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Concept: Perfusion (Giddens)
Definition: The flow of blood through arteries and capillaries to deliver nutrients and oxygen to cells
and remove cellular waste products
Alteration in perfusion may impair circulation of blood through the tissues
Scope of Concept
BLOOD FLOW THROUGH THE HEART (see image below – blue indicates deoxygenated blood, red
indicates oxygenated blood).
Mnemonics –
• RAT - right atrium tricuspid
• LAMB - (left atrium mitral (also known as bicuspid)
1. Right Atrium – receives venous blood from the Inferior and superior venae cavae, and coronary sinus
(not in image). The blood then passes through the 2. Tricuspid Valve (mnemonic RAT (right atrium tricuspid) – into the 3. Right Ventricle – with each contraction, the right ventricle pumps blood through the - 4. Pulmonic
Valve (also known as a semilunar valve) into the 5. Pulmonary Artery and to the
6. Lungs – oxygenated blood flows from the lungs by way of the 7. Pulmonary Veins – to the 8. Left Atrium – where oxygenated blood then passes through the
9. Mitral Valve (mnemonic: LAMB (left atrium mitral (also known as bicuspid) – into the - 10.
Left Ventricle – as the left ventricle contracts, blood is ejected through the
11. Aortic Valve (also known as a semilunar valve) into the
12. Aorta and thus enters the high-pressure systemic circulation
C. Clark Spring 2019 Adapted from Concepts of Nursing 2nd ed, Medical Surgical Nursing 10th ed, Maternal/Child Nursing 5th ed
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Normal Physiological Process
Central Perfusion
 Force of blood movement generated by cardiac output
 Requires adequate cardiac function, blood pressure, and blood volume
 Cardiac output (CO)- The amount of blood pumped by the ventricles in 1 minute
CO = HR (heart rate) x SV (stroke volume)
Factors affecting Cardiac Output – the factors that affect CO (cardiac output) include • HR: regulated primarily by the autonomic nervous system - consists of sympathetic (stress) and
parasympathetic (peace) nervous systems
• Stroke Volume (SV): amount of blood ejected from the ventricle with each heartbeat; affected by
preload, contractility, and afterload o Preload (image below): volume of blood in the ventricles
at the end of diastole, before the next contraction
 Preload can be increased by a number of conditions such as myocardial infarction, aortic
stenosis, and hypervolemia
o Contractility: contractility represents the intrinsic ability of the heart/myocardium to contract
 Can be increased by epinephrine and norepinephrine released by the sympathetic
nervous system
C. Clark Spring 2019 Adapted from Concepts of Nursing 2nd ed, Medical Surgical Nursing 10th ed, Maternal/Child Nursing 5th ed
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
o
Increases contractility raises the stroke volume by increasing ventricular emptying o
Afterload (image below): peripheral resistance against which the left ventricle must
pump
 Afterload is affected by the size of the ventricle, wall tension, and arterial BP
 If the arterial BP is elevated, the ventricles meet increased resistance by ejection of
blood, increasing the work demand. Eventually this results in ventricular hypertrophy
Increasing in preload, contractility and afterload increases workload of myocardium resulting
in ↑oxygen demand
Preload – volume of blood in the ventricles at the end of diastole, before the next contraction
Afterload - peripheral resistance against which the left ventricle must pump
C. Clark Spring 2019 Adapted from Concepts of Nursing 2nd ed, Medical Surgical Nursing 10th ed, Maternal/Child Nursing 5th ed
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Tissue or Local Perfusion
 Volume of blood that flows to target tissue
 Requires patent vessels, adequate hydrostatic pressure, and capillary permeability
Arteries carry oxygenated blood away from the heart, except for the pulmonary artery o Large arteries
have thick walls composed mainly of elastic tissue (cushions impact) o Arterioles have relatively little
elastic tissue and more smooth muscle; major control of B/P and blood distribution; respond readily to
changes in oxygen and CO by dilating and constricting
 Endothelium of arteries (L. image below) – innermost lining of the artery – serves to
maintain homeostasis, promote blood flow, and under normal conditions, inhibit
blood coagulation
o Capillaries – made up of endothelial with no elastic or muscle tissue.
 The exchange of cellular nutrients and metabolic end products takes place through
these thin-walled vessels.
 Capillaries connect the arterioles and venules
• Veins – large-diameter, thin-walled vessels that return blood to the right atrium. Veins carry
deoxygenated blood toward the heart, except for the pulmonary veins. Largest veins are the:
o Superior vena cava returns blood to the heart from the head, neck, and arms o Inferior vena
cava returns blood to the heart from the lower part of the body
o Note - elevated right atrial pressure can cause distended neck veins or liver engorgement
C. Clark Spring 2019 Adapted from Concepts of Nursing 2nd ed, Medical Surgical Nursing 10th ed, Maternal/Child Nursing 5th ed
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REGULATION OF THE CARDIOVASCULAR SYSTEM
Autonomic Nervous System consists of the sympathetic and parasympathetic nervous systems: (Memory
Aid: Sympathethic = stress; Parasympathetic = peace)
Sympathetic (“stress” also known as “fight or flight” response) system
• Cardiac effects: ↑HR, ↑speed of impulse conduction o effect is mediated by specific sites in the
heart called βeta – adrenergic receptors that receive the neurotransmitters norepinephrine and
epinephrine
• Vascular effects: the alpha @-adrenergic receptors are located in vascular smooth muscles.
Stimulation causes vasoconstriction; decreased stimulation causes vasodilation
Parasympathetic system – peace, known as “rest and digest” system; mediated by vagus nerve - below
• Cardiac effects: causes a ↓HR by slowing the SA node, rate and conduction through the AV node
• Vascular effects: selective distribution in blood vessels (e.g. dilates blood vessels in the GI system);
does not affect skeletal muscles.
Vagus Nerve
Baroreceptors (images below): located in the aortic arch and carotid sinus (located in the carotid artery)
• Baroreceptors play an important role in the maintenance of BP stability o When stimulated by an
increase in BP, baroceptors inhibit impulses to the sympathetic vasomotor center in the brainstem –
results in ↓HR, ↓force of contraction, and vasodilation in peripheral arterioles
o In contrast, a fall in BP, sensed by the baroreceptors, leads to activation of SNS – results in
increased HR, increased contractility of heart
• Chemoreceptors: located in the aortic arch and carotid body. Capable of initiating changes in HR
and arterial pressure with decreased arterial oxygen pressure, increased CO₂ pressure (hypercapnia)
and decreased plasma pH (e.g. respiratory acidosis). Result: increase in blood pressure
Aortic Arch
Carotid Sinus
C. Clark Spring 2019 Adapted from Concepts of Nursing 2nd ed, Medical Surgical Nursing 10th ed, Maternal/Child Nursing 5th ed
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BLOOD PRESSURE: the arterial blood pressure is a measure of the pressure exerted by blood
against the walls of the arterial system.
