NCLEX: Cardiovascular disorders

Cardiovascular disorders: Treatments

Focus topic: Cardiovascular disorders

Cardiovascular disorders: Balloon catheter treatments

Focus topic: Cardiovascular disorders

Balloon catheter treatments for cardiovascular disorders include percutaneous balloon valvuloplasty and percutaneous transluminal coronary angioplasty (PTCA).

Percutaneous balloon valvuloplasty

Percutaneous balloon valvuloplasty, which can be performed in the cardiac catheterization laboratory, seeks to improve valvular function. It does so by enlarging the orifice of a stenotic heart valve, which can result from congenital defect, calcification, rheumatic fever, or aging. A small balloon valvuloplasty catheter is introduced through the skin at the femoral vein. Although the treatment of choice for valvular heart disease remains surgery (valvuloplasty, valve replacement, or commissurotomy), percutaneous balloon valvuloplasty offers an alternative for those considered poor candidates for surgery.

Bursting the balloon

Focus topic: Cardiovascular disorders

Unfortunately, elderly patients with aortic disease commonly experience restenosis 1 to 2 years after undergoing valvuloplasty. Also, despite the decreased risks associated with more invasive procedures, balloon valvuloplasty can lead to complications, including:

  • worsening valvular insufficiency by misshaping the valve so that it doesn’t close completely
  • pieces breaking off of the calcified valve, which may travel to the brain or lungs and cause embolism (rare)
  • severely damaging delicate valve leaflets, requiring immediate surgery to replace the valve (rare)
  • bleeding and hematoma at the arterial puncture site
  • MI (rare), arrhythmias, myocardial ischemia, and circulatory defects distal to the catheter entry site.

Patient preparation

Before the procedure, take the following steps:

  • Reinforce the doctor’s explanation of the procedure, including its risks and alternatives.
  • Restrict food and fluid intake for at least 6 hours before the procedure or as ordered.

Monitoring and aftercare

The patient undergoing balloon valvuloplasty will be monitored in the cardiac ICU or PACU after the procedure. He’ll be transferred to the medical-surgical unit when his condition is stable. After transfer to the medical-surgical unit, take these steps:

  • Monitor the effects of I.V. medications such as heparin.
  • Assess the cannulation site for bleeding or infection.
  • Monitor peripheral pulses distal to the insertion site and the color, temperature, and capillary refill time of the extremity. If pulses are difficult to palpate, use a handheld Doppler instrument.
  • Notify the practitioner if pulses are absent.

Home care instructions

Before discharge, instruct the patient to:

  • resume normal activity
  • notify the practitioner if the patient experiences bleeding or increased bruising at the puncture site or recurrence of symptoms of valvular insufficiency, such as breathlessness or decreased exercise tolerance
  • comply with regular follow-up visits.

PTCA

PTCA offers a nonsurgical alternative to coronary artery bypass surgery. The doctor uses a balloon-tipped catheter to dilate a coronary artery that has become narrowed because of atherosclerotic plaque.
Performed in the cardiac catheterization laboratory under local anesthesia, PTCA doesn’t involve a thoracotomy, so it’s less costly and requires shorter hospitalization. Patients can usually walk the next day and return to work in 2 weeks.

Best working conditions

Focus topic: Cardiovascular disorders

PTCA works best when lesions are readily accessible, noncalcified, less than 10 mm, concentric, discrete, and smoothly tapered. Patients with a history of less than 1 year of disabling angina make good candidates because their lesions tend to be softer and more compressible. Complications of PTCA are acute vessel closure and late restenosis. To prevent restenosis, the patient may need to undergo such procedures as stenting, atherectomy, and laser angioplasty.

Cardiovascular disorders

Patient preparation

Before the procedure, take the following steps:

  • Tell the patient that a catheter will be inserted into an artery and a vein in the groin area and that he may feel pressure as the catheter moves along the vessel.
  • Advise the patient that the entire procedure lasts from 1 to 4 hours and that he’ll have to lie flat on a table during that time.
  • Explain to the patient that he’ll be awake during the procedure and may have to take deep breaths to allow visualization of the radiopaque balloon catheter and answer questions about how he’s feeling during the procedure.
  • Tell the patient to notify the cardiologist if he experiences any chest pain or pressure during the procedure.
  • Tell the patient he will have to remain on bed rest while the catheter is in place.

