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ATI - Medical Surgical - Unit 4 Nursing
Care of Clients with Cardiovascular
Disorders | Latest Version
Cardiovascular Disorders - Diagnostic Procedures : Overview Cardiovascular diagnostic procedures evaluate the functioning of the heart by monitoring for enzymes in the blood; using ultrasound to visualize the heart; determining the heart's response to exercise; and using catheters to determine blood volume, perfusion, fluid status, how the heart is pumping, and degree of artery blockage. Cardiovascular Disorders - Diagnostic Procedures : Procedures that Nurses should be familiar with o Cardiac enzymes (cardiac markers) and lipid profile o Echocardiogram o Stress testing (exercise electrocardiography) o Angiography Cardiovascular Disorders - Diagnostic Procedures : Cardiac Markers
- Cardiac enzymes are released into the bloodstream when the heart muscle suffers ischemia.
- Cardiac enzymes are a specific marker in diagnosing an MI. Cardiovascular Disorders - Diagnostic Procedures : Lipid Profile A lipid profile provides information regarding cholesterol levels and is used for early detection of heart disease. Cardiovascular Disorders - Diagnostic Procedures : Cardiac Markers : Indications o Angina o MI o Heart disease o Hyperlipidemia Cardiovascular Disorders - Diagnostic Procedures : Interpretation of findings: Cardiac Enzyme: CREATINE KINASE MB isoenzyme (CK-MB) - more sensitive to Myocardium EXPECTED REFERENCE RANGE: 0% of total CK (30 to 170 units/L)
ELEVATED LEVELS
(First detectable following myocardial injury) : 4 to 6 hours EXPECTED DURATION OF ELEVATED LEVELS: 3 days Cardiovascular Disorders - Diagnostic Procedures : Interpretation of findings: Cardiac Enzyme: TROPONIN T EXPECTED REFERENCE RANGE: less than 0.2 ng/L ELEVATED LEVELS (First detectable following myocardial injury) : 3 to 5 hours EXPECTED DURATION OF ELEVATED LEVELS: 14 to 21 days Cardiovascular Disorders - Diagnostic Procedures : Interpretation of findings: Cardiac Enzyme: TROPONIN I EXPECTED REFERENCE RANGE: less than 0.03 ng/L ELEVATED LEVELS (First detectable following myocardial injury) : 3 hours EXPECTED DURATION OF ELEVATED LEVELS: 7 to 10 days Cardiovascular Disorders - Diagnostic Procedures : Interpretation of findings: Cardiac Enzyme: MYOGLOBIN EXPECTED REFERENCE RANGE: less than 90 mcg/L ELEVATED LEVELS (First detectable following myocardial injury) : 2 hours EXPECTED DURATION OF ELEVATED LEVELS: 24 hours Cardiovascular Disorders - Diagnostic Procedures : Interpretation of findings: Lipid Profile Test: Cholesterol Total EXPECTED REFERENCE RANGE: Less than 200 mg / dl PURPOSE: Screening Test for heart disease Cardiovascular Disorders - Diagnostic Procedures : Interpretation of findings: Lipid Profile Test: HDL
Cardiovascular Disorders - Diagnostic Procedures : Echocardiogram : Interpretation of Findings An echocardiogram can be used to determine blood flow insufficiency, cardiac tissue damage, and valve disorders. This test can also be used to measure the size and depth of the heart, ejection fraction and cardiac output. Cardiovascular Disorders - Diagnostic Procedures : Echocardiogram : Preprocedure Nursing actions
- Explain the reason for the test to clients. The test is pain-free and takes up to 1 hour Cardiovascular Disorders - Diagnostic Procedures : Echocardiogram : Intraprocedure Nursing actions
- Position clients on left side with the head of the bed elevated 15° to 20° and instruct them to remain still. Cardiovascular Disorders - Diagnostic Procedures : Echocardiogram : Postprocedure Nursing actions
- Inform clients that the results of the test and a plan for follow-up care will be provided by the provider. There are no specific post procedure instructions that need to be followed. Cardiovascular Disorders - Diagnostic Procedures : Stress Testing (Exercise Electrocardiography)
