Digiulio M., Keogh J. Medical-Surgical Nursing Demystified
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CHAPTER 1 Cardiovascular System
NURSING INTERVENTION
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Place patient in a semi-Fowler’s position for comfort, which eases respira-
tory effort.
•
Record intake and output of fluids.
•
Monitor vital signs to assess for increased respiratory rate, arrythmias.
•
Monitor electrocardiogram to look for changes from previous tracing.
•
Explain to the patient: fluids restriction may be necessary as heart failure is
a concurrent disease with dilated cardiomyopathy.
•
Record daily weight and call physician if weight increases 3 lbs (1.4 kg).
•
No smoking or drinking alcohol.
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No straining during bowel movements.
•
Increase exercise.
Endocarditis
WHAT WENT WRONG?
Microorganisms, usually bacteria, enter the blood stream and attach to the inner
lining of the heart (endocardium) and heart valves, resulting in inflammation.
Ulceration and necrosis occur when microorganisms cover the heart valves. This
usually occurs in patients with rheumatic heart disease or degenerative heart dis-
ease; those with recent instrumentation (IV, GU, and respiratory procedures) or
dental procedures; and IV drug users.
PROGNOSIS
The prognosis depends on both the organism (as some are more virulent than others)
and the degree of damage to the heart. Myocarditis may recur.
HALLMARK SIGNS AND SYMPTOMS
•
Chills/fever—due to infectious process.
•
Petecchiae on the palate, beneath the fingernails, osler nodes (painful, dis-
colored, raised areas on fingers and feet), Janeway lesions (painful lesions on
palms and soles).
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Medical-Surgical Nursing Demystified
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Fatigue—due to infectious process.
•
Murmurs—new or changing.
INTERPRETING TEST RESULTS
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Blood culture and sensitivity test.
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Three sets of cultures one hour apart to determine the specific organism
so treatment can be started.
•
Echocardiogram is used to detect vegetation on valves or heart valves dam-
aged by the microorganism, and also to determine which valves are involved.
•
Transesophageal echocardiogram offers a view to detect vegetation on heart
valves or view heart valves damaged by a microorganism.
•
Chest x-ray to look for underlying cardiac abnormality and pulmonary
infiltrate.
TREATMENT
Treatment depends on the underlying infectious agent. Empiric treatment should
be started while waiting for culture results. Outcomes are affected by possible
valvular destruction, emboli, and growth of bacteria on the valves or endocardium.
•
Administer antibiotics based on the result of culture and sensitivity test.
•
Valve replacement may be necessary if damage to valves is significant.
•
Bed rest to decrease demand on heart.
NURSING DIAGNOSES
•
Decrease cardiac output
•
Risk for injury
•
Activity intolerance
NURSING INTERVENTION
•
Monitor for signs of heart failure due to increased stress on heart due to
altered valve function.
•
Breathing difficulties (dyspnea).
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CHAPTER 1 Cardiovascular System
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Heat rate >100 beats per minute (tachycardia).
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Crackles in lungs.
•
Neck vein distention.
•
Edema, usually of extremities; may also be of sacrum in bed-bound
patients.
•
Weight gain.
•
Monitor for embolism—a piece of vegetation from valve may have broken
off into circulation.
•
Blood in the urine (hematuria).
•
Pain with each breath due to pulmonary embolism.
•
Monitor renal function.
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Increased BUN (blood urea nitrogen).
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Increased creatinine clearance.
•
Decreased urine output.
•
Prophylatic antibiotics before, during, and after medical procedures that
expose the patient’s blood to microorganisms—otherwise it is easy for micro-
organisms to enter bloodstream and colonize the heart valves.
•
Explain to the patient:
•
Need to complete antibiotic course.
•
Can have a relapse.
•
Call the physician, nurse practitioner, or physician assistant if the patient
develops fever, chills, night sweats.
Heart Failure
[Congestive Heart Failure (CHF)]
WHAT WENT WRONG?
In congestive heart failure, the heart is unable to pump sufficient blood to maintain
adequate circulation. This results in a backup of blood and the extra pressure may
cause accumulation of fluid into the lungs. Heart failure is primarily due to prob-
lems with ventricular pumping action of the cardiac muscle, which may be caused
by diseases such as myocardial infarctions (heart attacks), endocarditis (infection in
the heart), hypertension (high blood pressure), or valvular insufficiency.
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Medical-Surgical Nursing Demystified
When disease affects primarily the left side of the heart, the blood will back up
into the lungs. When disease affects primarily the right side of the heart, the sys-
temic circulation may be overloaded. When the heart failure becomes significant,
the whole circulatory system may be compromised.
HALLMARK SIGNS AND SYMPTOMS
•
Extra heart sounds (normal heart sounds were described in the beginning):
•
S3: Soft sound caused by vibration of the ventricular wall caused by rapid
filling. Heard after S2 heart sound. Heard over the apex of the left ventri-
cle, fourth intercostal space along the mid-clavicular line. Best heard when
patient lies on left side. Usually indicates heart failure.