•
•
Systolic blood pressure (SBP) is the peak pressure exerted against the arteries when the heart
contracts; tricuspid and mitral valves are closed; aortic and pulmonic valves are opened.
Diastolic blood pressure (DBP) is the residual pressure on the arterial system during ventricular
relaxation (or filling); tricuspid and mitral valves are opened; aortic and pulmonic valves are closed.
The two main factors influencing BP are cardiac output (CO) and systemic vascular resistance
(SVR)
BP = CO (stroke volume x HR) x SVR
CO indicates the total blood flow through the systemic or pulmonary circulation per minute
SVR is the force opposing the movement of blood within the blood vessels. The radius of the small
arteries and arterioles is the principal factor that determines SVR – see image below o Normal BP is SBP
<120 mm Hg and DPB <80 mm Hg
The radius of small arteries is principle factor of SVR
Measurement of Arterial Blood Pressure can be invasive and noninvasive.
Invasive: consists of a catheter insertion in an artery. Catheter is attached to a transducer, pressure is
measured directly Noninvasive: indirect BP
• Can be done with a sphygmomanometer and stethoscope. After inflating cuff 20 to 30 mmHg
above normal systolic pressure, as the cuff is lowered, there artery is auscultated for Korotkoff sounds
There are five phases.
• Korotkoff sounds – sounds heard during assessment of a blood pressure reading.
• Phase 1 is SBP, caused by the spurt of blood into the constricted artery with cuff deflation o Phase 5 is
DBP, when sound disappears
o Auscultatory gap: loss of sound between SBP and DBP
C. Clark Spring 2019 Adapted from Concepts of Nursing 2nd ed, Medical Surgical Nursing 10th ed, Maternal/Child Nursing 5th ed
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•
Doppler ultrasonic flowmeter: handheld transducer over the artery
Variations and Consequences: Impaired Central Perfusion
Impairment of central perfusion occurs when cardiac output is inadequate.
Reduced cardiac output results in a reduction of oxygenated blood reaching the body tissues (systemic effect)
 If severe associated shock
 If untreated, leads to ischemia, cell injury, and cell death
Variations and Consequences: Impaired Tissue (Local) Pefusion)
Impairment of tissue perfusion is associated with loss of vessel patency or permeability, of inadequate central
perfusion
Results in impaired blood flow to the affected body tissue (Localized effect)
 Leads to ischemia and, ultimately, cell death if uncorrected.
Risk Factors: Populations at Greatest Risk
Impaired perfusion can potentially occur among all individuals, regardless of age, gender, race, or
socioeconomic status. The populations at greatest risk are:
 Middle-aged and older adults
 Men
 African Americans
Individual Risk Factors
Individual Risk Factors for Impaired Perfusion
Modifiable Risk Factors
• Smoking: Nicotine vasoconstricts
• Elevated serum lipids: Contribute to atherosclerosis
• Sedentary lifestyle: Contributes to obesity
• Obesity: Increases risk for type 2 diabetes and atherosclerosis
• Diabetes mellitus: Increases risk of atherosclerosis
• Hypertension: Increases work of myocardium
Unmodifiable Risk Factors
• Age: Increases with age
• Gender: Men > women
• Genetics: Family history
Source: Adapted from Wilson S, Giddens J: Health assessment for nursing practice, ed 5, St Louis, 2013, Elsevier.
ASSESSMENT DATA FOR PERFUSION
History of Present Illness - Ask pt what problem has brought him/her to the health care facility.
C. Clark Spring 2019 Adapted from Concepts of Nursing 2nd ed, Medical Surgical Nursing 10th ed, Maternal/Child Nursing 5th ed
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Past Health History: many illnesses affect Perfusion
• Ask patient about a history of chest pain, shortness of breath, edema, dizziness, fatigue, alcohol and
tobacco use, anemia, Diabetes, Renal failure, Hypertension
• Medications – assess patient’s current and past use of medications. This includes over-the-counter
(OTC) drugs, herbal supplements, and prescription drugs. Many non-cardiac drugs can adversely
affect perfusion and should be assessed
• Aspirin prolongs blood clotting time
• e.g. NSAIDs (Motrin) can increase BP
• corticosteroids – hypotension, edema, potassium depletion
Surgery or Other Treatments
Functional Health Problems – strong correlation between components of a patient’s lifestyle and
cardiovascular health
Health Perception – Health Management Pattern
Assess presence of risk factors, including:
o Hx of family members o Elevated lipids o Hypertension o
Tobacco – pack years o Sedentary lifestyle o Obesity o
Stress o Diabetes
o ETOH, include amount, frequency o Use of habit forming
drugs, including recreational drugs o Allergies. Include
reaction to shellfish (potential dye allergies)
o Noncardiac conditions such as asthma, renal disease, liver
disease, obesity can affect perfusion
Nutritional-Metabolic Pattern
• Underweight/overweight may indicate potential cardiovascular problems
• Diet: include amount of salt and saturated fats in a patient’s diet
Elimination Patterns
• Urinary elimination: include use of diuretics, pt may report nocturia
• Gastrointestinal: assess straining during a bowel movement (Valsalva maneuver) should be avoided in
a patient with some perfusion problems.
o Valsalva maneuver (def) – any forced expiratory effort against a closed airway such as when a
person holds the breath and tightens the muscles.
 Eg. strenuous coughing, straining during a bowel movement, or lifting a heavy wgt
(isometric exercises)
 Causes intrathoracic pressure and impedes return of venous blood to the heart
ASSESSMENT (Perfusion) - Objective Information includes:
Cerebral tissue perfusion is indicated by the patient's orientation to time, place, person, and situation; expected
bilateral movement and sensation; clear speech; the presence of carotid pulses; and the absence of carotid
bruit. Peripheral tissue perfusion is present when the patient's extremities are warm with color appropriate for
race and the radial and dorsalis pedis pulse rates are between 60 and 100 beats per minute with regular rhythm,
easily palpable upstroke, and smooth, rounded contour. Adequate peripheral tissue perfusion is also indicated
when the capillary refill time is less than 2 seconds and the ankle–brachial index is greater than 0.9. Patients'
C. Clark Spring 2019 Adapted from Concepts of Nursing 2nd ed, Medical Surgical Nursing 10th ed, Maternal/Child Nursing 5th ed
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reports of adequate perfusion include the presence of warm hands and feet and the absence of continuous pain
in fingers and toes or leg pain when walking.
