NCLEX: Physiological Integrity: Nursing Care of the Adult Client

Physiological Integrity: Nursing Care of the Adult Client: RESPIRATORY SYSTEM

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

IX. ASTHMA: sometimes called reactive airway disease (RAD) or reversible obstructive airway disease (ROAD); a complex inflammatory process that causes increased airway resistance and, over time, airway tissue damage. Characterized by airway inflammation and hyperresponsiveness to a variety of stimuli such as
allergens, cold air, dust, smoke, exercise, medications (e.g., aspirin), some food additives, and viral infections.
Immunologic asthma occurs in childhood and follows other allergic disease. Nonimmunologic asthma occurs in adulthood and is associated with a history of recurrent respiratory tract infections.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

A. Pathophysiology: triggers initiate the release of inflammatory mediators such as histamine, which produce airway obstruction through smooth muscle constriction, microvascular leakage, mucus plugging, and swelling. This process involves six sequential steps: (1) triggering—the allergic or antigenic stimuli activate the inflammatory (mast) cells; (2) these mast cells signal the systemic immune system to release proinflammatory
substances; (3) migration of circulating inflammatory cells to regions of inflammation in the respiratory tract; (4) migrating cells are activated by the proinflammatory mediators; (5) this results in tissue damage; and (6) resolution. The airways of many clients with asthma are chronically inflamed.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Immunologic, or allergic asthma in persons who are atopic (hypersensitivity state that is subject to hereditary influences); immunoglobulin E (IgE) usually elevated.
  • Nonimmunologic, or nonallergic asthma in persons who have a history of repeated respiratory tract infections; age usually more than 35 years.
  • Mixed, combined immunologic and nonimmunologic; any age, allergen or nonspecific stimuli.

B. Risk factors:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • History of allergies to identified or unidentified irritants; seasonal and environmental inhalants.
  • Recurrent respiratory infection.

C. Assessment:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Subjective data:
    a. History: upper respiratory infection (URI), rhinitis, allergies, family history of asthma.
    b. Increasing tightness of the chest → dyspnea (Differentiating Between Causes of Dyspnea).
    c. Anxiety, restlessness.
    d. Attack history:
    (1) Immunologic: contact with allergen to which person is sensitive; seen most often in children and young adults.
    (2) Nonimmunologic: develops in adults older than 35 years; aggravated by infections of the sinuses and respiratory tract.
  • Objective data:
    a. Peak flowmeter level drops.
    b. Respiratory assessment: increased rate, audible expiratory wheeze (also inspiratory when severe) on auscultation, hyperresonance on percussion, rib retractions, use of accessory muscles on inspiration.
    c. Tachycardia, tachypnea.
    d. Cough: dry, hacking, persistent.
    e. General appearance: pallor, cyanosis, diaphoresis, chronic barrel chest, elevated shoulders, flattened malar bones, narrow nose, prominent upper teeth, dark circles under eyes, distended neck veins, orthopnea.
    f. Expectoration of tenacious mucoid sputum.
    g. Diagnostic tests:
    (1) Forced vital capacity (FVC): decreased.
    (2) Forced expiratory volume in 1 second (FEV1): decreased.
    (3) Peak expiratory flow rate: decreased.
    (4) Residual volume: increased.
    h. Laboratory data: blood gases—elevated PCO2; decreased PO2, pH.Emergency note: Persons severely affected may develop status asthmaticus, a life-threatening asthmatic attack in which symptoms of asthma continue and do not respond to usual treatment. Could lead to respiratory failure and hypoxemia.

D. Analysis/nursing diagnosis:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Ineffective airway clearance related to tachypnea.
  • Impaired gas exchange related to constricted bronchioles.
  • Anxiety related to breathlessness.
  • Activity intolerance related to persistent cough.
  • Knowledge deficit (learning need) related to causal factors and self-care measures.

E. Nursing care plan/implementation:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Goal: promote pulmonary ventilation.
    a. Position: high-Fowler’s for comfort.
    b. Medications as ordered:
    (1) Rescue medications: corticosteroids (e.g., prednisone, methylprednisolone [Medrol]; beta-adrenergic agonists, such as albuterol [Proventil, Ventolin], metaproterenol [Alupent, Metaprel]).
    (2) Maintenance medications: nonsteroidal anti-inflammatory drugs: cromolyn (Intal), nedocromil (Tilade); corticosteroids: beclomethasone (Vanceril), triamcinolone (Azmacort); leukotriene inhibitors/receptor
    antagonists: zafirlukast (Accolate), zileuton (Zyflo); theophylline (Theo-Dur, Slo-Bid, Uni-Dur, theophylline ethylenediamino [Aminophylline]); anticholinergic: ipratropium (Atrovent); beta agonists: salmeterol (Serevent); mast cell stabilizers: nedocromil sodium (Tilade).
    (3) Antibiotics to control infection.
    c. Oxygen therapy with increased humidity as ordered.
    d. Frequent monitoring for respiratory distress.
    e. Rest periods and gradual increase in activity.
  • Goal: facilitate expectoration.
    a. High humidity.
    b. Increase fluid intake.
    c. Monitor for dehydration.
    d. Respiratory therapy: IPPB.
  • Goal: health teaching to prevent further attacks.
    a. Identify and avoid all asthma triggers.
    b. Teach importance of peak flowmeter readings.
    c. Medications—when to use, how to use, side effects, withdrawals.
    d. Using a metered-dose inhaler:
    (1) Shake vigorously.
    (2) Position inhaler about 1 inch in front of mouth. Use 2 fingers to measure the 1-inch distance.
    (3) A spacer is recommended: connect spacer device, shake, press down the canister; place lips on the mouthpiece and take a slow deep breath through mouth. Without spacer: breathe out all the way, open
    mouth wide, and take a slow deep breath through mouth. Press down the canister and continue to breathe in.
    (4) Once lungs are full, hold breath for 10 seconds if possible.
    (5) Exhale normally through pursed lips                                                                                                       (6) Wait 1 to 2 minutes between puffs. Depending on the particular medication, may need to rinse mouth with water or mouthwash after each treatment.
    e. Methods to facilitate expectoration—increase humidity, postural drainage when appropriate, percussion techniques.
    f. Breathing techniques to increase expiratory phase.
    g. Stress-management techniques.
    h. Importance of recognizing early signs of asthma attack and beginning treatment immediately.
    i. Steps to take during an attack.

F. Evaluation/outcome criteria:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • No complications.
  • Has fewer attacks.
  • Takes prescribed medications, avoids infections.
  • Adjusts lifestyle.
  • Pulmonary function tests return to normal.

