NCM112 A - Care of Clients with CV Complications and Peripheral Vascular Disorders PDF

NCM112 A - CARE OF CLIENTS WITH PROBLEMS IN ❖ radiates from back, shoulder, arms, axilla, OXYGENATION jaws & abdominal muscles Geraldine Parreno, RN MN...

NCM112 A - CARE OF CLIENTS WITH PROBLEMS IN ❖ radiates from back, shoulder, arms, axilla, OXYGENATION jaws & abdominal muscles Geraldine Parreno, RN MN ❖ NOT relieved by rest and Nitroglycerin ❖ occurs w/o cause / early AM ACUTE CORONARY SYNDROME (ACS) AND MYOCARDIAL ❖ S3, S4 & new onset of murmur INFARCTION ❖ blood pressure may be elevated ❖ dysrhythmias ❖ increased jugular vein distention (heart ACUTE CORONARY SYNDROME failure) - refers to a group of conditions due to decreased 2. RESPIRATORY: dyspnea, tachypnea, and crackles blood flow in the coronary arteries such that part of 3. GASTROINTESTINAL: nausea & vomiting, indigestion the heart muscle is unable to function properly or 4. GENITOURINARY: decreased urinary output dies 5. SKIN: cool, clammy, diaphoretic, & pale - an emergent situation char, by acute onset of 6. NEUROLOGIC: anxiety, restlessness, & myocardial ischemia that results in myocardial lightheadedness death (MI) if definitive interventions do not occur 7. PSYCHOLOGICAL: fear with feeling of impending promptly doom or 8. denial that anything is wrong 9. Elevated WBC; Blood sugar DIAGNOSTIC FINDINGS: ECG - ST Segment elevation ; T Wave Inversion; presence of abnormally large Q wave CARDIAC ENZYMES : - increased Troponin T AND I, CK-MB & Myoglobin levels MYOCARDIAL INFARCTION - Coronary Occlusion; Heart Attack - terminal stage of CAD characterized by permanent malocclusion leading to necrosis & scarring - CRITICAL PERIOD: - 6-8 hours after MI (PVC’s) - 24-48 hours → safest TYPES: 1. Transmural - infarcts extend through the whole thickness of the heart muscle 2. Subendocardial - involves a small area in the subendocardial Nursing Management (MI): wall Goal: ↓ myocardial workload a. Administer medication as ordered (narcotics) - Morphine sulfate (IV) - induces vasodilation & decreases levels of anxiety - S/E: respiratory depression b. Administer O2 inhalation: low flow at 2-3 LPM c. Enforce CBR without BP: bedside commode RISK FACTORS: (Modifiable and non-modifiable) d. Instruct client to avoid force of Valsalva Maneuver refer to CAD e. Place client on semi- Fowler’s position Prolonged use of OCPs f. Diet: general liquids to soft diet: low in Na, saturated Hypothyroidism fats & caffeine Clinical manifestations: g. Monitor VS, IO, ECG strictly 1. CARDIOVASCULAR: h. Administer medications as ordered: ❖ Levine’s sign Vasodilators- NTG; ISDN ❖ Persistent, excruciating, visceral, substernal Anti-arrhythmic agents- Lidocaine; pain Amiodarone  Beta-blockers - Sex as appetizer rather than a ACE inhibitor- limit the area of infarction ; dessert (sex before meals) decrease workload of the heart - Assume non – weightlifting position Thrombolytic/ Fibrinolytic Agents- - Resume steps if patient can tolerate Streptokinase; Urokinase 5 steps of stairs - should be administered within 12 Complications of MI: hours post MI Dysrhythmias : Ventricular Tachycardia - Monitor bleeding time for Strep & Heart Failure Urokinase Pericarditis Rupture of Heart Cardiogenic Shock Recurrent MI Sudden Cardiac Deat Nursing Diagnosis: 1. Ineffective cardiac tissue perfusion r/t decrease cardiac blood flow 2. Risk for ineffective peripheral tissue perfusion r/t decreased cardiac output 3. Death anxiety r/t cardiac event Anticoagulants- Heparin - monitor PTT - antidote: protamine sulfate COMPLICATIONS OF CARDIOVASCULAR DISEASES (HF (warfarin) Coumadin AND CHF) - PT - (vitamin K) Phytonadione; Aquamephyton HEART FAILURE - Given together. Coumadin takes - Inability of the heart to pump blood towards effect after 3 days systemic circulation Antiplatelets – ASA (aspirin) - Hypertrophy of LV i. Encourage pt. to take 20/30 cc/week of whiskey or - congestive heart failure (CHF) brandy- induces vasodilation - A complication j. Assist in surgical procedure – CABG FACTORS LEADING TO HF: k. Provide health teaching & discharge planning, Altered myocardial function Avoidance of precipitating factors, Prevent Left ventricular remodeling complications: Altered hemodynamics - Arrhythmias Neurohormonal changes - Cardiogenic shock 3 WAYS TO CLASSIFY HF: - oliguria as late sign Right Sided or Left Sided - L CHF Systolic or Diastolic - Thrombophlebitis Acute or Chronic - DRESSLER’S