Inadequate Central Perfusion: Infants and ChildrenInfants- Poor feeding, poor weight gain, failure to thrive, and dusky color
Toddlers and children- Squatting and fatigue, Developmental delay (failure to hit milestones)
Common Diagnostic Studies (Lewis)
Serum Cardiac Markers When myocardial cells are injured, they release their contents (includes
enzymes & proteins) into the blood stream. Biomarkers are useful in diagnosing myocardial injury &
necrosis
Blood Studies
Description and Purpose
Nursing Responsibility
Cardiac troponin is a myocardial muscle
Troponin (cardiac) –
Rapid point of care (bedside);
tests are available. Explain to
biomarker of choice in protein released into circulation after injury.
Detectable within hours (on average of 4 to 6 patient the purpose of serial
the diagnosis of MI
hours) of myocardial injury, peak at 10 to 24 sampling (eg. q6 to 8 hr x 3) in
hours, and can be detected for up to 10 to 14 conjunction with CK-MB and
days. There are two subtypes –
serial ECGs.
Troponin I (cTnI) –
Less than 0.5 mcg/L - negative
0.5-2.3 mcg/L - suspicious for injury to
myocardium
>2.3 ng/m mcg/L - positive for myocardial
injury
Troponin T (cTnT) Cardiospecific enzyme released in circulation Serial sampling often done in
CK-MB – a creatine
kinase enzyme specific to after myocardial injury and necrosis. Levels conjunction with troponin and
begin to rise 3 to 6 hs after symptom onset,
myocardial injury
ECGs
peak at 12 to 24 hrs and return to baseline
within 12 to 48 hours.
>4%-6% - highly indicative of MI.
Myoglobin – heme
A heme protein found in cardiac and skeletal Explain to pt the purpose of
protein found in cardiac
muscle. Myoglobin elevation is a sensitive
blood testing.
and skeletal muscle
indicator of very early myocardial injury but
lacks specificity for MI. Usefulness limited.
C. Clark Spring 2019 Adapted from Concepts of Nursing 2nd ed, Medical Surgical Nursing 10th ed, Maternal/Child Nursing 5th ed
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Protein produced by the liver during periods
of active inflammation. An increased level of
CRP is an independent risk factor for CAD.
The level of CRP may also predict the risk
for future cardiac events in pts with unstable
angina and MI, but studies have produced
conflicting results.
Amino acid produced during protein
catabolism (breakdown) that has been
identified as a risk factor for cardiovascular
disease.
C-reactive protein
(CRP)
Homocysteine
BNP (b-Type natriuretic
peptide)
ANP (atrial natriuretic
peptide)
Can be measured anytime
during the day – fasting and
non-fasting.
Hyperhomocysteinemia
resulting from dietary
deficiencies is treated with
folic acid, vitamin B₆ and B₁₂
deficiencies
Peptides that cause natriuresis. Indicates
presence of heart failure and may help
distinguish cardiac vs respiratory cause of
dyspnea. BNP > 100 pg/mL is diagnostic for
heart failure (pg/ml means picograms (one
trillionth of a gram/ml))
Peptide that originates in the atrium
BLOOD STUDIES - Serum Lipids – consist of triglycerides, cholesterol, and phospholipids. They circulate
In the blood bound to protein – they are often referred to as lipoproteins.
Healthy
Cholesterol
Levels
Hyperlipidemia
Study
Cholesterol is a
measure that
includes both
LDL & HDL
Triglycerides
Description and Purpose
Nursing Responsibility &
other
Cholesterol is a blood lipid. Elevated cholesterol is A lipid panel usually measures
considered a risk factor for cardiovascular heart
cholesterol, triglycerides and
disease.
LDL and HDL.
Normal: <200 mg/dl (varies with age and gender)
Lipoprotein and triglyceride
Triglycerides are mixtures of fatty acids.
levels must be obtained in a
Elevations are associated with cardiovascular
fasting state for at least 12 hr
disease and diabetes.
Normal: less than 150 mg/dl (varies with age)
C. Clark Spring 2019 Adapted from Concepts of Nursing 2nd ed, Medical Surgical Nursing 10th ed, Maternal/Child Nursing 5th ed
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LDLs contain more cholesterol than any of the other (except for water), and no
lipoproteins & have an affinity for arterial walls.
ETOH
Recommended LDL:
intake for 24 hr before testing
• LDL < 100 mg/dl
• Near Optimal: LDL 100-129 mg/dl
Elevations in triglycerides and
• Moderate risk for CAD: 130-159 mg/dL
LDL are strongly associated
with CAD.
• High risk for CAD: >160 mg/dL
HDLs carry lipids away from arteries and to the
HDL (highdensity
liver for metabolism. A high serum HDL is
lipoproteins)…
known as the
HDL level is associated with a
desirable.
decreased risk of CAD. High
“healthy
Recommended HDL
HDLs serve a protective role by
• men is >40 mg/dl
cholesterol”
mobilizing cholesterol from
• women is >50 mg/dl
tissues.
• Low risk CAD HDL ≥60 mg/dL
• High risk CAD HDL <40 mg/dL
Risk for cardiac
Although an association exists between elevated serum cholesterol levels and CAD, a
disease
measure of total cholesterol along is not sufficient for an assessment of CAD. A risk
assessment is calculated by comparing the total cholesterol to HDL ratio over time.
Assess by dividing the total cholesterol level by the HDL level and obtaining a ratio:
Low Risk: Ratio less than 3; Average risk: 3-5; Increased risk: Ratio greater than 5
(eg total cholesterol level is 150 and HDL level is 75 (150 ÷ 75 = 2); pt is low risk)
Lipoprotein (a) (Lp
Increased levels are associated with an
Levels can be obtained in a
(a))
increased risk of premature CAD and stroke
nonfasting state
Reference interval <30 mg/dL
Lipoproteinassociated Elevated levels of Lp-PLA₂ are associated with
Levels can be obtained in a
phospholipase A₂
vascular inflammation and increased risk for CAD nonfasting state
LDL (low density
lipoproteins)…
known as the
“lousy cholesterol”
(Lp-PLA₂)
Other
Basic
Metabolic
Panel
Description and Purpose
Includes serum glucose, sodium, potassium,
chloride, carbon dioxide, BUN, and creatinine.
Glucose – assts in dx of diabetes; K
level – detects ↑aldosteronism (cause
of 2⁰ HTN);
BUN & creatinine screens for renal
involvement.