X. BRONCHITIS: acute or chronic inflammation of bronchus resulting as a complication from colds and flu. Acute bronchitis is caused by an extension of upper respiratory infection, such as a cold, and can be given to others. It can also result from an irritation from physical or chemical agents. Chronic bronchitis is characterized by hypersecretion of mucus and chronic cough for 3 months per year for 2 consecutive years.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

A. Pathophysiology: bronchial walls are infiltrated with lymphocytes and macrophages; lumen becomes obstructed due to decreased ciliary action and repeated bronchospasms. Hyperventilation of alveolar sacs occurs. Long-term condition results in respiratory acidosis, recurrent pneumonitis, emphysema, or cor pulmonale.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

B. Risk factors:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Smoking.
  • Repeated respiratory infections.
  • History of living in area where there is much air pollution.

C. Assessment:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Subjective data:
    a. History: recurrent, chronic cough, especially when arising in the morning.
    b. Anorexia.
  • Objective data:
    a. Respiratory:
    (1) Shortness of breath.
    (2) Use of accessory muscles.
    (3) Cyanosis, dusky complexion: “blue bloater.”
    (4) Sputum: excessive, nonpurulent.
    (5) Vesicular and bronchovesicular breath sounds; wheezing.
    b. Weight loss.
    c.Fever.                                                                                                                                                          d. Pulmonary function tests:
    (1) Decreased forced expiratory volume.
    (2) PaO2 less than 90 mm Hg; PaCO2 greater than 40 mm Hg.
    e. Laboratory data:
    (1) RBC count: elevated to compensate for hypoxia (polycythemia).
    (2) WBC count: elevated to fight infection.

D. Analysis/nursing diagnosis:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Ineffective airway clearance related to excessive sputum.
  • Ineffective breathing pattern related to need to use accessory muscles for breathing.
  • Impaired gas exchange related to shortness of breath.
  • Activity intolerance related to increased energy used for breathing.

E. Nursing care plan/implementation:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Goal: assist in optimal respirations.
    a. Increase fluid intake.
    b. IPPB, chest physiotherapy.
    c. Administer medications as ordered:
    (1) Bronchodilators.
    (2) Antibiotics.
    (3) Bronchial detergents, liquefying agents.
  • Goal: minimize bronchial irritation.
    a. Avoid respiratory irritants (e.g., smoke, dust, cold air, allergens).
    b. Environment: air-conditioned, increased humidity.
    c. Encourage nostril breathing rather than mouth breathing.
  • Goal: improve nutritional status.
    a. Diet: soft, high calorie.
    b. Small, frequent feedings.
  • Goal: prevent secondary infections.
    a. Administer antibiotics as ordered.
    b. Avoid exposure to infections, crowds.
  • Goal: health teaching.
    a. Avoid respiratory infections.
    b. Medications: desired effects and side effects.
    c. Methods to stop smoking.
    d. Rest and activity balance.
    e. Stress management.

F. Evaluation/outcome criteria:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Stops smoking.
  • Acid-base balance maintained.
  • Respiratory infections less frequent.

XI. ACUTE ADULT RESPIRATORY DISTRESS
SYNDROME (ARDS) (formerly called by other names, including shock lung): noncardiogenic pulmonary
infiltrations resulting in stiff, wet lungs and refractory hypoxemia in an adult who was previously healthy. Acute hypoxemic respiratory failure without hypercapnea.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

A. Pathophysiology: damage to alveolar capillary membrane, increased vascular permeability creating noncardiac pulmonary edema, and impaired gas exchange; decreased surfactant production →atelectasis; severe hypoxia; refractory to ↑ FiO2 →possible death.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

B. Risk factors:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Primary:
    a. Shock, multiple trauma.
    b. Infections.
    c. Aspiration, inhalation of chemical toxins.
    d. Drug overdose.
    e. Disseminated intravascular coagulation (DIC).
    f. Emboli, especially fat emboli.
  • Secondary:
    a. Overaggressive fluid administration.
    b. Oxygen toxicity.
    c. Mechanical ventilation.

C. Assessment:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Subjective data:
    a. Restlessness, anxiety.
    b. History of risk factors.
    c. Severe dyspnea.
  • Objective data:
    a. Cyanosis.
    b. Tachycardia.
    c. Hypotension.
    d. Hypoxemia, acidosis.
    e. Crackles.
    f. X-ray—bilateral patchy infiltrates.
    g. Death if untreated.

D. Analysis/nursing diagnosis:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Anxiety related to serious physical condition.
  • Ineffective breathing pattern related to severe dyspnea.
  • Impaired gas exchange related to alveolar damage.
  • Altered tissue perfusion related to hypoxia.

E. Nursing care plan/implementation:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Goal: assist in respirations.
    a. May require mechanical ventilatory support to maintain respirations.
    b. May need to be transferred to ICU.
    c. May need oxygen to combat hypoxia.
    d. Suction prn.
    e. Monitor blood gas results to detect early signs of acidosis/alkalosis.
    f. If not on ventilator, assess vital signs and respiratory status every 15 minutes.
    g. Cough, deep breathe every hour.
    h. May need:
    (1) Rotation therapy and/or prone position.
    (2) Postural drainage, suction.
    (3) Bronchodilator medications.
  • Goal: prevent complications.
    a. Decrease anxiety and provide psychological care:
    (1) Maintain a calm atmosphere.
    (2) Encourage rest to conserve energy.
    (3) Emotional support.
    b. Obtain fluid balance:
    (1) Slow IV flow rate.
    (2) Diuretics: rapid acting, low dose.
    c. Monitor:
    (1) Pulmonary artery and capillary wedge pressure cardiac output.
    (2) Central venous pressure (CVP), peripheral perfusion, arterial line BP.
    (3) I&O.
    (4) Assess for bleeding tendencies, potential for disseminated intravascular coagulation.
    d. Protect from infection:
    (1) Strict aseptic technique.
    (2) Antibiotic therapy.
    (3) Deep vein thrombosis prophylaxis.
    e. Provide physiological support:
    (1) Maintain nutrition.
    (2) Skin care.
  • Goal: health teaching.
    a. Briefly explain procedures as they are happening (emergency situation can frighten client).
    b. Give rationale for follow-up care.
    c. Identify risk factors as appropriate for prevention of recurrence.

F. Evaluation/outcome criteria:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Client survives and is alert.
  • Skin warm to touch.
  • Respiratory rate within normal limits.
  • Laboratory values and pressures within normal limits.
  • Urinary output greater than 30 mL/hr.

XII. PNEUMOTHORAX: presence of air within the pleural cavity; occurs spontaneously or as a result of trauma (Pneumothorax).

