Digiulio M., Keogh J. Medical-Surgical Nursing Demystified
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CHAPTER 1 Cardiovascular System
moving in the body from vessels into tissue (third spacing), or dehydration.
External hemorrhage is loss of blood, plasma, fluids and electrolytes, due to
trauma, GI bleed, vomiting, or diarrhea. Third spacing can result from ascites or
pancreatitis.
PROGNOSIS
Prognosis depends on the etiology of the low volume; there may occasionally be
more than one reason.
HALLMARK SIGNS AND SYMPTOMS
•
Hypotension because blood volume in the body is decreased
•
Urine output less than 25 ml/hour because less blood is perfusing the kid-
neys, causing decreased urinary output
•
Heart rate >100 (tachycardia), because the heart attempts to compensate for
the decreased volume
•
Cold skin, because of peripheral vasoconstriction due to decreased volume
•
Restlessness, agitation; may be seen due to poor perfusion of the brain
INTERPRETING TEST RESULTS
•
Blood tests.
•
CBC anemia.
•
Chemistry to look at volume as depicted by the creatinine and BUN.
•
Coagulation studies.
•
Type and cross-match for blood transfusion.
•
Arterial Blood Gas (ABG)
•
Decrease pH—if not perfusing well, acidosis will occur.
•
Metabolic acidosis—byproducts of metabolism will accumulate.
•
Increase partial pressure of arterial carbon dioxide and decrease partial
pressure of arterial oxygen due to poor perfusion.
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Medical-Surgical Nursing Demystified
TREATMENT
Treatment depends on severity of symptoms. As always, maintaining open airway,
breathing, circulation, and fluid resuscitation is of vital importance. After stabi-
lization, the focus is on determining and treating the cause of the shock.
•
Control bleeding—CBC, stool guaiac test, [to find hidden (occult) blood in
stool], assess for bleeding.
•
Replace fluid—proper fluid replacement depends on the etiology of the shock;
IV fluid and/or blood products are the choices.
NURSING DIAGNOSES
•
Deficient fluid volume
•
Ineffective tissue perfusion
•
Decreased cardiac output
NURSING INTERVENTION
•
IV using 14G catheter (16 or 18 gauge also adequate if not able to obtain 14;
use largest possible):
•
Lactated Ringer’s solution (which contains electrolytes) or normal saline
(0.9 percent).
•
Blood replacement—type-specific or type O negative, which is the uni-
versal donor type.
•
Monitor every 15 minutes:
•
Blood pressure. If systolic lower than 80 mmHg, then increase oxygen
flow rate.
•
Vital Signs every 15 minutes.
•
Measure urine output each hour with indwelling urinary catheter. Increase
fluid rate if urine output is less than 30 ml/hour. Be alert for signs of fluid
overflow. These include, but are not limited to, crackles in the lungs and
dyspnea.
•
Assess for cool, pale, clammy skin, indicating hypovolemic shock.
•
Explain to the patient:
•
What caused the hypovolemia and how to avoid a recurrence.
•
The purpose of the treatment.
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CHAPTER 1 Cardiovascular System
Myocarditis
WHAT WENT WRONG?
Inflammation of the heart muscle is usually caused by infection, most often viral.
Infection can also be caused by alcohol poisoning from chronic alcohol abuse,
drugs, or diseases that can result in the degeneration of heart muscle. This reduces
the ability of the heart to pump blood efficiently, leading to congestive heart failure.
PROGNOSIS
Outcomes vary depending on the etiology. Improvement depends on the stresses
of the causative disease. Some resolve spontaneously; others develop dilated car-
diomyopathy, CHF.
HALLMARK SIGNS AND SYMPTOMS
•
Fever because of infectious process
•
Tachycardia
•
Difficulty breathing (dyspnea) because left side dysfunction leads to CHF
•
Chest pain
•
Hear sounds:
•
S3 gallop due to fluid overload
INTERPRETING TEST RESULTS
•
EKG.
•
ST-segment changes due to inflammatory changes in the heart due to the
irritability of the myocardium from an infectious process.
•
Endomyocardial biopsy to determine a specific organism and the presence of
inflammation after infection has resolved.
•
CXR—cardiomegaly.
•
Echocardiogram to assess cardiac size and function.
•
Labs—CK, MB, and troponins because of cell injury and death.
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Medical-Surgical Nursing Demystified
TREATMENT
Treatment is directed at the causative factor(s). Occasionally treatment may in-
clude support for CHF and antiarrhythmics, if needed.