Cardiovascular disorders

Monitoring and aftercare

The patient undergoing PTCA may be monitored in the cardiac ICU or interventional care recovery area after the procedure. The patient will be transferred to the medical-surgical unit when stable. After transfer to the medical-surgical unit, take these steps:

  • Monitor the effects of I.V. medications such as heparin.
  • Assess the cannulation site for bleeding or infection.
  • Monitor peripheral pulses distal to the insertion site and the color, temperature, and capillary refill time of the extremity. If pulses are difficult to palpate, use a Doppler stethoscope.
  • Notify the practitioner if pulses are absent.

Home care instructions

If the patient doesn’t experience complications from the procedure, he may go home in 6 to 12 hours. Instruct the patient to:

  • call his practitioner if he experiences any bleeding, bruising, or swelling at the arterial puncture site
  • return for a stress thallium imaging test and follow-up angiography, as recommended by his practitioner
  • report chest pain to the practitioner because restenosis can occur after PTCA.

Cardiovascular disorders: Emergency treatment for heart rhythm disturbance

Focus topic: Cardiovascular disorders

Emergency treatment for heart rhythm disturbance may include defibrillation and pacemaker insertion.

Defibrillation

With defibrillation, the heart receives a strong burst of electric current from defibrillator paddles applied to the patient’s chest. This brief electric shock completely depolarizes the myocardium, allowing the heart’s natural pacemaker to regain control of cardiac rhythm.

First choice

Focus topic: Cardiovascular disorders

Defibrillation is the treatment of choice for ventricular fibrillation and pulseless ventricular tachycardia. For every minute that defibrillation is delayed, the patient’s chance of surviving ventricular fibrillation drops 7% to 10%. If ventricular fibrillation lasts for more than a few minutes, it causes irreparable brain damage. Note that patients with certain arrhythmias such as stable ventricular tachycardia may require a technique similar to defibrillation called synchronized cardioversion.

Pacemaker insertion

Pacemakers are battery-operated generators that emit timed electrical signals to trigger contraction of the heart muscle, thus controlling heart rate. Whether temporary or permanent, they’re used when the heart’s natural pacemaker fails to work properly.

From the temp pool

Focus topic: Cardiovascular disorders

Temporary pacemakers are used to pace the heart during CPR or open-heart surgery, after cardiac surgery, and when sinus arrest, symptomatic sinus bradycardia, or complete heart block occurs. Temporary pacing may also correct tachyarrhythmias that fail to respond to drug therapy. In emergency situations, the patient may receive a temporary transvenous or transcutaneous pacemaker if time or his condition doesn’t permit or require implantation of a permanent pacemaker. The doctor may also use a temporary pacemaker to observe the effects of pacing on cardiac function so he can select an optimal rate before implanting a permanent pacemaker. The method of pacing depends on the device.

Permanent position

Focus topic: Cardiovascular disorders

Permanent pacemaker implantation is a common procedure; worldwide, about 110,000 people undergo it every year. Permanent pacemakers are inserted when the heart’s natural pacemaker becomes irreversibly disrupted. Indications for a permanent pacemaker include:

  • acquired atrioventricular (AV) block
  • chronic bifascicular and trifascicular block
  • AV block associated with acute MI
  • sinus node dysfunction
  • hypersensitive carotid sinus syndrome
  • hypertrophic and dilated cardiomyopathy.
    The many types of pacemakers are categorized according to capabilities. Choice of a pacemaker depends on the patient’s age and condition, the cardiologist’s preference and, increasingly, the cost of the device, which can be several thousand dollars.

Cardiovascular disorders

Cardiovascular disorders: Nursing diagnoses

Focus topic: Cardiovascular disorders

When caring for patients with cardiovascular disorders, you’ll find that you can use several nursing diagnoses frequently. These commonly used nursing diagnoses appear below, along with appropriate nursing interventions and rationales.

