Nursing care for patients with Cardiovascular Alterations

Hypertension related to age
Hypertension actually occurs more commonly in males below 55 years of age and also higher
Women get older 55 – and more at risk for developing strokes from their hypertension

Normal creatine kinase
36-160 Units/L (F)
50-204 units/L (M)

Normal Ck-MB
Less than 4-6% of total CK

Normal troponin
< 0.35 ng/ml (I) < 0.2 mcg/L (T)

Rise, Peak, Fall, of Ck-MB
Rise 4-6 hrs
Peak 18-24 hrs
Return to baseline 24-36 hrs

Rise, Peak, Fall, of troponin
Rise 2 – 6 hrs
Peak 15-24 hrs
Return to baseline 7-10 days

Total cholesterol range
< 200 mg/dL

Total LDL range
Without CAD <130mg/dL With CAD ≤100mg/dL(< 70)

Total HDL range
> 40 mg/dL (men)
> 60 mg/dl (women)

Total triglyceride range
< 150 L

Normal BNP
Less than 100

BNP Ranges
100-199 mild heart failure
200-400 moderate heart failure
More than 400 – moderate to severe heart failure

Normal homocysteine level
4.6-11.2 mcg/L

What happens if homocysteine level increases
Damage inside lining of artery
Encourage clot formation
Stroke
Heart disease

What is homocysteine
amino acid your body uses to make protein and to build and maintain tissue.

Prep for transesophageal echocardiogram
NPO for 6 hours prior to test
Consent
IV access
Remove dentures

Nursing care after transesophageal echocardiogram
Vital signs including pulse oximetry
No eating or drinking 2 hours after procedure, or until gag reflex returns
Monitor for shortness of breath, chest pain, bleeding, or fever

Standing orders for stress test
Consent
NPO
No caffeine for 12-24 hours
Hold medication that slows heart rate
– Beta blockers (Metoprolol, Carvedilol)
Digoxin (Lanoxin)
Calcium channel blockers (Diltiazem, Verapamil only)

Angiography nursing care
Invasive procedure using local anesthesia and conscious sedation
Consent required
NPO
Check for allergy to iodine, shellfish, xray dye

What is cardiac catheterization used to diagnose?
Coronary artery disease
Disease of heart valves
Etiology of Congestive heart failure
Structural defects

Standing orders for cardiac catheterization
Explain procedure
Consent
NPO
Intravenous access
Shave and prep right/left groin
Hold anticoagulants
Check allergy
Iodine, shellfish, contrast dye
If allergic, give Benadryl and Solucortef
Hold basal insulin and oral hypoglycemic agents

Preparation for cardiac catheterization
Several routine tests will be done:
-ECG
-Complete Blood Count (CBC)
– WBC Hgb, Hct, Platelets
-Electrolyte panel
– Sodium, Potassium, BUN, creatinine
-PT/INR (if on Coumadin)

Post Cardiac Catheter Nursing Care
Bed rest for 3 to 4 hours
Head of bed elevated 20 to 30 degrees
Keep the affected extremity straight
Frequent vital signs
Monitor groin site for bleeding
Check pedal pulses
After 3 to 4 hours & stable, check blood pressure and heart rate lying, sitting, and standing

Complications that can occur from cardiac catheterization
Dissection of aorta or coronary artery
MI (Heart Attack)
Thrombus/embolus
Stroke
Hematoma
Retroperitoneal bleed
Pseudoaneursym or A-V fistula
Allergic reaction to xray dye

Electrophysiology Study Standing Orders
NPO
Consent
Shave & prep groin
Catheter inserted right femoral vein
Bed rest 3-4 hours
Monitor vital signs and puncture site
Assess pedal pulses

Normal blood pressure
Less than 120 / less than 80

Prehypertension range
120-139 / 80 – 89

Stage 1 Hypertension range
140 – 159 / 90 – 99

What xray view is better to see fluid in the lungs?
Lateral

What do you make sure to check before doing an x-ray?
If the patient is pregnant

Hypokinesia
low muscle movement in that particular wall

Akinesia
Dead tissue (Myocardial infarction)

Ejection Fraction
Calculation of how much blood a ventricle can eject with one contraction

Pseudohypertension
False hypertension; occurs when walls of arteries are thickened; can’t really compress the artery until you get a really high reading. This tends to happen in elderly as their vessels have become more scarred, sclerotic, and hardened. Hard to compress it.

