NCLEX: 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

VIII. CARDIAC CATHETERIZATION: a diagnostic procedure to evaluate cardiac status. Introduces a catheter into the heart, blood vessels; analyzes blood samples for oxygen content, ejection fraction, cardiac output, pulmonary artery blood flow; done before heart surgery; frequently combined with angiography to visualize coronary arteries; also provides access for specialized cardiac techniques (e.g., internal pacing and percutaneous transluminal coronary angioplasty [PTCA]).

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

A. Approaches

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

  • Right-heart catheterization—venous approach (antecubital or femoral) → right atrium → right ventricle → pulmonary artery.
  • Left-heart catheterization—retrograde approach: right brachial artery or percutaneous puncture of femoral artery → ascending aorta → left ventricle.
    a. Transseptal: femoral vein → right atrium → septum → left atrium → left ventricle.
    b. Angiography/arteriography: done during leftheart catheterization.

B. Precatheterization

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

  • Assessment:
    a. Subjective data:
    (1) Allergies: iodine, seafood.
    (2) Anxiety.
    (3) Comfort.
    b. Objective data:
    (1) Vital signs: baseline data.
    (2) Distal pulses: mark for reference after catheterization.
  • 2. Analysis/nursing diagnosis:
    a. Anxiety related to fear of unknown.
    b. Knowledge deficit (learning need) related to limited exposure to information or sudden need for procedure.
  • Nursing care plan/implementation:
    a. Goal: provide for safety, comfort.
    (1) Signed informed consent.
    (2) NPO (except for medications 6 to 8 hours before).
    (3) Have client urinate before going to lab.
    (4) Give sedatives, as ordered, 30 minutes before procedure (e.g., midazolam HCl [Versed] IV, diazepam [Valium] PO).
    (5) Possible shaving of insertion site.
    b. Goal: health teaching.
    (1) Procedure: length (1 to 3 hours).
    (2) Expectations (strapped to table for safety, must lie still, awake but mildly sedated).
    (3) Sensations (hot, flushed feeling in head with dye injection; thudding in chest from premature beats during catheter manipulation; desire to cough, particularly with right-heart angiography and contrastmedium injection).
    (4) Alert physician to unusual sensations (coolness, numbness, paresthesia).

C. Postcatheterization

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

  • Assessment (potential complications):
    a. Subjective data:
    (1) Puncture site: increasing pain, tenderness.                                                                                                                                                                                       (2) Palpitations, chest pain.
    (3) Affected extremity: tingling, numbness, pain from hematoma or nerve damage.
    b. Objective data:
    (1) Vital signs: shock, respiratory distress (related to pulmonary emboli, allergic reaction).
    (2) Puncture site: bleeding (hematoma).
    (3) ECG: arrhythmias, signs of MI.
    (4) Affected extremity: color, temperature, peripheral pulses.
  • Analysis/nursing diagnosis:
    a. Decreased cardiac output related to arrhythmias or MI.
    b. Altered tissue perfusion related to bleeding following procedure.
    c. Pain related to puncture site tenderness.
  • Nursing care plan/implementation:
    a. Goal: prevent complications.
    (1) Bedrest: depends on size of catheter and closure procedure—Perclose dissolvable suture, 30 minutes; Angioseal (collagen plug), 2 hours; compression pump or 15-minute manual compression followed by sandbag, 4 to 5 hours; 12 to 24 hours with sheath or antiplatelet drip (abciximab [ReoPro]).
    (2) Vital signs: record q15 min for 1 hour, q30 min for 3 hours or until stable; check BP on opposite extremity.
    (3) Puncture site: observe for bleeding, swelling, or tenderness; check pulse distal to insertion site to determine patency of artery; report complaints of coolness, numbness, or paresthesia in extremity.
    (4) ECG: monitor, document rhythm.
    (5) Give medications as ordered: sedatives; mild narcotics; antiarrhythmics; antiplatelet (Plavix, aspirin) or low-molecular-weight heparin (enoxaparin [Lovenox]) with stent insertion.
    b. Goal: provide emotional support.
    (1) Explanations: brief, accurate; client anxious to learn results of test.
    (2) Counseling: refer as indicated.
    c. Goal: health teaching.
    (1) Late complications: infection.
    (2) Prepare for surgery if indicated.
    (3) Follow-up medical care.
    (4) Limitations following PTCA procedure : no lifting greater than 10 lb and no vigorous exertion for 1 to 2 weeks; return to normal work and sexual activity in 2 to 3 days.
  • Evaluation/outcome criteria: no complications (e.g., cardiac arrest, hematoma at insertion site).

IX. PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY (PTCA): A balloontipped catheter is threaded to site of coronary occlusion and inflated repeatedly until blood flow increases distal to the obstruction. It is a nonsurgical alternative to bypass surgery for coronary artery occlusion (Arterial balloon
angioplasty);
recommended for clients with poorly controlled angina, mild or no symptoms, multiple- or single-vessel disease with a noncalcified, discrete, and proximal lesion that can be reached by the catheter; costs less and requires shorter hospitalization and rehabilitation period; successful in 90% of clients; approximately 30% restenose by 3 months (for nursing process). Rotational atherectomy may also be done; a high-speed drill pulverizes plaque into small particles. An intravascular stent, steel mesh or coiled spring, may be placed in the coronary artery; the stent acts as a mechanical scaffold to reopen the blocked artery. The client receives low-molecular-weight heparin and/or platelet therapy following the procedure
and after discharge.

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

X. CARDIAC SURGERY: done to alter the structure of the heart or vessels when congenital or acquired disorders interfere with cardiac functioning: septal defects; transposition of great vessels; tetralogy of Fallot; pulmonary/aortic stenosis; coronary artery bypass; valve replacement. Cardiopulmonary bypass (open-heart surgery): blood from cardiac chambers and great vessels is diverted into a pump oxygenator; allows full visualization of heart during surgery; maintains perfusion and body functioning.