•
S4: Vibration of valves and the ventricular walls during the second phase
of ventricular filling when the atria contract. Heard before S1, in the same
location as S3, usually due to a “stiff heart.”
•
Murmur: Sounds of turbulence caused by blood flow. Heard anywhere
around the heart.
•
Congestive heart failure
•
Fatigue
•
Syncope
•
Chest pain
PROGNOSIS
Medications can help the heart to pump more efficiently. Some medications are
used for disease management; others are used for symptom control. Monitoring
dietary intake of sodium and fluids can also help with symptom control.
Heart failure is the main complication of heart disease, produced by an abnor-
mality of pumping function. The heart is unable to carry blood effectively to meet
metabolic needs. The resulting problems include acute left ventricular dysfunction
usually due to arrhythmias and myocardial infarction, and chronic failure due to
fluid overload, usually in valvular heart disease.
Heart failure is a compromise of any of the following:
•
Contractility of the muscle
•
Heart rate
•
Ventricular preload
•
Ventricular afterload
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CHAPTER 1 Cardiovascular System
While most hearts can tolerate some changes in the above items, some diseased,
older hearts may not be able to do so; heart failure results.
Treatment results of early disease are usually good. Long-term prognosis can
be variable, depending on the severity of the disease and associated conditions.
HALLMARK SIGNS AND SYMPTOMS
•
Early:
•
Basilar rales from fluid overload
•
Nocturia
•
Exertional dyspnea
•
Fatigue
•
Positive hepatojuglar reflux from liver congestion
•
S3 heart sound
•
Mid:
•
Cough
•
Orthopnea
•
Discomfort in right upper abdomen due to hepatomegaly
•
Cardiac rales
•
Edema
•
Cardiomegaly
•
Late:
•
Anasarca—generalized edema from ineffective pump function
•
Frothy or pink sputum from capillary permeability
INTERPRETING TEST RESULTS
•
B-type natriuretic peptide—elevated levels in CHF; produced when the ven-
tricles are stretched.
•
EKG may show signs of ischemia (T-wave inversion), tachycardia, or extra-
systole (extra beats).
•
CBC may show anemia—Hgb less than 12 in female, less than 14 in male;
HCT; less than 3 times the Hgb.
•
Chemistry may show renal problems, electrolyte disturbance.
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Medical-Surgical Nursing Demystified
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Chest x-ray.
•
Left-sided heart failure:
•
Pulmonary congestion because of accumulation of fluid in the lungs.
•
Enlarged left ventricle (LVH) because of the increased stress on the
heart to pump blood.
•
Right-sided heart failure:
•
Pulmonary congestion because of accumulation of fluid in the lungs.
•
Accumulation of fluid in the pleural cavity (pleural effusion).
•
Enlarged heart (cardiomegaly) because of the increased stress on the
heart to pump blood.
TREATMENT
Treatment is aimed at the underlying disease, i.e. ischemia, valve defects, arrhyth-
mias. Excreting volume with diuretics, supplemental oxygen, use of medications
to reduce workload of heart muscle, peripheral vascular resistance (afterload), and
venous return to the heart (preload) may all be used. Dietary indiscretions may be
a contributing factor, i.e. too much salt, too many calories.
•
Administer diuretics for symptom control resulting in patient comfort by
reducing blood volume.
•
Furosemide, bumetanide, metolazone, hydrochlorothiazide, spironolactone
—be aware of electrolyte imbalance—these medications may alter the
K+ level.
•
Administer ACE inhibitors to decrease afterload.
•
Captopril, enalapril, lisinopril.
•
Administer beta blockers, which help to raise ejection fraction, and decrease
ventricular size.
•
Administer inotrope to strengthen myocardial contractility:
•
Digoxin.
•
Administer vasodilator to reduce preload, relieve dyspnea:
•
nitroprusside, nitroglycerin ointment.
•
Administer anticoagulants in patients with severe heart failure, as they have
a propensity to develop thrombus and emboli; those with concurrent atrial
fibrillation will also need anticoagulation.
•
Reduce fluids as fluid overload is a causative factor in CHF.
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CHAPTER 1 Cardiovascular System
•
High Fowler’s position to ease breathing and enhance diaphragmatic
excursion.
•
Supplemental oxygen to meet increased demand of myocardium.
•
Low-sodium diet to prevent additional fluid retention.
NURSING DIAGNOSES
•
Impaired gas exchange
•
Decreased cardiac output
•
Excess fluid volume
NURSING INTERVENTION
•
Monitor vital signs and look for changes.
•
Record fluid intake and output—weigh daily to assess for fluid overload.
•
Position patient in semi-Fowler’s position to ease breathing.
•
Administer oxygen as ordered because it helps to decrease workload of heart.