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

A. Types:

  • Closed (spontaneous): rupture of a subpleural bulla, tuberculous focus, carcinoma, lung abscess, pulmonary infarction, severe coughing attack, or blunt trauma.
  • Open (traumatic): communication between atmosphere and pleural space because of opening in chest wall.
  • Tension: one-way leak; may occur during mechanical ventilation or cardiopulmonary resuscitation (CPR), or as a complication of any type of spontaneous or traumatic pneumothorax. Positive pressure within chest cavity resulting from accumulated air that cannot escape during expiration. Leads to collapse of lung, mediastinal shift, and compression of the heart and great vessels.

B. Pathophysiology: pressure builds up in the pleural space, lung on the affected side collapses, and the heart and mediastinum shift toward the unaffected lung.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

C. Assessment:

  • Subjective data:
    a. Pain:
    (1) Sharp, aggravated by activity.
    (2) Location—chest; may be referred to shoulder, arm on affected side.                                                                                                                                               b. Restlessness, anxiety.
    c. Dyspnea (Differentiating Between Causes of Dyspnea).
  • Objective data:
    a. Cough.
    b. Cessation of normal movements on affected side.
    c. Absence of breath sounds on affected side.
    d. Pallor, cyanosis.
    e. Shock.
    f. Tracheal deviation to unaffected side.
    g. X-ray: air in pleural space.

D. Analysis/nursing diagnosis:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Ineffective breathing pattern related to collapse of lung.
  • Impaired gas exchange related to abnormal thoracic movement.
  • Pain related to trauma to chest area.
  • Fear related to emergency situation.

E. Nursing care plan/implementation:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Goal: prevent damage until medical intervention available.
    a. Place sterile occlusive gauze dressing over wound.
    b. Tape dressing on three sides to allow air to escape during expiration.
    c. Place client on affected side to diminish possibility of tension pneumothorax.
  • Goal: protect against injury during thoracentesis.
    a. Provide sterile equipment.
    b. Explain procedure.
    c. Monitor vital signs for shock.
    d. Monitor for respiratory distress, mediastinal shift.
  • Goal: promote respirations.
    a. Position: Fowler’s.
    b. Oxygen therapy as ordered.
    c. Encourage slow breathing to improve gas exchange.
    d. Careful administration of narcotics to prevent respiratory depression (avoid morphine).
  • Goal: prepare client for closed chest drainage, physically and psychologically.
    a. Explain purpose of the procedure—to provide means for evacuation of air and fluid from pleural cavity; to reestablish negative pressure in pleural space; to promote lung re-expansion.
    b. Explain procedure and apparatus                                                                                                              c. Cleanse skin at tube insertion site; place client in sitting position, ensuring safety by having locked over-the-bed table for client to lean on, or have a nurse stay with client so appropriate position is maintained throughout the procedure.
  • Goal: prevent complications with chest tubes.
    a. Observe for and immediately report: crepitations (air under skin, also called subcutaneous emphysema), labored or shallow breathing, tachypnea, cyanosis, tracheal deviation, or signs of hemorrhage.
    b. Monitor for signs of infection.
    c. Ensure that tubing stays intact.
    d. Monitor proper tube function. Attach chest tube to a water-seal drainage apparatus and use wall suction for negative pressure. Monitor amount and color of tube drainage every 2 hours. Notify physician if bloody drainage exceeds 100 mL/hr. Chest drainage system should be at least 1 foot (30 cm) below the chest tube insertion site. Change dressing at tube insertion site every 48 hours. Air bubbles will continue in the water-seal chamber for 24 to 48 hours after insertion. Persistent air bubbles indicate an air leak between alveoli and pleural space. Fluctuation of fluid level is expected (when suction is off) because respiration changes the pleural pressure. If a clot forms in the tube, gently squeeze the tube, without occluding it, to move the clot, or follow specific orders as written. Make sure tube is free of kinks.
    When moving client, do not clamp tube; disconnect it from the wall suction. See key points for nursing intervention with chest tubes
    e. Change position every 1 to 2 hours.
    f. Arm and shoulder ROM.
  • Goal: health teaching.
    a. How to prevent recurrence by avoiding overexertion; avoid holding breath.
    b. Signs and symptoms of condition.
    c. Methods to stop smoking.
    d. Encourage follow-up care.

F. Evaluation/outcome criteria:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • No complications noted.
  • Closed system remains intact until chest tubes are removed.
  • Lung re-expands, breath sounds heard, pain diminished, symmetrical thoracic movements.

XIII. HEMOTHORAX: presence of blood in pleural cavity related to trauma or ruptured aortic aneurysm (see XII. PNEUMOTHORAX for assessment, analysis/nursing diagnosis, nursing care plan/implementation, and
evaluation/outcome criteria). Comparison of Pneumothorax and Hemothorax compares pneumothorax and hemothorax.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

XIV. CHEST TRAUMA
Flail chest: multiple rib fractures resulting in instability of the chest wall, with subsequent paradoxical breathing (portion of lung under injured chest wall moves in on inspiration while remaining lung expands; on expiration, the injured portion of the chest wall expands while unaffected lung tissue contracts).                                   Sucking chest wound: penetrating wound of chest wall with hemothorax and pneumothorax, resulting in lung collapse and mediastinal shift toward unaffected lung.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

A. Assessment:

  • Subjective data:
    a. Severe, sudden, sharp pain.
    b. Dyspnea.
    c. Anxiety, restlessness, fear, weakness.
  • Objective data:
    a. Vital signs:
    (1) Pulse: tachycardia, weak.
    (2) BP: hypotension.
    (3) Respirations: shallow, decreased expiratory force, tachypnea, stridor, accessory muscle breathing.
    b. Skin color: cyanosis, pallor.
    c. Chest:
    (1) Asymmetrical chest expansion (paradoxical movement).
    (2) Chest wound, rush of air through trauma site.
    (3) Crepitus over trauma site (from air escaping into surrounding tissues).
    (4) Lateral deviation of trachea, mediastinal shift.
    d. Pneumothorax: documented by absence of breath sounds, x-ray examination.
    e. Hemothorax: documented by needle aspiration by physician, x-ray examination.
    f. Shock; blood and fluid loss.
    g. Hemoptysis.
    h. Distended neck veins.

B. Analysis/nursing diagnosis:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Ineffective airway clearance related to shallow respirations.
  • Impaired gas exchange related to asymmetrical chest expansion.
  • Pain related to chest trauma.
  • Fear related to emergency situation.
  • Risk for trauma related to fractured ribs.
  • Risk for infection related to open chest wound.