Cardiovascular disorders: Activity intolerance

Focus topic: Cardiovascular disorders

Related to an imbalance between oxygen supply and demand, Activity intolerance may be associated with such conditions as acute MI, valvular disorders, heart failure, peripheral vascular disorders, and other ailments.

Expected outcomes

  • Patient states a desire to increase his activity level.
  • :Patient identifies controllable factors that cause fatigue.
  • Patient demonstrates skill in conserving energy while carrying out activities of daily living (ADLs) to tolerance level.

Nursing interventions and rationales

  • Discuss with the patient the need for activity, which will improve physical and psychosocial well-being.
  • Identify activities the patient considers desirable and meaningful to enhance their positive impact.
  • Encourage the patient to help plan activity progression. Make sure you include activities he considers essential to help compliance.
  • Instruct and help the patient to alternate periods of rest and activity to reduce the body’s oxygen demand and prevent fatigue.
  • Identify and minimize factors that diminish exercise tolerance to help increase activity level.
  • Monitor physiologic responses to increased activity (including respirations, heart rate and rhythm, and blood pressure) to ensure they return to normal a few minutes after exercising.
  • Teach the patient how to conserve energy while performing ADLs — for example, sitting in a chair while dressing, wearing lightweight clothing that fastens with Velcro or a few large buttons, and wearing slip-on shoes. These measures reduce cellular metabolism and oxygen demand.

Energy boost

Focus topic: Cardiovascular disorders

  • Demonstrate exercises for increasing strength and endurance, which will improve breathing and gradually increase activity level.
  • Support and encourage activity to the patient’s level of tolerance to help develop his independence.
  • Before discharge, formulate a plan with the patient and his caregivers that will enable the patient to continue functioning at maximum activity tolerance or to gradually increase the tolerance. For example, teach the patient and his caregivers how to monitor the patient’s pulse during activities; recognize the need for oxygen, if prescribed; and use oxygen equipment properly. Participation in planning encourages patient satisfaction and compliance.

Cardiovascular disorders: Decreased cardiac output

Focus topic: Cardiovascular disorders

Related to reduced stroke volume, Decreased cardiac output may be associated with such conditions as angina, bacterial endocarditis, heart failure, MI, valvular heart disease, and other ailments.

Expected outcomes

  • Patient maintains hemodynamic stability.
  • Patient exhibits no arrhythmias.
  • Patient maintains adequate cardiac output.

Nursing interventions and rationales

  • Monitor and record level of consciousness (LOC), heart rate and rhythm, oxygen saturation (using pulse oximetry), and blood pressure at least every 4 hours, or more often if necessary, to detect cerebral hypoxia possibly resulting from decreased cardiac output.
  • Auscultate heart and breath sounds at least every 4 hours. Report abnormal sounds as soon as they develop. Extra heart sounds may indicate early cardiac decompensation. Adventitious breath sounds may indicate pulmonary congestion and decreased cardiac output.
  • Measure and record intake and output. Reduced urine output without reduced fluid intake may indicate reduced renal perfusion, possibly from decreased cardiac output.
  • Promptly treat life-threatening arrhythmias to avoid the risk of death.
  • Weigh the patient daily before breakfast to detect fluid retention.
  • Inspect for pedal or sacral edema to detect venous stasis and decreased cardiac output.

Getting a facial

Focus topic: Cardiovascular disorders

  • Provide skin care every 4 hours to enhance skin perfusion and venous flow.
  • Gradually increase the patient’s activities within limits of the prescribed heart rate to allow the heart to adjust to increased oxygen demand. Monitor pulse rate before and after activity to compare rates and gauge tolerance.
  • Plan the patient’s activities to avoid fatigue and increased myocardial workload.
  • Maintain dietary restrictions as ordered to reduce complications and the risk of cardiac disease.
  • Teach the patient stress-reduction techniques to reduce anxiety and provide a sense of control.
  • Explain all procedures and tests to enhance understanding and reduce anxiety.

Teaching an old dog new tricks

Focus topic: Cardiovascular disorders

  • Teach the patient about chest pain and other reportable symptoms, prescribed diet, medications (name, dosage, frequency, therapeutic effects, and adverse effects), prescribed activity level, simple methods for lifting and bending, and stress-reduction techniques. These measures involve the patient and his family in care.