- The cardiac muscle is exercised by clients walking on a treadmill. This provides information regarding the workload of the heart. Once the client's heart rate reaches a certain rate, the test is discontinued. Cardiovascular Disorders - Diagnostic Procedures : Pharmacological Stress Test A pharmacological stress test may be used for clients who are disabled or unable to be physically challenged. A medication such as adenosine (Adenocard), is given to stress the heart instead of walking on the treadmill. Cardiovascular Disorders - Diagnostic Procedures : Stress Test - Indications o Angina
o Heart failure o MI o Dysrhythmia Cardiovascular Disorders - Diagnostic Procedures : Stress Test - Interpretation of Findings During the stress test, the client's heart will increase due to the workload of the heart. This is an expected finding for this test. Abnormal findings can include arrhythmias while the test is being completed, signs of coronary artery disease such as angina, and shortness of breath. Cardiovascular Disorders - Diagnostic Procedures : Stress Test - Preprocedure Nursing actions
- Verify that informed consent has been obtained.
- Explain to clients that they will be walking on a treadmill, and comfortable shoes and clothing are recommended.
- Clients are instructed to fast 2 to 4 hr before the procedure according to agency policy, and to avoid tobacco, alcohol, and caffeine before the test. Cardiovascular Disorders - Diagnostic Procedures : Stress Test - Intraprocedure Nursing Actions
- Remind clients that once the heart reaches a certain rate, the test will be discontinued. Cardiovascular Disorders - Diagnostic Procedures : Stress Test - Postprocedure Nursing Actions
- Clients are monitored by ECG and their blood pressure is checked frequently until they are stable.
- Monitor ECG and vital signs.
- The provider will discuss findings with client.
Instruct clients that they can be awake and sedated during procedure. A local anesthetic should be used. A small incision is made, often in the groin to insert the catheter. Clients can feel warm and flushed when the dye is inserted. After the procedure, clients must keep the affected leg straight. Pressure (a sandbag) can be placed on the incision to prevent bleeding. Cardiovascular Disorders - Diagnostic Procedures : ANGIOGRAPHY: Postprocedure: Nursing Actions
- Check vital signs every 15 min x 4, every 30 min x 2, every hour x 4, and then every 4 hr (follow hospital protocol).
- Check the groin site at the same intervals for:
- Bleeding and hematoma formation
- Thrombosis; document pedal pulse, color, temperature
- Maintain bed rest in prescribed position (supine or head of the bed to be elevated 30° to 45° with extremity straight for prescribed time.
- A vascular closure device may be used to hasten hemostasis following catheter removal.
- Assist with continuous cardiac monitoring for dysrhythmias (reperfusion following angioplasty can cause dysrhythmias).
- Monitor urine output and monitor IV fluids for hydration.
- Monitor pressure dressing after sheath removal. Cardiovascular Disorders - Diagnostic Procedures : ANGIOGRAPHY: Postprocedure: Nursing Actions: Administer medications as prescribed
- Administer medications as prescribed to prevent clot formation and restenosis.
- Aspirin
- Clopidogrel (Plavix), ticlopidine (Ticlid)
- Heparin
- Low molecular weight heparin (Enoxaparin, Lovenox)
- GP lIb/IlIa inhibitors, such as eptifibatide (Integrilin)
- Administer anxiolytics (Ativan) and analgesia (morphine) as needed. Cardiovascular Disorders - Diagnostic Procedures : ANGIOGRAPHY: Client Education
- Instruct clients to:
- Avoid strenuous exercise for the prescribed period of time.
- Immediately report bleeding from the insertion site, chest pain, shortness of breath, and changes in the color or temperature of the extremity.