C. Nursing care plan/implementation:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Goal: restore adequate ventilation and prevent further air from entering pleural cavity: MEDICAL EMERGENCY.
    a. In emergency situation: place air-occlusive dressing or hand over open wound as client exhales forcefully against glottis (Valsalva maneuver helps expand collapsed lung by creating positive intrapulmonary pressures); or place client’s weight onto affected side. Administer oxygen.
    b. Assist with endotracheal tube insertion; client will be placed on volume-controlled ventilator. (See discussion of ventilators under Oxygen Therapy in Chapter 11.)
    c. Assist with thoracentesis and insertion of chest tubes with connection to water-seal drainage as ordered.
    d. Monitor vital signs to determine early shock.
    e. Monitor blood gases to determine early acid-base imbalances.
    f. Pain medications given with caution, so as not to depress respiratory center.

D. Evaluation/outcome criteria:

  • Respiratory status stabilizes, lung re-expands.
  • Shock and hemorrhage are prevented.
  • No further damage done to surrounding tissues.
  • Pain is controlled.

XV. THORACIC SURGERY: used for bronchogenic and lung carcinomas, lung abscesses, tuberculosis, bronchiectasis, emphysematous blebs, and benign tumors.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

A. Types:

  • Thoracotomy—incision in the chest wall, pleura is entered, lung tissue examined, biopsy secured. Chest tube is needed postoperatively.
  • Lobectomy—removal of a lobe of the lung. Chest tube is needed postoperatively.
  • Pneumonectomy—removal of an entire lung. No chest tube is needed postoperatively.

B. Analysis/nursing diagnosis:

  • Risk for injury related to chest wound.
  • Impaired gas exchange related to pain from surgical procedure.
  • Ineffective airway clearance related to decreased willingness to cough due to pain.
  • Pain related to surgical incision.
  • Impaired physical mobility related to large surgical incision and chest tube drainage apparatus.
  • Knowledge deficit (learning need) related to importance of coughing and deep breathing to prevent complications.

C. Nursing care plan/implementation:

  • Preoperative care:
    a. Goal: minimize pulmonary secretions.
    (1) Humidify air to moisten secretions.
    (2) Use IPPB, as ordered, to improve ventilation.
    (3) Administer bronchodilators, expectorants, and antibiotics as ordered.
    (4) Use postural drainage, cupping, and vibration to mobilize secretions.
    b. Goal: preoperative teaching.
    (1) Teach client to cough against a closed glottis to increase intrapulmonary pressure for improved expiratory phase.
    (2) Instruct in diaphragmatic breathing and coughing.
    (3) Encourage to stop smoking.
    (4) Instruct and supervise practice of postoperative arm exercises—flexion, abduction, and rotation of shoulder—to prevent ankylosis.
    (5) Explain postoperative use of chest tubes, IV, and oxygen therapy.
  • Postoperative care:
    a. Goal: maintain patent airway.
    (1) Auscultate chest for breath sounds; report diminished or absent breath sounds on unaffected side (indicates decreased ventilation→ respiratory embarrassment).
    (2) Turn, cough, and deep breathe, every 15 minutes to 1 hour for first 24 hours and prn according to pulmonary congestion heard on auscultation.
    b. Goal: promote gas exchange.
    (1) Splint chest during coughing—support incision to help cough up sputum (most important activity postoperatively).                                                                                                                                             (2) Position: high-Fowler’s.
    (a) Turn client who has had a pneumonectomy to operative side (avoid extreme lateral positioning and mediastinal shift) to allow unaffected lung expansion and drainage of secretions; can also be turned onto back.
    (b) Client who has had a lobectomy or thoracotomy can be turned on either side or back because chest tubes will be in place.
    c. Goal: reduce incisional stress and discomfort—pad area around chest tube when turning on operative side to maintain tube patency and promote comport                                                                                      d. Goal: prevent complications related to respiratory function.
    (1) Maintain chest tubes to water-seal drainage system.
    (2) See Chest tubes section in Table 11.5.
    (3) Observe for mediastinal shift (trachea should always be midline; movement toward either side indicates shift).
    (a) Move client onto back or toward opposite side.
    (b) MEDICAL EMERGENCY: Notify physician immediately.
    e. Goal: maintain fluid and electrolyte balance.
    (1) Administer parenteral infusion slowly (risk of pulmonary edema due to decrease in pulmonary vasculature with removal of lung lobe or whole lung).                                                                                   f. Goal: postoperative teaching.
    (1) Prevent ankylosis of shoulder—teach passive and active ROM exercises of operative arm.
    (2) Importance of early ambulation, as condition permits.
    (3) Importance of stopping smoking.
    (4) Dietary instructions—nutritious diet to aid in healing process.
    (5) Importance of deep breathing, coughing exercises, to prevent stasis of respiratory secretions.
    (6) Importance of increased fluids in diet to liquefy secretions.
    (7) Desired and side effects of prescribed medications.
    (8) Importance of rest, avoidance of heavy lifting and work during healing process.
    (9) Importance of follow-up care; give names of referral agencies where client and family can obtain assistance.
    (10) Signs and symptoms of complications.

D. Evaluation/outcome criteria:

  • Client or significant other or both will be able to:
    a. Give rationale for activity restriction and demonstrate prescribed exercises.
    b. Identify name, dosage, side effects, and schedule of prescribed medications.
    c. State plans for necessary modifications in lifestyle, home.
    d. Identify support systems.
  • Wound heals without complications.
  • Obtains ROM in affected shoulder.
  • No complications of thoracotomy, such as:
    a. Respiratory—pulmonary insufficiency, respiratory acidosis, pneumonitis, atelectasis, pulmonary edema.
    b. Circulatory—hemorrhage, hypovolemia, shock, myocardial infarction.
    c. Mediastinal shift.
    d. Renal failure.
    e. Gastric distention.

XVI. TRACHEOSTOMY: opening into trachea, temporary or permanent. Rationale: airway obstruction due to foreign body, edema, tumor, excessive tracheobronchial secretions, respiratory depression, decreased gaseous diffusion at alveolar membrane, increased dead space (e.g., severe emphysema), or failure to wean from mechanical ventilator.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

A. Analysis/nursing diagnosis:

  • Ineffective airway clearance related to increased secretions and decreased ability to cough effectively.
  • Ineffective breathing pattern related to physical condition that necessitated tracheostomy.
  • Impaired verbal communication related to inability to speak when tracheostomy tube cuff inflated.
  • Fear related to need for specialized equipment to breathe.

B. Nursing care plan/implementation:

  • Preoperative care:
    a. Goal: relieve anxiety and fear.
    (1) Explain purpose of procedure and equipment.
    (2) Demonstrate suctioning procedure.
    (3) Establish means of postoperative communication (e.g., paper and pencil, “magic slate,” picture cards, and call bell). Specialized tubes such as a fenestrated tracheostomy tube or a tracheostomy button allow the individual to talk when the external opening is plugged.
    (4) Remain with client as much as possible.
  • Postoperative care:
    a. Goal: maintain patent airway (Tracheostomy Suctioning Procedure).
    b. Goal: alleviate apprehension.
    (1) Remain with client as much as possible.
    (2) Encourage client to communicate feelings using preestablished communication system.
    c. Goal: improve nutritional status.
    (1) Provide nutritious foods/liquids the client can swallow.
    (2) Give supplemental drinks to maintain necessary calories.
    d. Goal: health teaching.
    (1) Explain all procedures.
    (2) Teach alternative methods of communication (best if done before the tracheostomy if it is not an emergency situation).
    (3)Teach self-care of tracheostomy as soon as possible.