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

A. Preoperative

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

  • Assessment: see specific conditions for preoperative signs and symptoms (i.e., valvular defects, angina, MI); Establish complete baseline: daily weight; vital signs—integrity of all pulses, BP both arms; CVP or pulmonary artery pressures; neurological status; emotional status; nutritional and elimination patterns; laboratory values (urine, electrolytes, enzymes, coagulation studies, cholesterol); pulmonary function studies; echocardiogram, chest x-ray.
  • Analysis/nursing diagnosis:
    a. Decreased cardiac output related to myocardial damage.
    b. Activity intolerance related to poor cardiac function.
    c. Knowledge deficit (learning need) related to insufficient time for teaching.                                                                                                                                        d. Anxiety related to fear of unknown.
    e. Fear related to possible death.
    f. Risk for spiritual distress related to possible death.
  • Nursing care plan/implementation:
    a. Goal: provide emotional and spiritual support.
    (1) Arrange for religious consultation if desired.
    (2) Provide opportunity for family visit morning of surgery.                                                                                                                                                                     (3) Encourage verbalization/questions: fear, depression, despair frequently occur.
    (4) Involve family during explanations.
    b. Goal: health teaching.
    (1) Diagnostic procedures, treatments, specifics for surgery (i.e., internal mammarian artery or leg incision with use of saphenous vein in coronary artery bypass graft surgery) (Bypass).                                                                                                                                                                                                                         (2) Postoperative regimen: turn, cough, deep breathe, ROM, equipment used, medication for pain.
    (3) Tour ICU; meet personnel.
    (4) Alternative method of communication while intubated.
  • Evaluation/outcome criteria:
    a. Displays moderate anxiety level.
    b. Verbalizes/demonstrates postoperative expectations.
    c. Quits smoking before surgery.

B. Postoperative

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

  • Assessment:
    a. Subjective data:
    (1) Pain.
    (2) Fatigue—sleep deprivation.
    b. Objective data:
    (1) Neurological: level of consciousness; pupillary reactions; movement of limbs (purposeful, spontaneous).
    (2) Respiratory: rate changes (increases occur with obstruction, pain; decreases occur with CO2 retention); depth (shallow with pain, atelectasis); symmetry; skin color; patency/drainage from chest tubes, sputum (amount, color); endotracheal tube placement (bilateral breath sounds); arterial blood gases, O2 saturation.
    (3) Cardiovascular:
    (a) BP—hypotension may indicate: heart failure, tamponade, hemorrhage, arrhythmias, or thrombosis; hypertension may indicate: anxiety, hypervolemia.
    (b) Pulse: radial, apical, pedal; rate (>100 may indicate: shock, fever, hypoxia, arrhythmias); rhythm, quality. Check pacing wires.
    (c) CVP and PA catheter (elevated in cardiac failure); temperature (normal postoperative: 98.6° to 101.6°F oral).                                                                              (4) GI: nausea, vomiting, distention.
    (5) Renal: urine—minimum output (30 mL/hr); color Specific gravity (<1.010 occurs with overhydration,
    renal tubular damage; >1.020 present with dehydration, oliguria, blood in urine).
  • Analysis/nursing diagnosis:
    a. Decreased cardiac output related to decreased myocardial contractility or postoperative hypothermia.
    b. Pain (acute) related to incision.
    c. Ineffective airway clearance related to effects of general anesthesia.                                                                                                                                                d. Altered tissue perfusion related to postoperative bleeding or thromboemboli.
    e. Fluid volume deficit related to blood loss.
    f. Risk for infection related to wound contamination.
    g. Altered thought processes related to anesthesia or stress.
    h. Altered role performance related to uncertainty about future.
  • Nursing care plan/implementation:
    a. Goal: provide constant monitoring to prevent complications.
    (1) Respiratory:
    (a) Observe for respiratory distress: restlessness, nasal flaring, Cheyne-Stokes respiration, dusky/cyanotic skin; assisted or controlled ventilation via endotracheal tube common 6 to 24 hours; supplemental O2 after extubation.
    (b) Suctioning; cough, deep breathe.
    (c) Elevate head of bed at least 30 degrees.
    (d) Position chest tube to facilitate drainage; suction maintains patency—do not “milk” chest tube.                                                                                                    (2) Cardiovascular:
    (a) Vital signs: BP greater than 80 to 90 mm Hg systolic; CVP: range 5 to 15 cm H2O unless otherwise ordered; pulmonary artery line (PA catheter): mean pressure 4 to 12 mm Hg; I&O: report less than 30 mL/hr of urine from indwelling urinary catheter.
    (b) ECG; premature ventricular contractions (PVCs) occur most frequently following aortic valve replacement and bypass surgery.
    (c) Peripheral pulses if leg veins used for grafting.
    (d) Activity: turn q2h; ROM; progressive, early ambulation.
    (3) Inspect dressing for bleeding.
    (4) Medications according to therapeutic directives—cardiotonics (digoxin); coronary vasodilators (nitrates); antibiotics (penicillin); analgesics; anticoagulants (with valve replacements); antiarrhythmics (amiodarone, procainamide HCl [Pronestyl]); dobutamine [Dobutrex].
    b. Goal: promote comfort, pain relief.
    (1) Medicate: morphine sulfate—severe pain lasts 2 to 3 days.
    (2) Splint incision when moving or coughing.                                                                                                                                                                                          (3) Mouth care: frequent, especially if intubated; keep lips moist.
    (4) Position: use pillows to prevent tension on chest tubes, incision.
    c. Goal: maintain fluid, electrolyte, nutritional balance.
    (1) I&O; urine specific gravity.
    (2) Measure chest drainage—should not exceed 200 mL/hr for first 4 to 6 hours.
    (3) Give fluids as ordered; maintain IV patency, central line care.
    (4) Diet: clear fluids → solid food if no nausea, GI distention; sodium intake restricted, low fat; give H2 blocker as ordered.
    d. Goal: promote emotional adjustment.
    (1) Anticipate behavior disturbances (depression, disorientation often occur 3 days postoperatively) related to medications, fear, sleep deprivation.
    (2) Calm, oriented, supportive environment, as personalized as possible.
    (3) Encourage verbalization of feelings (family and client).
    (4) Encourage independence to avoid “cardiac cripple” role.
    e. Goal: promote early mobilization.
    (1) Out of bed within 24 hours postoperative to prevent deep vein thrombosis (DVT).
    (2) In chair three times daily by postoperative day 2.
    f. Goal: health teaching.                                                                                                                                                                                                                       (1) Alterations in lifestyle; activity, diet, work; resumption of sexual activity usually when client can climb two flights of stairs.
    (2) Refer to available community resources for cardiac rehabilitation (e.g., American Heart Association, Mended Hearts).
    (3) Drug regimen: purpose, side effects.
    (4) Potential complications: dyspnea, pain, palpitations common postoperatively.
  • Evaluation/outcome criteria:
    a. No complications; incision heals; no dysrhythmias; pacing wires discontinued.
    b. Activity level increases—no signs of overexertion (e.g., fatigue, dyspnea, pain).
    c. Relief of symptoms.
    d. Returns for follow-up medical care.
    e. Takes prescribed medications; knows purposes and side effects.

