Cardiac Dysrhythmias Sinus bradycardia (SB) Sinus bradycardia (SB) has the same conduction pathway as sinus rhythm, but the sinoatrial node fires at a rate of <60/min. Symptoms: - SB is classified as symptomatic if, in addition to a heart rate <60/min - Pt experiences such symptoms as dizziness, syncope, chest pain, and hypotension. Treatment: - The client with symptomatic SB is first treated with atropine. o If atropine is ineffective, transcutaneous pacing or an infusion of dopamine or epinephrine is considered. o A permanent pacemaker may be needed. If SB is the result of a medication (eg, beta blocker, digoxin), the drug may need to be held, discontinued, or given in a reduced dosage. Sinus Tachycardia The rate in sinus tachycardia is 101-200/min and regular. The P wave, PR interval (0.12-0.20 sec), and QRS complex (<0.12 sec) will be normal. Sinus tachycardia may be caused by hypovolemia, hypotension, pain, anxiety, stress, or fever. Treatment is based on the underlying cause. Premature ventricular contractions (PVCs) A premature ventricular contraction (PVC) is a contraction originating from an ectopic foci in the ventricle. It appears early in the rhythm and has a wide and distorted shape as compared to the underlying rhythm. A consecutive run of ≥3 PVCs is considered VT. - Occasional premature ventricular contractions (PVCs) are common dysrhythmias that may be precipitated by several factors, including electrolyte imbalances (eg, potassium), stimulants (eg, caffeine, nicotine), and stress. Occasional PVCs typically do not cause hemodynamic instability. The client who is stable one day post extubation can be safely transferred to a telemetry or medical-surgical unit, where the occasional PVCs may be further investigated and treated Ventricular bigeminy is a rhythm in which every other heartbeat is a premature ventricular contraction (PVC). PVCs in the presence of a myocardial infarction (MI) indicate ventricular irritability and increase the risk for a more serious dysrhythmia (eg, ventricular tachycardia, ventricular fibrillation). - Possible causes of ventricular bigeminy include electrolyte imbalances and ischemia. - After assessing the client's vital signs, the nurse should assess potassium and magnesium levels and apical-radial pulse, administer the scheduled amiodarone, and notify the HCP Premature atrial contractions (PACs) A PAC is a contraction starting from an ectopic focus in the atrium (other than the sinus node) and coming sooner than the next sinus beat. The P wave has a different shape than the P wave that originated in the sinus node. Atrial fibrillation (AF) Atrial fibrillation (AF) is a common dysrhythmia after cardiac surgery. Marked by total disorganization of atrial electrical activity that results in the loss of effective atrial contraction. EKG presentation: - P waves are not visible; they are replaced by fibrillatory waves. - The ventricular rate varies, but the rhythm is typically irregular and not evenly spaced out. Complications: - AF results in decreased cardiac output due to a loss of atrial kick and/or a rapid ventricular response. - Clots may form in the atria, putting the client at increased risk for stroke. Treatment: - Treatment includes a decrease in ventricular rate to <100/min and… - adequate anticoagulation to prevent thromboembolic complications. - Medications used for heart rate control include calcium channel blockers (eg, diltiazem, verapamil), beta blockers (eg, metoprolol), and digoxin. o The treatment goals are to reduce the ventricular rate to <100/min and prevent stroke. o Ventricular rate control is the priority. Medications used for rate control include calcium channel blockers (ie, diltiazem), beta blockers (ie, metoprolol), and digoxin. - Medications that convert to and maintain sinus rhythm include amiodarone, flecainide, and sotalol. - Electrical cardioversion may also be considered in hemodynamically unstable clients. Atrial fibrillation is a disorganization of electrical activity in the atria due to multiple ectopic foci. - It results in loss of effective atrial contraction and places the client at risk for embolic stroke due to thrombi formed in the atria from stasis of blood. - During atrial fibrillation, the atrial rate may be increased to 350-600/min. The ventricular response (pulse rate) can vary. The higher the ventricular rate, the more likely the client will have symptoms of decreased cardiac output (ie, hypotension). Treatment: - Ventricular rate control is a priority in clients with atrial fibrillation. o i.e., HR went from 158 to 86 - This client has an irregular heart rate of 140/min and is not currently hypotensive. - However, if the high ventricular response is allowed to continue, it is likely that the client will begin to show s/s of decreased cardiac output such as hypotension. - Therefore, giving the client diltiazem (a calcium channel blocker) is the priority as its purpose is to decrease the ventricular response rate to <100/min. Other medications such as beta blockers (metoprolol) or digoxin may also be used to control the ventricular rate. Note: - Anticoagulants (eg, rivaroxaban [Xarelto], dabigatran [Pradaxa], apixaban [Eliquis], and warfarin) are used for long-term prevention of atrial thrombus and embolic complications. This is not a priority. - The HCP will investigate possible causes of the atrial fibrillation; one of these is an overactive thyroid gland (hyperthyroidism). The thyroid function test would be useful for confirmation, but it is not a priority. Atrial flutter Atrial flutter is associated with underlying heart disease (eg, mitral valve disorders, cardiomyopathy, cor pulmonale). EKG presentation: - Atrial flutter is characterized by recurring, regular, sawtooth-shaped flutter waves after QRS Complete heart block (aka third degree AV block/ 3rd degree AV block) Complete heart block, or 3rd-degree atrioventicular (AV) block, is a form of AV dissociation in which no impulses from the atria are conducted to the ventricles. The atria are stimulated and contract independently of the ventricles. The ventricular rhythm is an escape rhythm. - There is no communication between the atria and ventricles; each is firing independently of the other. EKG presentation: - Complete heart block has more P waves than QRS complexes - PR intervals are variable o P waves are not associated with the QRS complexes on the cardiac monitor Treatment: - The client is typically symptomatic and requires immediate treatment with transcutaneous pacing until a permanent pacemaker can be inserted. Atropine, dopamine, and epinephrine can be used to increase heart rate and blood pressure until temporary pacing is available. 1st-degree AV block (First degree AV block) In 1st-degree AV block, every impulse is conducted to the ventricles, but the time of AV conduction is prolonged. This is evidenced by a prolonged PR interval of >0.20 second. Mobitz II – Second-degree atrioventricular block, type 2 Mobitz II (type II second-degree atrioventricular block) is often associated with conduction system disease or drug toxicity (eg, beta blockers, calcium channel blockers). EKG presentation: - Second-degree atrioventricular block, type 2 has more P waves than QRS complexes. - The PR interval is constant on conducted beats; it reflects an intermittent block of atrial impulses. Supraventricular tachycardia (SVT) Supraventricular tachycardia is a regular, narrow QRS complex tachycardia with a rate of around 150-220/min. The best treatment is vagal maneuvers and adenosine IV push. - Stimulants (eg, nicotine, caffeine, cocaine) and organic heart disease can cause SVT. EKG: - The rhythm is usually regular. P waves are often hidden. If visible, they may have an abnormal shape and the PR interval may be shortened. The QRS complex is usually narrow (<0.12 second). Nursing interventions: - The first interventions is to have pt get into a vagal maneuver. o The act of "bearing down" as if having a bowel movement (Valsalva) is an example of these maneuvers and may need to be attempted more than once. o Vagal maneuvers work by increasing intra-thoracic pressure and stimulating the vagus nerve, which supplies parasympathetic nerve fibers to the heart, resulting in slowed electrical conduction through the atrioventricular node. - Adenosine is the drug of choice to treat SVT and has a 5 – 6-second half-life (the time it takes for the drug to be reduced to half of its original concentration). o Placing the IV line as close as possible, not distal, to the heart is essential for the drug to have full effect. Adenosine is given rapidly over 1-2 seconds and then followed by a rapid 20-mL normal saline flush. o Transient asystole is common, and clients often experience flushing and dizziness. - Cardioversion (not defibrillation) is used with this type of arrhythmia when it is refractory to medication. Cardioversion delivers a synchronized electrical current to the heart. This works by stopping the electrical activity to the heart and briefly allowing a normal heartbeat to return. This client is experiencing paroxysmal supraventricular tachycardia (PSVT). In PSVT, the heart rate can be 150-220/min. With prolonged episodes, the client may experience evidence of reduced cardiac output such as hypotension, palpitations, dyspnea, and angina. Treatment - Vagal maneuvers such as Valsalva, coughing, and carotid massage. - Adenosine is the drug of choice for PSVT treatment. Due to its very short half-life, adenosine is administered rapidly via IVP over 1-2 seconds and followed by a 20-mL saline bolus. o An increased dose may be given twice if previous administration is ineffective. o Beta blockers, calcium channel blockers, and amiodarone can also be considered as alternatives. - If vagal maneuvers and drug therapy are unsuccessful, synchronized cardioversion may be used. Torsades de pointes Hypomagnesemia (normal range 1.5-2.5) causes a prolonged QT interval that increases the client's susceptibility to ventricular tachycardia. - Torsades de pointes is a type of polymorphic ventricular tachycardia coupled with a prolonged QT interval; it is a lethal cardiac arrhythmia that leads to decreased cardiac output and can develop quickly into ventricular fibrillation. - The American Heart Association recommends treatment with IV magnesium sulfate. Educational objective: In a client with hypomagnesemia, it is important to assess the QT interval. The client is most at risk for torsades de pointes, a serious complication that can develop quickly into ventricular fibrillation (lethal arrhythmia). Torsades de pointes (ie, "twisting of the points") is a polymorphic ventricular tachycardia characterized by QRS complexes that change size and shape in a characteristic twisting pattern. Ventricular fibrillation VF is characterized on the ECG by irregular waveforms of varying shapes and amplitudes. This represents the firing of multiple ectopic foci originating in the ventricle. Mechanically, the ventricle is quivering with no effective contraction or cardiac output. VF is considered a lethal dysrhythmia. It results in an unresponsive, pulseless, apneic state. If not treated rapidly, the client will not recover. The client in ventricular fibrillation will not have a pulse. - VF commonly occurs in acute myocardial infarction and myocardial ischemia and in chronic heart diseases such as heart failure and cardiac myopathy. It may occur in cardiac pacing or catheterization procedures due to catheter stimulation of the ventricle. - Treatment consists of rapid initiation of CPR, defibrillation, and the use of drug therapy (eg, epinephrine, vasopressin, amiodarone). o SYNCHONIZATION BUTTON IS TURNED OFF FOR VFIB o Synchronized cardioversion delivers a shock on the R wave of the QRS complex and would not be appropriate for a client in Vfib (no identifiable QRS complexes). Rhythms that are ideal for synchronized cardioversion are supraventricular tachycardia, ventricular tachycardia with a pulse, and atrial fibrillation with rapid ventricular response. If the defibrillator is not synchronized with the R wave in a client with a pulse, the shock may be delivered on the T wave and can cause a lethal arrhythmia (eg, Vfib) EKG: - Irregular, chaotic rhythm - Coase waveforms of varying shapes & amplitudes Ventricular tachycardia (VT) Ventricular tachycardia (VT) is a potentially life-threatening dysrhythmia characterized by a ventricular rate of 100-250/min. - Pulseless VT is treated with cardiopulmonary resuscitation (CPR) and defibrillation. - Clients in ventricular tachycardia (VT) can be pulseless or have a pulse. o Treatment is based on this important initial assessment EKG: - The rhythm is often regular, but it can be irregular. - QRS complexes are wider than 0.12 seconds - P wave is usually buried in the QRS complex, making a PR interval unmeasurable. Treatment: - Cardioversion (cardioversions are used in clients with tachydysrhythmias) - The unstable client in VT with a pulse is treated with synchronized cardioversion. The stable client in VT with a pulse is treated with antiarrhythmic medications (eg, amiodarone, procainamide, sotalol). Asystole Asystole is the total absence of ventricular electrical activity. The client in asystole has a total absence of ventricular electrical activity and is pulseless, apneic, and unresponsive. The nurse should first assess the client to verify the monitor reading. The nurse would next call for help and initiate cardiopulmonary resuscitation and oxygenated ventilation Advanced cardiovascular life-support measures for asystole include epinephrine IV every 3-5 minutes, possible placement of an advanced airway (ie, intubation), and treatment of reversible causes (eg, hypovolemia) REMEMBER: Defibrillation is not indicated when electrical activity is absent (asystole) or when pulseless electrical activity is present. Defibrillation is used for treating ventricular fibrillation and pulseless ventricular tachycardia. - DO NOT DEFIBRILATE A PT W/ ASYSTOLE Pacemakers & failure to capture Clients with an implanted permanent pacemaker should be assessed for both electrical capture of heart rhythm and mechanical capture of heart rate. Electrical capture: - In atrial pacing, pacer spikes precede P waves - In ventricular pacing, pacer spikes precede QRS complexes - Pacing spikes should be immediately followed by their appropriate electrical waveform, indicating electrical capture. - Remember: When the client arrives in the post-anesthesia care unit after pacemaker placement, the nurse should attach the cardiac monitor to assess the function of the pacemaker (cardiac patients heart function is priority over VS) Mechanical capture: - Ensures that the electrical activity of the heart corresponds to a pulsatile rhythm. - The best method for checking for a pulsatile rhythm is to assess a central pulse (eg, auscultation of apical, palpation of femoral). - This rate should be compared to the electrical rate displayed on the cardiac monitor to assess for pulse deficit. If the atrioventricular (dual-chambered) pacemaker is working properly, pacer spikes should be visible prior to the P waves and QRS complexes (electrical capture). - If the pacemaker is not working properly (eg, failure to capture, failure to sense), the HCP should be contacted immediately Signs and symptoms of a failing pacemaker include failure to capture (pacer spikes without associated QRS complexes) with bradycardia and hypotension. - The nurse should use a transcutaneous pacemaker to stabilize the client until the internal pacemaker can be repaired or replaced. Cardioversion Electrical cardioversion is a treatment modality considered for AF that has been unresponsive to drug therapy. - AF (rapid, irregular atrial contractions) results in ineffective atrial kick and predisposes to thrombus formation (blood clots) in the left atrium. o If a client is in AF for more than 48 hours, anticoagulation therapy is needed for 3-4 weeks before cardioversion. o Anticoagulation therapy is necessary as cardioversion may dislodge an atrial thrombus, putting the client at risk for a stroke or other sequelae of thromboembolism. o If 4 weeks of anticoagulation is not an option, TEE must be performed prior to cardioversion. REMEMBER: The synchronizer switch must be turned on when cardioversion is planned. - The synchronize circuit in the defibrillator is programmed to deliver a shock on the R wave of the QRS complex on the electrocardiogram (ECG). This allows the unit to sense this client's rhythm and time the shock to avoid having it occur during the T wave. o A shock delivered during the T wave could cause this client to go into a more lethal rhythm (eg, ventricular tachycardia, ventricular fibrillation). o However, if this client becomes pulseless, the synchronize function should be turned off and the nurse should proceed with defibrillation. - Synchronized cardioversion is indicated for ventricular tachycardia with a pulse, supraventricular tachycardia, and atrial fibrillation with a rapid ventricular response. Holter monitor A Holter monitor continuously records a client's electrocardiogram rhythm for 24-48 hours. Electrodes are placed on the client's chest and a portable recording unit is kept with the client. At