Secondary hypertension
Caused by another disease (such as kidney failure)

What lifestyle changes can be done to lower bp?
DASH, Sodium restriction, losing excess weight, exercise, smoking cessation, limiting alcohol, stress management

ALLHAT STUDY (Antihypertensive & Lipid Lowering Treatment to prevent Heart Attack Trial)
1st choice – diuretics

How do you assess tissue perfussion?
MAP

Risk factors for atherosclerosis
Tobacco Use
Dyslipidemia
Hypertension
Diabetes mellitus
Physical Inactivity
Obesity

Treatments for Atherosclerosis
Restrict Lipoprotein Production with statins, Niacin, Fibric acid derivatives, Increase lipoprotein removal with bile acid sequestrants, and decrease cholesterol absorption with zetia and vytorin

PAD s/s
Intermittent claudication
Calf pain
Buttock and thigh pain
Erectile dysfunction
Paresthesia
Changes to skin
Diminished or absent pulses

What are some complications of PAD?
Atrophy of the skin and muscles
Delayed healing
Wound infections
Tissue necrosis
Arterial ulcers
Gangrene
Amputation

Normal Ankle-Brachial Index
0.91-1.30

What does an ABI of less than 0.4 mean?
Severe PAD

Treatment for PAD
***Dangle or reverse trendelenburg for improved perfusion
Wear soft, roomy, protective shoes
Arterial ulcers – keep clean & dry, cover w/ drsg
Thrombosis or embolism – EMERGENCY!
Lubrication (avoid soaking ft)
Exercise

Cilostazol (Pletal)
inhibits platelet aggregation & vasodilates, significantly increases walking distance & QOL

Pentoxyfylline (Trental)
increase RBC flexibility

Nursing care for PAD
Assess peripheral pulses, skin color & temp, capillary refill, sensation, & movement
Aggressive pain management
Monitor for complications: bleeding, hematoma, thrombosis, embolization, & compartment syndrome
Avoid knee- flexed positions except w/ exercise
Prioritization: Notify dr. of significant change – increased level of pain, loss of palpable pulse distal to operative site, ext. pallor/cyanosis, cold ext, numbness or tingling.

Patient teaching for PAD
Risk factor management – NO TOBACCO!
Meticulous foot care
How to check pulses, temp & capillary refill
Gradual increase in physical activity post-op
Regular physical activity

Acute arterial ischemia
Causes: Thombosis, Embolism, Trauma
EMERGENCY!!!
Six P’s: Pain, Pallor, Pulselessness, Paresthesia, Paralysis, Poikilothermia (usually cool)
Treatment: Anticoagulation, Thrombolysis, Embolectomy, Surgical Revascularization, Amputation

Buerger’s disease
Rare, nonathersclerotic, inflammatory disorder
Common in young men
Affects: small and medium size arteries, veins, and nerves
upper and lower extremities
Strong correlation with smoking

Pathophysiology of Buerger’s disease
Inflammatory process damages arterial wall
Lymphocytes and giant cells infiltrate the vessel
Fibroblast proliferation
Thrombosis and fibrosis occur
Tissue ischemia develops

s/s Buerger’s
Often confused with PAD or autoimmune disorders
Intermittent claudication of feet, hands, or arms
Color and temperature changes in affected limbs
Paresthesia
Superficial thrombophlebitis
Cold sensitivity
Rest pain
Ischemic ulcerations

Treatment Buerger’s
Smoking cessation
Avoid trauma to the extremity
Medication therapy
Surgical therapy – Sympathectomy, bypass
Amputation

s/s raynaud’s
Vasospasm induced color changes of fingers, toes, nose, and ears
Pallor–decreased perfusion
Coldness and numbness
Cyanosis–decreased perfusion
Throbbing, aching pain
Rubor–hyperemia
Tingling and swelling
Precipitated by cold weather, emotional upsets, smoking, or caffeine use
Usually lasts for minutes

Treatment raynaud’s
Prevention of recurring episodes
Avoid temperature extremes
Smoking cessation
Avoid vasoconstrictors (caffeine, meds)
Coping strategies
Drug therapies: Ca-channel blockers
Surgical options: Sympathectomy

Diagnostic test for abdominal aneurysm
*Chest xray, ECG, Echo, Abdominal Ultrasound, CT SCAN MOST ACCURATE, MRI, Angiography

S/S Thoracic Anneurysm
Often asymptomatic
Deep, diffuse chest pain
Angina
Hoarseness
Dysphagia
Distended neck veins
Facial & upper extremity edema

S/S abdominal anneurysm
Often asymptomatic
Found on routine exam
Coincidence
Pulsatile mass
Bruit
Abdominal or back pain
Problems with bowel elimination
Distal embolization

Open Surgical Repair Care of Patient Pre-Op
Bowel prep, NPO, shower with antimicrobial soap, IV antibiotics