XI. MINIMALLY INVASIVE DIRECT CORONARY ARTERY BYPASS (MIDCAB): a variation of CABG for clients for whom sternotomy and cardiopulmonary bypass is contraindicated or unnecessary. The left internal mammary artery is anastomosed to the left anterior descending coronary artery through a thoracic incision without bypass. Small incision and minimal recovery time.

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

XII. HEART FAILURE (HF): inability of the heart to meet the peripheral circulatory demands of the body; cardiac decompensation; combined right and left ventricular heart failure.

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

A. Pathophysiology: increased cardiac workload or decreased effective myocardial contractility →decreased cardiac output (forward effects). Left ventricular failure → pulmonary congestion; right atrial and right ventricular failure → systemic congestion→ peripheral edema (backward effects). Compensatory mechanisms in HF include tachycardia, ventricular dilation, and hypertrophy of the myocardium; develops in 50% to 60% of clients
with heart disease.

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

B. Risk factors:

  • Decreased myocardial contractility:
    a. Myocarditis.
    b. MI.
    c. Tachyarrhythmias.
    d. Bacterial endocarditis.
    e. Acute rheumatic fever.
  • Increased cardiac workload:
    a. Elevated temperature.
    b. Physical/emotional stress.
    c. Anemia.
    d. Hyperthyroidism (thyrotoxicosis).
    e. Valvular defects.
    f. Uncontrolled hypertension.

C. Assessment:

  • Subjective data:
    a. Shortness of breath.
    (1) Orthopnea (sleeps on two or more pillows).
    (2) Paroxysmal nocturnal dyspnea (sudden breathlessness during sleep).
    (3) Dyspnea on exertion (climbing stairs).
    b. Apprehension; anxiety; irritability.
    c. Fatigue; weakness.
    d. Reported weight gain; feeling of puffiness.
    2. Objective data (Left Ventricular Compared with Right Ventricular Heart Failure):
    a. Vital signs:
    (1) BP: decreasing systolic; narrowing pulse pressure.
    (2) Pulse: pulsus alternans (alternating strong-weak-strong cardiac contraction), increased.
    (3) Respirations: crackles, Cheyne-Stokes.
    b. Edema: dependent, pitting (1+ to 4+ mm).
    c. Liver: enlarged, tender.
    d. Neck veins: distended.
    e. Chest x-ray:
    (1) Cardiac enlargement.
    (2) Dilated pulmonary vessels.
    (3) Diffuse interstitial lung edema.

D. Analysis/nursing diagnosis:

  • Decreased cardiac output related to decreased myocardial contractility.
  • Activity intolerance related to generalized weakness and inadequate oxygenation.
  • Fatigue related to edema and poor oxygenation.
  • Altered tissue perfusion related to peripheral edema and inadequate blood flow.
  • Fluid volume excess related to compensatory mechanisms.
  • Impaired gas exchange related to pulmonary congestion.
  • Anxiety related to shortness of breath.
  • Sleep pattern disturbance related to paroxysmal nocturnal dyspnea.