the end of the prescribed period, the client returns the unit to the health care provider's (HCP) office. The data can then be recalled, printed, and analyzed for any abnormalities. Client instructions include the following: 1. Keep a diary of activities and any symptoms experienced while wearing the monitor so that these may later be correlated with any recorded rhythm disturbances 2. Do not bathe or shower during the test period 3. Engage in normal activities to simulate conditions that may produce symptoms that the monitor can record Implantable cardioverter defibrillator (ICD) An implantable cardioverter defibrillator (ICD) can sense and defibrillate life-threatening dysrhythmias. It also includes pacemaker capabilities such as overdrive pacing for rapid heart rhythms or back-up pacing for bradycardias that may occur after defibrillation. The ICD consists of a lead system placed into the endocardium via the subclavian vein. The pulse generator is implanted subcutaneously over the pectoral muscle. Postoperative care and teaching are similar to those for pacemaker implantation: - Clients are instructed to refrain from lifting the affected arm above the shoulder (until approved by the health care provider) to prevent dislodgement of the lead wire on the endocardium - Firing of the ICD may be painful. Clients have described the feeling as a blow to the chest. - Driving may be approved by the HCP after healing has occurred. Long-term decisions are based on the ongoing presence of dysrhythmias, frequency of ICD firings, and state laws regarding drivers with ICDs. - Travel is not restricted. The ICD may set off the metal detector in security areas. A hand-held wand may be used but should not be held directly over the ICD. The client should carry the ICD identification card and a list of medications while traveling. Hypertension Hypertension is referred to as the "silent killer" as most clients are asymptomatic. Untreated chronic hypertension can result in damage of various organs and tissues and increases the risk for renal failure, coronary artery disease, stroke, and heart failure. Appropriate client screening based on risk factors is key to preventing complications. This client has both nonmodifiable (eg, African American ethnicity) and modifiable (eg, diabetes mellitus type 2, chronic stress, smoking) risk factors. - To prevent future comorbidities, the nurse should educate the client on smoking cessation, appropriate diabetes management, and therapeutic strategies for stress management at work. - Clients should be screened for potential hyperlipidemia. An LDL laboratory value of 94 mg/dL (2.43 mmol/L) is within recommended parameters (<100 mg/dL [<2.6 mmol/L]). DASH Diet The Dietary Approaches to Stop Hypertension (DASH) diet is often suggested to clients with hypertension due to its ability to reduce blood pressure. The diet focuses on elimination or reduction of foods and beverages high in sodium, sugar, cholesterol, and trans or saturated fats, which all contribute to increased blood pressure. The DASH diet focuses on: Including fresh fruits and vegetables, and whole grains in the daily diet Choosing fat-free or low-fat dairy products o Limiting milk intake is unnecessary; however, the nurse may need to educate the client about choosing low-fat or skim milk over whole milk. Choosing meats lower in cholesterol (eg, fish, poultry) and alternate protein sources (eg, legumes) instead of red meats Limiting intake of sweets, foods high in sodium (eg, potato chips, frozen meals, canned foods), and sugary beverages to the occasional treat Educational objective: The Dietary Approaches to Stop Hypertension (DASH) diet is often recommended to reduce blood pressure in clients with hypertension. The client is taught to limit intake of sugar, sodium, cholesterol, and trans or saturated fats, and instead choose healthier options (eg, fresh fruit and vegetables, lowfat dairy products). OTC medication and HTN Clients with hypertension should be instructed not to take potentially high-risk over-the-counter (OTC) medications such as high-sodium antacids, appetite suppressants, and cold and sinus preparations. It is appropriate to ask a client with hypertension about taking OTC cold medications as many cold and sinus medications contain phenylephrine or pseudoephedrine. - These sympathomimetic decongestants activate alpha-1 adrenergic receptors, producing vasoconstriction. - The resulting decreased nasal blood flow relieves nasal congestion. - These agents have both oral and topical forms. With systemic absorption, these agents can cause dangerous hypertensive crisis. Hypertensive crisis Hypertensive crisis is a life-threatening medical emergency characterized by severely elevated blood pressure (systolic ≥180 mm Hg and/or diastolic ≥120 mm Hg). - The client may have symptoms of hypertensive encephalopathy o including severe headache, confusion, nausea/vomiting, and seizure. - Hypertensive crisis poses a high risk for end-organ damage (eg, hemorrhagic stroke, kidney injury, heart failure, papilledema). - The nurse should assess for vision changes (eg, blurred vision, blind spot) or papilledema, as these are signs of progressing hypertensive crisis; however, assessment of LOC is the priority. The nurse should prioritize neurological assessment (eg, level of consciousness [LOC], cranial nerves) as decreased LOC may indicate onset of hemorrhagic stroke, which requires immediate surgical intervention. Treatment - IV nitrates or antihypertensives (eg, nitroprusside, labetalol, nicardipine) - Continuous monitoring (eg, blood pressure, telemetry, urine output) in a critical care setting. Educational objective: Hypertensive crisis is a life-threatening elevation in blood pressure (systolic ≥180 mm Hg and/or diastolic ≥120 mm Hg) that may cause end-organ damage (eg, stroke, kidney injury, heart failure, papilledema). The client's level of consciousness should be monitored, as a decreased level may indicate onset of hemorrhagic stroke. Hypertensive crisis is a life-threatening emergency due to the possibility of severe organ damage. - If not treated promptly, complications such as intracranial hemorrhage, heart failure, myocardial infarction (MI), renal failure, aortic dissection, or retinopathy may occur. Emergency treatment includes IV vasodilators such as nitroprusside sodium. - It is important to lower the blood pressure slowly, as too rapid a drop may cause decreased perfusion to the brain, heart, and kidneys. This may result in stroke, renal failure, or MI. o The main adverse effect is symptomatic hypotension (pts may report lightheadedness, be cold & clammy are likely due to hypotension; therefore it is necessary to monitoring blood pressure when admin nitroprusside!!! - The initial goal is usually to decrease the MAP by no more than 25% or to maintain MAP at 110-115 mm Hg. - The pressure can then be lowered further over a period of 24 hours. MAP is calculated by adding the systolic blood pressure (SBP) and double the diastolic blood pressure (DBP), and then dividing the resulting value by 3. o MAP = (2 x DBP + SBP) / 3 MAP (Normal 70-105) The MAP refers to the average pressure within the arterial system felt by the vital organs. A normal MAP is between 70-105 mm Hg. If the MAP falls below <60 mm Hg, vital organs may be underperfused and can become ischemic. MAP can be calculated using the formula below: Mean Arterial Pressure = Systolic Blood Pressure + (Diastolic Blood Pressure × 2) 3 A normal MAP is 70-105 mm Hg. The client with the BP of 106/42 mm Hg has a MAP of 63 mm Hg, in the abnormal range. The nurse should report this to the HCP and monitor the client closely. Educational objective: Mean Arterial Pressure = Systolic Blood Pressure + (Diastolic Blood Pressure × 2) 3 A normal MAP is 70-105 mm Hg. A MAP <60 mm Hg will not allow for adequate perfusion of vital organs. Hypertensive encephalopathy (HE) Hypertensive encephalopathy (HE) is a medical emergency caused by a sudden elevation in blood pressure (eg, hypertensive crisis) creating cerebral edema and increased intracranial pressure (ICP). Triggers of HE include an acute exacerbation of pre-existing hypertension, drug use, MAOItyramine interaction, head injury, and pheochromocytoma. Symptoms: - Severe headache Visual impairment Anxiety Confusion Observed epistaxis Seizures, or coma HE may precipitate life-threatening complications such as myocardial infarction, hemorrhagic stroke, and acute kidney injury. The client with a history of chronic hypertension and active signs of increased ICP (eg, anxiety, epistaxis) requires immediate assessment and treatment NOTE: The client with a unilateral, pulsating headache has symptoms consistent with migraine. Supportive care for this client includes pain and environmental management but is not a priority over a client with HE. Atherosclerosis and Vasculature Deep Vein Thrombosis (DVT) Symptoms: - Calf that feels warm to the touch - Erythema - Unilateral leg edema - Complains of unilateral leg pain o Especially after prolonged immobilization (eg, air travel, surgery/procedure) or those with obesity, pregnancy, or other hypercoagulable states (eg, cancer). Low-grade fever - AGAIN: - unilateral edema calf pain or tenderness to touch warmth and erythema low-grade temperature NOTE: blue cyanotic toes and dry/shiny/hairless skin is associated with arterial occlusion NOT DVT Risk factors: - Immobile (i.e., hospitalization, long plane ride) - Age >60 Nursing interventions: - Thorough neurovascular assessment of the extremities o Presence and quality of dorsalis pedis (DP) and posterior tibial (PT) pulses, temperature of the extremities, capillary refill, and circumference measurements of both calves and thighs. o Both extremities should be assessed for comparison. - Clients with active DVT are at risk for developing a pulmonary embolism (PE). o In the case of active DVT, the clot may become dislodged by massage or use of sequential compression devices on the affected extremity. o The nurse would intervene immediately if a client was observed massaging the site, as this may actually trigger an embolism. - The client should not be kept immobilized out of a fear of dislodging the clot. Immobility creates venous stasis and risks clot formation. o Ambulation is strongly encouraged after a full medical evaluation finds no risk of impending embolization. Bedrest with limb elevation may be prescribed initially for clients with severe pain and edema. Teaching points include the following: Drink plenty of fluids and limit caffeine and alcohol intake to avoid dehydration, which predisposes to blood hypercoagulability and venous thromboembolism Elevate legs on a footstool when sitting and dorsiflex the feet often to reduce venous hypertension, edema, and promote venous return Resume walking/swimming exercise program as soon as possible after getting home to promote venous return through contraction of calf and thigh muscles Change position frequently to promote venous return, circulation, and prevent venous stasis. Stop smoking to prevent endothelial damage and vasoconstriction as this promotes clotting. Avoid restrictive clothing (eg, Spanx, tight jeans) that interferes with circulation and promotes clotting. Inferior vena cava filter An inferior vena cava filter is a device that is inserted percutaneously, usually via the femoral vein. - The filter traps blood clots from lower extremity vessels (eg, embolus from deep venous thrombosis) and prevents them from migrating to the lungs and causing a pulmonary embolism (PE). It is prescribed when clients have recurrent emboli or anticoagulation is contraindicated Nursing interventions: - Clients should be questioned about and report any metallic implants (eg, vascular filters/coils) to the health care team prior to radiologic imaging, specifically MRI - Physical activity should be promoted, and clients should avoid crossing their legs to promote venous return from the legs - Leg pain, numbness, or swelling may indicate impaired neurovascular status distal to the insertion site and should be reported immediately - Symptoms of PE (eg, chest pain, shortness of breath) and vascular injury (bleeding causing back pain) are not expected findings after the procedure and should be reported immediately. Educational objective: An inferior vena cava filter traps thrombi migrating from the lower extremities to the lungs. Discharge teaching includes promotion of physical exercise, reporting of symptoms of pulmonary embolism (eg, chest pain, shortness of breath) and impaired lower extremity circulation (eg, pain, numbness), and notification of the health care team prior to MRI. Peripheral artery disease and Coronary artery disease Peripheral artery disease Peripheral arterial disease (PAD) is a chronic, atherosclerotic disease caused by buildup of plaque within the arteries. PAD commonly affects the lower extremities and can lead to tissue necrosis (gangrene). - Sx are d/t hardening of the arterial walls, which constricts blood flow and impairs transportation of nutrients to tissues. Symptoms: - Diminished pulses o First check for adequacy of blood flow to lower extremities by palpating for the presence of posterior tibial and dorsalis pedis pulses and their quality. o Poor circulation to the extremities can place the client at increased risk for development of arterial ulcers and infection. - Nonhealing ulcers on a toe - Shiny, cold, dry, hairless extremities - Ulcers and gangrene occur usually at the most distal part of the body - Intermittent claudication o Ischemic muscle pain d/t impaired circulation to the client's extremities; leg pain with movement d/t constricted arteries but stops with rest o Cramping pain in the muscles of the legs during exercise o However, with critical arterial narrowing, pain can be present at rest and is typically described as "burning pain" that is worsened by elevating the legs and improved when the legs are dependent o Home management instructions for PAD include: Lower the extremities below the heart when sitting and lying down - improves arterial blood flow Engage in moderate exercise (eg, 30- to 45-minute walk, twice daily) - promotes collateral circulation and distal tissue perfusion o Clients should be advised that a progressive walking program will aid the development of collateral circulation. Perform daily skin care, including application of lotion - prevents skin breakdown from dry skin Maintain mild warmth (eg, lightweight blankets, socks) - improves blood flow and circulation (BUT DON’T use heating pads bc they’re too hot) Stop smoking - prevents vessel spasm and constriction Avoid tight clothing and stress - prevents vasoconstriction Take prescribed medications (eg, vasodilators, antiplatelets) - increases blood flow and prevents blood clot development AVOID heating pads in pts with altered perfusion or sensation due to the increased risk for burns. The impaired perfusion from severe atherosclerosis results in skin atrophy, poor wound healing, and widespread hair follicle death (hair loss). - Failure of pinprick testing indicates peripheral neuropathy. - Loss of hair on the lower extremities indicates poor perfusion. The combination of these suggests peripheral neuropathy and peripheral arterial disease, likely from undiagnosed diabetes mellitus and atherosclerosis. Nearly a third of clients diagnosed with diabetes mellitus will already have complications from years of uncontrolled hyperglycemia. Diabetes mellitus dramatically accelerates the buildup of plaque on the arterial walls (atherosclerosis) when blood glucose levels are uncontrolled. Note: - Asymptomatic bradycardia in a healthy young adult is rarely pathological. Professional-level athletes will commonly develop athletic heart syndrome; increased efficiency results in resting sinus bradycardia (40-60/min). - The Joint National Committee guidelines recommend against treating blood pressure readings <150/90 mm Hg in clients age >60. Additional teaching for the client with PAD includes the following: Smoking cessation Regular exercise Achieving or maintaining ideal body weight Low-sodium diet Tight glucose control in diabetics Tight blood pressure control Use of lipid management medications Use of antiplatelet medications Proper limb and foot care Chronic venous insufficiency (CVI) Chronic venous insufficiency (CVI) occurs when the valves in the veins of the lower extremities consistently fail to keep venous blood moving forward, which causes chronic increased venous pressure. The increased pressure pushes fluid out of the vascular space and into the surrounding tissues, where tissue enzymes break down red blood cells. Symptoms: - Leg edema - Chronic inflammatory changes, - At risk for the development of venous leg ulcers. - Brownish skin discoloration (d/t destruction of red blood cells releases hemosiderin (a reddish-brown protein that stores iron) - Leathery - Breakdown and ulcerations (eg, venous leg ulcers), commonly on the inside of the ankle. Nursing interventions: - The client is taught to avoid any trauma to the limbs. The nurse should intervene when the HH aide is cutting the client's toenails as the toenails should be cut by a trained professional or podiatrist. - Eczema