SYNDROME or Post MI Pericarditis Syndrome A. RIGHT-SIDED OR LEFT-SIDED - Colchicine; Corticosteroids RIGHT- SIDED HEART FAILURE: - Result of ineffective right ventricular contraction causing blood to backflow to venous circulation Causes: a. Tricuspid valve stenosis b. Right Ventricular infarction c. Pulmonary embolism d. Left sided heart failure l. Regular adherence to medications m. Resumption of ADLs - especially sexual activity 2-3 weeks post cardiac rehabilitation which includes:  - there is alteration in ventricular contraction due to weakened heart muscle B. DIASTOLIC HF: Diagnostics (R HF): - stiff and non- compliant heart muscle 1. Chest X-ray- cardiomegaly (vetricles hard to fill) 2. CVP- measures pressure in R atrium 3. Echocardiography- reveals enlarged heart chamber 4. Liver enzymes- ^ damage; inflammation LEFT-SIDED HEART FAILURE - result of ineffective left ventricular contraction causing blood to backflow & pool into the lungs Acute or Chronic CAUSES: A. Acute heart failure a. Mitral valve stenosis - 90% - fluid status is normal or low - RHD; Aging - No sodium & water retention b. MI B. Chronic heart failure c. IHD (Ischemic Heart Disease) - signs & symptoms have been present for d. Aortic valve stenosis some time - fluid volume overload persists NON CV DISEASES THAT CAN CAUSE HF: 1. ANEMIA - cardiac stress; causes reduced renal blood flow; left ventricular hypertrophy 2. THYROID PROBLEMS - Thyroxin - tachycardia 3. MALNUTRITION - Decrease muscle mass = decrease CO Diagnostics: 4. PREGNANCY 1. CXR – cardiomegaly - Hemodynamic changes = 2nd trimester; 2. PAP – pulmonary arterial pressure pressure of uterus in the inferior vena cava - Measure pressure of the right ventricle 5. RAPID IV FLUID INFUSION 3. PCWP – pulmonary capillary wedge pressure - Fluid overload - provides an indirect estimate of left atrial Nursing Management: pressure Goal: Increase myocardial contraction → increase CO 4. Echocardiography – reveals enlarged heart A. Administer medications as ordered chamber ○ Cardiac glycosides 5. ABG Analysis – reveals elevated PCO2 & decreased Digoxin (Lanoxin) 0.5-2ng/mL PO2 (- domotropic effect) blocks electrical Serum BNP Level conduction between atria - B Type Natriuretic Peptide & ventricles - helps regulate BP and fluid volume (- chronotropic effect) - key diagnostic indicator of HF slowing ventricular - >100 pg/ml suggestive of HF contractions, decrease hr (+ inotropic effect) Systolic or Diastolic increases the strength & A. SYSTOLIC HF: efficiency of heart - “Left ventricle HF” contractions  Loop diuretics MURMUR Lasix S/S HEART FAILURE- dyspnea, edema, orthopnea, Bronchodilators oliguria, fatigue Aminophylline CARDIOMEGALY Narcotic analgesics PERICARDITIS Morphine sulfate Medical Management of RHD: Vasodilators GOALS: to control infection, prevent recurrence of infection; NTG & ISDN prevent complications Anti-arhythmic agents a. Antibiotic Therapy- Penicillin (DOC); Erythromycin Lidocaine b. Aspirin Bretyllium c. Corticosteroid- Prednisone B. Administer O2 inhalation d. Rest C. High Fowler’s e. Continued penicillin/ antibiotic therapy D. Restrict Na & fluids prophylaxis to prevent recurrence of RF E. Monitor strictly VS & IO & Breath Sounds Ex. penicillin (Penadur) deep IM injection F. Weigh pt. daily & assess for pitting edema at gluteal muscles , g. 21 or 22 needle G. Abdominal girth daily & notify physician Laboratory and Diagnostic Findings: H. Provide meticulous care skin care 1. throat culture- determine presence of streptococcal I. Provide a dietary intake which is low in saturated fats organisms & caffeine 2. Elevated WBC count J. Health teaching & discharge planning 3. C-Reactive Protein- increased during acute phase of - Prevent complications infection ✓Arrhythmia 4. Elevated Antistreptolysin – O (ASO) titer ✓Shock - Determine recent Strep infection ✓MI Nursing Diagnosis: - Regular adherence to medications Decreased cardiac output related to valve - Diet modifications (TLC) dysfunction - Importance of ff. up care Ineffective therapeutic regimen management Nursing Diagnosis: PERIPHERAL VASCULAR DISORDERS Excess fluid volume related to decreased cardiac output and decreased renal output Impaired Gas Exchange related to decreased CO and pulmonary edema Risk for Activity Intolerance related to edema, dyspnea, and fatigue INFLAMMATORY DISORDERS INFECTIOUS DISEASES OF THE HEART: 1. RHD 2. Infectious Endocarditis 3. Myocarditis 4. Pericarditis