Open Surgical Repair Care of Patient Post-Op
ICU
Graft patency: Maintain adequate BP, IV fluids, blood transfusion as needed
CV status: Telemetry monitoring, oxygen, electrolytes, ABGs, pain control
Infection: antibiotics, monitor for fever & leukocytosis, Strict aseptic technique – Foley, IVs, incisions

Discharge Teaching for Open Surgical Repair
Gradual increase in activity
Expect fatigue, poor appetite, & irreg. bowel habits at first
Avoid heavy lifting X 4-6 wks
Report any fever; redness, swelling, pain, or drainage from incision
Prophylactic antibiotics before future procedures
Possible sexual dysfunction

Most common loc of aortic dissection
thoracic Aorta
LIFE THREATENING!

Causes of aortic dissection
HTN, Marfan’s, Blunt Trauma

Complications of aortic dissection
Cardiac tamponade, exsanguination, death

Diagnostic tests for aortic dissection
CXR, Transesophageal echocardiogram, CT scan

Collaborative care of aortic dissection
Lower BP & myo. contractility, conservative rx if asx; emergency surgery

major causes of venous disorders
Weak and damaged vein walls
Stretched or injured one-way valves
Blood clot

Varicose vein treatment
Conservative Treatment
Weight loss
Exercise
Elevate leg
Compression stocking
Avoid activities that promote venous stasis

Pt edu after endovenous laser and ambulatory phlebectomy
Compression bandage to minimize bruising
Walking is encouraged immediately following the procedure
Compression stocking
Anti-inflammatory medication
Heavy exercise avoided for 2 weeks
Avoid hot tubs and swimming for 2 weeks

Pt Edu After Vein Litigation/Stripping
Monitor for bleeding
Assess extremities for color, movement, sensation, temperature, presence of edema
Check dorsalis pedis & posterior tibial
Compression stocking
Elevate leg
Anti-inflammatory pain medication
Resume normal activities in two weeks or less.
Exercise

Thrombophlebitis
Catheter greater than 3 days, not flushing line, highly irritating meds
S/s – redness, tenderness, pain
Treatment – immediate removal of catheter

Treatment for thrombophlebitis
Heat or cold application
Elevation of affected extremity
Pain management
Tylenol
Non-steroidal anti-inflammatory
drugs (NSAIDS)
Antibiotic Therapy if severe
Anticoagulants typically not
needed

Causes of DVT
Major surgery
Leg trauma–a broken hip or leg
Prolonged travel
Family history of a blood-clotting disorder
Cancer
Oral contraceptives/HRT
Smoking
Varicose Veins
Central venous lines (pacemaker & ICD leads)
Repetitive motion

Symptoms of DVT
Majority have no symptoms
Dull, aching pain in the affected extremity
Leg pain that may worsen when you walk or stand
Swelling
Redness
Warm to touch
Homan’s sign

Diagnostics for DVT
D-dimer
A blood test measuring fragments of fibrin as result of fibrin degradation & clot lysis.
Elevated result suggests deep vein thrombosis
– Normal: <230ng/ml - Abnormal: ≥ 230ng/mL

Surgical Treatment of DVT
Inserted in the inferior vena cava via femoral vein
Pre: Consent, check dye allergy, NPO, Shave
Post: same as angiography
May go home after 1-2 days

Anticoagulant Therapy
Subcutaneous
Baseline CBC, PTT, PT, INR, Platelet Count
No continuous PTT monitoring
Dose determined by weight of patient
1mg/kg every 12 hours
The average administration 7 days or until therapeutic goal of INR is achieved

Causes of chronic venous insuffiency
Smoking
Sitting/standing for prolonged periods of time
Varicose Veins
Superficial thrombophlebitis
DVT
Trauma

Symptoms of CVI
Leg pain
Leg/ankle swelling
Discoloration of the skin – hemosiderin
Thickened skin
Varicose veins
Leg ulcers

Venous Ulcer S/S
Dark red or purple over the affected area
Thick, dry itchy skin
Shallow wound
Moderate to heavy drainage
Slow to heal

Prevention & treatment
Lifelong Compression stockings
-Customized Jobst stockings
Prevention of venous ulcers
Elevation
Avoid sitting or standing for long periods of time
Lifestyle changes
Weight loss
Exercise

Lymphedma S/S
Puffiness and a feeling of heaviness in the affected limb
Tightness of the skin
Limited range of motion
Graded 1 – 4+

Drug treatment for lymphedma
Antibiotics
Coumadin
Lasix
Pain management
NSAIDs
Hydromorphone
( Dilaudid)

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