- Restrict lifting (less than 10 lb) for the prescribed period of time.
- Clients with stent placement will receive anticoagulation therapy for 6 to 8 weeks. Instruct clients to:
- Take the medication at the same time each day.
- Have regular laboratory tests to determine therapeutic levels.
- Avoid activities that could cause bleeding (use soft toothbrush, wear shoes when out of bed).
- Encourage clients to follow lifestyle guidelines (manage weight, consume a low fat/ low-sodium diet, get regular exercise, stop smoking, decrease alcohol intake). Cardiovascular Disorders - Diagnostic Procedures : ANGIOGRAPHY: Complications - Cardiac Tamponade
- Cardiac tamponade can result from fluid accumulation in the pericardial sac.
- Signs include hypotension, jugular venous distention, muffled heart sounds, and paradoxical pulse (variance of 10 mm Hg or more in systolic blood pressure between expiration and inspiration).
- Hemodynamic monitoring will reveal intracardiac and pulmonary artery pressures similar and elevated (plateau pressures).
- Nursing actions
- Notify the provider immediately.
- Administer IV fluids to combat hypotension as prescribed. Cardiovascular Disorders - Diagnostic Procedures : ANGIOGRAPHY: Complications - Hematoma Formation Hematoma formation
- Blood clots may form near the insertion site.
- Nursing actions
- Check the groin at prescribed intervals and as needed.
- Hold pressure for uncontrolled oozing/bleeding
Cardiovascular Disorders - Diagnostic Procedures : Electrocardiography: Indications Diagnoses
- Bradycardia
- Heart block
- Atrial fibrillation
- Supraventricular tachycardia
- Ventricular tachycardia
- Ventricular fibrillation
- Myocardial Infarction (size and extent) Cardiovascular Disorders - Diagnostic Procedures : Electrocardiography: Client Presentation
- Cardiovascular disease
- Myocardial infarction
- Hypoxia
- Acid-base imbalances
- Electrolyte disturbances
- Chronic renal failure, liver, or lung disease
- Pericarditis
- Drug or alcohol abuse
- Hypovolemia
- Shock Cardiovascular Disorders - Diagnostic Procedures : Electrocardiography: Interpretation of Findings An electrocardiography can identify dysrhythmias, heart ischemia, cardiac injury, chamber enlargement, or conduction abnormalities Cardiovascular Disorders - Diagnostic Procedures : Electrocardiography: Preprocedure
Nursing actions
- Prepare clients for a 12 - lead ECG by: o Positioning clients in a supine position with chest exposed. o Washing the client's skin to remove oils. o Attaching one electrode to each of the client's extremities by applying electrodes to flat surfaces above the wrists and ankles and the other six electrodes to the chest, avoiding chest hair. (Chest hair may need to be shaved on male clients). Cardiovascular Disorders - Diagnostic Procedures : Electrocardiography: Intraprocedure Nursing actions
- Instruct clients to remain still and breathe normally while the 12 - lead ECG is performed.
- Monitor clients for signs and symptoms of dysrhythmia (chest pain, decreased level of consciousness, and shortness of breath) and hypoxia. Cardiovascular Disorders - Diagnostic Procedures : Electrocardiography: Postprocedure Nursing actions
- Remove leads from client, print ECG report, and notify the provider.
- Apply a Holter monitor if clients are on a telemetry unit and/or need continuous cardiac monitoring.
- Continue to monitor clients for symptoms of dysrhythmia (chest pain, decreased level of consciousness, and shortness of breath) and hypoxia.
- Dysrhythmia treatment is based on the client's symptoms and the cardiac rhythm, which can require cardioversion or defibrillation after an ECG has been completed and a diagnosis has been found. Cardiovascular Disorders - Diagnostic Procedures : Electrocardiography:Dysrhythmias
- Dysrhythmias are classified by the: o Site of origin - sinoatrial (SA) node, atria, atrioventricular node, or ventricle.