RHEUMATIC HEART DISEASE (RHD) - Systemic inflammatory disease - 2° to repeated sore throat or pharyngitis - Group A beta- hemolytic streptococcus - Rheumatic Fever (RF) - damage valve/s (stenosis) - Regurgitation - Mitral & aortic valve Risk Factors: ASSESSMENT: 1. POVERTY 1. HEALTH HISTORY: 2. CONGESTION / OVERCROWDING - Cc: extremity pain (intermittent 3. SCHOOL AGE CHILDREN claudication) 4. POOR HYGIENE 2. PE: 5. MALNUTRITION RHD- Manifestations:  - Inspection of skin (color, temperature, - Buerger-Allen exercises texture, hairs) and palpation of peripheral pulses Acute: vasodilators to reduce pain - Peripheral pulses: especially the foot/ distal ○ Analgesics pulses ○ Prostaglandins (Limaprost) - Other changes: loss of hair; brittle nails; dry ○ Spinal cord stimulators under epidural and scaly skin; atrophy, alterations anesthesia Diagnostic Studies: ○ Hyperbaric oxygen therapy Angiogram Ankle-brachial index (ABI)- evaluates adequacy of Chronic leg circulation; BP in ankle and arm are measured - Lumbar sympathectomy- reduces and compared vasoconstriction Doppler ultrasound flow studies - Debridement- necrotic ulcers Lymphangiography - Amputation- gangrenous digits - Streptokinase- adjuvant therapy in some cases - Corticosteroids - Leech therapy Nursing Interventions: Positioning - Instruct client not to sit for long periods - Sleep on firm mattress - Never cross the legs of the knee Clothing BUERGER’S DISEASE (THROMBOANGITIS OBLTERANS) - Avoid constricting clothing - Limbs should be kept warm - Characterized by recurring inflammation of Prevention (health teaching) intermediate and smaller arteries and veins of the - Stop smoking lower and upper extremities - Good hygiene and daily skin assessment - Autoimmune vasculitis - Caution: extreme temp, trauma - Results to thrombus formation and occlusion of the - Diet: avoid caffeine, adequate hydration vessel Nursing Diagnosis: - Men (20-40 yrs) - Acute pain related to diminished arterial circulation - Heavy smoking or chewing of tobacco and oxygenation of tissues Clinical manifestations: Pain (claudication) RAYNAUD’S DISEASE Superficial thrombophlebitis Primary Raynaud’s Foot cramps after exercise - Characterized by intermittent vasospasm of Absent or diminished peripheral pulse the arteries of the hands that occurs with Paresthesia exposure to cold and stress Hair growth reduced Raynaud’s phenomenon (secondary Raynaud’s) Intense rubor - Connective tissue or collagen vascular Redness and cyanosis disease, medications, or occupational Ulceration trauma Gangrene Autoamputation (digits) Medical management: Goals: - Improve circulation; prevent progression of disease; protect extremities from trauma and infection  Locations: - Aorta - Coronary artery - Cerebral aneurysm Clinical manifestations: - Popliteal artery aneurysm - Cold fingers or toes - Mesenteric artery aneurysm - Color changes - Splenic artery aneurysm (pregnancy) - Numb, prickly feeling or stinging pain - Thick skin, brittle nails Medical/surgical management: Goal: avoid stimuli that provoke vasoconstriction - Calcium channel blockers - Debridement - Sympathectomy Nursing diagnosis: Clinical manifestations: (aortic aneurysm) - Acute pain related to tissue ischemia secondary to - Throbbing sensation in the abodem vasospasm - Back pain Nursing interventions: - abdominal/ flank pain - Avoid cold weather - Syncope - Stop tobacco use - Chest pain - Safety with sharp objects - Shock - Administer vasodilators as ordered - Retroperitoneal bleeding (Cullen, Grey-turner sign) - Wear leather gloves when getting anything from the ref - Immerse hands in warm water - Avoid vasoconstrictive food and drugs - Provide stress management strategies ANEURYSM - Aneurysm growth (spine or chest) - Coughing Localized, blood-filled balloon like bulge in the wall - Loss of voice of a blood vessel - Breathing difficulties Rupture → severe hemorrhage → sudden death - Problems swallowing Aorta- most common site Diagnostic tests and procedures: Causes/ risk factors: Ultrasound and echocardiography 1. Congenital, degenerative, mechanical, CT scan inflammatory, infectious MRI 2. Male, > 60 years old Angiography 3. Associated with PAD Management: 4. Familial Goal: prevent aneurysm rupture 5. Smoking Conservative: (4.0-5.5 cm), asymptomatic 6. Drug use ○ Serial UTZ, avoid pressure, modify lifestyle ○ Medications: Painkillers Beta-blockers- slows growth of thoracic aortic aneurysm Calcium channel