or stasis dermatitis is often present and itching is a common problem for this client population. Daily moisturizing helps to decrease the itching and cracking of the skin. - Compression stockings are a mainstay of therapy for the client with CVI. - Elevate the legs to promote venous return (but for PAD keep them down to promote arterial circulation) Stable Angina And Acute Coronary Syndrome Acute coronary syndrome (ACS) is a broad term that encompasses a range of cardiac events, including unstable angina and myocardial infarction (with or without ST-segment elevation). Clients with ACS require immediate treatment to prevent continued ischemia of cardiac muscle. - When teaching a client about risk factor modification related to CAD development, the nurse should focus on modifiable risk factors such as control of hypertension, diabetes, elevated serum lipid levels, cessation of tobacco use, reduction of BMI if client is overweight, increase in physical activity, and management of psychological state. Myocardial infarction A large anterior wall MI can affect the pumping ability of the left ventricle, putting the client at risk for developing heart failure and cardiogenic shock. - The new development of pulmonary congestion on x-ray, auscultation of a new S3 heart sound, crackles on auscultation of breath sounds, or jugular venous distension can signal heart failure and should be reported immediately to the HCP. Diagnosis - Serum cardiac markers are proteins released into the bloodstream from necrotic heart tissue after a myocardial infarction (MI). - Troponin is a highly specific cardiac marker for the detection of MI. o It has greater sensitivity and specificity for myocardial injury than creatine kinase (CK) MB. - Serum levels of troponin increase 4–6 hours after the onset of MI, peak at 10–24 hours, and return to baseline after 10–14 days. - A troponin value of 0.7 ng/mL (0.7 mcg/L) indicates cardiac muscle damage and should be the priority and immediate focus of the nurse. Normal values: troponin I <0.5; troponin T <0.1 Female, elderly, and diabetic clients tend to present with atypical symptoms of myocardial infarction (MI), such as diaphoresis, nausea, fatigue, or dyspnea, but may not always experience chest discomfort. - Pain may be absent or atypical or may radiate to unusual locations (eg, jaw, back). Some clients may report pain as "indigestion" (epigastric burning or gas). The nurse should obtain a 12-lead electrocardiogram (ECG) on any client with atypical MI symptoms to assess for evidence of ischemia, injury, or infarction (before assessing glucose) ST-segment elevation MI is life-threatening and requires rapid coronary intervention. Cardiac catheterization Cardiac catheterization helps assess and diagnose coronary artery disease (eg, coronary artery patency, atherosclerosis). - A catheter is advanced to the heart through a vein (eg, femoral, antecubital) for right-sided heart catheterization or an artery (eg, brachial, femoral) for left-sided heart catheterization. - After the procedure, a pressure dressing is applied and the client placed supine with the affected extremity flat for 2-6 hours to promote complete hemostasis. Nursing interventions: - The nurse monitors vital signs, extremity integrity (eg, pulses, sensation, capillary refill), and dressings for indications of bleeding according to institution policy. - If bleeding occurs, the nurse applies direct manual pressure to the vessel puncture site (ie, about 2.5 cm [1"] above the skin puncture site) to achieve hemostasis and keep the client hemodynamically stable. The HCP should be notified, as the client may require further surgical intervention. - The distal pulse is assessed routinely after cardiac catheterization to determine adequate blood flow to the extremities. However, the priority is to control active bleeding through manual pressure. - A new pressure dressing may be applied after the bleeding has stopped and hemostasis has been achieved per HCP prescription. Educational objective: If bleeding occurs after cardiac catheterization, the nurse first applies direct manual pressure to control the bleeding. Cardiac catheterization involves injection of iodine contrast using a catheter to examine for obstructed coronary arteries. Complications include: Allergic reaction: Clients with a previous allergic reaction to IV contrast may require premedication (eg, corticosteroids, antihistamines) or another contrast medium. Clients with shellfish allergies were once believed to be at higher risk, but this has been disproved. Contrast nephropathy: Iodine-containing contrast can cause kidney injury, although this risk can be reduced with adequate hydration. However, clients with renal impairment (eg, serum creatinine >1.3 mg/dL [115 µmol/L]) should not receive IV contrast unless absolutely necessary (Option 4). Lactic acidosis: Metformin (Glucophage) with IV iodine contrast increases the risk for lactic acidosis. Metformin is usually discontinued 24-48 hours before exposure and restarted after 48 hours, when stable renal function is confirmed. (Option 1) C-reactive protein, produced during acute inflammation, may reflect an elevated risk for coronary artery disease. However, it does not indicate an acute event and is not a safety concern for this procedure. (Option 3) First-degree atrioventricular block (ie, PR interval >0.20 second) may precede more serious conditions. However, clients are usually asymptomatic and do not require treatment except for stopping the causative medication (eg, beta blockers, digoxin). This would not prevent the test from proceeding. Educational objective: Cardiac catheterization uses IV contrast to assess for artery obstruction. Complications include allergic reactions, lactic acidosis, and kidney injury. Contrast is avoided in clients who had a previous allergic reaction to contrast agents, took metformin in the last 24 hours, or have renal impairment. Post-procedure care of a client who has undergone heart catheterization should focus on evaluating hemodynamics - blood pressure, heart rate, strength of the distal pulses, color, and temperature of extremities. The client should be also assessed several times per hour for active bleeding, hematoma, or pseudoaneurysm formation at the incision. The first hour after cardiac catheterization requires assessment every 15 minutes. - Any report of back or flank pain should be assessed for possible retroperitoneal bleeding as back pain, tachycardia, and hypotension may be the only indication of internal bleeding. More than a liter of blood can pool behind the peritoneum in the pelvis undetected, and it may take up to 12 hours before a significant drop in hematocrit can be measured. Internal bleeding after cardiac catheterization is particularly dangerous due to frequent use of anticoagulant prescriptions in these clients. Coronary arteriogram (angiogram) A coronary arteriogram (angiogram) is an invasive diagnostic study of the coronary arteries, heart chambers, and function of the heart. It requires that the client have an intravenous (IV) line started for sedating medications; the femoral or radial artery will be accessed during the procedure. The client should be instructed: 1. Not to eat or drink anything for 6-12 hours prior to the procedure (depending on the particular health care provider performing the procedure) 2. The client may feel warm or flushed while the contrast dye is being injected 3. Hemostasis must be obtained in the artery that was cannulated for the procedure. Most commonly, this is the femoral artery. - Compression is applied to the puncture site and the client may have to lie flat for several hours to ensure hemostasis 4. If the procedure is just a diagnostic study, the client often goes home the same day. Hospitalization for 1-3 days is only required if angioplasty or stent placement is performed. 5. General anesthesia is not used during coronary angiography. Sedating medications are given during the procedure. Educational objective: Coronary arteriogram requires that the client have nothing by mouth for 6-12 hours prior to the procedure and have an IV line started for sedation medications. The client may feel warm and flushed while the dye is being injected. The client is required to lie flat for several hours following the procedure to achieve hemostasis at the access site (femoral access). The client typically goes home the same day unless other interventions have been performed. Coronary artery bypass grafting (CABG) Discharge instructions for a client recovering from a CABG should include the following guidelines: 1. Explain the need for modification of cardiac risk factors, including smoking cessation, weight reduction, maintaining a healthy diet, and increasing activity levels through exercise. 2. Encourage a daily shower as a bath could introduce microorganisms into the surgical incision sites. o Surgical incisions are washed gently with mild soap and water and patted dry. o The incisions should not be soaked or have lotions or creams applied as this could introduce pathogens 3. Explain that light house work may begin in 2 weeks, but there is to be no lifting of any object weighing >5 lb (2.26 kg) without approval of the HCP o Lifting, carrying, and pushing heavy objects are isometric activities. Heart rate and blood pressure increase rapidly during isometric activities, which should be limited until approved by the HCP, generally about 6 weeks after discharge. Guide the client to gradually resume activity and possibly participate in a cardiac rehabilitation program. 4. Clarify no driving for 4-6 weeks or until the HCP approves. 5. If the client is able to walk 1 block or climb 2 flights of stairs without symptoms (eg, chest pain, shortness of breath, fatigue), it is usually safe to resume sexual activity 6. Notify the HCP if the following symptoms occur: o Chest pain or shortness of breath that does not subside with rest o Fever >101 F (38.3 C) o Redness, drainage, or swelling at the incision sites Educational objective: Discharge teaching for a client recovering from a CABG should include instructions related to medications, activity level, driving, sexual activity, and symptoms to report to the HCP. Incisions may take 4-6 weeks to heal. The nurse should instruct clients on how to care for their incisions; these instructions are as follows: Wash incisions daily with soap and water in the shower. Gently pat dry Itching, tingling, and numbness around the incisions may be present for several weeks due to damage to the local nerves Tub baths should be avoided due to risk of introducing infection Do not apply powders or lotions on incisions as these trap the bacteria at the incision Report any redness, swelling, and increase in drainage or if the incision has opened Wear a supportive elastic hose on the legs. Elevate legs when sitting to decrease swelling Clients who have undergone surgery (eg, coronary artery bypass graft) may experience some postoperative cognitive dysfunction (POCD). - This may include memory impairment and problems with concentration, language comprehension, and social integration. - Some clients may cry easily or become teary. - The risk for POCD increases with advanced age and in clients with preexisting cognitive deficits, longer operative times, intraoperative complications, and postsurgical infections. POCD can occur days to weeks following surgery. - Most symptoms typically resolve after complete healing has occurred. In some cases, this condition can become a permanent disorder Minimally invasive direct coronary artery bypass (MIDCAB) graft MIDCAB does not involve a sternotomy incision or placement on cardiopulmonary bypass. - Several small incisions are made between the ribs. - A thoracotomy scope or robot is used to dissect the internal mammary artery (IMA) that is used as a bypass graft. Radial artery or saphenous veins may be used if the IMA is not available. Recovery time is typically shorter with these procedures and clients are able to resume activities sooner than with traditional open chest coronary artery bypass graft surgery. - However, clients may report higher levels of pain with MIDCAB due to the thoracotomy incisions made between the ribs. Educational objective: The nurse should teach the client that incisional pain from thoracotomy incisions between the ribs may be very painful after MIDCAB surgery. The nurse should encourage the client to take pain medication before the pain is too intense. The client should also be instructed to cough, breathe deeply while splinting the chest with a pillow, and use the incentive spirometer routinely to reduce the incidence of postop complications. Carotid endarterectomy A carotid endarterectomy is a surgical procedure that removes atherosclerotic plaque from the carotid artery. Clients with carotid artery disease are at increased risk for transient ischemic attack and stroke. Post-surgical risks include cerebral ischemia and infarction as well as bleeding. Blood pressure is closely monitored during the first 24 hours post surgery. Hypertension may strain the surgical site and trigger hematoma formation, which can cause hemorrhage or airway obstruction. Systolic blood pressure is maintained at 100-150 mm Hg to ensure adequate cerebral perfusion and avoidance of hemorrhage or strain. Angina pectoris Angina pectoris is defined as chest pain brought on by myocardial ischemia (decreased blood flow to the heart muscle). Any factor that increases oxygen demand or decreases oxygen supply to cardiac muscle may cause angina, including the following: Physical exertion (eg, exercise, sexual activity): Increases heart rate and reduces diastole (time of maximum blood flow to the myocardium) Intense emotion (eg, anxiety, fear): Initiates the sympathetic nervous system and increases cardiac workload Temperature extremes: Usually cold exposure and hypothermia (vasoconstriction); occasionally hyperthermia (vasodilation and blood pooling) Tobacco use and second-hand smoke inhalation: Replaces oxygen with carbon monoxide; nicotine causes vasoconstriction and catecholamine release Stimulants (eg, cocaine, amphetamines): Increase heart rate and cause vasoconstriction Coronary artery narrowing (eg, atherosclerosis, coronary artery spasm): Decreases blood flow to myocardium (Option 4) Deep sleep doesn't increase oxygen demand. Educational objective: Angina pectoris is chest pain caused by myocardial ischemia. Any factor that increases oxygen demand or decreases oxygen supply may deprive the myocardium of necessary oxygen needed to function effectively. • • • • Stable angina – Pain that does not change in intensity or presentation – Brought on my exertion – Relieved by rest and some medication Unstable angina (non ST elevation myocardial infarction - NSTEMI) – Pain that changes in intensity, but not presentation – Occurs at exertion or rest – Most often relieved by rest and some medication Myocardial infarction (ST elevation MI – STEMI) – Pain that changes in intensity and presentation – Secondary symptoms (nausea, vomiting, diaphoresis, radiating pain) – Not relieved by medication Prinzmetal’s angina (Variant angina) – Vasospasm Sublingual nitroglycerin (NTG) NTG is a vasodilator used to treat stable angina. Directions: - It is a sublingual tablet or spray that is placed under the client's tongue. - It usually relieves pain in about 3 minutes and lasts 30-40 minutes. - The recommended dose is 1 tablet or 1 spray taken sublingually for angina every 5 minutes for a maximum of 3 doses - If symptoms are unchanged or worse 5 minutes after the first dose, emergency medical services (EMS) should be contacted - Previously, clients were taught to call EMS after the third dose was taken, but newer studies suggest that this leads to a significant delay in treatment. - Headache and flushing are common side effects of NTG due to systemic vasodilation. - The client should lie down before taking the pill as it can cause dizziness from possible orthostatic hypotension. Nursing interventions: - NTG should be easily accessible at all times. - Tablets are packaged in a light-resistant bottle with a metal cap. - They should be stored away from light and heat sources, like body heat, to protect from degradation. o Clients should be instructed to keep the tablets in the original container. o Once opened, the tablets lose potency and should be replaced every 6 months. o The car is not a good place to store NTG due to heat - NTG should cause a slight tingling sensation under the tongue if it is potent; otherwise, the medication is likely outdated. The oral mucosa needs to be moist for adequate absorption of NTG, and clients should be instructed to take a drink of water before administration if needed for dry mouth. Sublingual tablets should never be swallowed . If using a spray, the client should not inhale it but direct it onto/under the tongue instead. NOTE: Waking up at night with chest pain can signify that angina is occurring at rest and is no longer considered stable angina. This should be reported to the HCP. Adverse drug interactions: - Nitrate drugs are prescribed to treat angina. The concurrent use sildenafil (Viagra) and nitrates is contraindicated as it can cause life-threatening