sided failure shows pulmonary congestion, cardiomegaly and pleural effusions on chest x-ray. Nursing Diagnosis • Activity intolerance related to decreased cardiac output • Fluid volume excess related to pump failure and fluid retention • Ineffective tissue perfusion related to increased preload and pump failure Nursing Interventions Interventions include keeping the patient in semi-fowler’s position to increase chest expansion and improve ventilation. Administer O 2 to enhance arterial oxygenation. Monitor patient for fluid gain. Plan periods of relaxation for patients with cardiac failure. Restrict fluid intake after two consecutive days of weight gain. Monitor vital signs every four hours for changes, monitor apical heart rate to detect arrhythmias and S3 or S4. Assess for hypoxia (restlessness, tachycardia, and angina). Auscultate lung sounds for crackles. Observe for signs of edema by weighing daily, monitoring I&O and measuring abdominal girth. Limit sodium intake. Elevate lower extremities while sitting. Check apical heart rate prior to administration of digitalis; withhold medication and call physician if rate is <60 bpm. Diet Low-sodium diet, fluid restriction. Medical Interventions ACE inhibitors (Captopril, Lisinopril), Morphine Sulfate, Digoxin, Inotropic agents (Dopamine), Diuretics (Lasix), Nitrates, and vasodilators.