E. Nursing care plan/implementation:

  • Goal: provide physical rest/reduce emotional stimuli.
    a. Position: sitting or semi-Fowler’s until tachycardia, dyspnea, edema resolved; change position frequently; pillows for support.
    b. Rest: planned periods; limit visitors, activity, noise. Chair and commode privileges.
    c. Support: stay with client who is anxious; have family member who is supportive present; administer sedatives/tranquilizers as ordered.
    d. Warm fluids if appropriate.
  • Goal: provide for relief of respiratory distress; reduce cardiac workload.
    a. Oxygen: low flow rate; encourage deep breathing (5 to 10 minutes q2h); auscultate breath sounds for congestion, pulmonary edema.
    b. Position: elevating head of bed 20 to 25 cm (8 to 10 inches) alleviates pulmonary congestion.
    c. Medications as ordered:
    (1) Digitalis preparations.
    (2) ACE inhibitors—captopril, enalapril.
    (3) Inotropic agent—dobutamine, dopamine.
    (4) Diuretics—thiazides, furosemide, metolazone.                                                                                                                                                                                 (5) Tranquilizers—phenobarbital, diazepam (Valium), chlordiazepoxide HCl (Librium).
    (6) Vasodilators—hydralazine, isosorbide.
  • Goal: provide for special safety needs.
    a. Skin care:
    (1) Inspect, massage, lubricate bony prominences.
    (2) Use foot cradle, heel protectors; sheepskin.
    b. Side rails up if hypoxic (disoriented).
    c. Vital signs: monitor for signs of fatigue, pulmonary emboli.
    d. ROM: active, passive; elastic stockings, DVT prophylaxis.
  • Goal: maintain fluid and electrolyte balance, nutritional status.
    a. Urine output: 30 mL/hr minimum; estimate insensible loss in client who is diaphoretic. Monitor: BUN, serum creatinine, and electrolytes, B-type natriuretic peptide (BNP).
    b. Daily weight; same time, clothes, scale.
    c. IV: IV infusion pump to avoid circulatory overloading; strict I&O.
    d. Diet:
    (1) Low sodium as ordered.
    (2) Small, frequent feedings.
    (3) Discuss food preferences with client.
  • Goal: health teaching.
    a. Diet restrictions; meal preparation.
    b. Activity restrictions, if any; planned rest periods.
    c. Medications: schedule (e.g., diuretic in early morning to limit interruption of sleep), purpose, dosage, side effects (importance of daily pulse taking, daily weights, intake of potassium-containing foods).
    d. Refer to available community resources for dietary assistance, weight reduction, exercise program.

F. Evaluation/outcome criteria:

  • Increase in activity level tolerance—fatigue decreased.
  • No complications—pulmonary edema, respiratory distress.
  • Reduction in dependent edema.

XIII. PULMONARY EDEMA: sudden transudation of fluid from pulmonary capillaries into alveoli. Life-threatening condition.

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

A. Pathophysiology: increased pulmonary capillary permeability; increased hydrostatic pressure (pulmonary
hypertension); decreased blood colloidal osmotic pressure; fluid accumulation in alveoli →decreased compliance → decreased diffusion of gas → hypoxia, hypercapnia.

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

B. Risk factors:

  • Left ventricular failure.
  • Pulmonary embolism.
  • Drug overdose.
  • Smoke inhalation.
  • CNS damage.
  • Fluid overload.
  • Valvular disorders.

C. Assessment:

  • Subjective data:
    a. Anxiety.
    b. Restlessness at onset, progressing to agitation.
    c. Stark fear.
    d. Intense dyspnea, orthopnea, fatigue.
  • Objective data:
    a. Vital signs:
    (1) Pulse: tachycardia; gallop rhythm.
    (2) Respirations: tachypnea, moist, bubbling, wheezing, labored, ↓ O2 saturation.
    (3) Temperature: normal to subnormal.
    b. Skin: pale, cool, diaphoretic, cyanotic.
    c. Auscultation: crackles, wheezes.
    d. Cough: productive of large quantities of pink, frothy sputum.
    e. Right ventricular heart failure: distended (bulging) neck veins, peripheral edema, hepatomegaly, ascites.
    f. Mental status: restless, confused, stuporous.
    g. Arterial blood gases: hypoxia; pulse oximetry: decreased O2 saturation.
    h. Chest x-ray: haziness of lung fields, cardiomegaly. Echocardiogram.

D. Analysis/nursing diagnosis:

  • Decreased cardiac output related to decreased myocardial contractility.
  • Impaired gas exchange related to pulmonary congestion.
  • Altered tissue perfusion related to inadequate blood flow.
  • Anxiety, severe, related to difficulty breathing.
  • Fear related to life-threatening situation.

E. Nursing care plan/implementation:

  • Goal: promote physical, psychological relaxation measures to relieve anxiety.
    a. Slow respirations: morphine sulfate 3 to 10 mg IV/SQ/IM, as ordered, to reduce respiratory rate, sedate, and produce vasodilation.
    b. Remain with client.
    c. Encourage slow, deep breathing; assist with coughing.
    d. Work calmly, confidently, unhurriedly.
    e. Frequent rest periods.
  • Goal: improve cardiac function, reduce venous return, relieve hypoxia.
    a. O2: slow respiratory rate, provide uniform ventilation via nasal cannula, ventimask,100% non-rebreather mask, or intubation, depending on O2 need. Possibly PEEP. Smallvolume nebulizer treatment with ipratropium (Atrovent) or albuterol (Proventil).
    b. Give aminophylline, as ordered, to lower venous pressure and increase cardiac output.
    c. IV: D5W.
    d. Position: high Fowler’s, extremities in dependent position, to reduce venous return and facilitate breathing.
    e. Medications as ordered: digitalis; diuretics—furosemide (Lasix); inotropic agents —dobutamine (Dobutrex), dopamine; nitroglycerin, nitroprusside.
    f. Vital signs; auscultate breath sounds.
    g. Diet: low sodium; fluid restriction as ordered.
  • Goal: health teaching (include family or significant other).
    a. Medications.
    (1) Side effects.
    (2) Potassium supplements if indicated.
    (3) Pulse taking.
    b. Exercise; rest.
    c. Diet: low sodium.
    d. Signs of complications: edema; weight gain of 2 to 3 lb (0.9 to 1.4 kg) in a few days; dyspnea.
    F. Evaluation/outcome criteria:
    1. No complications; vital signs stable; clear breath sounds.
    2. No weight gain; weight loss if indicated.
    3. Alert, oriented, calm.

XIV. SHOCK: a critically severe deficiency in nutrients, oxygen, and electrolytes delivered to body tissues, plus
deficiency in removal of cellular wastes; results from: cardiac failure, insufficient blood volume, or increased vascular bed size.