hypotension. ***** Instructions for proper NTG administration include: Tablets are heat and light sensitive: They should be kept in a dark bottle and capped tightly. An opened bottle should be discarded after 6 months Take up to 3 pills in a 15-minute period: Take 1 pill every 5 minutes (up to 3 doses). Emergency medical services (EMS) should be called if pain does not improve or worsens 5 minutes after the first tablet has been taken. Previously, clients were taught to call after the third dose was taken, but newer studies suggest this causes a significant delay in treatment o The client should be instructed to take 1 pill (or 1 spray) every 5 minutes for up to 3 doses, but emergency medical services (EMS) should be called if pain is unimproved or worsening 5 minutes after the first tablet. Previously, clients were taught to call EMS after the third dose, but newer studies suggest that this causes a significant delay in treatment Avoid fatal drug interactions: Concurrent use of erectile dysfunction drugs (sildenafil, tadalafil, vardenafil) or alpha blockers (terazosin, tamsulosin) is contraindicated due to potentially fatal hypotension Headache may occur: Headache and flushing are common side effects of NTG due to systemic vasodilation and do not warrant medication discontinuation Intravenous nitroglycerin Intravenous nitroglycerin (glyceryl trinitrate) is used to increase cardiac blood flow and provide pain relief for clients with ACS until a definitive treatment plan (eg, percutaneous coronary intervention, thrombolytic therapy, bypass surgery) is determined. - Because nitroglycerin is a vasodilator, continuous hemodynamic monitoring is required to prevent severe hypotension. - The infusion rate is titrated by the nurse based on pain level and blood pressure (BP), usually every 3-5 minutes until pain is relieved and BP is stable. - If systolic BP drops to <90 mm Hg or falls >30 mm Hg below client baseline, the infusion rate should be decreased or stopped. Nitroglycerin patches (transdermal nitroglycerin) Nitroglycerin patches are transdermal patches used to prevent angina in clients with coronary artery disease. - They are usually applied once a day (not as needed) and worn for 12–14 hours and then removed. - Continuous use of patches without removal can result in tolerance. - No more than one patch at a time should be worn. - The patch should be applied to the upper body or upper arms. - Clean, dry, hairless skin that is not irritated, scarred, burned, broken, or calloused should be used. - A different location should be chosen each day to prevent skin irritation. - Patches may be worn in the shower - Headaches are common with the use of nitrates. The client may need to take an analgesic. - Phosphodiesterase inhibitors used in erectile dysfunction (eg, tadalafil, sildenafil, vardenafil) are contraindicated with the use of nitrates. Both have similar mechanisms and cause vascular smooth muscle dilation. Combined use can result in severe hypotension. Long-acting nitrates Long-acting nitrates are used to reduce the incidence of anginal attacks. Nitrates are effective if the client is able to do activities without the incidence of chest pain. The client should be taught to report any increase in chest pain and how to manage headaches, a common side effect of nitrates. Educational objective: The ability to perform activities without chest pain is a desirable client outcome of long-acting nitrate use. The nurse would want to assess for this outcome in clients taking these medications. Pharmacologic nuclear stress test A pharmacologic nuclear stress test utilizes vasodilators (eg, adenosine, dipyridamole) to simulate exercise when clients are unable to tolerate continuous physical activity or when their target heart rate is not achieved through exercise alone. - These drugs produce vasodilation of the coronary arteries in pts w/ suspected coronary heart disease. A radioactive dye is injected so that a special camera can produce images of the heart. Based on these images, the HCP can visualize if there is adequate coronary perfusion. Pre-procedure client instructions include the following: Do not eat, drink, or smoke on the day of the test (NPO for at least 4 hours). Small sips of water may be taken with medications Avoid caffeine products 24 hours before the test Avoid decaffeinated products 24 hours before the test as these contain trace amounts of caffeine Do not take theophylline 24-48 hours prior to the test If insulin/pills are prescribed for diabetes, consult the HCP about appropriate dosage on the day of the test. Hypoglycemia can result if the medicine is taken without food Some medications can interfere with the test results by masking angina. Do not take the following cardiac medications unless the HCP directs otherwise, or unless needed to treat chest discomfort on the day of the test: o Nitrates (nitroglycerine or isosorbide) o Dipyridamole o Beta blockers Educational objective: Clients scheduled for cardiac nuclear pharmacologic stress testing should not eat, drink, or smoke on the day of the test; avoid both caffeinated and decaffeinated products for 24 hours before the test; and avoid taking theophylline or antianginal medications unless otherwise instructed by the health care provider. Heart Failure Right-sided heart failure - Results from pulmonary hypertension, right ventricular myocardial infarction, or left-sided heart failure. The right ventricle cannot effectively pump blood to the lungs, which results in incomplete emptying of the right ventricle. The resulting decrease in forward blood flow causes blood to back up into the right atrium and then into venous circulation, resulting in venous congestion and increased venous pressure throughout the systemic circulation. Symptoms - - Peripheral and dependent edema (eg, sacrum, legs, hands), especially in the lower extremities Jugular venous distension Increased abdominal girth due to venous congestion of the gastrointestinal tract (eg, hepatomegaly, splenomegaly) and ascites. o Nausea and anorexia may also occur as a result of increased abdominal pressure and decreased gastrointestinal circulation Hepatomegaly due to hepatic venous congestion. Left-sided heart failure Blood is not effectively pumped into systemic circulation, resulting in the backup of blood into the pulmonary vessels that causes congestion of the pulmonary vessels and, potentially, pulmonary edema. Symptoms: - - Orthopnea (dyspnea with recumbency) Paroxysmal nocturnal dyspnea (PND) Crackles in lung bases Congestive heart failure Clients with a diagnosis of chronic congestive heart failure experience clinical manifestations of both right-sided (systemic venous congestion) and left-sided (pulmonary congestion) failure. Symptoms: - Crackles are discontinuous, adventitious lung sounds usually heard on inspiration and indicate the presence of pulmonary congestion (left-sided failure) - Increased jugular venous distention reflects an increase in pressure and volume in the systemic circulation, resulting in elevated central venous pressure (CVP) (right-sided failure) - Dependent edema (pitting; new onset) of the extremities is related to sodium and fluid retention (right-sided failure) in this client. - Weight gain Note: - Dry mucous membranes are associated with dehydration (increased serum sodium level), not fluid overload (heart failure). - Poor skin turgor or "tenting" is associated with skin moisture and elasticity. It is usually associated with dehydration, not fluid overload. - Rhonchi are continuous lung sounds usually heard on expiration that indicate the presence of secretions in the larger airways. They are not a classic manifestation of chronic heart failure. Chronic heart failure Chronic heart failure involves the inability of the heart to fill and pump blood effectively to meet the body's oxygen demands. As a result, clients can develop dilutional hyponatremia (serum sodium <135 mEq/L [135 mmol/L]), an electrolyte disturbance caused by an excess of total body water in relation to total sodium content. Nursing interventions: - Furosemide (Lasix) is a fast-acting loop diuretic prescribed to decrease preload in clients with heart failure who are fluid overloaded and experiencing manifestations of pulmonary congestion (eg, crackles, dyspnea). Appropriate diuresis in this client would remove excess free water and correct dilutional hyponatremia. - Potassium chloride is administered to clients receiving furosemide to prevent or treat diureticassociated hypokalemia. The nurse should not question this prescription. - Fluid restriction is prescribed to correct dilutional hyponatremia (sodium <135 mEq/L [135 mmol/L]) in a client with heart failure. In addition, all heart failure clients require a low-salt diet. Excess salt causes retention of more water. This client's low sodium is due to excess free water and not to low dietary sodium. - The nurse should question the prescription for the maintenance IV line. An infusion of an isotonic solution of 0.9% normal saline at 85 mL/h is contraindicated in this client as it would increase the circulating extracellular fluid volume, worsen the symptoms, and exceed the <2 L/day fluid restriction (ie, 85 mL × 24 hours = 2040 mL). Converting the running IV line to a lock for medication administration would be appropriate. - The client with chronic heart failure is at risk for exacerbations. Clients should be instructed to report a weight gain of 3 lb (1.36 kg) over 2 days or a 3–5 lb (1.36–2.26 kg) gain over a week. The nurse's priority assessment should be any physiological signs or symptoms of fluid overload (i.e., presence of SOB, coughing, edema) Educational objective: Dilutional hyponatremia (serum sodium <135 mEq/L [135 mmol/L]) is an electrolyte disturbance caused by an excess of total body water in relation to total sodium content and can occur in clients with heart failure. Treatment includes the administration of diuretics and fluid/salt restriction. Diagnostic test used to determine exacerbation of heart failure: - Brain (or b-type) natriuretic peptide (BNP) is secreted in response to ventricular stretch and wall tension when cardiac filling pressures are elevated. The BNP level is used to differentiate dyspnea of heart failure from dyspnea of noncardiac etiology. The level of circulating BNP correlates with both severity of left ventricular filling pressure elevation and mortality. - A normal BNP level is <100 pg/mL [<100 pmol/L]. The nurse would expect a high BNP in a client exhibiting symptoms of acute decompensated heart failure. - BNP is a peptide that causes natriuresis. B-type natriuretic peptides are made, stored, and released primarily by the ventricles. They are produced in response to stretching of ventricles due to the increased blood volume and higher levels of extracellular fluid (fluid overload) that accompany heart failure. Elevation of BNP >100 pg/mL helps to distinguish cardiac from respiratory causes of dyspnea. - Jugular venous distention (JVD) Directions: - Distension of jugular neck veins should be performed with the client sitting with the head of the bed at a 30- to 45-degree angle. - The nurse will observe for distension and prominent pulsation of the neck veins. - The presence of JVD in the client with heart failure may indicate an exacerbation and possible fluid overload. Central Venous Pressure CVP is a measurement of right ventricular preload (volume within the ventricle at the end of diastole) and reflects fluid volume problems. The normal CVP is 2-8 mm Hg. - An elevated CVP can indicate right ventricular failure (right sided HF) or fluid volume overload. Clinical signs of fluid volume overload include the following: Peripheral edema Increased urine output that is dilute Acute, rapid weight gain Jugular venous distension S3 heart sound in adults Tachypnea, dyspnea, crackles in lungs Bounding peripheral pulses (Options 2 and 3) Dry mucous membranes and hypotension are signs of deficient fluid volume or dehydration. Pulmonary edema Pulmonary edema, a life-threatening condition. In the presence of acute left ventricular failure, pulmonary vasculature overload causes increased pulmonary venous pressure that forces fluid out of the vascular space into the pulmonary interstitium and, if untreated, into the alveoli. Clinical manifestations of pulmonary edema include: A history of orthopnea and/or paroxysmal nocturnal dyspnea Anxiety and restlessness Tachypnea (RR often >30/min), dyspnea, and use of accessory muscles Frothy, blood-tinged sputum (pink frothy sputum) Crackles on auscultation Treatment: - The priority of care is to improve oxygenation by reducing pulmonary pressure and congestion. Next, diuretics (eg, furosemide) are prescribed to remove excess fluid in pulmonary edema. Management of acute decompensated heart failure (ADHF) may also include oxygen therapy, vasodilators (eg, nitroglycerin, nesiritide), and positive inotropes (eg, dopamine, dobutamine). o Vasodilators decrease preload thus improving cardiac output and decreasing pulmonary congestion. o Positive inotropes improve contractility but are only recommended if other medications have failed or in the presence of hypotension. Note: - Digoxin is a positive inotropic drug (improves contractility) used in long-term treatment of heart failure. Dopamine, a positive inotropic drug, is used as a short-term treatment for ADHF; however, it does not resolve the fluid overload affecting oxygenation. Educational objective: In the presence of acute decompensated heart failure (ADHF) and pulmonary edema, diuretic (eg, furosemide) administration is effective in removing excess fluid to reduce pulmonary congestion and improve oxygenation. Vasodilators (eg, nitroglycerin, nesiritide) and positive inotropes (eg, dopamine, dobutamine) are also used in the treatment of ADHF. Drugs used to treat HF - - Diuretics Drugs that inhibit RAAS (already discussed) o ACE Inhibitors o ARBs o Aldosterone Antagonists o Direct Renin Inhibitors Digoxin Hydralazine (already discussed) Beta Blockers (already discussed in Autonomic Nervous System – will briefly review in CV II) Permanent pacemaker Discharge teaching for the client with a permanent pacemaker should include the following: Report fever or any signs of redness, swelling, or drainage at the incision site Keep a pacemaker ID card with you, and wear a medic alert bracelet Microwave ovens are safe to use and do not interfere with the pacemaker Learn to take your pulse and report it to the HCP if it is below the predetermined rate Do not place a cell phone in a pocket located directly over the pacemaker. Also, when talking on the cell phone, hold it to the ear on the opposite side of the pacemaker's implantation site MRI scans can affect or damage a pacemaker Avoid lifting your arm above the shoulder on the side that the pacemaker is implanted until approved by the HCP. It can cause dislodgement of the pacemaker lead wires o Avoid performing shoulder ROM exercises Air travel is not restricted. Notify security personnel that you have a pacemaker, which may set off the metal detector. A handheld screening wand should not be held directly over the pacemaker Avoid standing near antitheft detectors in store entryways. Walk through at a normal pace and do not linger near the device. Educational objective: Clients with a pacemaker should avoid heavy lifting and above-the-shoulder exercises until the HCP approves. They should carry a pacemaker ID card, wear a medic alert bracelet, avoid MRI scans, never place a cell phone over the pacemaker, and inform airline security personnel. Microwave ovens are safe. Heart transplant Clients receiving transplanted organs are prescribed lifelong immunosuppressive medications (eg, cyclosporine, mycophenolate) to prevent rejection. - Posttransplant infection is the most common cause of death. - Signs of infection may include fever >100.4 F (38 C), productive or dry cough, and changes in secretions; however, common signs of infection (eg, redness, swelling) may be absent due to immunosuppression. - Critical postoperative infection control measures incorporate vigilant hand washing, aseptic technique for line/dressing changes, and possibly reverse isolation. Aneurysms Abdominal aortic aneurysms An aneurysm is an outpouching or dilation of a vessel wall. - An abdominal aneurysm occurs on the aorta. - A bruit, a swishing or buzzing sound that indicates turbulent blood flow in the aneurysm, is best heard with the bell of the stethoscope. - It may be auscultated over the aortic aneurysm in the periumbilical or epigastric area slightly left of the midline. ***SYMPTOMS: - Back/abdominal pain - Bruit - Pulsatile mass in the periumbilical area Treatment: - Repair of abdominal aortic aneurysms can be done via femoral percutaneous placement of a stent graft (endovascular aneurysm repair) or via an open surgical incision of the aneurysm and placement of a synthetic graft. Complications: - Renal perfusion status is monitored closely in a client who has had abdominal aneurysm repair. o Hypotension, dehydration, prolonged aortic clamping during surgery, blood loss, or embolization can lead to decreased renal perfusion and potential kidney injury. o The nurse should routinely