blockers Statins  Vasopressor Antibiotic Anti-seizure drugs ○ Rehabilitation therapy Impaired speech and bodily movements Surgery ○ Endovascular surgery Less invasive procedure Graft is attached to the end of the catheter which is inserted through an artery and threaded up into the Risk factors: aorta - Increase incidence with increase age ○ Surgical clipping - Hereditary Tiny mental clip is placed on the - Women neck of the aneurysm to block off - Occupation that requires prolonged standing the blood flow to it - Pregnancy ○ Endovascular coiling Clinical manifestations: Wire coils up inside the aneurysm Dull aches and disrupts the blood flow, making Muscle cramps (nocturnal) it clot Muscle fatigue in legs ○ Ventricular catheter Feeling heaviness of legs Reduce the pressure on the brain Ankle edema Deep veins- S/S of chronic venous insufficiency (edema, pain, pigmentation, ulcerations) Diagnostic findings: Trendelenburg test- evaluates the venous system and to asess the severity of varicose veins Duplex ultrasound scanning- assess for venous obstructions, turbulence, and the direction of the flow of venous blood Plethysmography- measures and reocrds the variations in volume and pressure as blood flows through the tissues Contrast venography- injection of contrast media to identify extact locations of venous obstructions CT scans and MRI- helpful in identifying obstructions in the pelvic venous system or the iliac vein Nursing diagnosis: Ineffective tissue perfusion related to decreased arterial blood flow Risk for deficient fluid volume related to hemorrhage VARICOSE VEINS Medical management: 1. Ligation and stripping - Abnormally dilated, tortuous, superficial veins 2. Thermal ablation- non surgical approach using caused by incompetent venous valves thermal energy 3. Sclerotherapy- injection of an irritating chemical into a vein to produce localized phlebitis and fibrosis- obliterating the lumen of vein Nursing management: - Bed rest discouraged (walk 5-10 mins/h, 1st 24 hrs) - Elevate food of ed - Discourage standing and sitting  - Analgesics (exercise and move legs) - Incidence- 80% in critically ill patients - Inspect dressings for bleeding (groin) - Be alert for report of “pins and needles”; hypersensitivity= nerve damage - Shower after 24 hrs - Dry incision: “patting” technique - No lotion; only sunscreen or zinc oxide Prevention: - Avoid activities that cause venous stasis Clinical manifestations: - Elevate legs when they are tired - Redness - Getting up to walk for several minutes of every hour - edema/ swelling of extremity - Graduated compression stockings (knee high) - Tenderness - Reduce weight - Warm - Homan’s sign THROMBOPHLEBITIS - Pain in the calf after the foot is sharply - Inflammation of the wall of a vein with associated dorsiflexed thrombosis Pharmacologic therapy: Causes: Heparin- SC - preventive - Formation of venous clot depends on the presence Oral anticoagulant- Warfarin of at least one of the VIRCHOW’S TRIAD factors: Thrombolytic therapy 1. Venous stasis 2. Injury to vessel wall Surgery- thrombectomy 3. Hypercoagulable state Clinical manifestations: Nursing management: - Inflammation (swelling) 1. Frequently monitor patients’ lab results for those on - Pain anticoagulant therapy - Skin redness D-dimer: assess blood for fibrin degradation - Warmth and tenderness over the vein fragment Medical management: Pt, platelet count, Hg, Hct level, fibrinogen - Reduce swelling or pain and aPPT - Aspirin or ibuprofen Close monitoring for bleeding - Heparin ○ If bleeding occurs- report - Antibiotics immediately - Surgery ○ Anticoagulant discontinued Nursing diagnosis: 2. Monitor and manage complications - Ineffective peripheral tissue perfusion related to Bleeding (urine, bruises, gums, nosebleed) decreased blood flow and venous stasis Antidote for bleeding Nursing interventions: FFP, prothrombin concentrate - Elevate legs when in bed or chair as indicated Thrombocytopenia - Apply heat to the leg for 15-30 mins 2-3x daily Measure leg circumference - Support hose or stockings Observe for S/S of pulmonary embolism - Instruct client to avoid rubbing/ massaging the 3. Provide comfort affected extremities - Pneumatic compression devices Note: 50% or about half of the people with DVT blood clots - Sequential Compression Devices have no symptoms. - Fit and wear properly, clean, precaution VENOUS THROMBOEMBOLISM - Deep Vein Thrombosis (DVT) - Pulmonary Embolism (PE)