Platelets
Prothrombin
time(PT)
Partial
thromboplastin
time(aPTT)
INR
Study
Number of platelets available to maintain platelet
clotting functions
Assessment of extrinsic coagulation by
measurement of factors
Assessment of intrinsic coagulation by measuring
factors. Longer in patients using heparin
Standardized system of reporting PT based on a
reference calibration model
DIAGNOSTIC STUDIES
Description and Purpose
Nursing Responsibility
C. Clark Spring 2019 Adapted from Concepts of Nursing 2nd ed, Medical Surgical Nursing 10th ed, Maternal/Child Nursing 5th ed
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Chest x-ray
Patient is placed in the upright
position to examine the lung fields
and size of the heart. The two
common positions are posteroanterior
(PA) and lateral. Normal heart size
and contour for the individual’s age,
sex, and size are noted
Electrodes
Electro / cardio / gram: (electrical activity
/ heart are placed on the chest and
extremities, allowing the ECG
machine to record a cardiac electrical
activity from different views. Can
detect rhythm of heart, activity of
pacemaker, conduction abnormalities,
position of heart, size of atria and
ventricles, presence of injury, and
history of MI
/ record)
Inquire about frequency of
recent xrays and possibility
to pregnancy. Provide lead
shielding to areas not being
viewed. Remove any
jewelry or metal objects –
may obstruct view
Prepare skin and apply
electrodes and leads.
Inform patient that no
discomfort is involved.
Instruct to
avoid moving to decrease
motion artifact
FYI: “ST” depression and “T” wave
inversion: usually means ischemia in the
area of the heart
Ambulatory ECG
Monitoring (also known as Holter
Monitoring). It can be performed on an
inpatient or outpatient basis.
Recording of ECG rhythm for 28-48
hours and then correlating rhythm
changes with symptoms recorded in
diary. Normal pt activity is
encouraged to simulate conditions
that produce symptoms
Prepare skin and apply
electrodes and leads.
Explain importance of
keeping an accurate diary
of activities and
symptoms. Tell pt that no
bath or shower can be
taken during monitoring
C. Clark Spring 2019 Adapted from Concepts of Nursing 2nd ed, Medical Surgical Nursing 10th ed, Maternal/Child Nursing 5th ed
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Exercise or Stress Testing
Study
Echo cardio gram (sound /
heart / record)
Various protocols are used to evaluate
the effect of exercise tolerance on
cardiovascular function. A common
protocol used 3 minute stages at set
speeds and elevation of the treadmill
belt. Pt exercises to peak hr
(subtracting the pt’s age from 220) or
peak exercise tolerance. The test is
terminated for chest discomfort,
significant changes if VS, cardiac
ischemia. Continual monitoring of
vital signs and ECG rhythms for
ischemic changes is important in the
diagnosis of CAD. An exercise bike
may be used if pt is unable to walk
DIAGNOSTIC STUDIES
Description and Purpose
Transducer that emits and receives
ultrasound waves is placed in four
positions on the chest about the
heart. Transducer records sound
waves that are bounced off the heart.
Also records direction and flow of
blood. Through heart and transforms
it to audio and graphic data that
measures valvular abnormalities,
congenital cardiac defects, wall
motion, ejection fraction (percentage
of end-diastolic blood volume that is
ejected during systole)…provides
info about left ventricle function. IV
contrast agent may be used to
enhance images.
Instruct pt to wear
comfortable shoes and
clothes that can be used
for walking and running.
Instruct pt about
procedure and reporting
any symptoms that may
occur. Monitor VS, ECG
before exercise. Βblockers may be held 24
hours before the test
because they will blunt
the heart rate and limit
pt’s ability to achieve
maximal heart rate.
Caffeine containing food
and fluids can be held for
24 hours. Pt must refrain
from smoking and
strenuous exercise 3 hours
before test.
Nursing Responsibility
Place patient in a left side-lying
position facing equipment. Instruct
pt about procedure and sensations
(pressure and mechanical
movement from head of
transducer). No contraindications
to procedure exist
Other diagnostics to determine an individual’s perfusion status include: 24hr urine, Electronic fetal
monitoring, Ankle-brachial index (ABI), and Urinalysis
Clinical Management: Primary Prevention
 Smoking and nicotine cessation
 Diet
C. Clark Spring 2019 Adapted from Concepts of Nursing 2nd ed, Medical Surgical Nursing 10th ed, Maternal/Child Nursing 5th ed
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

Exercise
Weight control
Box 18-1(Giddens)
American Heart Association Health Promotion Recommendations
1. Eat a variety of fruits, vegetables, grains, legumes, fat-free or low-fat dairy products, fish, poultry, and lean
meats:
• Reduce sodium (salt) intake to less than 1500 a day.
• Reduce saturated and trans fats to less than 10% of calories.
2. Participate in physical activity:
• Adults older than 20 years of age: At least 150 minutes/week of moderate-intensity activity
• Children 12–19 years of age: At least 60 minutes of moderate intensity activity every day
3. Refrain from smoking and have no exposure to environmental tobacco smoke.
4. Maintain blood pressure:
• Adults older than 20 years of age: <120/80 mm Hg
• Children 8–19 years of age: <90th percentile
5. Maintain total cholesterol
• Adults older than 20 years of age: <200 mg/dL
• Children 6–19 years of age: <70 mg/dL
6. Maintain fasting blood glucose
• Adults older than 20 years of age: <100 mg/dL
• Children 12–19 years of age: <200 mg/dL
7. Achieve and maintain desirable weight
• Adults older than 20 years of age: 25 kg/m
• Children 12–19 years of age: <85th percentile
2
Source: Data from Lloyd-Jones DM, et al.: Defining and setting national goals for cardiovascular health promotion and disease reduction: The American Heart
Association's strategy impact goal through 2020 and beyond, Circulation 121:586–613, 2010
Clinical Management: Secondary Prevention (Screening)
Blood pressure screening- simple and cost-effective screening recommended across the lifespan.
Beginning in infancy, blood pressure screening is recommended at every well-child visit and at least annually.
Among adults, the U.S. Preventive Services Task Force (USPSTF) recommends screening for high blood
pressure in adults ages 18 years or older. For patients who have hypertension, the Joint National Committee on
Prevention, Detection, Evaluation, and Treatment of High Blood Pressure recommends screening every 2
years when blood pressures are less than 120/80 mm Hg. This same committee recommends screening every
year when systolic blood pressures are 120–139 mm Hg or diastolic pressures are 80–90 mm Hg.