monitor the client's blood urea nitrogen (BUN) and creatinine levels as well as urine output. Urine output should be at least 30 mL/hr. - With either procedure, postop monitoring for graft leakage or separation is a priority. Manifestations of graft leakage include: o Adequate blood pressure is necessary to maintain graft patency, and prolonged hypotension can lead to the formation of graft thrombosis. o Signs of graft leakage include a decreasing blood pressure and increasing pulse rate. o Ecchymosis of the groin, penis, scrotum, or perineum o Increased abdominal girth o Tachycardia o Weak or absent peripheral pulses o Decreasing hematocrit and hemoglobin o Increased pain in the pelvis, back, or groin o Decreased urinary output (UO is decreased d/t inadequate perfusion to the kidney if a newly placed graft were leaking, causing hypotension) - NOTE: Diminished breath sounds in the lung bases are a common occurrence after surgery, especially in a client who has an abdominal incision that is painful with deep inspiration. The nurse should medicate the client for pain and encourage coughing, deep breathing, and use of an incentive spirometer. - During abdominal surgeries, it is customary to insert a nasogastric tube that is left in place during the immediate postoperative period. Green bile-colored drainage would be expected. Endovascular abdominal aortic aneurysm repair is a minimally invasive procedure that involves the placement of a sutureless aortic graft inside the aortic aneurysm via the femoral artery. - The nurse will need to monitor the puncture sites in the groin area for bleeding or hematoma formation - Peripheral pulses should be palpated and monitored frequently in the early post-op period and routinely afterward - Renal artery occlusion can occur due to graft migration or thrombosis so careful monitoring of urine output and kidney function should be part of nursing care - NOTE: There is no abdominal incision in an endovascular repair and Chest tubes are not used in endovascular repair Aortic Dissection Aortic dissection is a tear in the inner lining of the aorta that allows blood to surge between the layers of the arterial wall, separating and weakening the aortic wall. - Perfusion to vital organs may become impaired, and the dissection can rapidly progress to lifethreatening cardiac tamponade or aortic rupture. Symptoms: - Acute onset of excruciating, sharp or "ripping" “tearing” chest pain that radiates to the back. - Pts may complain about coldness or numbness in their left arm bc it’s influencing the flow of blood through the left subclavian artery o Blood pressure and pulse unobtainable left arm due to obstruction - Pts may complain of light headedness if obstructing the left common carotid artery Nursing interventions: - Emergency surgical repair is usually required. - Before surgical repair, the priority is decreasing the risk of aortic rupture by maintaining normal blood pressure in the aorta. o Administering IV beta blocker medication (eg, labetalol, metoprolol, propranolol) helps achieve this by lowering the heart rate and blood pressure, which are often elevated with aortic dissection o Although bed rest and a low-stimulation environment help lower heart rate and blood pressure, but antihypertensive medication is more effective and rapid-acting, making it the highest priority. Educational objective: Before emergency surgical repair of aortic dissection, the priority is decreasing the risk of aortic rupture by maintaining normal pressure in the aorta. Administering an IV beta blocker helps achieve this by rapidly lowering elevated heart rate and blood pressure. Pericardial effusion Pericardial effusion is a buildup of fluid in the pericardium. Tamponade, a serious complication of pericardial effusion, develops as the effusion increases in volume and results in compression of the heart. - The heart struggles to contract effectively against the fluid, and cardiac output can decrease drastically. This life-threatening complication requires an emergency pericardiocentesis (a needle inserted into the pericardial sac to remove fluid). Signs and symptoms of cardiac tamponade include: Hypotension with narrowed pulse pressure Muffled or distant heart tones Jugular venous distension Pulsus paradoxus Dyspnea, tachypnea Tachycardia Weak, thready pulses (r/t decreased cardiac output) Note: Decreased breath sounds on the left side are not specific to the development of cardiac tamponade. Decreased breath sounds could indicate conditions such as atelectasis, pleural effusion, or pneumothorax. Pulsus paradoxus Pulsus paradoxus is defined as an exaggerated fall in systemic BP >10 mm Hg during inspiration. The procedure for measurement of pulsus paradoxus is as follows: 1. Place client in semirecumbent position 2. Have client breathe normally 3. Determine the SBP using a manual BP cuff 4. Inflate the BP cuff to at least 20 mm Hg above the previously measured SBP 5. Deflate the cuff slowly, noting the first Korotkoff sound during expiration along with the pressure 6. Continue to slowly deflate the cuff until you hear sounds throughout inspiration and expiration; also note the pressur 7. Determine the difference between the 2 measurements in steps 5 and 6; this equals the amount of paradox 8. The difference is normally <10 mm Hg, but a difference >10 mm Hg may indicate the presence of cardiac tamponade. Mediastinal chest tubes Mediastinal chest tubes are used to drain air or fluid from the mediastinal space and/or pericardial cavity (ie, after cardiac surgery). - Obstruction (eg, clot) of the chest tube will result in excess fluid buildup in the pericardium, leading to inhibited cardiac contractility and eventual diagnosis of cardiac tamponade. - Cardiac tamponade is a life-threatening form of obstructive shock marked by decreased cardiac output and eventually obstructive cardiac arrest if untreated. If chest tube drainage is markedly decreased, the nurse should quickly assess for signs of cardiac tamponade (Option 1) and if no such signs are present should troubleshoot other possible causes of chest tube occlusion. Pericarditis Acute pericarditis The most common cause of acute pericarditis is a recent viral infection. It is an inflammation of the visceral and/or parietal pericardium. Symptoms: - Pleuritic chest pain that is sharp - Aggravated during inspiration and coughing. - Pain is typically relieved by sitting up and leaning forward. o This position reduces pressure on the inflamed parietal pericardium, especially during lung inflation o The pain is different than that experienced during myocardial infarction. Assessment shows a pericardial friction rub (scratchy or squeaking sound). Treatment includes a combination of nonsteroidal anti-inflammatory drugs (NSAIDS) or aspirin plus colchicine. Educational objective: Pericarditis is characterized by typical pleuritic chest pain that is sharp. It is aggravated during inspiration and coughing. Pain is typically relieved by sitting up and leaning forward. Treatment includes a combination of NSAIDs or aspirin plus colchicine. Endocarditis In Infective Endocarditis, the vegetations over the valves can break off and embolize to various organs, resulting in life-threatening complications. These include the following: 1. Stroke - paralysis on one side 2. Spinal cord ischemia - paralysis of both legs 3. Ischemia to the extremities - pain, pallor, and cold in one foot or arm 4. Intestinal infarction - abdominal pain 5. Splenic infarction - left upper-quadrant pain The nurse or the client (if at home) should report these manifestations immediately to the HCP. Symptoms: - Fever, arthralgias (multiple joints pains), weakness, and fatigue. These are expected and do not need to be reported during the initial stages of treatment. Splinter hemorrhages can occur with infection of the heart valves (endocarditis). They may be caused by vessel damage from swelling of the blood vessels (vasculitis) or tiny clots that damage the small capillaries (microemboli). The presence of splinter hemorrhages is not as critical as the macroemboli causing stroke or painful cold leg. Treatment: - IE clients typically require intravenous antibiotics for 4-6 weeks. Fever may persist for several days after treatment is started. If the client is persistently febrile after 1-2 weeks of antibiotics, this must be reported as it may indicate ineffective antibiotic therapy. Valvular Heart Disease Mitral valve regurgitation Mitral valve regurgitation is the result of a disrupted papillary muscle(s) or ruptured chordae tendineae, allowing a backflow of blood from the left ventricle through the mitral valve into the left atrium. This backflow can lead to dilation of the left atrium, reduced cardiac output, and pulmonary edema. - Clients are often asymptomatic but are instructed to report any new symptoms indicative of heart failure (eg, dyspnea, orthopnea, weight gain, cough, fatigue). - This client should be assessed first due to possible heart failure, which would require immediate intervention. Mitral valve prolapse (MVP) Clients with MVP may have palpitations, dizziness, and lightheadedness. Chest pain can occur but its etiology is unknown in this client population. It may be a result of abnormal tension on the papillary muscles. Chest pain that occurs in MVP does not typically respond to antianginal treatment such as nitrates. Beta blockers may be prescribed for palpitations and chest pain. Symptoms: - Palpitations Dizziness Lightheadedness Chest pain can occur but its etiology is unknown in this client population. o It may be a result of abnormal tension on the papillary muscles. o Chest pain that occurs in MVP does not respond to antianginals meds like nitrates Treatment: - Beta blockers may be prescribed for palpitations and chest pain. Nursing interventions: Adopt healthy eating habits and avoid caffeine as it is a stimulant and may exacerbate symptoms Check ingredients of over-the-counter medications or diet pills for stimulants such as caffeine or ephedrine as they can exacerbate symptoms Reduce stress and avoid alcohol use Clients should be taught to begin or maintain an exercise program, preferably aerobic exercise, to achieve optimal health. Although MVP may place the client at an increased risk for infective endocarditis, there is no clinical evidence to support the need for prophylactic antibiotics prior to dental procedures. Antibiotic prophylaxis is indicated for clients who have prosthetic valve replacement, repaired valves, or a history of infectious endocarditis. Aortic stenosis Aortic stenosis is a narrowing of the aortic valve, which obstructs blood flow from the left ventricle to the aorta. As stenosis progresses, the heart cannot overcome the worsening obstruction, and ejects a smaller fraction of blood volume from the left ventricle during systole. This decreased ejection fraction results in a narrowed pulse pressure (ie, the difference between systolic and diastolic blood pressures) and weak, thready peripheral pulses. With exertion, the volume of blood that is pumped to the brain and other parts of the body is insufficient to meet metabolic demands, resulting in exertional dyspnea, anginal chest pain, and syncope. Symptoms: - Many clients with aortic stenosis are asymptomatic. - Symptoms usually develop with exertion as the left ventricle cannot pump enough blood to meet the body's demands due to aortic obstruction (stenosis). o These include dyspnea, angina, and, in severe cases, syncope on exertion(reduced blood flow to the brain). o Clients usually do not experience symptoms at rest. Nursing interventions: - The client should restrict activity. The incidence of sudden death is high in this population, and it is therefore prudent to decrease the strain on the heart while awaiting surgery. Educational objective: Clients with severe aortic stenosis are at risk for developing syncope and sudden death with exertion. The left ventricle cannot push enough blood into the aorta to meet the body's demands due to the valve stenosis. Mechanical prosthetic valves (Mechanical Valve Replavement) Mechanical prosthetic valves are more durable than biological valves but require long-term anticoagulation therapy due to the increased risk of thromboembolism. The client should be taught ways to reduce the risk of bleeding. Teaching topics for clients on anticoagulants: Take medication at the same time daily Depending on medication, report for periodic blood tests to assess therapeutic effect Avoid any action that may cause trauma/injury and lead to bleeding (eg, contact sports, vigorous teeth brushing, use of a razor blade) Use an electric razor instead of a razor blade Avoid aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) Limit alcohol consumption Avoid changing eating habits frequently (eg, dramatically increasing intake of foods high in vitamin K such as kale, spinach, broccoli, greens) and do not take vitamin K supplements Consult with HCP before beginning or discontinuing any medication or dietary/herbal supplement (eg, Ginkgo biloba and ginseng affect blood clotting and may increase bleeding risk) Wear a medical alert bracelet indicating what anticoagulant is being taken Early in the recovery period, care of the incision site typically includes washing with soap and water and patting it dry. Ointments (eg, vitamin E) may be applied only after the incision has healed. Clients with any form of prosthetic material in their heart valves (i.e., prosthetic valve like a mechanical aortic valve replacement) or who have unrepaired cyanotic congenital heart defect or prior history of IE should take prophylactic antibiotics prior to dental procedures to prevent development of IE. Congenital Heart Disease Patent ductus arteriosus (PDA) Patent ductus arteriosus (PDA) is an acyanotic congenital defect more common in premature infants. - When fetal circulation changes to pulmonary circulation outside the womb, the ductus arteriosus should close spontaneously. This closure is caused by increased oxygenation after birth. - If a PDA is present, blood will shunt from the aorta back to the pulmonary arteries via the opened ductus arteriosus. - Many newborns are asymptomatic except for a loud, machine-like systolic and diastolic murmur. - The PDA will be treated with surgical ligation or IV indomethacin to stimulate duct closure. Symptoms: - Systolic murmur with a machine sound - Poor feeding is expected - Nonurgent as it commonly resolves within 48 hours in most newborns Ventricular septal defect Congenital heart defects that cause blood to shunt from the higher pressure left side of the heart to the lower pressure right side (eg, patent ductus arteriosus, atrial septal defect, ventricular septal defect) increase pulmonary blood flow. Left-to-right shunting results in pulmonary congestion, causing increased work of breathing and decreased lung compliance. Compensatory mechanisms (eg, tachycardia, diaphoresis) result from sympathetic stimulation. Clinical manifestations of acyanotic defects may include: Tachypnea Tachycardia, even at rest Diaphoresis during feeding or exertion Heart murmur or extra heart sounds Signs of congestive heart failure Increased metabolic rate with poor weight gain Ventricular septal defect is a cardiac abnormality, with a septal opening between ventricles, that may progress to congestive heart failure (CHF). The client should be closely monitored for respiratory exertion and signs of CHF (eg, dyspnea, tachypnea grunting). (Option 1) Clubbing of the fingertips is associated with chronic hypoxia caused by decreased pulmonary circulation as occurs with right-to-left heart defects. (Option 2) Right-to-left congenital heart defects (eg, cyanotic defects) impede pulmonary blood flow (eg, tetralogy of Fallot, transposition of the great vessels) and cause cyanosis, which is evident shortly after birth and during periods of physical exertion. Atrial septal defect This defect is an abnormal opening between the right and left atria, allowing blood from the higher pressure left atrium to flow into the lower pressure right atrium. The back-and-forth flow of blood between the 2 chambers causes a vibration that is heard as a murmur on auscultation. - ASD has a characteristic systolic murmur with a fixed split second heart sound. Some clients may also have a diastolic murmur. Atrioventricular (AV) septal defect Atrioventricular (AV) canal defect is a cardiac anomaly often associated with trisomy 21 (Down syndrome). - Trisomy 21 (Down syndrome) is often associated with the cardiac anomaly AV canal defect. Assessment typically includes a loud murmur that requires no immediate action when vital signs are stable. Surgery will correct the anomaly when the neonate grows in size and can tolerate the invasive procedure better. Nursing interventions: - Expect and order for an echocardiogram and genetic screening Note: - A knee-chest position is used to treat episodes of hypoxia and cyanosis in infants and young children with tetralogy of Fallot (TOF). This neonate likely has an AV canal defect, not TOF. There is also no indication of cyanosis or hypoxia that would necessitate knee-chest positioning. - The normal respiratory rate in a neonate is 30-60/min; pulse can