C. Evaluation/outcome criteria:

  • Airway patent.
  • Acid-base balance maintained.
  • No respiratory infection/obstruction.
Physiological Integrity: Nursing Care of the Adult Client
Physiological Integrity: Nursing Care of the Adult Client
Physiological Integrity: Nursing Care of the Adult Client
Physiological Integrity: Nursing Care of the Adult Client

Physiological Integrity: Nursing Care of the Adult Client: CARDIOVASCULAR SYSTEM

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

I. HYPERTENSION: sustained, elevated, systemic arterial blood pressure; diastolic elevation more serious,
reflecting pressure on arterial wall during resting phase of cardiac cycle (Imbalances in Blood Pressure: Comparative Assessment of Hypotension and Hypertension).

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

A. Pathophysiology: increased peripheral resistance leading to thickened arterial walls and left ventricular
hypertrophy.

B. Risk factors:

  • Black race (2:1).
  • Use of birth control pills.
  • Overweight.
  • Smoking.
  • Stress.
  • Excessive sodium intake or saturated fat.
  • Lack of activity.
  • Genetics, heredity.

C. Classifications:

  • Essential (primary or idiopathic): occurs in 90% to 95% of clients; etiology unknown; diastolic pressure is ≥90 mm Hg, and other causes of hypertension are absent. Benign hypertension (diastolic pressure ≤ 120 mm Hg) considered controllable; asymptomatic until complications develop.
  • Secondary: occurs in remaining 5% to 10%; usually renal, endocrine, neurogenic, or cardiac in origin.
  • Malignant hypertension (diastolic > 140 to 150 mm Hg); uncontrollable. May arise from both types.
  • Labile (prehypertensive): a fluctuating blood pressure; increases during stress, otherwise normal or near normal.

D. Assessment:

  • Subjective data:
    a. Early-morning headache, usually occipital.
    b. Light-headedness, tinnitus                                                                                                                         c. Palpitations.
    d. Fatigue, insomnia.
    e. Forgetfulness, irritability.
    f. Altered vision: white spots, blurring, or loss.
  • Objective data:
    a. Epistaxis (nosebleeds).
    b. Elevated blood pressure: systolic greater than 120 mm Hg, diastolic greater than 90 mm Hg; narrowed pulse pressure. Rise in diastolic from sitting to standing with essential; fall in BP from sitting to standing with secondary.
    c. Retinal changes; papilledema.
    d. Shortness of breath on slight exertion.
    e. Cardiac, cerebral, and renal changes.
    f. Laboratory data: urinalysis, ECG, chest x-ray to rule out complications of hypertension.

E. Analysis/nursing diagnosis:

  • Knowledge deficit (learning need) regarding condition, treatment plan, and self-care and discharge needs.
  • Risk for decreased cardiac output related to ventricular hypertrophy, vasoconstriction, or myocardial ischemia.
  • Risk for injury related to complications of hypertension.
  • Impaired adjustment related to required lifestyle changes.
  • Activity intolerance related to weakness, fatigue.

F. Nursing care plan/implementation:

  • Goal: provide for physical and emotional rest.
    a. Rest periods before/after eating, visiting hours; avoid upsetting situations.
    b. Give tranquilizers, sedatives, as ordered.
  • Goal: provide for special safety needs.
    a. Monitor blood pressure: both arms; standing, sitting, lying positions.
    b. Limit/prevent activities that increase pressure (anxiety, anger, frustration, upsetting visitors, fatigue).
    c. Assist with ambulation; change position gradually to prevent dizziness and light headedness (postural hypotension).
    d. Monitor for electrolyte imbalance when on low-sodium diet, diuretic therapy; I&O to prevent fluid depletion and arrhythmias from potassium loss.
    e. Observe for signs of hemorrhage, shock, stroke, which may occur following surgery.
  • Goal: health teaching (client and family).
    a. Procedures to decrease anxiety; relaxation techniques, stress management.
    b. Side effects of hypotensive drugs: initial therapy includes diuretics and beta blockers; if response inadequate may use angiotensinconverting enzyme (ACE) inhibitors, adrenergic blockers, vasodilators, calcium channel blockers (faintness, nausea, vomiting, hypotension, sexual dysfunction).
    c. Weight control to reduce arterial pressure.
    d. Restrictions: stimulants (tea, coffee, tobacco), sodium, calories, fat.
    e. Lifestyle adjustments: daily exercise needed; reduce occupational and environmental stress; importance of rest.
    f. Blood pressure measurement: daily, same conditions, both arms, position preference of physician; use of self-monitoring cuff; check at least twice per week.
    g. Signs, symptoms, complications of disease (headache, confusion, visual changes, nausea/vomiting, convulsions).
    h. Causes of intermittent hypotension: alcohol, hot weather, exercise, febrile illness, hot bath.

G. Evaluation/outcome criteria:

  • Blood pressure within normal range for age (diastolic less than 90 mm Hg)—stable.
  • Minimal or no pathophysiological or therapeutic complications (e.g., visual changes, stroke, drug side effects).
  • Reduces weight to reasonable level for height, bone structure.
  • Takes prescribed medications regularly, even after symptoms have resolved.
  • Complies with restrictions: no smoking; restricted sodium, fat.
  • Exercises regularly—program compatible with personal and health-care goals.

II. CARDIAC ARRHYTHMIAS (DYSRHYTHMIAS): any variations in normal rate, rhythm, or configuration of waves on ECG (Interpretation of normal cardiac cycle).

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

A. Pathophysiology:

  • Dysfunction of sinoatrial (SA) node, atria, atrioventricular (AV) node, or ventricular conduction.
  • Primary heart problem or secondary systemic problem.

B. Risk factors:

  • Myocardial infarction.
  • Drug toxicity.
  • Stress.
  • Cardiac surgery.
  • Hypoxia.
  • Congenital.

C. Assessment: see Comparison of Selected Cardiac Dysrhythmias for specific dysrhythmias.

D. Analysis/nursing diagnosis:

  • Decreased cardiac output related to abnormal ventricular function.
  • Altered tissue perfusion related to inadequate cardiac functioning.
  • Knowledge deficit (learning need) regarding cause/treatment of condition, self-care, and discharge needs.
  • Anxiety related to dependence, fear of death.

