Digiulio M., Keogh J. Medical-Surgical Nursing Demystified
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CHAPTER 1 Cardiovascular System
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Explain to the patient:
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Stop smoking.
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Avoid cold.
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Inspect skin regularly for cracks and treat immediately to prevent infections.
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Moisturizers.
Rheumatic Heart Disease
WHAT WENT WRONG?
Rheumatic fever usually results from a prior upper respiratory infection with
group A streptococcus. It may lead to permanent valve disease and cardiac dam-
age, with the mitral valve being more commonly affected.
PROGNOSIS
Prognosis of rheumatic heart disease (RHD) depends on the amount of damage
done to the valves. When progressive valve disease occurs in the mitral valve, it is
imperative to recognize the early onset of atrial fibrillation, to ensure early initia-
tion of anticoagulation to prevent emboli.
HALLMARK SIGNS AND SYMPTOMS
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A new murmur of insufficiency S3
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Joint pain because of the inflammation
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Increased temperature greater than 100.3°F because it may signify infection
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Carditis—chest pain, heart failure, friction rub
INTERPRETING TEST RESULTS
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Increase in cardiac enzymes to look for other causes of chest pain
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Positive C-reactive protein, ESR which are elevated in inflammation
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Increase in WBC because it may be of infectious origin
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Echocardiogram to assess for damage to valves
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Medical-Surgical Nursing Demystified
TREATMENT
Treatment of RHD is based on the severity of the valve damage. Valve replace-
ment may be necessary. If a fibrillation (contracting of the heart) is present, ensure
adequate anticoagulation with an International Normalized Ratio between 2 and 3.
Rheumatic fever prophylaxis may be required; antibiotics are recommended for
prevention of recurrent episodes.
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Administer nonsteroidal anti-inflammatory medication to decrease inflam-
mation and pain:
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aspirin
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indomethacin
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Administer antibiotics if an infectious process is confirmed:
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erythromycin
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penicillin
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Repair or replacement of heart valves due to irreparable damage.
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Antibiotic prophylaxis for unsterile procedures—usually penicillin; if aller-
gic to penicillin, clindamycin is usually the drug of choice.
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Anticoagulation if atrial fibrillation.
NURSING DIAGNOSES
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Decrease cardiac output
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Activity intolerance
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Risk for infection
NURSING INTERVENTION
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Monitor for difficulty breathing (dyspnea) and hacking, nonproductive cough,
because these are signs of heart failure.
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Determine if patient is allergic to penicillin.
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Monitor for infection because rheumatic fever may recur:
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Red, sore throat with pain when swallowing.
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Swollen cervical lymph glands.
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Headache.
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Temperature greater than 100°F.
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CHAPTER 1 Cardiovascular System
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Explain to patient:
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Anticoagulation use, interference with foods and medications, need for
frequent lab monitoring.
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Avoid contact with anyone who has a respiratory tract infection.
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Maintain good dental hygiene.
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Call the physician, nurse practitioner, or physician assistant if detect signs
of heart failure: shortness of breath, weight gain, nonproductive cough.
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Return to normal activities slowly.
Thrombophlebitis
WHAT WENT WRONG?
Throbmophlebitis is the inflammation of a vein as a result of the formation of
one or more blood clots (thrombus). It is usually seen in the lower extremities,
calves, or pelvis. This may be the result of injury to the area, may be precipitated
by certain medications or poor blood flow, or may be the result of a coagulation
disorder.
PROGNOSIS
Prognosis is usually good unless embolization, or moving of the clot, occurs. It
may move to the lung or brain, which can be life-threatening.
HALLMARK SIGNS AND SYMPTOMS
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May be asymptomatic
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Edema, tenderness, and warmth in the affected area as part of an inflamma-
tory response
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Palpable tender cord
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Positive Homan’s sign—pain on dorsiflexion of the ipsalateral foot—is an
unreliable sign
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Cramping because blood flow to the area is impaired due to the presence of
the clot
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Medical-Surgical Nursing Demystified
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If the clot dislodges from the vein and travels to the lung, other symptoms
will develop:
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Difficulty breathing (dyspnea) when the clot has traveled to the lungs
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Rapid breathing >20 breaths per minute (tachypnea) because of a clot in
the lungs
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Chest pain in the area of clot
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Crackle sounds in lungs in the area of clot
INTERPRETING TEST RESULTS
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Ultrasound determines if blood is flowing to the affected area.
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Photoplethysmography depicts any defects in venous filling in the affected
area.
