Cardiovascular Problems of the Adult Client PDF

**Cardiogenic shock** occurs with severe damage (more than 40%) to the left ventricle. - Classic signs include **hypotension**; a **rapid pulse** that becomes weaker; decreased **urine output;** and **cool, clammy skin**. - Respiratory rate increases as the body develops metabolic acid...

**Cardiogenic shock** occurs with severe damage (more than 40%) to the left ventricle. - Classic signs include **hypotension**; a **rapid pulse** that becomes weaker; decreased **urine output;** and **cool, clammy skin**. - Respiratory rate increases as the body develops metabolic acidosis from shock. **Cardiac tamponade** is accompanied by **distant, muffled heart sounds and prominent neck vessels.** **Pulmonary embolism** presents suddenly with **severe dyspnea** accompanying the **chest pain**. **Dissecting aortic aneurysms** usually are **accompanied by back pain.** **Metformin** needs to be withheld **24 hours before and for 48 hours after cardiac catheterization because of the injection of contrast medium during the procedure.** If the **contrast medium affects kidney function**, with metformin in the system the client would be at increased risk for **lactic acidosis.** **Sinus bradycardia is noted with a heart rate less than 60** **beats per minute**. This rhythm becomes a concern when the client becomes symptomatic. Hypotension and dizziness are signs of decreased cardiac output. Transcutaneous pacing provides a temporary measure to increase the heart rate and thus perfusion in the symptomatic client. Defibrillation is used for **treatment of pulseless ventricular tachycardia and ventricular fibrillation**. Digoxin will further decrease the client's heart rate. Continuing to monitor the client delays necessary intervention. Extreme dyspnea, tachycardia, and lung crackles in a client with heart failure indicate pulmonary edema, a **life-threatening event**. In **pulmonary edema**, the **left** ventricle fails to eject sufficient blood, and pressure increases in the **lung**s because of the accumulated blood. Oxygen is always prescribed, and the client is placed in a **high-Fowler's position** to **ease the work of breathing.** - Furosemide, a rapid-acting diuretic, will eliminate accumulated fluid. - **A Foley catheter is inserted to measure output accurately**. - Intravenously administered morphine sulfate **reduces venous return (preload),** decreases anxiety, and also **reduces the work** of breathing. Pulmonary edema is characterized by **extreme breathlessness, dyspnea, air hunger, and the production of frothy, pink-tinged sputum.** - Auscultation of the lungs reveals crackles. - Fine crackles is also known as **RALES.** - It can be described as being similar to **the sound of wood burning in a fireplace.** - It can be heard in both phases of respiration **(inspiration and expiration)** - It can be auscultated at the **lung bases.** - Early CRACKLES -- **CHRONIC BRONCHITIS** - LATE CRACKLES- **PNEUMONIA, CONGESTIVE HEART FAILURE OR ATELECTASIS.** - **Rhonchi and diminished breath sounds are not associated** with pulmonary edema. - **Stridor** is a **crowing** sound **associated with laryngospasm or edema of the upper airway.** **Dysrhythmias** commonly occur as a result of **decreased oxygenation and severe damage to greater than 40% of the myocardium**. - Classic signs of cardiogenic shock as they relate to **myocardial ischemia include low blood pressure and tachycardia**. - The central venous pressure would rise as the backward effects of the severe left ventricular failure became apparent. - **Pulsus paradoxus** is a finding associated with **cardiac tamponade.** - The **client** who **undergoes cardiac surgery** is **at risk for renal injury** from poor perfusion, hemolysis, low cardiac output, or vasopressor medication therapy. - Renal injury is signaled by decreased urine output and increased blood urea nitrogen (BUN) and creatinine levels. - Normal reference levels are\ **BUN, 10 to 20 mg/dL (3.6 to 7.1 mmol/L),** - and **creatinine 0.6 to 1.2 mg/dL (53 to 106 mcmol/L) for males and 0.5 to 1.1 mg/dL (44 to 97 mcmol/L) for females.** - The client **may need medications** to **increase renal perfusion and possibly could need peritoneal dialysis or hemodialysis.** - Normal sinus rhythm is defined as a regular rhythm, with an overall rate of 60 to 100 beats per minute. - The **PR** (0.12 and 0.20 seconds ) and **QRS measurements are normal** (0.04 and 0.10 seconds) respectively**.