E. Nursing care plan/implementation:

  • Goal: provide for emotional and safety needs.
    a. Document ECG tracing for presence of life-threatening arrhythmia.
    b. Encourage discussion of fears, feelings (client and significant other).
    c. Bed rest: restricted activities; quiet environment; limit visitors.
    d. Oxygen, if ordered.
    e. Check vital signs frequently for shock, heart failure (HF), drug toxicity.
    f. Prepare for cardiac emergency: CPR.
    g. Give cardiac medications; check laboratory tests for digitalis and potassium levels, to prevent drug toxicity.
  • Goal: prevent thromboemboli.
    a. Apply antiembolic stockings (TED hose); segmental compression device.
    b. Give anticoagulants as ordered. (Check for bleeding—gums, urine; monitor laboratory tests Lee-White clotting time and activated partial thromboplastin time with heparin; prothrombin time or international normalized ratio [INR] with warfarin [Coumadin].)
    c. Encourage flexion and extension of feet.
  • Goal: prepare for cardioversion with atrial fibrillation if indicated (usually if pulse greater than 140 beats/min, symptomatic, or no conversion after 3 days of drug therapy and anticoagulated).
    a. Give Cardizem or amiodarone as ordered at least 24 hours before.
    b. NPO 8 hours before.
    c. Hold digoxin morning of cardioversion per order.
    d. Give conscious sedation medications as ordered.
  • Goal: provide for physical and emotional needs with pacemaker insertion.
    a. General concerns:
    (1) Report excessive bleeding/infection at insertion site—hematoma may contribute to wound infection.
    (2) Encourage verbalization of feelings.
    (3) Report prolonged hiccups, which may indicate pacemaker failure.
    (4) Know pacing mode: fixed-rate or demand (most common); type of insertion (temporary or permanent), sensitivity.
    b. Temporary pacemaker:
    (1) Limit excessive activity of extremity if antecubital insertion, to prevent displacement; subclavian insertion increases catheter stability.
    (2) Secure wires to chest to prevent tension on catheter.
    (3) Do not defibrillate over insertion site, to avoid electrical hazards.
    (4) Electrical safety (grounding; disconnect electric beds/call lights; use battery-operated equipment).
    (5) Check settings.
    c. Permanent pacemaker:
    (1) Limit activity of shoulder for 48 to 72 hours after insertion of transvenous catheter to prevent dislodgement; avoid extending arms over head for 8 weeks.
    (2) Postinsertion ROM (passive) at least once per shift after 48 hours to prevent frozen shoulder.
    (3) If defibrillation is required, place paddles at least 4 inches from pulse generator.
    (4) Check site.                                                                                                                                                                                                                                        d. Health teaching following permanent pacemaker:
    (1) Explain procedure: duration, equipment, purpose, type of pacemaker.
    (2) Medic Alert bracelet; pacemaker information card.
    (3) Daily pulse taking on arising (report variation of ± 5 beats).
    (4) Signs, symptoms of malfunction (vertigo, syncope, dyspnea, slowed speech, confusion, fluid retention); infection (fever, heat, pain, skin breakdown at insertion site).
    (5) Restrictions: limit vigorous arm and shoulder motion for 6 to 8 weeks; contact sports; electromagnetic interferences (few)—TV/radio transmitters, improperly functioning microwave oven (maintain distance of 3 feet), certain cautery machines; may trigger airport metal-detector alarm.

F. Evaluation/outcome criteria:

  • Regular cardiac rhythm, monitors own radial pulse.
  • No complications (e.g., pacemaker malfunction).
  • Returns for regular follow-up of pacemaker function.
  • Tolerates physical or sexual activity.
  • Wears identification bracelet; carries pacemaker identification card.
  • Reports anxiety is reduced to manageable level.

III. CARDIAC ARREST: sudden unexpected cessation of heartbeat and effective circulation leading to inadequate perfusion and sudden death.

A. Risk factors:

  • Myocardial infarction.
  • Multiple traumas.
  • Respiratory arrest.
  • Drowning.
  • Electrical shock.
  • Drug reactions.
  • Multisystem failure.

B. Assessmentobjective data:

  • Unresponsive to stimuli (i.e., verbal, painful).
  • Absence of breathing, carotid pulse.
  • Pale or bluish: lips, fingernails, skin.
  • Pupils: dilated.

C. Analysis/nursing diagnosis:

  • Decreased cardiac output related to heart failure.
  • Impaired gas exchange related to breathlessness.
  • Altered tissue perfusion related to pulselessness.

D. Nursing care plan/implementation:

  • Goal: prevent irreversible cerebral anoxic damage: initiate CPR within 4 to 6 minutes; continue until relieved; document assessment factors, effectiveness of actions; presence or absence of pulse at 1 minute and every 4 to 5 minutes.
  • Goal: establish effective circulation, respiration.

E. Evaluation/outcome criteria:

  • Carotid pulse present; check after 1 minute and every few minutes thereafter.
  • Responds to verbal stimuli.
  • Pupils constrict in response to light.
  • Return of spontaneous respiration; adequate ventilation.

IV. ARTERIOSCLEROSIS: loss of elasticity, thickening, hardening of arterial walls; symptoms depend on organ system involved; common type—atherosclerosis. Atherosclerosis (coronary heart disease [CHD]) precedes angina pectoris and myocardial infarction.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

A. Pathophysiology:

  • Atherosclerotic plaque, discrete lumpy thickening of arterial wall; cholesterol-lipid-calcium deposits in lining.
  • Narrows lumen, can occlude vessel.

B. Risk factors:

  • Increased serum cholesterol (low-density lipids ≥160 mg/dL).
  • Hypertension.
  • Cigarette smoking.
  • Diabetes mellitus.
  • Family history of premature CHD. See following sections V. ANGINA PECTORIS and VI. MYOCARDIAL INFARCTION for nursing implications.

V. ANGINA PECTORIS: transient paroxysmal episodes of substernal or precordial pain. Types: stable (follows an event, same severity); unstable (at rest or minimal exertion, recent onset, increasing severity); Prinzmetal’s variant (at rest, caused by coronary spasms).

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

A. Pathophysiology:

  • Insufficient blood flow through coronary arteries. Oxygen demand exceeds supply.
  • Temporary myocardial ischemia.

B. Risk factors:

  • Cardiovascular:
    a. Atherosclerosis.
    b. Thromboangiitis obliterans.
    c. Aortic regurgitation.
    d. Hypertension.
  • Hormonal:
    a. Hypothyroidism.
    b. Diabetes mellitus.
  • Blood disorders:
    a. Anemia.
    b. Polycythemia vera.
  • Lifestyle choices:
    a. Smoking.
    b. Obesity.
    c. Cocaine use.
    d. Inactivity.