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

A. Types, pathophysiology, and risk factors:

  • Hypovolemic (hemorrhagic, hematogenic)—markedly decreased volume of blood (hemorrhage or plasma loss from intestinal obstruction, burns, physical trauma, or dehydration) →decreased venous return, cardiac output →decreased tissue perfusion.
  • Cardiogenic—failure of cardiac muscle pump (myocardial infarction) → generally decreased cardiac output → pulmonary congestion, hypoxia → inadequate circulation; high mortality rate.
  • Distributive:
    a. Neurogenic—massive vasodilation from reduced vasomotor, vasoconstrictor tone (e.g., spinal shock, head injuries, anesthesia, pain); interruption of sympathetic nervous system; blood volume is normal but inadequate for vessels → decreased venous return → tissue hypoxia.
    b. Vasogenic (anaphylactic, septic, systemic inflammatory response syndrome [SIRS], endotoxic—severe reaction to foreign protein (insect bites, drugs, toxic substances, aerobic, gram-negative organisms) → histamine release vasodilation, venous stasis → diminished venous return.

B. Assessment: varies, depending on degree of shock (Signs of Hypovolemic Shock).

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

  • Subjective data:
    a. Anxiety; restlessness.
    b. Dizziness; fainting.
    c. Thirst.
    d. Nausea.
  • Objective data:
    a. Vital signs:
    (1) BP—hypotension (postural changes in early shock; systolic less than 70 mm Hg in late shock).
    (2) Pulse—tachycardia, thready; irregular (cardiogenic shock); could be slow if conduction system of heart damaged.
    (3) Respirations—increased depth, rate; wheezing (anaphylactic shock), O2 saturation ↓ 90%.
    (4) Temperature—decreased (elevated in septic shock).                                                                                                                                                                       b. Skin:
    (1) Pale (or mottled), cool, clammy (warm to touch in septic shock).
    (2) Urticaria (anaphylactic shock).
    c. Level of consciousness: alert, oriented →acute alteration in mental status →unresponsive.                                                                                                             d. CVP:
    (1) Below 5 cm H2O with hypovolemic shock, also anaphylactic or septic shock.
    (2) Above 15 cm H2O with cardiogenic shock.
    e. Urine output: decreased (<30 mL/hr).
    f. Capillary refill: slowed; normally nailbed “pinks up” within 2 seconds after blanching (nailbed pressure).
    C. Analysis/nursing diagnosis:
    1. Altered tissue perfusion related to vasodilation or decreased myocardial contractility.
    2. Impaired gas exchange related to ventilationperfusion imbalance.
    3. Decreased cardiac output related to loss of circulating blood volume or diminished cardiac contractility; peripheral vasodilation.
    4. Altered urinary elimination related to decreased renal perfusion.
    5. Fluid volume deficit related to blood loss.
    6. Anxiety related to severity of condition.

D. Nursing care plan/implementation: Goal: promote venous return, circulatory perfusion.

  • Position: foot of bed elevated 20 degrees (12 to 16 inches), knees straight, trunk horizontal, head slightly elevated; avoid Trendelenburg position.
  • Ventilation: monitor respiratory effort, loosen restrictive clothing; O2 as ordered.
  • Fluids:
    a. Maintain IV infusions—with sepsis, may receive 2 to 6 L to keep CVP greater than 12 mm Hg to prevent end organ hypoxia and organ failure. Mean arterial pressure greater than 60 mm Hg.
    b. Give blood, plasma expanders as ordered (exception—stop blood immediately in anaphylactic shock).
  • Vital signs:
    a. CVP (decreased with hypovolemia) arterial line, PA catheter (increased pulmonary artery wedge pressure indicating cardiac failure). Check central venous O2 (scvO2).
    b. Urine output (insert catheter for hourly output).
    c. Monitor ECG (increased rate, dysrhythmias).
  • 5. Medications (depending on type of shock) as ordered:
    a. Adrenergics—dobutamine, norepinephrine (Levophed), isoproterenol (Isuprel), dopamine (Intropin) (cardiogenic, neurogenic, septic shock).
    b. Antiarrhythmics (cardiogenic shock).
    c. Cardiac glycosides (cardiogenic shock).
    d. Adrenocorticoids (anaphylactic shock).
    e. Antibiotics (septic shock).                                                                                                                                                                                                                   f. Vasodilators—nitroprusside (cardiogenic shock).
    g. Antihistamines—epinephrine, vasopressin, Benadryl IV, methlyprednisone.
  • Mechanical support: military (or medical) antishock trousers (MAST) or pneumatic antishock garment (PASG); used to promote internal autotransfusion of blood from legs and abdomen to central circulation; at lower pressures may control bleeding and promote hemostasis; do not remove (deflate) suddenly to examine underlying areas or BP will drop precipitously; compartment syndrome may result with prolonged use and high pressure; controversial.

E. Evaluation/outcome criteria:

  • Vital signs stable, within normal limits.
  • Alert, oriented.
  • Urine output greater than 30 mL/hr.

XV. DISSEMINATED INTRAVASCULAR COAGULATION (DIC): diffuse or widespread coagulation initially within arterioles and capillaries leading to hemorrhage.

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

A. Pathophysiology: activation of coagulation system from tissue injury → fibrin microthrombi form throughout the vascular system → microinfarcts, tissue necrosis → red blood cells, platelets, prothrombin, other clotting factors trapped in capillaries, destroyed in process → excessive clotting →release of fibrin split products → inhibition of platelet clotting → profuse bleeding.

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

B. Risk factors:

  • Obstetric complications (50% of cases).
  • Neoplastic disease.
  • Low perfusion states (e.g., burns, hypothermia); hypovolemia.
  • Infections, sepsis.

C. Assessmentobjective data:

  • Skin, mucous membranes: petechiae, ecchymosis.
  • Extremities (fingers, toes): cyanosis.
  • Bleeding: venipuncture sites, wound, oral, rectal, vaginal.
  • Urine output: oliguria → anuria.
  • Level of consciousness: ↓ LOC progressing to coma.
  • Laboratory data: prolonged—prothrombin time (PT) greater than 15 seconds; decreased—platelets, fibrinogen level.