- Electrophysiological study determines the area of the heart causing the dysrhythmia. Ablation of the area is possible.
Cardiovascular Disorders - Diagnostic Procedures : Electrocardiography: CARDIOVERSION AND DEFIBRILLATION: Indications o Cardioversion - elective treatment of atrial dysrhythmias, supraventricular tachycardia, and ventricular tachycardia with a pulse. Cardioversion is the treatment of choice for clients who are symptomatic. o Defibrillation - ventricular fibrillation or pulseless ventricular tachycardia. Cardiovascular Disorders - Diagnostic Procedures : Electrocardiography: CARDIOVERSION AND DEFIBRILLATION: Preprocedure o Clients who have atrial fibrillation of unknown duration must receive adequate anticoagulation prior to cardioversion therapy to prevent dislodgement of thrombi into the bloodstream. An anesthesiologist may administer a short acting anesthetic IV bolus for sedation. o Nursing actions
- Prepare clients for cardioversion, if prescribed.
- Explain the procedure to clients and verify consent.
- Administer oxygen.
- Document preprocedure rhythm.
- Have emergency equipment available. Cardiovascular Disorders - Diagnostic Procedures : Electrocardiography: CARDIOVERSION AND DEFIBRILLATION: Postprocedure o Nursing actions
- After cardioversion or defibrillation, check the client's vital signs, check airway patency, and obtain an ECG.
- Provide clients and their families with reassurance and emotional support. o Client education
- Teach clients and families how to check pulse rate.
- Advise clients to report palpitations or irregularities.
Cardiovascular Disorders - Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures Overview
- Invasive cardiovascular procedures are methods used to maintain an acceptable cardiac rhythm or improve blood flow for arteries and veins that have become occluded.
- Invasive cardiovascular procedures are indicated if symptoms persist after non-invasive interventions have been tried, such as diet, exercise, and medications.
- Invasive cardiovascular procedures that nurses should be knowledgeable about include: o Pacemaker insertion and care o Angioplasty o Coronary artery bypass grafts o Peripheral bypass grafts Cardiovascular Disorders - Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures - Pacemakers Overview
- An artificial pacemaker is a battery-operated device that electrically stimulates the heart when the natural pacemaker of the heart fails to maintain an acceptable rhythm.
- Pacemakers may be temporary or permanent.
- Nurses should be familiar with the various types of pacemakers, how they function, and the care involved with their placement/insertion.
- Conduction of electrical impulses through the sinoatrial node may be slowed with aging, causing bradycardia and conduction defects. Cardiovascular Disorders - Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures - Pacemakers: Two parts Pacemakers are composed of two parts: o The pulse generator houses the energy source (battery) and the control center. o The electrodes are wires that attach to the myocardial muscle on one side and connect to the pulse generator on the other.
o Can be programmed to pace the atria, ventricles, or both (AV sequential pacing) Cardiovascular Disorders - Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures - Pacemakers: Permanent Pacemakers - Pacemaker modes Pacemaker modes
- Fixed rate (asynchronous) - fires at a constant rate without regard for the heart's electrical activity
- Demand mode (synchronous) - detects the heart's electrical impulses and fires at a preset rate only if the heart's intrinsic rate is below a certain level
- Antidysrhythmic function - can overpace a tachydysrhythmia or deliver an electrical shock Cardiovascular Disorders - Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures - Pacemakers: Placement - Indications o Diagnoses
- Symptomatic bradycardia
- Complete heart block
- Sick sinus syndrome
- Sinus arrest
- Asystole
- Atrial tachydysrhythmias
- Ventricular tachydysrhythmias Cardiovascular Disorders - Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures - Pacemakers: Placement - Client presentation Symptoms 0 Dizziness 0 Palpitations 0 Chest pain or pressure 0 Anxiousness 0 Fatigue
0 Nausea o Breathing difficulties Cardiovascular Disorders - Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures - Pacemakers: Placement - Signs 0 Bradycardia 0 Tachycardia 0 Abnormal ECG 0 Dyspnea, tachypnea 0 Restlessness 0 Distended jugular vein 0 Vomiting 0 Hypotension 0 Diaphoresis 0 Decreased cardiac output Cardiovascular Disorders - Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures - Pacemakers: Client Outcomes o The client will be able to tolerate activities of daily living free of cardiac symptoms. o The client will use strategies to reduce stress and improve cardiac health. o The client will recognize cardiac symptoms and seek medical attention immediately when needed. Cardiovascular Disorders - Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures - Pacemakers: Preprocedure - Nursing Actions
- Determine the client's knowledge of the procedure and need for pacemaker (if nonemergent situation).