Lipid screening- Recommendations for screening of lipids vary between men and women. The USPSTF
strongly recommends screening men ages 35 years or older for lipid disorders and screening men ages 20–35
years if they are at increased risk for coronary artery disease. For women, the USPSTF strongly recommends
screening those ages 45 years or older for lipid disorders if they are at increased risk for coronary heart
disease. Among younger women, ages 20–45 years, the USPSTF recommends lipid screening if they are at
increased risk for coronary heart disease.
Clinical Management: Collaborative InterventionsTreatment strategies depend on underlying condition
The most common strategies include:
 Diet modification and smoking cessation
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

Increased activity (conditioning)
Pharmacotherapy
Pharmacotherapy: Impaired Central Perfusion
 Antihypertensives
 Antiarrhythmics
 Inotropics
 Antianginal agents
 Vasopressors
 Vasodilators
Pharmacotherapy: Impaired Tissue (Local) Perfusion
 Anticoagulants
 Thrombolytics
 Lipid lowering agents
 Vasodilators
 Antiplatelet agents and plantlet inhibitors
Other Collaborative Interventions:
Central Perfusion
Tissue (Local Perfusion)
 Pacemaker insertion
Bypass and/or graft surgery
 Electrical cardioversion
Stent or angioplasty
 Ablation therapy
Endarterectomy
 Intraaortic balloon pump
 Cardiac valve surgery
 Cardiac transplant
Interrelated Concepts
Patients complain of Pain when perfusion is impaired by Clotting, whether it be in the coronary arteries,
causing chest pain, or in the iliac or femoral arteries, causing leg pain when walking. Impaired tissue perfusion
leading to ischemia creates lactic acid that contributes to pain. Because impaired tissue perfusion to the legs
causes pain during walking, peripheral arterial disease reduces the Mobility of patients due to the pain they
experience. Walking is beneficial to exercise the heart and improve central perfusion, an important health
promotion behavior. Nutrition also is an important health promotion consideration for heart and vessel
health—and adequate perfusion in the gastrointestinal system is necessary for the digestion and metabolism of
nutrients. Inflammation occurs when there is tissue damage, which is linked to ischemia. Also, it is the
inflammation that develops after damage to the endothelium of arteries that initiates atherosclerosis. Impaired
perfusion results in impaired Gas Exchange because the blood carries oxygen from alveoli to cells and carbon
dioxide away from cells to alveoli for exhalation. Elimination from the kidneys is an indirect indicator of
cardiac output because blood flows from the heart through the aorta to the renal arteries and through nephrons
that produce urine. Cognition is altered when perfusion to the brain is impaired. The neurons require a
consistent supply of oxygen and glucose to maintain function. Patient Education is central to the prevention
of cardiovascular disease as well as management of cardiovascular disease.
C. Clark Spring 2019 Adapted from Concepts of Nursing 2nd ed, Medical Surgical Nursing 10th ed, Maternal/Child Nursing 5th ed
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Exemplars
Hypertension
A persistent systolic blood pressure of 140 mm Hg or greater, a persistent diastolic blood pressure of
90 mm Hg or greater, or current use of antihypertensive medication is classified as hypertension. Adequate
blood pressure is needed to maintain tissue perfusion in rest and activity. Elevated blood pressure increases
with workload of the heart and damages endothelium contributing to atherosclerosis. Because hypertension
has no symptoms, people should routinely have their blood pressures measured. One in three adults in the
United States has high blood pressure. The overall risk for hypertension increases with age.
Etiolgy: Primary or Essential and Secondary
Clinical Manifestations of Hypertension - hypertension is referred to as the “silent killer” because patients
are frequently asymptomatic until it becomes severe and target organ disease occurs. A patient with severe
hypertension may experience a variety of symptoms secondary to effects on blood vessels in the various
organs and tissues or to the increased workload of the heart.
Complications – the most common complications of hypertension are target organ diseases occurring in the
heart (hypertensive heart disease), brain (cerebrovascular disease), peripheral vasculature (peripheral vessels),
kidneys (nephrosclerosis), and eye (retinal damage)
COMMON COMPLICATIONS OF HYPERTENSION: TARGET ORGAN DISEASES
Organ
Manifestations
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Hypertensive Heart Disease
Coronary Artery Disease (CAD) hypertension is a risk
factor
Left ventricular hypertrophy: sustained high BP increases
the cardiac workload and produces left ventricular
hypertrophy (LVH)
Heart Failure: occurs when heart’s compensatory
adaptations are overwhelmed and heart can no longer
pump – pt complains of shortness of breath on exertion,
paroxysmal nocturnal dyspnea, fatigue
Cerebrovascular Disease
Cerebral atherosclerosis and stroke - hypertension is a
major risk factor
Peripheral Vascular Disease
Atherosclerosis - hypertension speeds up the process of
atherosclerosis in the peripheral blood vessels.
Intermittent claudication (ischemic muscle pain
precipitated by activity and relieved with rest) Risk for
aortic aneurysm, aortic dissection
**see bottom page of notes
Nephrosclerosis – hypertension is one
of the leading causes chronic kidney
disease, especially among African
Americans
Elevated BUN (blood urea nitrogen) and creatinine
Microscopic hematuria
Proteinuria
Microalbuminuria
Damage to the retinal vessels provides an indication of
concurrent vessel damage in the heart, brain and kidneys
Retinal Damage – blood vessels of the
retina can be directly visualized with
an ophthalmoscope
**Peripheral artery disease (PAD) involves thickening of artery walls. This results in a progressive narrowing
of the arteries of the upper and lower extremities. PAD prevalence increases with age. It typically becomes
symptomatic in the sixth to eighth decades of life. In people with diabetes mellitus, PAD occurs earlier. In the
United States, PAD prevalence is higher in those of lower socioeconomic status, women, and African
Americans.
PAD is strongly related to other types of cardiovascular disease (CVD) and their risk factors. Patients with
PAD have a significantly higher risk of mortality (in general), CVD mortality, major coronary events, and
stroke. PAD is a marker of advanced systemic atherosclerosis. Patients with PAD are more likely to have
coronary artery disease (CAD) and/or cerebral artery disease.
Unfortunately, low levels of public awareness of PAD and its risk factors exist in the United States. In general,
PAD remains underdiagnosed and undertreated.
Etiology and Pathophysiology
The leading cause of PAD is atherosclerosis, a gradual thickening of the intima (the innermost layer of the
arterial wall) and media (middle layer of the arterial wall). This results from the deposit of cholesterol and
lipids within the vessel walls and leads to progressive narrowing of the artery. Although the exact cause of
atherosclerosis is unknown, inflammation and endothelial injury play a major role.