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Lab work to look for clotting disorders.
TREATMENT
Patients with large deep vein thrombosis (DVT), or with comorbidities (a disease
coexisting with, and often impacting on, another disease present), and/or advanced
age should be managed in the hospital. Treatment consists of anticoagulation to
prevent further occurrences.
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Administer anti-inflammatory medication to decrease the inflammation within
the vessel
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aspirin, indomethacin
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Administer anticoagulant medication to prevent the clot from becoming
larger:
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heparin, warfarin, dalteparin, enoxaparin
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Limit activity initially to diminish risk of moving clot—bedrest with bath-
room priviledges
NURSING DIAGNOSES
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Ineffective tissue perfusion
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Acute pain
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Impaired skin integrity
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CHAPTER 1 Cardiovascular System
NURSING INTERVENTION
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Monitor breathing because changes in respiratory status can signal that a clot
has dislodged and moved to the lung.
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Monitor labs because the patient is receiving anticoagulants. Monitor for
therapeutic effect.
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Apply warm moist compresses over affected area because it enhances blood
flow to area.
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Explain to the patient:
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Report signs of bleeding—anticoagulant may be too much.
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Report signs of clotting—pain in affected area, shortness of breath—
patient may have underlying clotting disorder.
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Move about frequently when allowed—discourages chances of develop-
ing another clot.
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Don’t cross legs—avoid constriction of lower extremity vessels.
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Don’t use oral contraceptives—increases risk of clot formation.
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Support hose.
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Elevate affected area.
Atrial Fibrillation
WHAT WENT WRONG?
Uncoordinated firing of electrical impulses in the wall of the atria (upper chambers
of the heart) causes the heart to quiver instead of beating regularly, resulting in inef-
fective contractions. This is usually due to an abnormality in the electrical system of
the heart. Blood is ineffectively pumped to the ventricles (lower chambers of the
heart) and may result in not enough blood being pumped throughout the body.
Usually the heart beats rapidly; however, this is not always the case. Atrial fibrilla-
tion (also called AF or “a fib”) is the most common chronic arrhythmia and is not
life-threatening on its own, but increases the patient’s risk for blood clots and strokes.
PROGNOSIS
The arrhythmia usually goes away once the cause of atrial fibrillation is identi-
fied and treated. If left untreated or if it returns, there is a risk of stroke and other
complications.
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Medical-Surgical Nursing Demystified
HALLMARK SIGNS AND SYMPTOMS
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Asymptomatic
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Irregular pulse
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Feeling faint (near syncope)
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Palpitations
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Lightheadedness
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Dyspnea
INTERPRETING TEST RESULTS
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Electrocardiogram will show irregularities characteristic of the disease:
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QRS complexes are of irregular duration and structure.
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PR interval barely noticeable.
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Erratic, low-voltage, or absent P-waves.
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Echocardiogram to look for structural abnormalities.
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Thyroid function tests as hyperthyroidism can lead to atrial fibrillation.
TREATMENT
Treatment is directed towards restoring the regular heart rate and rhythm. If the
atrial fibrillation is less than 72 hours old, chemical or electrocardioversion is
endeavored. Electrocardioversion, or shocking the heart, often restores normal
sinus rhythm. If greater than 72 hours, anticoagulation is begun as the risk of
thromboembolism is great.
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Administer antiarrhythmics once patient stabilizes—these medications may
be effective in restoring a regular rhythm and also for in long-term therapy:
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amiodarone
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digoxin
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diltiazem
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verapamil
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Unstable patient: Synchronized cardioversion is a treatment that involves an
electrical shock delivered to the heart, which is synchronized with the R- or
S-wave of the EKG, in an attempt to restore coordinated firing of electrical
impulses.
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CHAPTER 1 Cardiovascular System
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Install a pacemaker.
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If atrial fibrillation is the ongoing rhythm, warfarin therapy will be initiated
to reduce the risk of emboli.
NURSING DIAGNOSES
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Impaired gas exchange
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Decreased cardiac output
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Ineffective tissue perfusion
NURSING INTERVENTION
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Monitor for signs of decreased blood flow to tissues or organs (hypoperfusion)
because decreased cardiac output, as indicated by these symptoms, can occur
as a result of atrial fibrillation:
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Decreased pulse pressure.
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Cool extremities.
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Altered mental state.
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Rapid resting heart rate.
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Alternating breathing between deep and shallow.
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Increased BUN.