- Verify informed consent.
~ Insulate pacemaker terminals and leads with nonconductive material when not in use (rubber gloves). ~ Keep spare generator, leads, and batteries at the client's bedside. ~ Secure the pacemaker battery pack. Take care when moving clients and ensure that there is enough wire slack.
- For a permanent pacemaker: ~ Provide clients with a pacemaker identification card including the manufacturer's name, model number, mode of function, rate parameters, and expected battery life. Cardiovascular Disorders - Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures - Pacemakers: Postprocedure - Client Education - Permanent pacemaker discharge teaching, Part I
- Temporary pacemakers are only used in a controlled facility-like environment with telemetry for continuous ECG monitoring. If needed, a permanent pacemaker is inserted before discharge to home.
- Permanent pacemaker discharge teaching
- Instruct clients to carry a pacemaker identification card at all times.
- Reinforce to clients that batteries last 10 years on average.
- Tell clients to wear a sling when out of bed, if prescribed.
- Reinforce to clients not to raise the arm on the surgical side above the shoulder for 1 to 2 weeks.
- Reinforce to clients to take pulse daily at the same time.
- Reinforce to clients to set the rate of the pacemaker. Notify the provider if the heart rate is less than 5 beats below the pacer rate.
- Instruct clients to report signs of dizziness, fainting, fatigue, weakness, chest pain, hiccupping, or palpitations. Cardiovascular Disorders - Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures - Pacemakers: Postprocedure - Client Education - Permanent pacemaker discharge teaching, Part II
- For clients with pacer-defibrillators, inform clients and their families that anyone touching the client when the device delivers a shock will feel a slight electrical impulse but that the impulse will not harm the person.
- Inform clients of activity restrictions as prescribed, including no contact sports or heavy lifting for 2 months.
- Inform clients that they can resume sexual activity as desired, avoiding positions that put stress on the incision site. Cardiovascular Disorders - Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures - Pacemakers: Postprocedure - Client Education - Permanent pacemaker discharge teaching, Part III o Inform clients that household appliances should not affect pacemaker function unless held directly over pacer generator. This includes garage door openers, burglar alarms, microwave ovens, and antitheft devices. o Instruct clients to inform airport security agents that airport security detectors will be set off. Inform clients that this should not affect pacemaker functioning. o Instruct clients to inform other providers and dentists about the pacemaker. Some tests, such as magnetic resonance imaging and therapeutic diathermy (heat therapy), may be contraindicated Cardiovascular Disorders - Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures - Pacemakers: Insertion Complications - Infection or hematoma o The insertion site can develop an infection or hematoma. o Nursing actions ~ Monitor the incision site for redness, pain, drainage, or swelling. ~ Treat an infection with antibiotics as prescribed. ~ Monitor coagulation and CBC. Cardiovascular Disorders - Diagnostic and Therapeutic Procedures: Invasive Cardiac Procedures - Pacemakers: Insertion Complications - Pneumothorax or hemothorax o Trauma during the procedure can cause a pneumothorax or hemothorax. o Nursing actions ~ Monitor the client's breath sounds and chest movement. ~ Monitor oxygen saturation. ~ Obtain a chest x-ray after the procedure.