•
Administer antiarrhythmics to stabilize an irritable heart:
•
quinidine
•
procainamide
NURSING DIAGNOSES
•
Hyperthermia
•
Decreased cardiac output
•
Activity intolerance
NURSING INTERVENTION
•
Temporarily limit the patient’s activities to decrease stress on the heart.
•
Provide bedside commode.
•
Monitor for:
•
Difficulty breathing (dyspnea) because fluid overload.
•
Heart rate >100 beats per minute (tachycardia) because infection or inflam-
mation may increase the heart rate.
•
No competitive sports.
•
Return to normal activities slowly once physician approves.
Pericarditis
WHAT WENT WRONG?
The membrane that encloses the heart (pericardium) is inflamed. Pericarditis is
either acute or chronic.
Acute pericarditis is most commonly associated with viral infections. Upper
respiratory symptoms are not uncommon and can occur a few weeks prior to the
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CHAPTER 1 Cardiovascular System
onset of pericarditis. Pericarditis may be caused by any infectious agent, AMI,
malignancy, autoimmune diseases, or drug reaction.
PROGNOSIS
Outcome of acute pericarditis is often self-limited, resolving in two to six weeks.
Patients are typically treated with nonsteroidal anti-inflammatories (NSAIDs) to
decrease the inflammation of the pericardium.
HALLMARK SIGNS AND SYMPTOMS
•
Acute:
•
A grating heart sound heard (pericardial friction rub) due to friction from
inflammation between the layers surrounding the heart
•
Sudden sharp pain over the precordium (mid- to lower sternum area) radi-
ating to the neck, shoulders, back, and arm
•
Pain decreases when the patient leans forward, sits up
•
Teeth pain, anxiety, myalgias
•
Difficulty breathing (dyspnea), rapid breathing (tachypnea)
•
Arrhythmias
•
Chronic:
•
Enlarged liver (hepatomegaly), ascites because of liver congestion
•
Increased fluid retention due to ineffective pumping
•
Pericardial friction rub
INTERPRETING TEST RESULTS
•
Increase WBC and sed rate (the rate at which red blood cells settle in a test
tube. A high rate indicates inflammation), thyroid studies, renal function, Rh
factor, ANA complement.
•
May see increased CK (creatine kinase), LDH (lactate dehydrogenase), liver
enzymes levels.
•
EKG.
•
Sinus tachycardia.
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Medical-Surgical Nursing Demystified
•
ST-segment elevation.
•
Echocardiogram shows echo-free space between pericardium and the ven-
tricular wall due to effusion; also shows fluid in the pericardial space.
•
CXR may show fluid in spaces.
TREATMENT
Treatment is directed at resolving the underlying etiology.
Pericardiocentesis is done to remove fluid from the pericardial sac to relieve
pressure on the heart or for diagnostic testing. A long cardiac needle is inserted
near the xiphoid process and fluid is aspirated during careful cardiac monitoring.
Pericardial biopsy
•
Administer corticosteroids to decrease inflammation of pericardium.
•
Methylprednisolone.
•
Administer nonsteroidal anti-inflammatory (NSAID) drugs to decrease in-
flammation of the pericardium and provide for pain relief.
•
Aspirin, indomethacin.
NURSING DIAGNOSES
•
Acute pain
•
Decreased cardiac output
•
Risk for activity intolerance
NURSING INTERVENTION
•
Place the patient in full Fowler’s position to ease breathing.
•
Explain to the patient:
•
He/she will recover.
•
Slowly resume daily activities.
•
Plan for rest periods during the day due to fatigue.
•
Perform coughing and deep breathing exercises—patient may have been
avoiding deep breathing due to discomfort.
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CHAPTER 1 Cardiovascular System
Pulmonary Edema
WHAT WENT WRONG?
Fluid builds up in the lungs as a result of ineffective pumping of blood by the heart
as a result of left-sided heart failure, AMI, worsening of heart failure, or volume
overload. The patient experiences hypoxia, which is insufficient oxygen supply to
tissues, caused by decreased oxygenation of the blood. Several noncardiac issues
may lead to pulmonary embolism.
PROGNOSIS
Poor heart function results in fluid overload, which results in further diminished
cardiac function, causing marked dyspnea.
HALLMARK SIGNS AND SYMPTOMS
•
Difficulty breathing even when sitting upright (because of the fluid in the
lungs)
•
Rapid breathing: greater than 20 breaths per minute (tachypnea), because the
body is trying to get more oxygen
•
Frothy sputum with a tinge of blood due to capillary permeability
•
Cyanosis
•
Cool, clammy skin because the body is diverting blood flow from the
periphery
•
Restlessness and fear due to lack of oxygenation
•
Distended jugular vein due to increased pressure within chest
•
Crackles, wheezing heard in the lungs as the air moves through the fluid
INTERPRETING TEST RESULTS
•
Oxygen saturation under 90 percent.