D. Analysis/nursing diagnosis:

  • Altered tissue perfusion related to peripheral microthrombi.
  • Risk for injury (death) related to bleeding.
  •  Risk for impaired skin integrity related to ischemia.
  • Altered urinary elimination related to renal tubular necrosis.

E. Nursing care plan/implementation: Goal: prevent and detect further bleeding.

  • Carry out nursing measures designed to alleviate underlying problem (e.g., shock, birth of fetus, surgery/irradiation for cancer, antibiotics for infection).
  • Medications: heparin sodium IV, 1,000 units/hr, if ordered, to reverse abnormal clotting (controversial).
    Possible human recombinant activated protein C.
  • IVs: blood to lessen shock; platelets, cryoprecipitate, fresh plasma to restore clotting factors, fibrinogen.
  • Observe: vital signs, CVP (normal 5 to 15 mm Hg), PA pressure (normal 20 to 30 systolic and 8 to 12 diastolic), and I&O for signs of shock or fluid overload from frequent infusions; specimens for occult blood (urine, stool).
  • Precautions: avoid IM injections if possible; pressure 5 minutes to venipuncture sites; no rectal temperatures.

F. Evaluation/outcome criteria:

  • Clotting mechanism restored (increased platelets, normal PT).
  • Renal function restored (urine output >30 mL/hr).
  • Circulation to fingers, toes; no cyanosis.
  • No irreversible damage from renal, cerebral, cardiac, or adrenal hemorrhage.

XVI. PERICARDITIS: inflammation of parietal or visceral pericardium or both; acute or chronic condition; may occur with or without effusion. Cardiac tamponade may result.

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

A. Pathophysiology: fibrosis or accumulation of fluid in pericardium → compression of cardiac pumping→ decreased cardiac output → increased systemic, pulmonic venous pressure.

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

B. Risk factors:

  • Bacterial, viral, fungal infections.
  • Tuberculosis.
  • Collagen diseases.
  • Uremia.
  • Transmural MI.
  • Trauma.

C. Assessment:

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

  • Subjective data:
    a. Pain:
    (1) Type—sharp, moderate to severe.
    (2) Location—wide area of pericardium, may radiate: right arm, jaw/teeth.
    (3) Precipitating factors—movement, deep inspiration, swallowing.
    b. Chills; sweating.
    c. Apprehension; anxiety.
    d. Fatigue.                                                                                                                                                                                                                                               e. Abdominal pain.
    f. Shortness of breath.
  • Objective data:
    a. Vital signs:
    (1) BP: decreased pulse pressure; pulsus paradoxus—abnormal drop in systolic BP of greater than 8 to 10 mm Hg during inspiration.
    (2) Pulse: tachycardia.
    (3) Temperature: elevated; erratic course; low grade.
    b. Pericardial friction rub.
    c. Increased CVP; distended neck veins; dependent pitting edema; liver engorgement.
    d. Restlessness.
    e. Laboratory data: elevated aspartate aminotransferase (AST, or serum glutamic-oxaloacetic transaminase [SGOT]), WBC count; CT or magnetic resonance imaging (MRI)— pericardial thickening; troponin, LDH.
    f. Serial ECGs: increased ST segment; echocardiogram: pericardial fluid.

D. Analysis/nursing diagnosis:

  • Decreased cardiac output related to impaired cardiac muscle contraction.
  • Pain related to pericardial inflammation.
  • Anxiety related to unknown outcome.
  • Fatigue related to inadequate oxygenation.

E. Nursing care plan/implementation:

  • Goal: promote physical and emotional comfort.
    a. Position: semi-Fowler’s (upright or sitting); bedrest.
    b. Vital signs: q2–4h and prn; apical and radial pulse; notify physician if heart sounds decrease in amplitude or if pulse pressure narrows, indicating cardiac tamponade; see i below.
    c. O2 as ordered.
    d. Medications as ordered:
    (1) Analgesics—aspirin, morphine sulfate, meperidine or codeine.
    (2) Nonsteroidal anti-inflammatory agents—indomethacin, ketorolac [Toradol].
    (3) Antimicrobial.
    (4) Digitalis and diuretics, if heart failure present.
    e. Assist with aspiration of pericardial sac (pericardiocentesis) if needed: medicate as ordered; elevate head 60 degrees; monitor ECG; have defibrillator and pacemaker available.
    f. Prepare for pericardiectomy (excision of constricting pericardium) as ordered.
    g. Continual emotional support.
    h. Enhance effects of analgesics: positioning; turning; NPO.                                                                                                                                                                 i. Monitor for:
    Signs of cardiac tamponade: tachycardia; tachypnea; hypotension; pallor; narrowed pulse pressure; pulsus paradoxus; distended neck veins; ECG changes.
  • Goal: maintain fluid, electrolyte balance.
    a. Parenteral fluids as ordered; strict I&O.
    b. Assist with feedings; low-sodium diet may be ordered.

F. Evaluation/outcome criteria:

  • Relief of pain, dyspnea.
  • No complications (e.g., cardiac tamponade).
  • Return of normal cardiac functioning.

XVII. CHRONIC ARTERIAL OCCLUSIVE DISEASE: arteriosclerosis obliterans most common occlusive disorder of the arterial system (aorta, large and medium-size arteries); frequently involves the femoral, iliac, and popliteal arteries (Buerger’s disease).

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

A. Pathophysiology: fatty deposits in intimal, medial layer of arterial walls; plaque formation → narrowed
arterial lumens; decreased distensibility → decreased blood flow; ischemic changes in tissues.