C. Assessment:

  • Subjective data:
    a. Pain—typical (Comparison of Physical Causes of Chest Pain).
    (1) Type: squeezing, pressing, burning.
    (2) Location: retrosternal, substernal, left of sternum, radiates to left arm (Angina pectoris).
    (3) Duration: short, usually 3 to 5 minutes, less than 30 minutes.
    (4) Cause: emotional stress, overeating, physical exertion, exposure to cold; may occur at rest.
    (5) Relief: rest, nitroglycerin.
    b. Note: Atypical complaints by women include jaw and upper back pain and persistent gastric upset.
    c. Dyspnea.
    d. Palpitations.
    e. Dizziness; faintness.
    f. Epigastric distress; indigestion; belching.
  • Objective data:
    a. Tachycardia.
    b. Pallor.
    c. Diaphoresis.
    d. ECG changes during attack.

D. Analysis/nursing diagnosis:

  • Altered cardiopulmonary tissue perfusion related to insufficient blood flow.
  • Pain related to myocardial ischemia.
  • Activity intolerance related to onset of pain.

E. Nursing care plan/implementation:

  • Goal: provide relief from pain.
    a. Rest until pain subsides.
    b. Nitroglycerin or amyl nitrite, beta-adrenergic blockers, as ordered.                                                                                                                                                         c. Identify precipitating factors: large meals, heavy exercise, stimulants (coffee, smoking), sex when fatigued, cold air.
    d. Vital signs: hypotension.
    e. Assist with ambulation; dizziness, flushing occurs with nitroglycerin.
  • Goal: provide emotional support.
    a. Encourage verbalization of feelings, fears.
    b. Reassurance; positive self-concept.
    c. Acceptance of limitations.
  • 3. Goal: health teaching.
    a. Pain: alleviation, differentiation of angina from myocardial infarction, precipitating factors (see Comparison of Physical Causes of Chest Pain).
    b. Medication: frequency, expected effects (headache, flushing); carry fresh nitroglycerin; loses potency after 6 months (“stings” under tongue when potent); may use nitroglycerin paste—instruct how to apply.                                                                                                                                                               c. Diet: restricted calories if weight loss indicated; restricted fat, cholesterol, gas-producing foods; small, frequent meals.
    d. Diagnostic tests if ordered (e.g., thallium stress test, cardiac catheterization; interventional [stents];
    e. Exercise: regular, graded, to promote coronary circulation.
    f. Prepare for coronary artery bypass graft (CABG) surgery, if necessary.
    g. Behavior modification to assist with lifestyle changes (e.g., stress reduction, stop smoking).

F. Evaluation/outcome criteria:

  • Relief from pain.
  • Fewer attacks.
  • No myocardial infarction.
  • Alters lifestyle; stress management; complies with limitations.
  • No smoking.

VI. MYOCARDIAL INFARCTION (MI, HEART ATTACK): localized area of necrotic tissue in myocardium from cessation of blood flow; leading cause of death in North America.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

A. Pathophysiology:

  • Coronary occlusion due to thrombosis, embolism, or hemorrhage adjacent to atherosclerotic plaque.
  • Insufficient blood flow from cardiac hypertrophy, hemorrhage, shock, or severe dehydration.

B. Risk factors:

  • Age (35 to 70 years).
  • Men more than women until menopause.
  • Lifestyle: obesity, smoking, sedentary, amphetamine or cocaine use.
  • Stress or type A personality.
  • High levels of low-density lipoproteins, and high serum triglyceride levels.
  • Chronic illness (diabetes, hypertension).

C. Assessment:

  • Subjective data:
    a. Pain (Comparison of Physical Causes of Chest Pain).
    (1) Type: sudden, severe, crushing, heavy tightness. May be absent in elderly or those who have diabetes.
    (2) Location: substernal; radiates to one or both arms, jaw, neck. May be confused with indigestion.
    (3) Duration: greater than 30 minutes.
    (4) Cause: unrelated to exercise; frequently occurs when sleeping (rapid-eye-movement [REM] stage).
    (5) Relief: oxygen, narcotics; not relieved by rest or nitroglycerin.
    b. Nausea.
    c. Shortness of breath.
    d. Apprehension, fear of impending death.
    e. History of cardiac disease (family); occupational stress.
  • Objective data:
    a. Vital signs: shock; rapid (>100), thready pulse; fall in blood pressure; S3 gallop; tachypnea, shallow respirations; elevated temperature within 24 hours (100° to 103°F).
    b. Skin: ashen or clammy; diaphoretic.
    c. Emotional: restless.
    d. Laboratory data: increased—WBC count (12,000 to 15,000/microL), troponin T and I levels, serum enzymes (creatine kinase-MB [CK-MB]; lactate dehydrogenase (LDH): LDH1 > LDH2—“flipped LDH”); changes—ECG (elevated ST segment, inverted T wave, arrhythmia).

D. Analysis/nursing diagnosis:

  • Decreased cardiac output related to myocardial damage.
  • Impaired gas exchange related to poor perfusion, shock.
  • Pain related to myocardial ischemia.
  • Activity intolerance related to pain or inadequate oxygenation.
  • Fear related to possibility of death.