** - **Sudden loss of electrocardiographic complexes** indicates ventricular asystole or possibly electrode displacement. - **Accurate assessment of the client is necessary to determine the cause and identify the appropriate intervention.** - **Ventricular tachycardia** is characterized by the avsence of P waves, wide QRS complexes (longer than 0.12 seconds), and typically a rate between 140 and 180 impulses per minute. The rhythm is regular. - **Ventricular tachycardia is a life-threatening dysrhythmia** that results from an **irritable ectopic focus that takes over as the pacemaker for the heart.** - Ventricular tachycardia can deteriorate into ventricular fibrillation at any time. - Clients frequently experience a feeling of impending doom. - The low cardiac output that results can lead quickly to cerebral and myocardial ischemia. - Ventricular tachycardia is treated with antidysrhythmic medications, cardioversion (**if the client is awake**), or defibrillation (**loss of consciousness**). - **Premature ventricular contractions** can cause hemodynamic compromise. Therefore, the priority is to monitor the blood pressure and oxygen saturation. The **shortened ventricular filling time** can **lead to decreased cardiac output.** The client may be **asymptomatic or may feel palpitations.** - **Premature ventricular contractions can be caused by cardiac disorders**; states of hypoxemia; any number of physiological stressors, such as infection, illness, surgery, or trauma; and intake of caffeine, nicotine, or alcohol. - The client with uncontrolled atrial fibrillation with a ventricular rate more than 100 beats per minute is at risk for low cardiac output because of loss of atrial kick. - The nurse **assesses the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins.** - **Hypertension and flat neck veins** are **NOT** associated with the loss of cardiac output. - **Atrial fibrillation** is characterized by a **loss of P waves** and fibrillatory waves before each QRS complex. - The **atria quiver, which can lead to thrombus formation.** - Until the **defibrillator is attached and charged**, the client is resuscitated by using cardiopulmonary resuscitation. - Once the defibrillator has been attached, the **electrocardiogram is checked to verify that the rhythm is ventricular fibrillation or pulseless ventricular tachycardia**. - Leads also are checked for any loose connections. - A nitroglycerin patch, if present, is removed. - The **energy level** used for all defibrillation attempts with a monophasic defibrillator is **360 joules**. - After defibrillation, the client requires continuous monitoring of electrocardiographic rhythm, hemodynamic status, and neurological status. - **Respiratory and metabolic acidosis** develop during ventricular fibrillation because of **lack of respiration and cardiac output**. These can cause **cerebral and cardiopulmonary complications.** - Arousable status, adequate BP, and a sinus rhythm indicate successful response to defibrillation. - **Nursing responsibilities after cardioversion** include maintenance **first of a patent airway**, and then **oxygen administration**, assessment of vital signs and level of consciousness, and dysrhythmia detection. - The nurse who is **caring for the client after insertion of an automatic internal cardioverter-defibrillator** needs to assess device settings, similar to after insertion of a permanent pacemaker. Specifically, the nurse **needs to know whether the device is activated**, the heart rate cutoff above which it will fire, and the number of shocks it is programmed to deliver. - **Sinus tachycardia** has the characteristics of normal sinus rhythm, including a regular PP interval and normal-width PR and QRS intervals; however, the rate is the differentiating factor. In sinus tachycardia, the **atrial and ventricular rates are greater than 100 beats per minute.