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

B. Risk factors:

  • Age (>50).
  • Sex (men).
  • Diabetes mellitus.
  • Hyperlipidemia—obesity.
  • Cigarette smoking.
  • Hypertension.
  • Family history.

C. Assessment:

  • Subjective data:
    a. Pain:
    (1) Type—cramplike.
    (2) Location—foot, calf, thigh, buttocks.
    (3) Duration—variable, may be relieved by rest.
    (4) Precipitating causes—exercise (intermittent claudication), but occasionally may occur when at rest.
    b. Tingling, numbness in toes, feet.
    c. Persistent coldness of one or both lower extremities.
  • Objective data:
    a. Lower extremities:
    (1) Pedal pulses—absent or diminished.
    (2) Skin—shiny, glossy; dry, cold, chalky white, decreased/absent hair, ulcers, gangrene.
    b. Laboratory data: increased serum cholesterol, triglycerides, complete blood count (CBC), platelets.
    c. Arteriography—indicates location, nature of occlusion. Noninvasive: ultrasound, segmental limb pressure, exercise testing.

D. Analysis/nursing diagnosis:

  • Altered tissue perfusion related to peripheral vascular disease.
  • Risk for activity intolerance related to pain and sensory changes.
  • Pain related to ischemia.
  • Risk for impaired skin integrity related to poor circulation.
  • Risk for injury related to numbness of extremities.

E. Nursing care plan/implementation:

  • Goal: promote circulation; decrease discomfort.
    a. Position: elevate head of bed on blocks (3 to 6 inches), because gravity aids perfusion to thighs, legs; elevating legs increases pain.
    b. Comfort: keep warm: avoid chilling or use of heating pads, which may burn skin; apply bed socks.
    c. Circulation: check pedal pulses, skin color, temperature four times daily.
    d. Medications:
    (1) Vasodilators.
    (2) Antiplatelet—acetylsalicylic acid (ASA), ticlopidine, dipyridamole.
    (3) Dihydropyridines—nifedipine, amlodipine.
    (4) Xanthine derivatives—pentoxifylline.
  • Goal: prevent infection, injury.
    a. Skin care: use bed cradle, sheepskin, heel pads; mild soap; dry thoroughly; lotion; do not massage, to prevent release of thrombus.
    b. Foot care: wear properly fitting shoes, slippers when out of bed; inspect for injury or pressure areas; nail care by podiatrist.
  • Goal: health teaching.
    a. Skin care; inspect daily.
    b. Activity: balance exercise, rest to increase collateral circulation; walk only until painful.
    c. Exercises: walking, Buerger-Allen exercises (gravity alternately fills and empties blood vessels).
    d. Diet: low-fat, heart-healthy diet to slow disease progression.
    e. Lifestyle choices: avoid smoking.
    f. Recognize and report signs of occlusion (e.g., pain, cramping, numbness in extremities; color changes—white or blue; temperature changes—cool to cold).

F. Evaluation/outcome criteria:

  • Decreased pain.
  • Skin integrity preserved; no loss of limb.
  • Quits smoking.
  • Does exercises to increase collateral circulation.

XVIII. ANEURYSMS (thoracic or abdominal aortic): localized or diffuse dilations/outpouching of a vessel wall, usually an artery; exerts pressure on adjacent structures; affects primarily men over age 60; greater than 6 cm in diameter, 50% will rupture; resected surgically, reconstructed with synthetic or vascular graft.

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

A. Risk factors:

  • Atherosclerosis.
  • Trauma.
  • Syphilis.
  • Congenital weakness.
  • Local infection.
  • Cigarette smoking.
  • Uncontrolled hypertension.

B. Assessment:

  • Subjective data:
    a. Pain:
    (1) Constant, boring, neuralgic, intermittent—low back, abdominal.
    (2) Angina—sudden onset may mean rupture or dissection, which is an emergency condition.
    b. Dyspnea; orthopnea—pressure on trachea or bronchus.
  • Objective data:
    a. Vital signs:
    (1) Radial pulses differ.
    (2) Tachycardia.
    (3) Hypotension following rupture leading to shock.
    b. Pulsating mass: abdominal, chest wall pulsation; edema of chest wall (thoracic aneurysm); periumbilical (abdominal aneurysm); audible bruit over aorta.          c. Skin: cyanosis, mottled below level of aneurysm.
    d. Veins: dilated, superficial—neck, chest, arms.
    e. Cough: paroxysmal, brassy.
    f. Diaphoresis, pallor, fainting following rupture.
    g. Peripheral pulses:
    (1) Femoral present.
    (2) Pedal weak or absent.
    h. Stool: bloody from irritation.

C. Analysis/nursing diagnosis:

  • Risk for injury related to possible aneurysm rupture.
  • Pain related to pressure on lumbar nerves.
  • Anxiety related to risk of rupture.

D. Nursing care plan/implementation:

  • Goal: provide emergency care before surgery for dissection or rupture.
    a. Vital signs: frequent, depending on severity (systolic BP <100 mm Hg and pulse >100 with rupture).
    b. IVs: may have 2 to 4 sites; lactated Ringer’s solution may be ordered.
    c. Urine output: monitored every 15 to 30 minutes.                                                                                                                                                                                d. O2: usually via nasal prongs.
    e. Medications as ordered: antihypertensives to prevent extension of dissection.
    f. Transport to operating room quickly.
    g. for general preoperative care.
  • Goal: prevent complications postoperatively.
    a. Position: initially flat in bed; avoid sharp flexion of hip and knee, which places pressure on femoral and popliteal arteries; turn gently side to side; note erythema on back from pooled blood.
    b. Vital signs: CVP; hourly peripheral pulses distal to graft site, including neurovascular check of lower extremities; absent pulses for 6 to 12 hours indicates occlusion; check with Doppler blood flow detector.
    c. Urine output: hourly from indwelling catheter.
    (1) Immediately report anuria or oliguria (<30 mL/hr).
    (2) Check color for hematuria.
    (3) Monitor daily blood urea nitrogen (BUN) and creatinine.
    d. Observe for signs of atheroembolization (patchy areas of ischemia); report change in color, motor ability, or sensation of lower extremities.
    e. Observe for signs of bowel ischemia (decreased/ absent bowel sounds, pain, guaiac-positive diarrhea, abdominal distention); may have nasogastric tube.                                                                                                                                                                                                                                                        f. Measure abdominal girth; increase seen with graft leakage.
  • Goal: promote comfort.
    a. Position: alignment, comfort; prevent heel ulcers.
    b. Medication: narcotics.
  • Goal: health teaching.
    a. Minimize recurrence: avoid trauma, infection, smoking, high-cholesterol diet, obesity.
    b. Regular medical supervision.