be up to 160/min. Tetralogy of Fallot Tetralogy of Fallot is a congenital cardiac defect that typically has 4 characteristics: - pulmonary stenosis right ventricular hypertrophy overriding aorta ventricular septal defect Nursing interventions: - An infant can experience a hypercyanotic episode, or "tet spell," which is an exacerbation of tetralogy of Fallot that can happen when a child cries, becomes upset, or is feeding. o The child should first be placed in a knee-to-chest position Flexion of the legs provides relief of dyspnea as this angle improves oxygenation by reducing the volume of blood that is shunted through the overriding aorta and the ventricular septal defect. - Tetralogy of Fallot (TOF) is a cyanotic cardiac defect. Infants with TOF will normally maintain oxygen saturations of 65%-85% until the defect is surgically corrected. Remember: The normal range for hemoglobin in a 1-month-old is 12.5-20.5. Hemoglobin of 24.9 g/dL is diagnostic of polycythemia (elevated hemoglobin levels). o Infants with cyanotic cardiac defects can develop polycythemia as a compensatory mechanism due to prolonged tissue hypoxia (clubbing is another manifestation of prolonged hypoxia) o Polycythemia will increase blood viscosity, placing an infant at risk for stroke or thromboembolism Common symptoms: - Irritability - Clubbing of fingers Raynaud phenomenon Raynaud phenomenon is a vasospastic disorder resulting in an episodic vascular response related to cold temperatures or emotional stress. It most commonly affects women age 15-40. - - Vasospasms induce a characteristic color change in the appendages (eg, fingers, toes, ears, nose). When vasoconstriction occurs, the affected appendage initially turns white from decreased perfusion, followed by a bluish-purple appearance due to cyanosis. o Clients usually report numbness and coldness during this stage. When blood flow is subsequently restored, the affected area becomes reddened and clients experience throbbing or aching pain, swelling, and tingling. Acute vasospasms are treated by immersing the hands in warm water. Client teaching regarding prevention of vasospasms includes: Wear gloves when handling cold objects Dress in warm layers, particularly in cold weather Avoid extremes and abrupt changes in temperature o Avoid cold water as it will cause vasoconstriction and worsen the condition. Avoid vasoconstricting drugs (eg, cocaine, amphetamines, ergotamine, pseudoephedrine) Avoid excessive caffeine intake Refrain from use of tobacco products Implement stress management strategies (eg, yoga, tai chi) If conservative management is unsuccessful, clients may be prescribed calcium channel blockers to relax arteriole smooth muscle and prevent recurrent episodes. Buerger's disease (thromboangiitis obliterans) Buerger's disease (thromboangiitis obliterans) is a nonatherosclerotic vasculitis involving the arteries and veins of the lower and upper extremities. It occurs most often in young men (age <45) with a long history of tobacco or marijuana use and chronic periodontal infection, but no other cardiovascular risk factors. Clients experience thrombus formation, resulting in distal extremity ischemia, ischemic digit ulcers, or digit gangrene. They often have intermittent claudication of the feet and hands. Over time, rest pain and ischemic ulcerations may occur. Many clients also develop secondary Raynaud phenomenon (cold sensitivity). Treatment: - Cessation of all tobacco and marijuana use in any form. o Nicotine replacement products (eg, nicotine patch) are contraindicated. - However, bupropion and varenicline can be used for smoking cessation. - Clients may have to choose between continued use of tobacco and marijuana and their affected limbs. - Conservative management includes avoidance of cold exposure to affected limbs, a walking program, antibiotics for any infected ulcers, analgesics for ischemic pain, and avoidance of trauma to the extremities. - Clients should avoid exposure to cold (not warm) weather to prevent vasoconstriction and worsening of symptoms. - Warfarin is an anticoagulant and is not indicated in the treatment of Buerger's disease. Calcium channel blockers, cilostazol, and sildenafil have been used, but there is insufficient evidence to support their effectiveness. Intravenous iloprost has been shown to improve rest pain, promote healing of ulcers, and decrease the need for amputation. Educational objective: Buerger's disease is a nonatherosclerotic vasculitis involving small to medium arteries and veins of the upper and lower extremities. Young male smokers are typically affected. Clients should avoid exposure to cold weather and cease using tobacco and marijuana in all forms. Smoking cessation can be achieved with bupropion or varenicline but not with nicotine replacement products. Kawasaki disease (KD) Kawasaki disease (KD), mucocutaneous lymph node syndrome, is a systemic vasculitis of childhood that causes inflammation of arterial walls (vasculitis). The coronary arteries are affected in KD, and some children develop coronary aneurysms. The etiology of KD is unknown; there are no diagnostic tests to confirm the disease, and it is not contagious. Symptoms: - ≥5 days of fever Nonexudative conjunctivitis Lymphadenopathy Mucositis (strawberry tongue) Hand and foot swelling Rash w/ peeling (peeling aka desquamation) KD has 3 phases: - - - Acute - sudden onset of high fever that does not respond to antibiotics or antipyretics. The child becomes very irritable and develops swollen red feet and hands. The lips become swollen and cracked, and the tongue can also become red (strawberry tongue). Subacute - skin begins to peel from the hands and feet. The child remains very irritable. Convalescent - symptoms disappear slowly. The child's temperament returns to normal. Treatment: - First-line treatment consists of IV immunoglobulin (IVIG) and aspirin to prevent coronary artery aneurysms. o IVIG creates high plasma oncotic pressure, and signs of fluid overload and pulmonary edema develop if it is given in large quantities. o Therefore, the child should be monitored for symptoms of heart failure (eg, decreased UO, additional heart sounds, tachycardia, difficulty breathing). o KD is one of the few pediatric illnesses in which aspirin therapy is warranted due to its antiplatelet and anti-inflammatory properties. Parents should be cautioned about the risk of Reye syndrome. Nursing interventions: - - - - . When children with KD are discharged home, parents are instructed to monitor them for fever by checking the temperature (orally or rectally) every 6 hours for the first 48 hrs following the last fever. Temperature should also be checked daily until the follow-up appointment. If the child develops a fever, the HCP should be notified as this may indicate the acute phase of KD recurrence. o The child may require additional treatment with IV immunoglobulin to prevent development of coronary artery aneurysms and occlusions. o Coronary artery aneurysms are the most serious potential sequelae in untreated clients, leading to complications such as myocardial infarction and death. Echocardiography is used to monitor these cardiovascular complications. The child will be very irritable during the acute phase of KD. A non-stimulating, quiet environment will help to promote rest. After a KD episode, it is important for parents to understand that their child's irritability may last for up to 2 months and that follow-up appointments for cardiac evaluation are important. During the acute phase (painful swollen lips and tongue), the child should be given soft foods and clear liquids as these are tolerated best. Medications Beta-blockers (metoprolol) Side effect - Causes bradycardia (<60/min). o The nurse should hold this medication if HR is <60 Nonselective beta-blocker (Propranolol) Propranolol is a nonselective beta-blocker that inhibits beta1 (heart) and beta2 (bronchial) receptors. It is used for many indications (eg, essential tremor) in addition to blood pressure control. Blood pressure decreases secondary to a decrease in heart rate. - Bronchoconstriction may occur due to the effect on the beta2 receptors. The presence of wheezing in a client taking propranolol may indicate that bronchoconstriction or bronchospasm is occurring. The nurse should assess for any history of asthma or respiratory problems with this client and notify the health care provider (HCP). ACE inhibitors Side effects: - - - - Intractable dry cough is a common side effect of ACE inhibitors. It is thought to be related to the accumulations of kinins (bradykinin). o ARBs (i.e., Valsartan) are recommended for clients unable to tolerate ACE inhibitor coughs o Asians, especially those of Chinese descent, have a high risk (15%-50%) for ACE inhibitor-related cough. o Persons of African descent are also at high risk of developing cough and angioedema. Angioedema is swelling that usually affects areas of the face (lips, tongue), larynx, extremities, gastrointestinal tract, and genitalia. The swelling often starts in the face and can quickly become life-threatening as it progresses to the airways. The dosage of angiotensin-converting enzyme (ACE) inhibitors (eg, lisinopril, enalapril, ramipril) should be adjusted for clients with renal impairment. o I.e., if a serum creatinine of 2.5 mg/dL indicates renal impairment (normal 0.6-1.3). The nurse should notify the HCP so that the dosage can be decreased or held. o Evaluation of kidney function is essential for clients taking medications that are excreted renally or can worsen renal injury. These include ACE inhibitors (eg, lisinopril, enalapril), aminoglycosides (eg, gentamicin), and digoxin. ACE inhibitors increase serum potassium by decreasing urinary potassium excretion. The nurse should assess blood pressure and serum potassium levels prior to administration o Because ACE inhibitors have the potential to cause hyperkalemia, the nurse should assess the potassium level when available. The nurse should check the client's blood pressure (BP) prior to administration as ACE inhibitors can lower BP. Orthostatic hypotension. ACE inhibitors are contraindicated in pregnancy due to teratogenic effects on the fetus (eg, oligohydramnios, fetal kidney injury). Calcium channel blockers (nifedipine, amlodipine, felodipine, nicardipine) Calcium channel blockers (nifedipine, amlodipine, felodipine, nicardipine) are vasodilators used to treat hypertension and chronic stable angina. They promote relaxation of vascular smooth muscles leading to decreased systemic vascular resistance and arterial blood pressure. Side effects: - Orthostatic hypotension; dizziness o The reduced blood pressure may initially cause orthostatic hypotension. The client should be taught to change positions slowly to prevent falls. o The nurse should tell the client not to eat grapefruit or drink grapefruit juice while taking calcium channel blockers due to the possible development of severe hypotension. The nurse should report this client's statement to the HCP. - Flushing - Headache - Peripheral edema o Leg elevation and compression can help to reduce the edema. - Constipation o Constipation should be prevented with daily exercise and increased intake of fluids, fruits/vegetables, and high-fiber foods. Note: - ACE inhibitors prevent the breakdown of bradykinin, which may produce a nonproductive cough in susceptible individuals. Discontinuation of the medication stops the cough. - Adverse effects of beta-blockers include bradycardia, bronchospasm, depression, and decreased libido with erectile dysfunction. Statin drugs (eg, simvastatin, atorvastatin, rosuvastatin) Statin drugs (eg, simvastatin, atorvastatin, rosuvastatin) are prescribed to lower cholesterol and reduce the risk of atherosclerosis and coronary artery disease. - - Most of the cholesterol in the body is synthesized by the liver during the fasting state, at night. o Prior to starting therapy with statin meds (eg, rosuvastatin, simvastatin, pravastatin, atorvastatin), the client's liver function tests should be assessed. The drug is metabolized by the hepatic enzyme system and could cause drug-induced hepatitis and increased liver enzymes. Liver function tests should be assessed prior to the start of therapy. Trials have found greater reductions in total and LDL cholesterol when statins (especially those that are short-acting; eg, simvastatin) are taken in the evening or at bedtime as opposed to during the day. - Remember: The client taking a statin drug such as simvastatin should be taught to take the medication with the evening meal or at bedtime to promote maximal effectiveness. - The nurse should teach all clients taking statin drugs (eg, atorvastatin, rosuvastatin) to immediately report any muscle aches or weakness, as these can lead to rhabdomyolysis, a muscle disintegration that can cause serious kidney injury. Statins are preferred agents to reduce low-density lipoprotein (LDL) cholesterol, total cholesterol, and triglyceride levels. - This client's LDL level has decreased to a target range (diabetic client <100) - Total cholesterol has decreased to a normal range (adult <200) - Triglyceride level has decreased to a normal range (adult <150) Central-acting alpha2 agonists (eg, clonidine, methyldopa) Central-acting alpha2 agonists (eg, clonidine, methyldopa) decrease the sympathetic response from the brainstem to the peripheral vessels, resulting in decreased peripheral vascular resistance and vasodilation. Nursing interventions: - Clonidine is a highly potent antihypertensive. - ***Abrupt discontinuation (including the patch) can result in serious rebound hypertension due to the rapid surge of catecholamine secretion that was suppressed during therapy. o Clonidine should be tapered over 2-4 days. Abrupt withdrawal of beta blockers can also result in rebound hypertension and in precipitation of angina, myocardial infarction, or sudden death. - Other common side effects of clonidine include dizziness, drowsiness, and dry mouth (the 3 Ds). - Beta blockers, another class of blood pressure medications, can result in withdrawal symptoms if discontinued suddenly. Milrinone (Primacor) Milrinone (Primacor) is a phosphodiesterase-3 inhibitor given via IV infusion to increase contractility and promote vasodilation. Milrinone, an inotropic agent, is often prescribed to clients with heart failure unresponsive to other pharmacologic therapies. - - The medication is usually infused over 48-72 hours in a hospital setting; however, home infusion through a central line is becoming more common as a palliative measure for endstage heart failure. Milrinone infusion requires central venous access (eg, peripherally inserted central catheter) as the medication is a vesicant and can cause extravasation if infused through a peripheral IV line. The home health nurse should perform the following: Ensure that an infusion pump is used to control the rate, and instruct the family on basic troubleshooting Evaluate medication effectiveness and possible side effects. Monitor the central line insertion site for infection. Change the central line dressing as prescribed Monitor daily weight Monitor blood pressure for possible hypotension Implement safety precautions as hypotension increases the client's risk of falling. Dopamine (Intropin) Dopamine (Intropin) is a sympathomimetic inotropic medication used therapeutically to improve hemodynamic status in clients with shock and heart failure. It enhances cardiac output by increasing myocardial contractility, increasing heart rate, and elevating blood pressure through vasoconstriction. Renal perfusion is also improved, resulting in increased urine output. The lowest effective dose of dopamine should be used as dopamine administration leads to an increased cardiac workload. Adverse effects - Tachycardia o A heart rate of 120/min may indicate that the dopamine infusion needs to be reduced - Dysrhythmias - Myocardial ischemia. Note: - Normal central venous pressure is 2-8 mm Hg - Normal MAP ([systolic blood pressure + (2 x diastolic blood pressure)]/3) is 70-105 mm Hg - Normal systemic vascular resistance is 800-1200 dynes/sec/cm-5. Educational objective: Dopamine is a sympathomimetic inotropic agent that increases heart rate, blood pressure, cardiac output, and urine output. Vital signs should be monitored closely in these clients as a higher dose can result in dangerous tachycardia and tachyarrhythmias. NSAIDs contraindication for HF and HTN patients Over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen can cause cardiovascular side effects, including heart attack, stroke, high blood pressure, and heart failure from fluid retention. Also, use of NSAIDs increases the risk of thrombotic events (eg, heart attack, stroke) in clients with cardiovascular disease (eg, coronary artery disease [CAD]), especially with long-term use. - These drugs also decrease the effectiveness of diuretics and other blood pressure medications. - The risks can be even higher in the client who already has cardiovascular disease or takes NSAIDs routinely or for a long time. - In addition, long-term use of NSAIDs is associated with peptic ulcers and chronic kidney disease. - The use of any NSAIDS is also contraindicated as they