** - An **expected outcome** of aortoiliac bypass graft surgery is warmth, redness, and edema in the surgical extremity because of increased blood flow. - **Coronary artery bypass grafting (CABG), also called heart bypass surgery**, is a medical procedure to improve blood flow to the heart. It may be **needed** when the arteries supplying blood to the heart, called coronary arteries, are narrowed or blocked. - In patient **with cardiac tamponade** in following pericardiocentesis, the client usually expresses immediate relief. Heart sounds are **no longer muffled or distant and blood pressure increases**. [Distended neck veins are a sign of increased venous pressure, which occurs with cardiac tamponade]. - Following **abdominal aortic aneurysm resection or repair**, the nurse monitors the client for signs of acute kidney injury. - Acute kidney injury can occur because often much blood is lost during the surgery and, depending on the aneurysm location, the renal arteries may be hypo perfused for a short period during surgery. - Normal reference levels are BUN 10 to 20 mg/dL (3.6 to 7.1 mmol/L), and creatinine 0.6 to 1.2 mg/dL (53 to 106 mcmol/L) for males and 0.5 to 1.1 mg/dL (44 to 97 mcmol/L) for females. - Continuing to monitor urine output or checking other parameters can wait. - Urine output lower than 30 mL/hr is reported to the PHCP for urgent treatment - Variant angina, or Prinzmetal's angina, is **prolonged and severe and occurs at the same time each day, most often at rest.** - The pain is a result of **coronary artery spasm.** The treatment of choice is usually a calcium channel blocker, which relaxes and dilates the vascular smooth muscle, thus relieving the coronary artery spasm in variant angina. - Adverse effects can include peripheral edema, hypotension, bradycardia, and heart failure. - Grapefruit juice interacts with calcium channel blockers and should be avoided. - If bradycardia occurs, the client should contact the primary health care provider or cardiologist. - Clients should also be taught to change positions slowly to prevent orthostatic hypotension. - Physical exertion does not cause this type of angina; therefore, the client should be able to continue morning walks with her or his spouse. - **Ventricular fibrillation** is characterized by irregular chaotic undulations of varying amplitudes. - Ventricular fibrillation has no measurable rate and no visible P waves or QRS complexes and results from electrical chaos in the ventricles. - In response to heparin therapy: - Common **laboratory ranges for activated partial thromboplastin time (aPTT) are 30 to 40 seconds**. - Because the aPTT should be **1.5 to 2.5 times the normal value**, the client's aPTT would be **considered therapeutic if it was 60 seconds**. - **Prothrombin time** assesses response to **warfarin therapy.** - **Aspirin-containing products** need to be avoided when a client is taking this medication warfarin soduim. - **Alcohol consumption should be avoided** by a client taking warfarin sodium. - Taking the prescribed medication at the **same time** each day **increases client compliance**. - The **MedicAlert bracelet** provides health care personnel with **emergency information.** - The **optimal therapeutic range** for digoxin is **0.5 to 2.0** ng/mL (0.63 to 2.56 nmol/L). - Digoxin -- limit -- 0.5-dos - If the client is experiencing symptoms such as **anorexia and is experiencing hypokalemia as evidenced by a low potassium level**, digoxin toxicity is a concern. - **Procainamide** is a medication used to manage and treat ventricular arrhythmias, supraventricular arrhythmias, atrial flutter, atrial fibrillation, AV nodal re-entrant tachycardia, and Wolf-Parkinson-White syndrome. **It is a Class 1A antiarrhythmic agent.** - **Signs of toxicity from procainamide** include confusion, dizziness, drowsiness, decreased urination, nausea, vomiting, and tachydysrhythmias. - If the client complains of dizziness, the nurse should **assess the vital signs first**. - Although measuring the QRS duration on the rhythm strip and obtaining a 12-lead electrocardiogram may be interventions, these would be done after the vital signs are taken. - **Dizziness** directly following the procainamide indicates that the medication was the likely cause and **should be addressed before assessing for other possible causes such as hypoglycemia.** - **Beta blockers** are medicines that lower blood pressure. They also may be called beta-adrenergic blocking agents. The medicines block the effects of the hormone epinephrine, also known as adrenaline. Beta blockers cause the heart to beat more slowly and with less force. - Audible expiratory wheezes may indicate a serious **adverse reaction, bronchospasm.** Beta blockers may induce this reaction, particularly in clients with **chronic obstructive pulmonary disease or asthma.