E. Nursing care plan/implementation:

  • Goal: reduce pain, discomfort.
    a. Narcotics—morphine; note response. Avoid IM.
    b. Humidified oxygen 2 to 4 L/min; mouth care—oxygen is drying.
    c. Position: semi-Fowler’s to improve ventilation.
  • Goal: maintain adequate circulation, stabilize heart rhythm.
    a. Monitor vital signs and urine output; observe for cardiogenic shock.                                                                                                                                                            b. Monitor ECG for arrhythmias.
    c. Give medications as ordered: antiarrhythmics—lidocaine HCl, amiodarone, atropine, beta blockers, procainamide (Pronestyl), bretylium (Bretylol); propranolol (Inderal); verapamil; anticoagulants—heparin sodium, bishydroxycoumarin or dicoumarin; thrombolytic agents—streptokinase (tPA), APSAC/anistreplase (Eminase), reteplase followed by IV heparin or a glycoprotein IIB/IIIA inhibitor (Integrilin).
    d. Diagnostic tests—echocardiogram, prepare for cardiac catheterization, possible interventional cardiology (stents), possible CABG surgery.
    e. Recognize heart failure: edema, cyanosis, dyspnea, cough, crackles.
    f. Check laboratory data—normal; troponin; serum enzymes (CK 20 to 220 IU/L depending on gender; CK-MB 0 to 12 IU/L; LDH<115 IU/L; LDH1 < LDH2); blood gases (pH 7.35 to 7.45; PCO2 35 to 45 mEq/L; PO2 80 to 100 mm Hg; HCO3 22 to 26); electrolytes (K+ 3.5 to 5.0 mEq/L; Mg++ 1.3 to 2.1 mg/dL); clotting time (aPTT 25 to 41 seconds; prothrombin time [PT] 11 to 15 seconds).
    g. CVP—zero level at right atrium; fluctuates with respiration; normal range 5 to 15 cm H2O; note trend; increases with heart failure.
    h. ROM of lower extremities; TED hose/antiembolic stockings.
  • Goal: decrease oxygen demand/promote oxygenation, reduce cardiac workload.
    a. O2 as ordered.
    b. Activity: bedrest (24 to 48 hours) with bedside commode; planned rest periods; control visitors.
    c. Position: semi-Fowler’s to facilitate lung expansion and decrease venous return.
    d. Anticipate needs of client: call light, water.
    e. Assist with feeding, turning.
    f. Environment: quiet, comfortable.
    g. Reassurance; stay with client who is anxious.
    h. Give medications as ordered: cardiotonics, calcium channel blockers, vasodilators, vasopressors.
  • Goal: maintain fluid, electrolyte, nutritional status.
    a. IV (keep vein open); CVP; vital signs.
    b. Urine output—30 mL/hr.
    c. Laboratory data within normal limits (Na+ 135 to 145 mEq/L; K+ 3.5 to 5.0 mEq/L; Mg++ 1.3 to 2.1 mg/dL).
    d. Monitor ECG—hyperkalemia: peaked T wave; hypokalemia: depressed T wave.
    e. Diet: progressive low calorie, low sodium, low cholesterol, low fat, without caffeine.
  • Goal: facilitate fecal elimination.
    a. Medications: stool softeners to prevent Valsalva maneuver (straining); mouth breathing during bowel movement; recognize complications of Valsalva maneuver—chest pain, cyanosis, diaphoresis, arrhythmias.
    b. Bedside commode if possible.
  • Goal: provide emotional support.
    a. Recognize fear of dying: denial, anger, withdrawal.
    b. Encourage expression of feelings, fears, concerns.
    c. Discuss rehabilitation, lifestyle changes: prevent cardiac invalid syndrome by promoting self-care activities, independence.
  • Goal: promote sexual functioning.
    a. Encourage discussion of concerns regarding activity, inadequacy, limitations, expectations, use of drugs for erectile dysfunction—include partner (usually resume activity 5 to 8 weeks after uncomplicated MI or when client can climb two flights of stairs).
    b. Identify need for referral for sexual counseling.
  • Goal: health teaching.
    a. Diagnosis and treatment regimen.
    b. Caution about when to avoid sexual activity: after heavy meal, alcohol ingestion; when fatigued, tense, under stress; with unfamiliar partners; in extreme temperatures.
    c. Information about sexual activity: less fatiguing positions (side to side; noncardiac partner on top); vasodilators, if ordered, before intercourse; select comfortable, familiar environment.
    d. Referral to available community resources for information, support groups (e.g., American Heart Association, Stop Smoking Clinics).
    e. Medications: administration, importance, untoward effects, pulse taking.
    f. Control risk factors: rest, diet, exercise, no smoking, weight control, stress-reduction techniques.
    g. Need for follow-up care for regulation of medications, evaluating risk factors.
    h. Prepare for angioplasty or coronary bypass if planned.

F. Evaluation/outcome criteria:

  • No complications: stable vital signs; relief of pain.
  • Adheres to prescribed medication regimen, demonstrates knowledge about medications.
  • Activity tolerance is increased, participates in program of progressive activity.
  • Reduction or modification of risk factors. Plans to alter lifestyle (e.g., loses weight, quits smoking).

VII. CARDIAC VALVULAR DEFECTS: alteration in the structure of a valve; impede flow of blood or permit regurgitation.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

A. Pathophysiology:

  • Stenosis—narrowing of valvular opening due to adherence, thickening, and rigidity of valve cusp from fibrosis, scarring, and calcification.
  • Insufficiency (incompetence)—incomplete closure of valve due to contraction of chordae tendineae, papillary muscles; or to calcification, scarring of leaflets. Results in regurgitation.
  • Mitral stenosis:
    a. Most common residual cardiac lesion of rheumatic fever.
    b. Affects women younger than 45 years more often than men.
    c. Narrowing of mitral valve.
    d. Interferes with filling of left ventricle.
    e. Produces pulmonary hypertension, right ventricular failure.
  • Mitral insufficiency (incompetence):
    a. Leaking/regurgitation of blood back into left atrium.
    b. Results from rheumatic fever, bacterial endocarditis; less common.
    c. Affects men more often.
    d. Produces pulmonary congestion, right ventricular failure.
  • Aortic stenosis:
    a. Fusion of valve flaps between left ventricle and aorta.
    b. Congenital or acquired from atherosclerosis or from rheumatic fever and bacterial endocarditis; seen in men more often; pulmonary circulation congested, cardiac output decreased.
  • Aortic insufficiency:
    a. Incomplete closure of valve between left ventricle and aorta (regurgitation).
    b. Left ventricular failure leading to right ventricular heart failure.

B. Risk factors:

  • Congenital abnormality.
  • History of rheumatic fever.
  • Atherosclerosis.

C. Assessment: Comparison of Symptomatology for Valvular Defects.

D. Analysis/nursing diagnosis:

  • Decreased cardiac output related to inadequate ventricular filling.
  • Fluid volume excess related to compensatory response to decreased cardiac output.
  • Impaired gas exchange related to pulmonary congestion.
  • Activity intolerance related to impaired cardiac function.
  • Fatigue related to poor oxygenation.

E. Nursing care plan/implementation:

  • Goal: reduce cardiac workload.
  • Goal: promote physical comfort and psychological support.
  • Goal: prevent complications.
  • Goal: prepare for surgery (commissurotomy, valvuloplasty [valvotomy], or valvular replacement, depending on defect and severity of condition).
  • See section X. CARDIAC SURGERY, pp. 422–425, for specific nursing actions.

F. Evaluation/outcome criteria:

  • Relief of symptoms.
  • Increase in activity level.
  • No complications following surgery.

Physiological Integrity: Nursing Care of the Adult Client
Physiological Integrity: Nursing Care of the Adult Client
Physiological Integrity: Nursing Care of the Adult Client
Physiological Integrity: Nursing Care of the Adult Client
Physiological Integrity: Nursing Care of the Adult Client
Physiological Integrity: Nursing Care of the Adult Client
Physiological Integrity: Nursing Care of the Adult Client
Physiological Integrity: Nursing Care of the Adult Client
Physiological Integrity: Nursing Care of the Adult Client
Physiological Integrity: Nursing Care of the Adult Client
Physiological Integrity: Nursing Care of the Adult Client
Physiological Integrity: Nursing Care of the Adult Client

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