contribute to sodium retention, and therefore fluid retention - These clients should use NSAIDs cautiously, at the lowest dose necessary and for a short time. o The nurse should notify the health care provider that this client is routinely taking ibuprofen!!! Educational objective: NSAIDs may cause heart attack, stroke, high blood pressure, and possible heart failure after longterm use. NSAIDs decrease the effectiveness of diuretic and blood pressure medications. Long-term use is also associated with chronic kidney disease and peptic ulcers. Clients with cardiovascular disease (eg, coronary artery disease) should be cautioned against taking nonsteroidal anti-inflammatory drugs (eg, naproxen) due to the increased risk of thrombotic events (eg, heart attack, stroke). OTC medication and HTN Clients with hypertension should be instructed not to take potentially high-risk over-the-counter (OTC) medications such as high-sodium antacids, appetite suppressants, and cold and sinus preparations. It is appropriate to ask a client with hypertension about taking OTC cold medications as many cold and sinus medications contain phenylephrine or pseudoephedrine. - These sympathomimetic decongestants activate alpha-1 adrenergic receptors, producing vasoconstriction. - The resulting decreased nasal blood flow relieves nasal congestion. - These agents have both oral and topical forms. With systemic absorption, these agents can cause dangerous hypertensive crisis. Clonidine Clonidine is a potent antihypertensive agent and is available as a transdermal patch. The patches should be replaced every 7 days and can be left in place during bathing. Instructions for using the clonidine (transdermal) patch: Apply the patch to a dry hairless area on the upper outer arm or chest once every 7 days Do not shave the area before applying the patch. The skin should be free from cuts, scrapes, calluses, or scars Wash hands with soap and water before and after applying the patch as some medication may remain on the hands after application Wash the area with soap and water, then rinse and wipe with a clean, dry tissue. Remove the patch from the package. Do not touch the sticky side. Rotate sites of patch application with each new patch. Remove the old patch only when applying a new one. Do not wear more than 1 patch at a time unless directed by the HCP When removing the patch, fold it in half with the sticky sides together. Discard the patch out of the reach of children and pets. Even after it has been used, the patch contains active medicine that may be harmful if accidentally applied or ingested. Notify the HCP if you are experiencing side effects such as dizziness or slow pulse rate. Do not remove the patch without discussing this with the HCP as rebound hypertension can occur. Educational objective: The nurse should teach a client receiving a clonidine patch to: Apply patch to a dry hairless area on the upper arm or chest (but don’t shave right before) Wash hands before and after application Rotate sites with each new patch application Discard patch away from children or pets with sticky sides folded together (in half) Never wear more than 1 patch at a time Never stop using the patch abruptly Furosemide Loop diuretics (eg, furosemide [Lasix], bumetanide [Bumex]) are "potassium-wasting" diuretics, meaning that clients may experience potassium loss and hypokalemia. - Hypokalemia in a client with heart failure creates a risk for life-threatening cardiac dysrhythmias. - Therefore, clients taking loop diuretics usually require potassium supplementation. o Potassium is an erosive substance that can cause pill-induced esophagitis. To prevent esophageal erosion, the client should take potassium tablets with plenty of water (at least 4 oz) and remain sitting upright for ≥30 minutes after ingestion. This prevents the tablet from becoming lodged in the esophagus or refluxing from the stomach o Pill-induced esophagitis is also common with tetracyclines (eg, doxycycline) and bisphosphonates ("dronates": alendronate, ibandronate, pamidronate, risedronate), so clients taking these medications should be given similar instructions. Nursing interventions: - Monitor the client's vital signs (especially BP), serum electrolytes (potassium), and kidney function tests (blood urea nitrogen, creatinine) prior to administration to prevent side effects such as hypokalemia, hypotension, and kidney injury. - IV furosemide may cause ototoxicity, particularly when high doses are administered in clients with compromised renal function. The rate of administration should not exceed 4 mg/min in doses >120 mg. To determine the correct rate of administration for the dose above, use the following formula: (160 mg) / (4 mg/min) = 40 min o High doses of IV furosemide should be administered slowly to prevent ototoxicity. Note: - Bradycardia is an adverse effect of beta blockers (eg, metoprolol, atenolol), calcium channel blockers (eg, verapamil), and digoxin. It is not an adverse effect of furosemide. - Hypokalemia is common with furosemide administration due to the potassium-wasting effects of this loop diuretic. However, slower infusion is unlikely to prevent this adverse effect. - Although nephrotoxicity can occur with IV furosemide administration, it is dependent on the dose, not the rate of administration. Bumetanide Bumetanide is a potent loop diuretic (eg, furosemide, torsemide) used to treat edema associated with heart failure and liver and renal disease. - - Most clients with heart failure are prescribed a loop diuretic (eg, furosemide, torsemide, bumetanide) to reduce fluid retention. If the client has signs and symptoms of excessive fluid accumulation, the nurse will need to assess the situation by asking the client about dietary and fluid intake, adherence to prescribed medications, and the presence of any other associated symptoms (eg, shortness of breath). If the client is stable, the nurse may anticipate the need to increase the dosage of the prescribed loop diuretic (eg, bumetanide). The diuretic inhibits reabsorption of sodium and water from the tubules and promotes renal excretion of water and potassium. The nurse should question the bumetanide prescription as the client with heart failure has hypokalemia (potassium <3.5 mEq/L [3.5 mmol/L]) and is already at increased risk for life-threatening cardiac dysrhythmias associated with this electrolyte imbalance NOTE: - Isoniazid is a first-line antitubercular drug used to treat latent or active tuberculosis. The nurse should question this prescription as increased liver function tests (eg, alanine aminotransferase, aspartate aminotransferase) can indicate development of drug-induced hepatitis (Option 4). - Calcium acetate (PhosLo) is a phosphate binder used to treat hyperphosphatemia (normal phosphorous: 2.4-4.4 mg/dL [0.78-1.42 mmol/L]) in clients with chronic kidney disease. Calcium acetate lowers the serum phosphorous level by binding to dietary phosphate and excreting it in feces. - Carvedilol (Coreg) is a beta blocker used to improve cardiac output and slow the progression of heart failure. B-type natriuretic peptide (BNP) (normal: <100 pg/mL [100 pmol/L]) is secreted from the ventricles in response to the increased ventricular stretch. Elevated BNP is expected in a client with heart failure; the nurse need not question this prescription. - Metronidazole (Flagyl) is the first-line anti-infective drug used to treat infectious diarrhea caused by Clostridium difficile. Leukocytosis is expected with this bacterial infection. - Losartan, valsartan, and candesartan (sartans) are the commonly used angiotensin II receptor blockers. They are used in clients who cannot take ACE inhibitors (eg, lisinopril, ramipril). They block the renin-angiotensin-aldosterone system but will not affect the fluid status of the client with acute heart failure. Isosorbide (nitrate) and hydralazine are used in African American clients with heart failure; this combination decreases cardiac workload by reducing preload and afterload. However, it does not decrease excess fluid. - Potassium-sparing diuretics (eg, spironolactone, amiloride, triamterene eplerenone) Potassium-sparing diuretics (eg, spironolactone, amiloride, triamterene eplerenone) are generally very weak diuretics and antihypertensives. - However, they are useful when combined with thiazide diuretics to reduce potassium (K+) loss. Thiazide diuretics can cause hypokalemia when used as monotherapy. o Potassium-sparing diuretics (eg, spironolactone, amiloride, triamterene, eplerenone) are often combined with thiazide diuretics to reduce potassium loss. - A potassium level of 4.2 mEq/L (4.2 mmol/L) falls in the normal range (3.5-5.0 mEq/L [3.5-5.0 mmol/L]), which indicates that spironolactone has been effective in preventing hypokalemia in this client receiving a thiazide diuretic (eg, hydrochlorothiazide, chlorthalidone) (Option 2). Severe hyperkalemia High potassium >7.0 mEq/L requires urgent treatment. Severe hyperkalemia increases the risk for life-threatening ventricular dysrhythmias (eg, ventricular tachycardia and fibrillation, asystole). - IV administration of 50 mL 50% dextrose with 10 units of regular insulin is the priority intervention as it is most effective in reducing the potassium level quickly. The insulin temporarily shifts the potassium from the extracellular fluid back into the intracellular fluid. The dextrose prevents hypoglycemia associated with the increase of insulin in the body and can be eliminated if the client has hyperglycemia - If the client has ECG changes (eg, tall peaked T waves), calcium gluconate should be given before insulin/dextrose. This will stabilize the cardiac muscle until the potassium level can be reduced with insulin/dextrose. Potassium chloride - hypokalemia Treatment of hypokalemia may require an IV infusion of potassium chloride (KCL). The infusion rate should not exceed 10 mEq/hr (10 mmol/hr). Therefore, IVPB KCL must be given via an infusion pump so the rate can be regulated. IV KCL should be diluted and never given in a concentrated amount. Furthermore, too rapid infusion can cause cardiac arrest. The charge nurse would need to intervene if the new nurse was attempting to administer IVPB KCL via gravity infusion instead of a pump. - - The recommended rates for an intermittent IV infusion of potassium chloride (KCl) are no greater than 10 mEq (10 mmol) over 1 hour when infused through a peripheral line and no greater than 40 mEq/hr (40 mmol/hr) when infused through a central line (follow facility guidelines and policy). If the nurse were to administer the medication as prescribed, the rate would exceed the recommended rate of 10 mEq/hr (10 mmol/hr) (ie, 10 mEq [10 mmol] over 30 minutes = 20 mEq/hr [20 mmol/hr]). A too rapid infusion can lead to pain and irritation of the vein and postinfusion phlebitis. Contacting the health care provider to verify this prescription is the priority action. Note: - Hydromorphone is indicated for moderate to severe pain. A pain rating of 7 would warrant its administration. - Occasional premature ventricular contractions (PVCs) in the normal heart are not significant but PVCs in a pt with coronary artery disease or myocardial infarction indicate ventricular irritability and may lead to life-threatening dysrhythmia such as ventricular tachycardia. - With the complete removal of the lung in a pneumonectomy, the client should be positioned on the surgical side to promote adequate expansion and ventilation of the remaining lung. Licorice root Licorice root is an herbal remedy sometimes used for GI disorders such as stomach ulcers, heartburn, colitis, and chronic gastritis. Clients with heart disease or hypertension should be cautious about using licorice root. - When used in combination with a diuretic such as hydrochlorothiazide, it can increase potassium loss, leading to hypokalemia. Hypokalemia can cause dangerous cardiac dysrhythmias. Thiazide diuretics are considered "potassium-wasting" diuretics, so this client is already at risk for hypokalemia. The addition of licorice root could potentiate the potassium loss. The nurse should discourage the client from using this herbal remedy and report the client's use to the PHCP. Heprin / Warfarin Heparin administered IV or Sub q. - The duration of the drug 2-6 hours intravenously and 8-12 hours subcutaneously. - It is measured by the aPTT (activated partial thromboplastin time) laboratory value. - The goal during anticoagulation therapy is a PTT 1.5-2 times the normal reference range of 25-35 seconds o A PTT value >100 seconds would be considered critical - An aPTT value above the therapeutic range places the client at risk for excess bleeding. just held instead of administering an antidote when the values are too high. Warfarin (Coumadin) is taken orally - Onset/therapeutic effects reached after 2-7 days. - It is measured by prothrombin time (PT) or International Normalized Ratio (INR). - Clients on warfarin must eat the same amount of dark green leafy vegetables because these foods contain vitamin K and will alter the effects of warfarin. - Vitamin K = antidote for warfarin o The heparin administration would need to be stopped or decreased. - Protamine sulfate = antidote for heparin o However, due to the short half-life of heparin, usually the dose is NOTE: Warfarin begins to take effect in 48-72 hours and then takes several more days to achieve a maximum effect. Therefore, an overlap of a parenteral anticoagulant like heparin with warfarin is required. - The typical overlap is 5 days or until the INR reaches the therapeutic level. The nurse will need to explain this overlap of the 2 medications to the client and the spouse. Heprin Unfractionated heparin is used as an anticoagulant in unstable angina. It prevents the conversion of fibrinogen to fibrin and prothrombin to thrombin, both components of clot formation. - The normal aPTT is 25–35 seconds. - Heparin infusions are titrated to obtain a therapeutic value of aPTT, typically 1.5–2 times the normal value. Therefore, the therapeutic value for aPTT is 46–70 seconds. With a heparin drip infusion, the goal is to reach the therapeutic range of the drug's effect and not the "normal" or "control value." - Once the therapeutic effect range has been reached (usually 1.5-2.0 times the control value), it usually remains within this range without titrating the heparin infusion rate. Heparin has a short duration (approximately 2-6 hours IV). - Therefore, if it is not being infused, the aPTT level will go back to the control value (aPTT level without administration of anticoagulants). - In addition, the volume of heparin being infused is small (because the standard concentration is 100 units/mL) so it is possible to miss an infiltration. - PTT is used to measure the therapeutic effect of heparin IV infusion (should be 1.5-2.0 times the control value). Due to the short half-life, the possibility of infiltration should be assessed if the PTT level suddenly drops despite heparin administration. There are 2 forms of heparin-induced thrombocytopenia: - The first form (platelets >100,000/mm3) and normalizes within a few days - The second form (platelets <40,000/mm3) is a life-threatening autoimmune process that requires immediate heparin discontinuation. Warfarin A therapeutic INR level is dependent on the reason the client is receiving the warfarin (an anticoagulant). A therapeutic INR for most conditions is 2-3 but can be up to 3.5 for heart valve disease. However, it is never between 4 and 5 - Typically the therapeutic INR range should be 1.5-2 times the normal "control" value (INR of 23) for medical reasons such as deep vein thrombosis, atrial fibrillation, or stroke. - An INR of 3 to 3.5 is desired for the client with a mechanical heart valve. - An INR of 5.0 or higher places the client at risk for bleeding and requires a dosage adjustment of the warfarin or the administration of vitamin K as an antidote. Nursing interventions: - Intestinal bacteria produce vitamin K; most antibiotics kill these bacteria, leading to vitamin K deficiency. Warfarin is a vitamin K antagonist; therefore, INR would overshoot in the setting of vitamin K deficiency, placing the client at risk for bleeding (ANTIOBIOTICS can affect INR level) - Leafy-green vegetables contain a high amount of vitamin K, which may lower a client's INR and make it difficult to maintain a therapeutic INR. Clients do not have to avoid consumption of leafy-green vegetables, but they should eat a consistent quantity and have their INR checked periodically - It is important to take warfarin at the same time daily to maintain a consistent therapeutic drug level. o Clients should call their health care provider if they miss or forget to take a warfarin dose. Double dosing is contraindicated. - Clients are educated to avoid aspirin, drugs containing aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and alcohol when taking warfarin due to an increased risk for bleeding - Warfarin is usually administered for 3-6 months following PE (pulmonary embolism) to prevent further thrombus formation. A longer duration (lifelong) of anticoagulation is recommended in clients with recurrent PE. Prothrombin time and INR must be monitored regularly to adjust