Cardiovascular disorders

  • Carry out the care plan, as ordered. Collaborative practice enhances overall care.
  • Administer oxygen as ordered to increase the supply to the myo cardium.

Cardiovascular disorders: Deficient knowledge

Focus topic: Cardiovascular disorders

Related to heart disease, Deficient knowledge can apply to a particular disorder or the risk factors related to cardiovascular disease.

Expected outcomes

  • Patient expresses an interest in learning new behaviors.
  • Patient sets realistic learning goals.
  • Patient practices new health-related behaviors during hospitalization (for example, selects appropriate diet, weighs himself daily, and monitors intake and output).

Nursing interventions and rationales

  • Establish an environment of mutual trust and respect to enhance learning. Comfort with growing self-awareness, ability to share this awareness with others, receptiveness to new experiences, and consistency between actions and words form the basis of a trusting relationship.
  • Help the patient develop goals for learning. Involving him in planning meaningful goals will encourage follow-through.
  • Select teaching strategies (discussion, demonstration, role playing, or visual materials) appropriate for the patient’s individual learning style (specify) to enhance teaching effectiveness.
  • Teach skills that the patient must use every day. Have him demonstrate each new skill to help him gain confidence.
  • Have the patient incorporate learned skills into his daily routine during hospitalization (specify skills) to allow him to practice new skills and receive feedback.
  • Provide the patient with the names and telephone numbers of resource people or organizations to provide continuity of care and follow-up after discharge.

Cardiovascular disorders: Common cardiovascular disorders

Focus topic: Cardiovascular disorders

Below are several common cardiovascular disorders, along with their causes, pathophysiology, signs and symptoms, diagnostic test findings, treatments, and nursing interventions.

Cardiovascular disorders: Aneurysm, abdominal aortic

Focus topic: Cardiovascular disorders

Abdominal aortic aneurysm, an abnormal dilation in the arterial wall, most commonly occurs in the aorta between the renal arteries and iliac branches. More than 50% of patients with untreated abdominal aneurysms 6 cm or larger die within 2 years of diagnosis, primarily from aneurysmal rupture. More than 85% of patients with large aneurysms die within 5 years.

What causes it

Aneurysms commonly result from atherosclerosis, which weakens the aortic wall and gradually distends the lumen. Other causes include:

  • fungal infection (mycotic aneurysms) of the aortic arch and descending segments
  • congenital disorders, such as coarctation of the aorta, Marfan syndrome, and collagen vascular disorders
  • trauma
  • syphilis
  • hypertension.

Pathophysiology

Degenerative changes in the muscular layer of the aorta (tunica media) create a focal weakness, allowing the inner layer (tunica intima) and outer layer (tunica adventitia) to stretch outward. The resulting outward bulge is called an aneurysm. Blood pressure within the aorta progressively weakens the vessel walls and enlarges the aneurysm.

What to look for

Signs and symptoms of an aneurysm include:

  • asymptomatic pulsating mass in the periumbilical area
  • possible systolic bruit over the aorta on auscultation
  • possible abdominal tenderness on deep palpation
  • lumbar pain that radiates to the flank and groin (imminent
    rupture).

If the aneurysm ruptures, look for:

  • severe, tearing abdominal and back pain
  • weakness
  • sweating
  • tachycardia
  • hypotension
  • circulatory collapse.

What tests tell you

  • Serial ultrasonography or computed tomography (CT) angiography determines aneurysm size, shape, and location.
  • Anteroposterior and lateral X-rays of the abdomen can detect aortic calcification, which outlines the mass, in at least 75% of patients.
  • Aortography shows the condition of vessels proximal and distal to the aneurysm and the extent of the aneurysm. However, this test may underestimate aneurysm diameter because it shows only the flow channel and not the intraluminal clot or dilated walls.

How it’s treated

Usually, abdominal aneurysm requires resection of the aneurysm and replacement of the damaged aortic section with a Dacron graft.