•
CXR: aleveolar fluid, large heart.
•
Echocardiogram to determine ejection fraction percentages in the heart.
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Medical-Surgical Nursing Demystified
TREATMENT
Treatment may continue at home unless a worsening change in condition merits
hospitalization. Immediate treatment of heart failure, while searching for underly-
ing correctable conditions, is necessary.
•
Administer supplemental oxygen, which increases arterial pO
2
. Mechanical
ventilation may be necessary.
•
Administer morphine, which lowers left atrial pressure, decreases myocar-
dial oxygen demand, lowers anxiety, and relieves pain.
•
Administer diuretics to remove excess fluid:
•
furosemide, bumetanide, meolazone
•
Administer cardiac glycosides to increase contractions of the heart:
•
digoxin
•
Administer cardiac inotropics to strengthen the heart:
•
dobutamine
•
inamrinone
•
milrinone
•
Administer nitrates to decrease BP, and left ventricular filling pressures:
•
isosorbide dinitrate
NURSING DIAGNOSES
•
Impaired gas exchange
•
Anxiety
•
Excess fluid volume
NURSING INTERVENTION
•
Place the patient in full Fowler’s position to enhance air exchange and
diaphragmatic movement, sitting with legs dangling over sides of bed.
•
Monitor cardiovascular function for changes in heart sounds, extra sounds,
murmurs.
•
Monitor respirations for changes in lung sounds, chest expansion.
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CHAPTER 1 Cardiovascular System
•
Check oxygen saturation (pulse oximetry).
•
Record fluid intake and output.
•
Weigh the patient daily. Call physician if patient gains 2 lbs daily.
•
Call physician if BUN and creatinine increase.
•
Record characteristics of sputum.
•
Explain to the patient:
•
Call the physician, nurse practitioner, or physician assistant if the patient
detects fluid overload: weight gain, shortness of breath, fatigue, chest pains.
•
Call 911 if in respiratory distress.
•
Decrease sodium in diet.
•
Sleep with head elevated i.e. three pillows, or blocks under head of bed
frame.
Raynaud’s Disease
WHAT WENT WRONG?
Blood flow to the extremities decreases as peripheral arteries narrow from
vasospasm when exposed to cold or emotional stress. This results in the fingers,
toes, nose, and ears blanching to a pale shade and/or turning blue and red as blood
flow decreases. It usually occurs bilaterally, often sparing the thumbs, and begins
to resolve with warming of affected areas. Raynaud’s is a benign condition usually
controlled by avoidance of underlying factors, i.e., cold and stress. Secondary
Raynaud’s can be seen with other disorders, mostly inflammatory and/or connec-
tive tissue diseases. This is more common in older men, usually involves the
hands, and can have other complications.
PROGNOSIS
Prognosis for primary Raynaud’s is good. Symptoms may be controlled by avoid-
ance or by medications. In secondary Raynaud’s, long-term ischemic complica-
tions may develop, such as loss of fat pads of fingers, gangrene due to diminished
sensation, and propensity to develop frostbite.
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Medical-Surgical Nursing Demystified
HALLMARK SIGNS AND SYMPTOMS
•
Discoloration of extremities progressing from pale, to blue, and then red
because of decreased blood flow
•
Tingling and numbness in the extremities because of poor perfusion
INTERPRETING TEST RESULTS
•
Vasospasm is detected in an arteriograph.
•
Labwork to look for underlying disease process—CBC may show anemia;
sed rate (ESR), rheumatoid arthritis (RA), antinuclear antibody (ANA) (these
autoimmune tests will be positive).
TREATMENT
Treatment is outpatient and consists of avoidance of aggravating factors and may
need medication for primary, and treatment of underlying disorders and ischemia
in secondary.
•
Administer calcium channel blockers to ameliorate symptoms:
•
diltiazem
•
nifedipine
•
Administer vasodilators to aid in blood flow.
•
Avoid cold and stress because this may causes vasospasms.
•
Avoid smoking because it causes vasoconstriction.
•
Surgical removal of a part of a sympathetic nerve (sympathectomy) because
it can eliminate symptoms.
NURSING DIAGNOSES
•
Risk for injury
•
Risk for peripheral neurovascular dysfunction
•
Ineffective tissue perfusion
NURSING INTERVENTION
•
Teach patient to wear mittens rather than gloves when exposed to the cold
because it allows for air flow around fingers to hold body heat.