Risk factors for PAD are similar, but not identical, to coronary artery disease. Important risk factors for PAD
are tobacco use (most important), chronic kidney disease, diabetes, hypertension, and
hypercholesterolemia. The additive presence of risk factors dramatically increases the risk of PAD, especially
C. Clark Spring 2019 Adapted from Concepts of Nursing 2nd ed, Medical Surgical Nursing 10th ed, Maternal/Child Nursing 5th ed
18
in women and African Americans. Other risk factors include elevated C-reactive protein, family history,
hypertriglyceridemia, increasing age, hyperhomocysteinemia, hyperuricemia, obesity, sedentary lifestyle, and
stress.
Atherosclerosis more commonly affects certain segments of the arterial tree. These include the coronary
carotid and lower extremity arteries. Clinical symptoms occur when vessels are 60% to 75% blocked.
Diagnostic Studies include –
•
H&P examination, including an ophthalmic examination
•
Routine urinalysis – assess for renal involvement
•
Basic metabolic panel – serum glucose, sodium, potassium, chloride, carbon dioxide, BUN,
and creatinine
•
Complete blood count
•
Serum lipid profile •
Serum uric acid – establish baseline, levels often rise with diuretic therapy
•
12-lead ECG
Clinical Manifestations
Generally, the severity of the clinical manifestations depends on the site and extent of the blockage and the
amount of collateral circulation. The classic symptom of lower extremity PAD is intermittent claudication.
Management
• Cardiovascular disease risk factor modification
• Tobacco cessation
• Regular physical exercise
• Achieve or maintain ideal body weight
• Follow Dietary Approaches to Stop Hypertension (DASH) diet
• Tight glucose control in diabetics including A1C monitoring
• Tight BP control
• Treatment of hyperlipidemia and hypertriglyceridemia
• Antiplatelet agent (aspirin or clopidogrel [Plavix])
• Angiotensin-converting enzyme inhibitors
• Treatment of claudication symptoms
• Structured walking or exercise program
• Cilostazol (Pletal) or pentoxifylline
• Nutritional therapy
• Physical/occupational therapy
• Proper foot care
Surgical Therapy
• Percutaneous transluminal balloon angioplasty with or without stent
• Percutaneous transluminal atherectomy
• Percutaneous transluminal cryoplasty
• Peripheral artery bypass surgery
• Patch graft angioplasty, often in conjunction with bypass surgery
• Endarterectomy (for localized stenosis but rarely done as a stand-alone procedure)
• Thrombolytic therapy or mechanical clot extraction therapy (for acute ischemia only)
• Sympathectomy (for pain management only)
• Amputation
C. Clark Spring 2019 Adapted from Concepts of Nursing 2nd ed, Medical Surgical Nursing 10th ed, Maternal/Child Nursing 5th ed
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Comparison of Peripheral Artery and Venous Disease
Characteristic
Peripheral Artery Disease
Venous Disease
Peripheral pulses
Decreased or absent
Present, may be difficult to
palpate with edema
Capillary refill
>3 sec
<3 sec
Ankle-brachial
index
≤0.90
>0.90
Edema
Absent unless leg constantly in
dependent position
Lower leg edema
Hair
Loss of hair on legs, feet, toes
Hair may be present or absent
• Location
Tips of toes, foot, or lateral
malleolus
Near medial malleolus
• Margin
Rounded, smooth, looks “punched
out”
Irregularly shaped
• Drainage
Minimal
Moderate to large amount
• Tissue
Black eschar or pale pink
granulation
Yellow slough or dark red,
“ruddy” granulation
Pain
Intermittent claudication or rest
pain in foot
Ulcer may or may not be painful
Dull ache or heaviness in calf or
thigh
Ulcer often painful
Nails
Thickened; brittle
Normal or thickened
Skin color
Dependent rubor, elevation pallor
Bronze-brown pigmentation
Varicose veins may be visible
Skin texture
Thin, shiny, taut
Skin thick, hardened, and
indurated
Skin temperature
Cool, temperature gradient down
the leg
Warm, no temperature gradient
Dermatitis
Rarely occurs
Frequently occurs
Pruritus
Rarely occurs
Frequently occurs
Ulcer
C. Clark Spring 2019 Adapted from Concepts of Nursing 2nd ed, Medical Surgical Nursing 10th ed, Maternal/Child Nursing 5th ed
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HYPERTENSIVE CRISIS – a term used to indicate either a hypertensive urgency or emergency. This is
determined by the degree of target organ damage and how quickly the BP must be lowered • A hypertensive
emergency develops over hours to days. It is a situation in which a patient’s BP is severely elevated (often
above 220/140 mm Hg) with evidence of acute target organ damage.
o
Hypertensive emergencies can cause encephalopathy, intracranial or subarachnoid hemorrhage, acute
left ventricular failure, MI, renal failure, dissecting aortic aneurysm, and retinopathy
•
Hypertensive urgency develops over days to weeks. This is a situation in which a patient’s BP is
severely elevated (usually above 180/120) but there is no clinical evidence of target organ disease.
The rate of rise of BP is more important than the absolute value in determining the need for emergency
treatment o Patients w/ chronic hypertension can tolerate much higher BP than normotensive people
o
Hypertensive crisis occurs more commonly in pts with a hx of HTN who have failed to comply with
medications or who have been under-medicated
•
HTN Crisis r/t cocaine or crack use is becoming a more frequent problem, other causes include:
o
Amphetamines o PCP
o
LSD
o
Exacerbation of chronic hypertension o Renovascular hypertension o Preeclampsia
o
Head injury
Clinical Manifestations
•
A hypertensive emergency is often manifested as hypertensive encephalopathy, a syndrome in which a
sudden rise in BP is associated with headache, nausea, vomiting, seizures, confusion, stupor, and coma o
retinal exam – hemorrhages, exudates and/or papilledema is found
•
Renal insufficiency ranging from minor impairment to complete renal failure can occur
•
Hypertensive emergencies require hospitalization, IV antihypertensive drugs, and intensive monitoring
o
IV vasodilator drugs for hypertensive emergencies may include: nitroprusside (most effective drug),
nitroglycerin, hydralazine, nicardipine, etc
•
Mean Arterial Pressure (MAP) usually guides therapy
MAP = (SBP + 2 DBP) / 3
MAP reflects perfusion pressure felt by organs
MAP is decreased by no more than 25% within minutes to one hour; if stable, target BP to 160/100 to
110 mg Hg over the next 2 to 6 hours
•
Lowering BP too quickly may cause a stroke, acute MI or renal failure
•
Assess BP and pulse every 2 to 3 minutes during the initial administration of these drugs. Use
monitoring device
•
Frequent neuro checks
Pre-Eclampsia (Perry)
Preeclampsia is a pregnancy-specific condition in which hypertension and proteinuria develop after 20 weeks
of gestation in a woman who previously had neither condition. The signs and symptoms of preeclampsia also
can develop for the first time during the postpartum period.