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Prepare for synchronized cardioversion, if patient is unstable.
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Assess for life-threatening arrhythmias.
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Assess for signs of drug toxicity and withhold if the patient is toxic—i.e.,
seizures, respiratory arrest, arrhythmias.
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Limit patient’s activities to reduce cardiac workload.
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Explain to the patient:
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The need for warfarin therapy, as well as monitoring of INR, diet modifi-
cations, use of NSAIDs, and aspirin.
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The importance of regular examinations to ascertain for any changes in
rhythm.
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Call the physician if the patient feels light-headed or dizzy, as this can be
a symptom of a change in rhythm.
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Avoid ethanol, caffeine, nicotine as they can trigger an arrhythmia.
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Medical-Surgical Nursing Demystified
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Proper care and restrictions if the patient has a pacemaker—frequent
monitoring of the pacemaker battery, who will follow up with the cardi-
ologist, and so on. Frequency depends on the type of pacemaker and the
cardiologist.
Asystole
WHAT WENT WRONG?
Asystole is defined as no cardiac electrical activity. This causes ventricles to stop
contractions, leading to no cardiac output and no blood flow. Cardiac standstill is a
medical emergency. Treatment must be started immediately, while simultaneously
attempting to understand the etiology of a non-beating heart. Asystole is a criterion
for certifying that the patient is dead. Asystole may be caused by disruption in the
electrical conduction system, causing life-threatening arrhythmias, sudden cardiac
death, hypovolemia, cardiac tamponade, massive pulmonary embolism, acute
myocardial infarction, metabolic disorder, or drug overdoses. In case of a drug
overdose—usually PEA (pulseless electrical activity)—reverse overdose or treat.
PROGNOSIS
Prognosis is poor unless the heart can be started. The longer asystole continues,
the more tissue is lost.
HALLMARK SIGNS AND SYMPTOMS
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No pulse
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Cyanosis
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Apnea
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No palpable blood pressure
INTERPRETING TEST RESULTS
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Electrocardiogram—P-, QRS–, T-waves are barely noticeable or absent.
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Arterial blood gases.
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CHAPTER 1 Cardiovascular System
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Lab work—CBC, electrolytes, drug levels, coagulation studies.
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No atrial or ventricular rhythm on the electrocardiogram.
TREATMENT
Treatment consists of restarting the heart and, when that has occurred, determin-
ing the cause of the asystole. Basic Life Support (CPR) should optimally be started
within two minutes (once asystole is established, CPR should be initiated imme-
diately when asystole is detected, and Advanced Cardiac Life Support within eight
minutes.
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Cardiopulmonary resuscitation.
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Advanced Cardiac Life Support.
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Oxygen.
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Start IVs to maintain access.
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Transcutaneous pacing, where electrodes are placed on the front and back of
the chest while high current is delivered to the patient to pace the ventricles.
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Endotracheal intubation.
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Administer buffering agent to correct acidosis:
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sodium bicarbonate
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Administer antiarrhythmics to control arrhythmia:
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atropine
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epinephrine
NURSING DIAGNOSES
•
Impaired gas exchange
•
Decreased cardiac output
•
Ineffective tissue perfusion
NURSING INTERVENTION
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Begin CPR.
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Prepare to administer medication per physician’s order or protocol.
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Medical-Surgical Nursing Demystified
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Explain to the patient:
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Note: If asytole exists, patient is not conscious. Talk to family members if
they are present. Refer to Basic Life Support (BLS) protocol.
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Call the physician, nurse practitioner, or physician assistant if the patient
experiences dizziness.
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The importance of regular examinations.
Ventricular Fibrillation
WHAT WENT WRONG?
Electrical impulses, that trigger the ventricles to contract, fire erratically. This causes
the ventricles to quiver and prevents regular effective contractions, resulting in the
disruption of blood flow to the body. The usual causes are ventricular tachycardia,
electrolyte disturbances, myocardial infarction, electric shock, and drug toxicities.
PROGNOSIS
Prognosis depends on how long it takes to establish a beating heart.
HALLMARK SIGNS AND SYMPTOMS
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No pulse
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Breathing is stopped (apnea)
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No palpable blood pressure
INTERPRETING TEST RESULTS
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Electrocardiogram:
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Chaotic ventricular rhythm.
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QRS irregular and wide.
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P-wave barely noticeable.
TREATMENT
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Cardiopulmonary resuscitation (CPR).
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Advanced Cardiac Life Support (ACLS).
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