E. Evaluation/outcome criteria:

  • Surgical intervention before rupture.
  • No loss of renal function.

XIX. RAYNAUD’S PHENOMENON: a primary vasospastic disease that affects digits of both hands (rarely feet).

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

A. Pathophysiology: constriction of small arteries and arterioles from vasospasm or obstruction → spasm→ hypoxia → hyperthermia as spasm stops.

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

B. Risk factors:

  • Cigarette smoking.
  • Caffeine.
  • Cold temperature.
  • Emotional upsets (stress reaction).
  • Autoimmune conditions:
    a. Systemic lupus erythematosus (SLE).
    b. Rheumatoid arthritis (RA).
    c. Scleroderma.
  • Women between teenage years and age 40.

C. Assessment:

  • Subjective data:
    a. Numbness and sensations of cold. Pain.
    b. During “red phase”: throbbing, paresthesia, tingling in one or more digits.
  • Objective data:
    a. Intermittent episodes of classic color changes, occurring in sequence in digits: pallor (arterial spasm starts) → bluish (cyanosis from hypoxia)→ redness (hyperthermia, as arterial spasm stops); ↓ capillary refill.
    b. Skin and subcutaneous tissue: atrophy.
    c. Nails: brittle.

D. Analysis/nursing diagnosis:

  • Pain (acute/chronic) related to vasospasm/ altered perfusion of affected tissues and ischemia of tissues.
  • Altered peripheral tissue perfusion related to vasospastic disease.
  • Risk for injury related to numbness.

E. Nursing care plan/implementation:

  • Goal: maintain warmth in extremities.
    a. Use wool gloves (when handling cold objects or touching refrigerator/freezer), wool socks and insulated shoes in cold weather.
    b. Avoid prolonged exposure to cold material, environment.
  • Goal: increase hydrostatic pressure, and therefore circulation.                                                                                                                                                              a. Vigorous exercise of arms.
    b. Meds: vasodilators, including calcium channel blockers, nitrates.
  • Goal: health teaching:
    a. Avoid smoking.
    b. Biofeedback for stress management.
    c. Identify and avoid precipitating factors (e.g., cold, stress).

F. Evaluation/outcome criteria:

  • Severity and frequency of attacks are reduced.
  • Tissue perfusion is maintained.
  • Verbalization of less numbness and tingling.
    Relief from discomfort.

XX. VARICOSE VEINS: abnormally lengthened, tortuous, dilated superficial veins (saphenous); result of incompetent valves, especially in lower extremities; process is irreversible.

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

A. Pathophysiology: dilated vein → venous stasis→ edema, fibrotic changes, pigmentation of skin, lowered resistance to trauma.

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

B. Risk factors:

  • Heredity.
  • Obesity.
  • Pregnancy.
  • Chronic disease (heart, liver).
  • Occupations requiring long periods of standing.

C. Assessment:

  • Subjective data:
    a. Dull aches; heaviness in legs.
    b. Pain; muscle cramping.
    c. Fatigue in lower extremities, increased with hot weather, high altitude, history of risk factors.
  • Objective data:
    a. Nodular protrusions along veins.
    b. Edema.
    c. Diagnostic tests: Trendelenburg test; phlebography; Doppler flowmeter.

D. Analysis/nursing diagnosis:

  • Altered tissue perfusion related to venous valve incompetence.
  • Pain related to edema and muscle cramping.
  • Risk for activity intolerance related to leg discomfort.
  • Body image disturbance related to disfigurement of leg.

E. Nursing care plan/implementation:

  • Goal: promote venous return from lower extremities.
    a. Activity: walk every hour.
    b. Discourage prolonged sitting, standing, sitting with crossed legs.
    c. Position: elevate legs q2–3h; elastic stockings or Ace wraps. Compression stockings.
  • Goal: provide for safety.
    a. Assist with early ambulation.
    b. Surgical asepsis with wounds, leg ulcers.
    c. Observe for hemorrhage—if occurs: elevate leg, apply pressure, notify physician.
    d. Observe for allergic reactions if sclerosing drugs used; have antihistamine available.
  • Goal: health teaching.
    a. Weight-reducing techniques, dietary approaches if indicated.
    b. Preventive measures: leg elevation; avoiding prolonged standing, sitting, high chairs, tight girdles, constrictive clothing; wear support hose.
    c. Expectations for Trendelenburg test:
    (1) While client is lying down, elevate leg 65 degrees for approximately 1 minute to empty veins.
    (2) Apply tourniquet high on upper thigh (do not constrict deep veins).
    (3) Client stands with tourniquet in place.
    (4) Filling of veins is observed.                                                                                                                                                                                                         (5)Normal response is slow filling from below in 20 to 30 seconds, with no change in rate when tourniquet is removed.
    (6) Incompetent veins distend very quickly with backflow.
    d. Prepare for sclerotherapy or vein ligation and stripping.
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F. Evaluation/outcome criteria:

  • Relief or control of symptoms.
  • Activity without pain.

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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