The 2013 ACOG Task Force on Hypertension in Pregnancy eliminated several criteria that had traditionally
been used to diagnose severe features of preeclampsia. These include proteinuria, oliguria, presence of
intrauterine growth restriction (IUGR), or fetal growth restriction as a requirement for the diagnosis of
preeclampsia. In the absence of proteinuria, preeclampsia may be defined as hypertension along with either
thrombocytopenia, impaired liver function, new-onset renal insufficiency, pulmonary edema, or new-onset
cerebral or visual disturbances
•
C. Clark Spring 2019 Adapted from Concepts of Nursing 2nd ed, Medical Surgical Nursing 10th ed, Maternal/Child Nursing 5th ed
21
Etiology- Preeclampsia is a condition unique to human pregnancy. It occurs in approximately 2% to 7% of
healthy nulliparous pregnant women. The incidence and severity of preeclampsia is substantially higher in
women with multifetal gestation, a history of preeclampsia, chronic hypertension, preexisting diabetes, and
preexisting thrombophilias. Women with limited sperm exposure with the same partner before conception also
have a greater risk for developing preeclampsia. Paternal factors also contribute to the risk for preeclampsia.
Men who have fathered a preeclamptic pregnancy are nearly twice as likely to father another preeclamptic
pregnancy with a different woman, regardless of whether the new partner has a history of a preeclamptic
pregnancy
Risk Factors for Pregnancy -Related Hypertension
• Nulliparity
• Age >40 years
• Pregnancy with assisted reproductive techniques
• Interpregnancy interval >7 years
• Family history of preeclampsia
• Woman born small for gestational age
• Obesity/gestational diabetes mellitus
• Multifetal gestation
• Preeclampsia in previous pregnancy
• Poor outcome in previous pregnancy
• Preexisting medical/genetic conditions
• Chronic hypertension
• Renal disease
• Type 1 (insulin-dependent) diabetes mellitus
• Antiphospholipid antibody syndrome
• Factor V Leiden mutation
Assessment- The frequency of assessments will vary according to the severity of the woman's preeclampsia.
Weigh her on admission and then daily. Check vital signs every 4 hours, and auscultate the chest for moist breath
sounds that suggest pulmonary edema. Assess the location and severity of edema at least every 4 hours. Measure
urine output hourly. An indwelling catheter is often ordered. Check the urine for protein every 4 hours. Apply
an electronic fetal monitor to identify changes in fetal heart rate or variability, which suggest poor placental
perfusion or other problems.
Check brachial, radial, and patellar reflexes for hyperreflexia, which indicates cerebral irritability. Clonus
(rapidly alternating muscle contraction and relaxation) may be present when reflexes are hyperactive. Question
the woman carefully about symptoms she may be experiencing, such as headache, visual disturbances, epigastric
pain, nausea or vomiting, or a sudden increase in edema.
An open-ended question such as “How do you feel?” may not be adequate. Ask targeted questions, such as
“Do you have a headache? Describe it for me.” “Do you have any pain in the abdomen? Show me where it is,
and describe it.” “Have you had an upset stomach or vomiting?” “Do you see spots before your eyes? Flashes
of light? Double vision?” “Is your vision blurred?” “Does light bother your eyes?” “Have you had an increase
in swelling? Where is it located? When did you notice it?” A psychosocial assessment may also be warranted as
well as assessments for magnesium toxicity.
C. Clark Spring 2019 Adapted from Concepts of Nursing 2nd ed, Medical Surgical Nursing 10th ed, Maternal/Child Nursing 5th ed
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Generalized edema is a possible sign identified with preeclampsia, although it may occur in both normal pregnancy or in a
pregnancy complicated by another disorder. A, Facial edema may be subtle. B, Pitting edema of the lower leg.
Grade
Deep Tendon Reflex Response
0
No response
1+
Sluggish or diminished
2+
Active or expected response
3+
More brisk than expected, slightly hyperactive
4+
Brisk, hyperactive, with intermittent or transient
clonus
InterventionsDiet A regular diet without salt or fluid restriction is usually prescribed. Women who also have chronic
hypertension or diabetes should have diet management appropriate to these disorders, whether they are
inpatient or outpatient.
Activity- Activity is usually restricted, although full bed rest is not required. The woman will most likely need
to stop working for the duration of home management, although computer-based work may be possible. Lying
down for at least 1.5 hours per day in a side-lying position maximizes placental blood flow.
Intrapartum Care- The family must be taught to use electronic blood pressure equipment, readily available at
grocery and discount stores and pharmacies. Blood pressure should be checked two to four times per day on
the same arm and with the woman in the same position. The woman often keeps a record of fetal movements,
also called a “kick count”. She should report a significant decrease in movements or absence of movement
during a 4-hour period. The woman should weigh herself each morning, preferably on the same scale and in
similar clothing. A urine dipstick test for protein, using the first voided midstream specimen, should be
performed daily. The physician may request that the woman test at other times also. Fetal surveillance includes
sonography for fetal growth and quantity of amniotic fluid or as part of a biophysical profile (BPP). A
diminishing amount of amniotic fluid suggests placental impairment. Corticosteroids can be given to
accelerate fetal lung maturity if the pregnancy is less than 34 completed weeks. Amniocentesis can be
C. Clark Spring 2019 Adapted from Concepts of Nursing 2nd ed, Medical Surgical Nursing 10th ed, Maternal/Child Nursing 5th ed
23
performed to evaluate fetal lung maturity before labor induction. Referrals to specialists including
perinatology and neonatology may be ordered
Initiating preventive measures.
In the presence of cerebral irritability, seizures may be precipitated by excessive visual or auditory stimuli.
Nurses should reduce external stimuli by:
• Admitting the woman to a room in the quietest section of the unit and keeping the door to the room closed.
The need for intense nursing observation and care exists regardless of the room location.
• Reducing noise when the door must be opened and closed.
• Keeping lights low and noise to a minimum; this may include blocking incoming telephone calls or visitors.
• Grouping nursing assessments and care to allow the woman periods of undisturbed quiet.