the dose and maintain a therapeutic anticoagulant level. - Clients should be taught to avoid trauma or injury to decrease the risk for bleeding. o Preventive measures include gently brushing teeth with a soft-bristled toothbrush o Avoid use of alcohol-based mouthwash o Avoid contact sports or rollerblading, and using a straight razor (use electric razor instead). o Flossing should also be avoided in general, but waxed dental floss may be used with care in some pts. Vitamin K-rich foods: Large amounts of Vit K can decrease the anticoagulant effects of warfarin therapy. Clients are not instructed to remove those foods from their diet but are encouraged to be consistent in the intake of foods high in vit K - Leafy green vegetables - Asparagus - Broccoli - Kale, Brussels sprout - Spinach - Several beverages also affect warfarin therapy. Green tea, grapefruit juice, and cranberry juice may alter its anticoagulant effects. Warfarin (antidote Vitamin K) Vitamin K (phytonadione) is admin as an antidote for warfarin-related bleeding. This medication prescription should be questioned as vitamin K reverses the anticoagulant effect of warfarin, and the client's coagulation studies are in the therapeutic range (aPTT 46-70 sec, INR 2-3). Warfarin (Coumadin) is a vitamin K antagonist used for long-term anticoagulation that is started about 5 days before a continuous heparin infusion is discontinued. An overlap of the parenteral and oral anticoagulant is required for about 5 days as this is the time it takes warfarin to reach therapeutic level. This is an appropriate prescription for this client. Educational objective: Anticoagulants stop thrombus formation by interfering with the coagulation cascade. Parenteral heparin and oral warfarin affect the clotting cascade differently; therefore, a 5-day overlap for the 2 drugs is required. This allows warfarin to reach a therapeutic level before the continuous heparin infusion is stopped. Enoxaparin (Lovenox) Enoxaparin is a low-molecular-weight heparin used in the prevention and treatment of DVT. - It is administered as a deep subcutaneous injection and is usually given in the abdomen. - Clients or family members may be taught how to administer the injections. The injection should be made on the right or left side of the abdomen, at least 2 in from the umbilicus. o An inch of skin should be pinched up and the injection made into the fold of skin with the needle inserted at a 90-degree angle. Educational objective: The nurse can teach a client or caregiver to inject subcutaneous enoxaparin. The appropriate site of injection is on the right or left side of the abdomen at least 2 in from the umbilicus. Antiplatelet agents (eg, clopidogrel, ticagrelor, prasugrel, aspirin) Antiplatelet agents (eg, clopidogrel, ticagrelor, prasugrel, aspirin) prevent platelet aggregation and are given to clients to prevent stent re-occlusion. - Antiplatelet therapy (eg, aspirin, clopidogrel, prasugrel, ticagrelor) is initiated to prevent platelet aggregation in clients at risk for myocardial infarction, stroke, or other thrombotic events. Nursing interventions: - Antiplatelets prolong bleeding time and should not be taken by clients with a bleeding peptic ulcer, active bleeding, or intracranial hemorrhage. - Ginkgo biloba also interferes with platelet aggregation and can cause increased bleeding time. o Antiplatelet agents and Ginkgo biloba should not be taken together. If this were to occur, this client would be at an increased risk for bleeding. This information should be reported to the prescribing health care provider before the client is discharged. - Antiplatelets increase bleeding risk, so clients should be assessed for bruising, tarry stools, and other signs of bleeding (eg, hematuria, bleeding gums, epistaxis). Clients should be taught to self-monitor for these signs. o In addition, they may cause thrombotic thrombocytopenic purpura, so platelets should be monitored periodically (Option 1) This blood pressure is slightly elevated, but is unaffected by antiplatelet agents. (Option 2) Normal heart rate is between 60/min-100/min. (Option 3) This is a normal platelet count (150,000/mm3-400,000/mm3 [150-400 x 109/L]). Thrombolytic therapy Thrombolytic therapy is aimed at stopping the infarction process of an acute myocardial infarction, this is done by dissolving the thrombus in the coronary artery, and reperfusion of the myocardium. - This treatment is used in facilities without an interventional cardiac catheterization laboratory or when one is too far away to transfer the client safely. - Client selection is important because all thrombolytics lyse the pathologic clot and may lyse other clots (eg, postoperative site). Minor or major bleeding can be a complication of therapy. - Inclusion criteria for thrombolytic therapy are chest pain typical of acute MI 6 hours or less in duration, 12-lead electrocardiogram findings consistent with acute MI, and no absolute contraindications. o i.e., notify MD if pt has a cerebral aneurysm as admin. the thrombolytic could lead to rupture Educational objective: The client being considered for thrombolytic therapy should be screened for absolute and relative contraindications. The nurse should immediately notify the HCP if the client reports a history of cerebral aneurysm as it is an absolute contraindication to the use of thrombolytics. Thrombolytic therapy can stop the infarction process in a STEMI and dissolve the clot, allowing for reperfusion of the myocardium. It is given within the first 12 hours of symptom onset. - The most reliable clinical indicator of reperfusion is a return of the ST segment to the baseline on an ECG Glycoprotein (GP) IIb/IIIa receptor inhibitors (eg, abciximab, eptifibatide, tirofiban) Used as platelet inhibitors to prevent the occlusion of treated coronary arteries during percutaneous coronary intervention procedures and prevent acute ischemic complications. Side effects: - GP IIb/IIIa receptor inhibitors can cause serious bleeding. Nursing interventions: - The nurse should closely monitor the client for any bleeding at the groin puncture site after the percutaneous coronary intervention. - The nurse should check the client's baseline complete blood count (eg, hemoglobin, platelet count). Some clients may develop serious thrombocytopenia within a few hours, further increasing the bleeding risk. - Hypotension, tachycardia, changes in heart rhythm, blood in the urine, abdominal/back pain, mental status changes, and black tarry stools may also indicate internal bleeding and should be monitored carefully when GP IIb/IIIa receptor inhibitors are administered - During and after the infusion of GP IIb/IIIa receptor inhibitors, no traumatic procedures (initiation of IV sites, intramuscular injections) should be performed due to the risk of bleeding. Fondaparinux (Arixtra) Fondaparinux (Arixtra), unfractionated heparin, and low molecular weight heparin (eg, enoxaparin, dalteparin) are anticoagulants commonly used for deep vein thrombosis and pulmonary embolism prophylaxis after hip/knee replacement or abdominal surgery. - However, fondaparinux is not administered until more than 6 hours after any surgery, and anticoagulants are not given while an epidural catheter is in place Fondaparinux is associated with epidural hematoma. Any bleeding in the tight epidural space, which does not expand, could result in spinal cord compression. Signs of epidural spinal hematoma can include severe back pain and paralysis. Thrombin inhibitors dabigatran (Pradaxa) Thrombin inhibitors such as dabigatran (Pradaxa) reduce the risk of clot formation and stroke in clients with chronic atrial fibrillation. - The nurse should educate the client about implementing bleeding precautions (eg, using a soft-bristle toothbrush, shaving with an electric razor). o Red urine or blood in the stool may indicate internal bleeding caused by thrombin inhibitors. The client should report these symptoms to the health care provider. - Dabigatran capsules should be kept in their original container or blister pack until time of use to prevent moisture contamination - Thrombin inhibitor capsules should not be crushed or opened as crushing pills increases absorption and risk of bleeding. Digoxin Digoxin (Lanoxin) is a cardiac glycoside that increases cardiac contractility but slows the heart rate and conduction. It is used in heart failure (to increase cardiac output) and atrial fibrillation (to reduce the heart rate). Drug toxicity is common with digoxin due to its narrow therapeutic range (0.5-2.0) Signs and symptoms of digoxin toxicity include the following: 1. Gastrointestinal symptoms (eg, anorexia, nausea, vomiting, abdominal pain) are frequently the earliest symptoms 2. Neurologic manifestations (eg, lethargy, fatigue, weakness, confusion) 3. Visual symptoms are characteristic and include alterations in color vision, scotomas “yellowhalos”, or blindness 4. Cardiac arrhythmias – most dangerous - Digoxin toxicity can result in bradycardia and heart block. Clients are instructed to check their pulse and report to the HCP if it is low or has skipped beats. 5. Hypokalemia… However, in the absence of other factors, potassium does not need to be increased just because a client is on digoxin. If the client also takes some other potassiumdepleting medications, such as diuretics, potassium supplements may be needed. Nursing interventions: - Teach the pt that there is no need to routinely check blood pressure before taking digoxin as it does not affect blood pressure. Clients should check the pulse prior to administration. - For a client receiving digoxin, the apical heart rate should be assessed for 1 full minute. If the heart rate is <60/min, the nurse should consider holding the dose based on the health care provider's instructions. - In addition to the apical heart rate, digoxin and potassium levels should be assessed if available. Digoxin has a very narrow therapeutic range (0.5-2.0 ng/mL), and hypokalemia can potentiate digoxin toxicity (>2.0 ng/mL). Pt teaching for administration of digoxin: Inform pt of the pulse rate at which to hold the medication based on HCP prescription. o In general, digoxin is held if pulse <90-110/min for infants and young children or <70/min for an older child or <60 for adults Administer oral liquid in the side and back of the mouth (for infants) Do not mix the drug with food or liquids as the refusal to take these would result in inaccurate intake of medication If a dose is missed, do not give an extra dose or increase the dose. Stay on the same schedule. If more than 2 doses are missed, notify the HCP If the pt vomits, do not give a second dose. o Nausea, vomiting, or slow pulse rate could indicate toxicity. Notify the HCP Give water or brush the client's teeth after administration to remove the sweetened liquid Estrogen therapy Clients taking estrogen therapy are at an increased risk for hypercoagulability and thromboembolic complications. - Signs or symptoms of deep venous thrombosis (eg, leg swelling, redness, pain) should be reported to the health care provider immediately. Nursing interventions: - Estrogen places clients at an increased risk for developing blood clots, due to hypercoagulability, and therefore adverse thrombotic events (eg, stroke, myocardial infarction, venous thromboembolism). - Signs and symptoms of deep venous thrombosis (eg, leg swelling, redness, pain) should be reported to HCP immediately. - The client should also be taught smoking cessation and diabetes management, and to avoid long periods of immobilization to further decrease the risk of thrombus formation. - Transgender women clients are often prescribed antiandrogen medications (eg, spironolactone) to reduce androgen levels (eg, testosterone) and estrogen therapies to induce feminizing traits (eg, breast enlargement, reduction in body hair, decrease in testicular size and erectile function). o Normal side effects of estrogen therapy: breast tenderness and enlargement, generalized weight gain during estrogen therapy is caused by fluid retention, nausea and vomiting can occur with estrogen therapy and may be remedied with dosage adjustments or taking oral estrogen with food. Drugs that cause Orthostatic Hypotension Drugs commonly associated with orthostatic hypotension include: 1. Most antihypertensive medications, particularly sympathetic blockers such as beta blockers (eg, metoprolol) and alpha blockers (eg, terazosin) 2. Antipsychotic medications (eg, olanzapine, risperidone) and antidepressants (eg, selective serotonin reuptake inhibitors) 3. Volume-depleting medications such as diuretics (eg, furosemide, hydrochlorothiazide) 4. Vasodilator medications (eg, nitroglycerine, hydralazine) 5. Narcotics (eg, morphine) Clients at risk for developing orthostatic hypotension should be instructed to: 1. Take medications at bedtime, if approved by the health care provider 2. Rise slowly from a supine to standing position, in stages (especially in the morning) 3. Avoid activities that reduce venous return and worsen orthostatic hypotension (eg, straining, coughing, walking in hot weather) 4. Maintain adequate hydration Note: - - Muscle cramps and liver injury, not orthostatic hypotension, are the major adverse effects of statin medications (eg, atorvastatin). Major side effects of metformin are lactic acidosis and gastrointestinal disturbances (metallic taste in the mouth, nausea, and diarrhea). Unlike insulin, metformin does not usually cause hypoglycemia. Orthostatic hypotension is not a common side effect. Proton pump inhibitors (eg, omeprazole) are associated with increased risk of pneumonia, Clostridium difficile diarrhea, and calcium malabsorption (osteoporosis), but not orthostatic hypotension. Drugs that cause bradycardia The client has sinus bradycardia, which can be caused by: Drugs (eg, beta blockers, calcium channel blockers, digoxin). Consider withholding beta blockers if systolic blood pressure <100 mm Hg or heart rate <60 and notify the provider. o Medications that decrease the heart rate should be held in clients with bradycardia. These include beta blockers such as metoprolol and timolol (including eye drops) and some types of calcium channel blockers (eg, diltiazem, verapamil). Vagal stimulation (eg, carotid sinus massage, Valsalva maneuver) Diseases (eg, hypothyroidism, myocardial infarction, increased intracranial pressure) The clinical significance of sinus bradycardia depends on how the client tolerates the effect of slow heart rate on cardiac output. Sinus bradycardia is usually asymptomatic. - However, symptomatic bradycardia can manifest as pale, cool skin; hypotension; weakness; confusion; dyspnea; chest pain; and syncope. Sumatriptan Sumatriptan is a selective serotonin agonist prescribed to treat migraine headaches, which are thought to be caused by dilated cranial blood vessels. - Triptan drugs, like sumatriptan, work by constricting cranial blood vessels, and clients should be instructed to take a dose at the first sign of a migraine to help prevent and relieve symptoms. Contraindications: - Sumatriptan is contraindicated in clients with coronary artery disease and uncontrolled hypertension because its vasoconstrictive properties increase the risk of angina, hypertensive urgency, decreased cardiac perfusion, and acute MI. The nurse should question the client about a past medical history of uncontrolled hypertension and report this to the HCP Educational objective: Sumatriptan relieves migraines by constricting dilated cranial blood vessels. Sumatriptan is contraindicated in clients with coronary artery disease and uncontrolled hypertension because the vasoconstrictive effects can cause hypertensive urgency, angina, decreased cardiac perfusion, and acute myocardial infarction. Polypharmacy Polypharmacy and physiologic changes associated with aging (eg, decreased renal and hepatic function, orthostatic hypotension, decreased visual acuity, balance and gait problems) place the elderly at increased risk of adverse drug effects. The Beers criteria provide a list that classifies potentially harmful drugs to avoid or administer with caution in the elderly due to the high incidence of drug-induced toxicity, cognitive dysfunction, and falls. Some commonly used medications in this list include antipsychotics, anticholinergics, antihistamines, antihypertensives, benzodiazepines, diuretics, opioids, and sliding insulin scales. Note: - Amitriptyline (Elavil) is a tricyclic antidepressant used to treat depression and neuropathic pain; its anticholinergic properties may cause dry mouth, constipation, blurred vision, and dysrhythmias - Chlorpheniramine (ChlorTrimeton) is a sedating histamine H1 antagonist used to treat allergy symptoms. Increased central nervous system effects (eg, drowsiness, dizziness) may occur due to its reduced clearance in the elderly - Lorazepam (Ativan) is a benzodiazepine with a long half-life (10-17 hours). Side effects include drowsiness, dizziness, ataxia, and confusion - Docusate is a stool softener and does not increase risk of injury in the elderly. - Donepezil (Aricept) is an acetylcholinesterase inhibitor used to treat Alzheimer dementia. It does not place the elderly at increased risk of adverse effects.