** - Normal decreases in blood pressure and heart rate are expected. Insomnia is a frequent mild side effect and should be monitored. - When a client is receiving warfarin for **clot prevention due to atrial fibrillation,** an **INR of 2 to 3** is appropriate for most clients. - Until the INR has achieved a **therapeutic range**, the client should be maintained on a continuous heparin infusion with **the aPTT ranging between 60 and 80** seconds. Therefore, the nurse should collaborate with the HCP to obtain a prescription to increase the heparin infusion and to administer the warfarin as prescribed. - **Tissue plasminogen activator** is a thrombolytic. **Hemorrhage** is a complication of any type of **thrombolytic medication**. - The client is monitored for **bleeding.** - Monitoring for renal failure and monitoring the client's psychosocial status are important **but are not the most critical interventions.** - **Heparin** may be administered after thrombolytic therapy, but the question is not asking about followup medications. - **Thiazide diuretics** such as hydrochlorothiazide are **sulfa-based medications**, and a client with a sulfa allergy is at risk for an allergic reaction. - Also, clients are at risk for hypokalemia, hyperglycemia, hypercalcemia, hyperlipidemia, and hyperuricemia. - **Nicotinic acid**, even an over-the-counter form, should be avoided because it may lead to liver abnormalities. - All **lipid-lowering medications also can cause liver abnormalities**, so a combination of nicotinic acid and cholestyramine resin needs to be avoided. - Constipation and bloating are the 2 most common adverse effects. - Walking and the reduction of fats in the diet are therapeutic measures to reduce cholesterol and triglyceride levels. - Digoxin is a cardiac glycoside. - Cardiac glycosides are medicines for treating heart failure and certain irregular heartbeats.  - The **risk of toxicity** can occur with the use of this medication. Toxicity can lead to **life-threatening events** and the nurse needs to monitor the client closely for signs of toxicity. - **Early signs** **of toxicity** include gastrointestinal manifestations such as anorexia, nausea, vomiting, and diarrhea. - Subsequent manifestations include headache; visual disturbances such as diplopia, blurred vision, yellow-green halos, and photophobia; drowsiness; fatigue; and weakness. - Cardiac rhythm abnormalities can also occur. - The nurse also **monitors the digoxin level.** The optimal therapeutic range for digoxin is 0.5 to 2.0 ng/mL (0.63 to 2.56 nmol/L). - An **increased risk of toxicity** exists in clients with hypercalcemia, hypokalemia, hypomagnesemia, hypothyroidism, and impaired renal function. - The normal range for magnesium is **1.8--2.6** mEq/L (0.74--1.07 mmol/L). - Bumetanide is a diuretic and expected outcomes include increased urine output, decreased crackles, and decreased weight. - **Potassium loss** is a side effect rather than an expected effect of the diuretic. - Frothy pink sputum indicates progression to pulmonary edema. - A BNP greater than 100 pg/mL (100 ng/L) is indicative of heart failure; thus, a rise from a previous level indicates worsening of the condition. - The antidote to heparin is protamine sulfate; it should be readily available for use if excessive bleeding or hemorrhage should occur. - Vitamin K is an antidote for warfarin sodium. - Potassium chloride is administered for a potassium deficit. - Aminocaproic acid is the antidote for thrombolytic therapy. - **Thrombolytic Therapy**:\ The client is experiencing an anaphylactic reaction. Therefore, the priority action is to stop the infusion and notify the RRT. - The client may be treated with antihistamines. - Raising the head of the bed would not be helpful, as that may exacerbate the hypotension. - Protamine sulfate is the antidote for heparin, so **it is not useful** for a client receiving alteplase. - **Thrombolytic therapy is contraindicated in severe uncontrolled hypertension because of the risk of cerebral hemorrhage**. Therefore, the nurse would report the results of the blood pressure to the PHCP before initiating therapy. - About **nicotinic acid** prescribed for **hyperlipidemia**:\ Flushing is an adverse effect of this medication. - Aspirin or a nonsteroidal anti-inflammatory drug, as prescribed, can be taken 30 minutes prior to taking the medication to decrease flushing. - Alcohol consumption needs to be avoided because it will enhance this effect. The medication should be taken with meals to decrease gastrointestinal upset; however, taking the medication with meals has no effect on the flushing. - **Clay-colored stools** are a sign of **hepatic dysfunction** and should be reported to the primary health care provider (PHCP) immediately.