• Moving carefully and calmly around the room and avoiding bumping into the bed or startling the woman.
• Collaborating with the woman and her family to restrict visitors.
Monitoring for signs of impending seizures.
Maternal findings that may precede seizures include:
• Hyperreflexia, the presence of clonus, or both
• Increasing signs of cerebral irritability (headache, visual disturbances)
• Epigastric or right upper quadrant pain, nausea, or vomiting
None of these signs is a predictor of imminent seizure in any woman. Nurses must be alert for subtle changes
and be prepared for seizures in all women with preeclampsia.
Preventing seizure-related injury.
Hard side rails should be padded and the bed kept in the lowest position with the wheels locked to prevent trauma
during a seizure.
Oxygen and suction equipment should be assembled and ready to use to remove secretions and to provide
oxygen if it is not already being administered. Check equipment and connections when the woman arrives and
at the beginning of each shift for use readiness. Common emergency supplies include a medium plastic airway,
an Ambu bag with mask, endotracheal tubes in assorted sizes, an ophthalmoscope, a tourniquet, a reflex hammer,
syringes, and needles. Calcium gluconate should be immediately available to reverse the effects of excess
magnesium sulfate.
Protecting the woman and fetus during a seizure.
The nurse's primary responsibilities to protect the woman and the fetus during a generalized seizure are to:
• Remain with the woman and press the emergency bell for assistance.
• Attempt to turn the woman onto her side when the tonic phase begins. A side-lying position permits greater
circulation through the placenta and can help prevent aspiration.
• Note the time and occurrences during the seizure.
• Insert an airway after the seizure, and suction the woman's mouth and nose to clear secretions and prevent
aspiration. Provide oxygen by mask at 8 to 10 L/min to increase oxygenation of the placenta and all maternal
body organs.
• Observe fetal monitor patterns for nonreassuring signs, such as bradycardia, tachycardia, or decreased
variability. These may resolve within a few minutes as maternal oxygenation is restored.
• Notify, or have another nurse notify, the physician that a seizure has occurred. Administer medications and
prepare for additional medical interventions as directed by the physician.
C. Clark Spring 2019 Adapted from Concepts of Nursing 2nd ed, Medical Surgical Nursing 10th ed, Maternal/Child Nursing 5th ed
24
Monitoring for signs of magnesium toxicity.
Magnesium excess depresses the entire central nervous system, including the brainstem, which controls
respiration and cardiac function, and the cerebrum, which controls memory, mental processes, and speech.
Carbon dioxide accumulates if the respiratory rate or depth is inadequate, leading to respiratory acidosis and
further CNS depression, which could end in respiratory arrest.
Signs of magnesium toxicity include:
• Respiratory rate less than 14 breaths per minute (hospital protocols may specify a respiratory rate of less than
12 breaths per minute)
• Maternal pulse oximeter reading lower than 95%
• Absence of DTRs
• Sweating, flushing
• Altered sensorium (confusion, lethargy, slurring of speech, drowsiness, disorientation)
• Hypotension
• A serum magnesium concentration greater than the therapeutic range of 4 to 8 mg/dL
Responding to signs of magnesium toxicity.
Discontinue magnesium and notify the physician for signs of magnesium toxicity. Magnesium is excreted by
the kidneys, and the physician should be notified if the urinary output falls below 30 mL/hr.
Calcium opposes the effects of magnesium at the neuromuscular junction. Magnesium toxicity can be
reversed by slow IV administration of 1 g calcium gluconate (10 mL of 10%) at 1 mL/min.
Box 12.3 ( Perry)
Care of the Woman with Preeclampsia Receiving Magnesium Sulfate
Patient and Family Teaching
• Explain technique, rationale, and reactions to expect
• Route and rate
• Purpose of “piggyback” infusion
• Reasons for use
• Tailor information to woman's readiness to learn.
• Explain that magnesium sulfate is used to prevent disease progression.
• Explain that magnesium sulfate is used to prevent seizures, not to decrease blood pressure.
• Reactions to expect from medication
• Initially the woman appears flushed and feels hot, sedated, and nauseated. She may experience burning at
the IV site, especially during the bolus.
• Sedation continues.
• Monitoring to anticipate
• Maternal: Blood pressure, pulse, respiratory rate, DTRs, level of consciousness, urine output (indwelling
catheter), headache, visual disturbances, epigastric pain
• Fetal: FHR and activity
Administration
• Verify physician's order.
• Position woman in side-lying position.
• Prepare solution and administer with an infusion control device (pump).
• Piggyback solution of 40 g of magnesium sulfate in 1000 mL lactated Ringer's solution with infusion-control
device at the ordered rate: loading dose—initial bolus of 4 g to 6 g over 15 to 30 minutes; maintenance
dose—2 g/hour, according to unit protocol or specific physician's order.
C. Clark Spring 2019 Adapted from Concepts of Nursing 2nd ed, Medical Surgical Nursing 10th ed, Maternal/Child Nursing 5th ed
25
Maternal and Fetal Assessments
• Vital signs and assessments are performed as ordered by the health care provider and per hospital protocol.
• Monitor blood pressure, pulse, respiratory rate every 15 to 30 minutes, depending on woman's condition.
• Monitor FHR and contractions continuously.
• Monitor level of consciousness, intake and output, proteinuria, DTRs, headache, visual disturbances, and
epigastric pain at least hourly.
• Restrict hourly fluid intake to a total of no more than 125 mL/hour; urinary output should be at least 25 to
30 mL/hour.
Reportable Conditions
• Blood pressure: systolic ≥160 mm Hg or diastolic ≥110 mm Hg
• Respiratory rate: <12 breaths/minute
• Urinary output: <25 to 30 mL/hour
• Presence of headache, visual disturbances, decrease in level of consciousness, or epigastric pain
• Increasing severity or loss of DTRs, increasing edema, proteinuria
• Any abnormal laboratory values (magnesium level, platelet count, creatinine clearance, levels of uric acid,
AST, ALT, prothrombin time, partial thromboplastin time, fibrinogen, fibrin split products)
• Any other significant change in maternal or fetal status
Emergency Measures
• Keep emergency drugs and intubation equipment immediately available.
• Keep side rails up.
• Keep lights dimmed, and maintain a quiet environment.
Documentation
• All of the above
ALT, Alanine aminotransferase; AST, aspartate aminotransferase; DTR, deep tendon reflex; FHR, fetal heart
rate; IV, intravenous.
C. Clark Spring 2019 Adapted from Concepts of Nursing 2nd ed, Medical Surgical Nursing 10th ed, Maternal/Child Nursing 5th ed