•
Tell the patient:
•
Eat foods low in sodium to avoid fluid retention. (For these patients, there
is no such thing as “low-salt” cold cuts.)
•
Raise legs when sitting to lessen dependent edema.
•
Call the physician, nurse practitioner, or physician assistant if experienc-
ing fluid retention, such as a weight gain of several pounds in 1 to 2 days.
Hypertension (HTN)
WHAT WENT WRONG?
Pressure inside blood vessels exceeds 140 mmHg systolic and 90 mmHg diastolic
on more than one occasion resulting from a primary disease or no known cause.
These are the classifications of hypertension:
•
Normal <120 mmHg systolic / <80 mmHg diastolic
•
Prehypertension: 120–139 mmHg systolic / 80–89 mmHg diastolic
•
Stage 1 hypertension: 140–159 mmHg systolic / 90–99 mmHg diastolic
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Medical-Surgical Nursing Demystified
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Stage 2 hypertension: ⱖ160 mmHg / systolic ⱖ100 mmHg diastolic
•
In diabetic patients: hypertension is defined as 130/80 or higher
PROGNOSIS
The vast majority of patients have primary hypertension, or high blood pressure,
that is not caused by other disease. Patients are typically asymptomatic and need
to understand the importance of treatment to avoid long-term complications. End
organ damage can affect the heart, kidneys, brain, or eyes. Adequate control of
blood pressure is possible with medications and lifestyle modification, but these
need to be maintained for the long term, often for the rest of the patient’s life.
Many patients will ultimately need to be on multiple medications to achieve ade-
quate blood pressure control.
HALLMARK SIGNS AND SYMPTOMS
•
Asymptomatic
•
Headache
•
Dizziness
INTERPRETING TEST RESULTS
•
Blood pressure readings higher than 140/90 mmHg on at least three occasions.
•
Ventricular hypertrophy depicted on EKG or chest x-ray.
•
Blood test to look for associated cardiovascular risks.
•
High cholesterol—often associated with hypertension.
•
Check electrolytes for imbalance—sodium, potassium, chloride, CO
2
.
•
Monitor BUN and creatinine for renal function, a sign of impaired organ
damage.
•
Chemistry to check for diabetes mellitus.
TREATMENT
Treatment is aimed at decreasing the risk of CVA, CAD, heart failure, renal disease,
and other long-term sequelae of hypertension. Risk factors need to be assessed:
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CHAPTER 1 Cardiovascular System
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Smoking
•
Dyslipidemia—elevated cholesterol, LDL, triglycerides, low HDL
•
Diabetes
•
Age greater than 60
•
Men and postmenopausal females
•
Family history
Non-pharmacologic interventions are tried first, then medications are pre-
scribed.
There is a four-step treatment plan:
•
Step 1:
•
Lifestyle changes
•
Reduce caloric intake and exercise to reduce weight
•
Low-sodium diet
•
No smoking
•
Reduce alcohol intake
•
Reduce caffeine intake
•
Step 2: Begin medication
•
Administer diuretics to reduce circulating blood volume:
•
furosemide, spironolactone, hydrochlorothazide, bumetanide
•
Beta-adrenergic blockers to lower heart rate and cardiac output:
•
propranolol, metroprolol, atenolol
•
Calcium channel blockers to cause peripheral vasodilation, less tachycardia:
•
verapamil, diltiazem, nicardipine
•
Administer ACE to inhibit the rennin angiotensin aldosterone system. In
diabetes, ACE inhibitors also delay the progression of renal disease.
•
enalapril, lisinopril, benazepril, captopril, fosinopril, quinapril, perin-
dopril
•
Step 3:
•
Increase dosages of currently administered medication
•
Step 4:
•
Combination of agents in above classes
•
Multiple drugs may be needed to control blood pressure
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Medical-Surgical Nursing Demystified
NURSING DIAGNOSES
•
Imbalanced nutrition: more than the body requires.
•
Knowledge deficit
•
Excess fluid volume
NURSING INTERVENTION
•
Monitor blood pressure with multiple readings—lying, sitting, and standing,
bilateral both arms.
•
Record fluid intake and output.
Reduce stress by providing a quiet environment.
•
Explain to the patient:
•
No smoking—smoking contributes to cardiovascular disease, raising blood
pressure.
•
Change to a low-sodium and low-cholesterol diet—salt adds to elevated
blood pressure in some patients by contributing to fluid retention; lower
cholesterol intake lowers risk for associated hyperlipidemia.
•
Reduce alcohol intake—reduces risk for end organ damage from alcohol
intake.
•
Reduce weight—decreased risk for obesity, better BP control with better
weight control.
•
Exercise.
•
Call physician when BP is elevated.
•
Side effects of medications.
Hypovolemic Shock
WHAT WENT WRONG?
Rapid fluid loss causes inadequate circulation resulting in inadequate perfusion
of organs. Hypovolemic shock can be caused by external hemorrhage, fluids
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