Risky business

Focus topic: Cardiovascular disorders

Large aneurysms or those that produce symptoms involve a significant risk of rupture and require immediate repair. If the aneurysm appears small and asymptomatic, the practitioner may delay surgery, opting first to treat the patient’s hypertension and reduce risk factors. Keep in mind,however, that even small aneurysms may rupture. The patient must undergo regular physical examinations and ultrasound checks to detect enlargement, which may indicate imminent rupture.
Endovascular grafting may also be used to repair an abdominal aortic aneurysm. In this minimally invasive procedure, the surgeon will insert a catheter with an attached graft through the femoral or iliac artery and advance it over a guide wire into the aorta, where he’ll position it across the aneurysm. A balloon on the catheter expands, affixing the graft to the vessel wall and excluding the aneurysm.

What to do

  • Be alert for signs of rupture, which is life-threatening. Watch closely for any signs of acute blood loss, such as hypotension, increasing pulse and respiratory rate, cool and clammy skin, restlessness, and decreased sensorium.
  •  If rupture occurs, get the patient to surgery immediately.
  • Evaluate the patient. Note whether the patient is free from pain and if he has adequate tissue perfusion with warm, dry skin; adequate pulse and blood pressure; and absence of fatigue.

Cardiovascular disorders: Aneurysms, femoral and popliteal

Focus topic: Cardiovascular disorders

Progressive atherosclerotic changes in the medial layer of the femoral and popliteal arteries may lead to aneurysm. Aneurysmal formations may be fusiform (spindle-shaped) or saccular (pouchlike). Fusiform aneurysms are three times more common than saccularan eurysms.
Femoral and popliteal aneurysms may occur as single or multiple segmental lesions, in many cases affecting both legs, and commonly occur with aneurysms in the abdominal aorta or iliac arteries. This condition occurs most commonly in men over age 50. Elective surgery before complications arise greatly improves prognosis.

What causes it

Femoral and popliteal aneurysms can result from:

  • atherosclerosis
  • congenital weakness in the arterial wall (rare)
  • blunt or penetrating trauma
  • bacterial infection.

Pathophysiology

An aneurysm is a localized out pouching or dilation of a weakened arterial wall. This weakness can result from either atherosclerotic plaque formation that erodes the vessel wall or the loss of elastin and collagen in the vessel wall.

What to look for

If large enough to compress the medial popliteal nerve and vein, popliteal aneurysms may cause:

  • pain in the popliteal space
  • edema
  • vessel distention and widened pulse

Cardiovascular disorders

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  • possibly symptoms of severe ischemia (in the leg or foot). Signs of a femoral aneurysm include a wide, pulsating mass above or below the inguinal ligament found on palpation.

What tests tell you

  • When palpation doesn’t provide a positive identification, duplex ultrasonography, CT angiography, or arteriography may help identify femoral and popliteal aneurysms. These tests may also help detect associated aneurysms, especially those in the abdominal aorta and the iliac arteries.
  • Ultrasound can also help identify aneurysms and may help to determine the size of the popliteal or femoral artery.

How it’s treated
Femoral and popliteal aneurysms require surgical bypass and reconstruction of the artery, usually with an autogenous saphenous vein graft replacement or patch arterioplasty. Arterial occlusion that causes severe ischemia and gangrene may require leg amputation if adequate blood flow can’t be restored.

What to do

  • Administer prophylactic antibiotics, antihypertensives, or anticoagulants, as ordered.
  • Prepare the patient for surgery. (For information on nursing care of patients who undergo vascular surgery.
  • Evaluate the patient. Document whether the patient shows good color and temperature of extremities and if he no longer has pain. Pulses should be present in his extremities.

Cardiovascular disorders: Arterial occlusive disease

Focus topic: Cardiovascular disorders

A common complication of atherosclerosis, arterial occlusive disease may affect any artery but typically affects the peripheral arteries, such as the carotid (and its branches) and the lower extremity arteries (femoral, popliteal, posterior tibial, anterior tibial, and peroneal). The upper extremity arteries (subclavian, axillary, brachial, radial, and ulnar) are less commonly affected. Arterial occlusions may be acute or chronic. Men suffer from arterial occlusive disease more commonly than women.

Cardiovascular disorders

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