Janell Cardio by w6JLcR7

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									                                                                    Cardiovascular Disorder (20 questions)

RISK FACTORS FOR CAD (demographic data, pt hx, modifiable vs. nonmodifable)

             o        Coronary artery disease: includes chronic stable angina and acute coronary syndromes. It affects the arteries that provide blood, oxygen, and
                      nutrients to the myocardium.
             o        When blood flow is partially or completely blocked  ischemia and infarction of myocardium may result.
                                Ischemia = insufficient oxygen.
                                Infarction = necrosis or cell death; occurs when severe ischemia is prolonged and decreased perfusion causes irreversible damage to
                                 tissue.
             o        **Atherosclerosis – is the primary factor in the development of CAD

Nonmodifiable Risk Factors = Age, gender, family history and ethnic background

            Age – important risk factor in women; older women are more likely to have the disease; women who have MIs have a greater risk of dying during
             hospitalization; older than 50, women are more likely to die than men within 1 year after their MI
            Gender – postmenopausal women are 2-3xs more likely than menopausal women to have CAD; women with waist and abdominal obesity (greater waist-
             hip ratio) are more likely to experience CVD than are women with excess fat in their buttocks, hips, and thighs; men have a higher risk for CAD than
             women of all ages, except in the oldest age-group of 80 years and older
            Family hx – A positive fam hx for CAD in a first-degree relative (parent, sibling, or child) is a major risk factor. It is more important than other factors such
             as HTN, obesity, diabetes, or sudden cardiac death. 90% of CAD pts have at least one of these major risk factors:
                                               High cholesterol levels, HTN, diabetes, and current cigarette use.
            Ethnic background:
                                               African-American and Hispanic women have higher CAD risk factors than white women of the same socioeconomic
                                                status.
                                               American Indians and Alaskan Natives 18 years of age and older, about 64% of men and 81% of women have one or more
                                                CAD risk factors (HTN, smoking, high cholesterol, excess wt, DM)

Modifiable Risk Factors =

Smoking/tobacco use: Tar, nicotine, and carbon monoxide

Obesity/overweight : Obesity = BMI > 30 is particularly a problem for African-American women, Mexican Americans, and native Hawaiians. (Early onset of obesity)

Physical inactivity/sedentary lifestyle : Recommended exercise guideline is 30 mins daily of light to moderate exercise = 30-min brisk walk.

Psychological variables

Diabetes mellitus

HTN/High blood pressure

Hyperlipidemia/elevated serum lipid levels

                Elevated levels of LDL combined with low levels of HDL increase the risk of MI.
                A 10% reduction in serum cholesterol my result in  a 30% reduction in the incidence of CAD and MI
                The fasting total cholesterol should be  < 200 mg/dL; those at high risk < 70 mg/dL; low or moderate risk  < 100 mg/dL
                Recommended triglyceride level  < 135 mg/dL in women, < 150 mg/dL in men

Stress

                Highly competitive, overly concerned about meeting deadlines, often hostile or angry are at higher risk for heart disease; psychological stress, anger,
                 depression, and hostility are all closely assoc w/ risk of developing heart disease  d/t constant arousal of sympathetic NS may influence BP, serum
                 fatty acids and lipids, and clotting mechanisms.

Excessive alcohol

                MI

Medical hx:

                DM, renal disease, anemia, high BP, stroke, bleeding disorders, connective tissue diseases, chronic pulmonary disease, heart disease, and
                 thrombophlebitis  these conditions can influence the pt’s CV status.
                Recurrent tonsillitis, streptococcal infections, and rheumatic fever -> these condition may lead to valvular abnormalities of the heart
                Women with diabetes or have HTN who are taking oral contraceptives or estrogen replacement have a high risk for an MI or stroke
                Social history: people who report an annual household income of less than $10,000 or cannot work have a greater risk for CVD than people who have an
                 income of over $50,000

LAB TESTS (serum lipids, PT/INR, & aPTT [know normal range & therapeutic range])

                                                                                       1
             o  Serum lipids (pp 719)
Serum Lipids (desired range)            Range                                                     Significance of Abnormal Findings
Total lipids                            400-1000 mg/dL                                            Elevations indicates increased risk of CAD
Cholesterol                             122-200 mg/dL, or 3.16-6.5 mmol/L                         Elevations indicates increased risk of CAD
(<200 mg/dL)                            Older adult (>70 yr): 144-280 mg/dL
Triglycerides                           Females: 35-135 mg/dL                                     Elevation indicates increased risk of CAD
(<150 mg/dL)                            Males: 40-160 mg/dL
                                        Older adult: (>65 yr): 55-260 mg/dL
HDLs                                    Females: mean, 40 mg/dL                                   Elevations protect against CAD
(>40 mg/dL)                             Males: mean, 40 mg/dL
                                        Older adult range increases with age
LDLs                                    0-180 mg/dL                                               Elevation indicates risk of CAD
(<70 mg/dL in high risk CV pts, <       Older adult (>65 yr): 92-221 mg/dL
100 mg/dL in pts w/ moderate risk
factors)
VLDL                                    25%-50%                                                   Elevated level indicates risk of CAD
C-reactive protein (CRP)                <1.0 mg/dL                                                Elevation may indicate tissue infarction or damage

                                                   Normal Range                                        Therapeutic Range
PT                                                 11-12.5 sec, 85%-100% or 1:1.1 pt-control           16??
                                                   ratio
INR                                                0.7-1.8                                             1.5-2.0
aPTT                                               30-40 sec                                           1.5-2 times the normal [45-60, 60-80] (notify
                                                                                                       physician if > 70 seconds)???

PT and INR are used when initiating and maintaining therapy with oral anticoagulants such as sodium warfarin (Coumadin). INR is the most reliable way to monitor
anticoagulant status in warfarin therapy. Therapeutic ranges vary significantly based on the reason for anticoagulation and pt’s hx.

PTT is assessed in pts receiving heparin (Hepalean)


CARDIAC CATH (pt prep, pre-procedure protol, and follow-up care, pp 722-724)

            o    General Information: The most definitive but most invasive test in the diagnosis of heart disease is cardiac catheterization. Cardiac catheterization
                 may include studies of the R or L side of the heart and the coronary arteries.
            o    Pt Prep
                            Assessment of the patient's physical and psychosocial readiness and knowledge level is an important aspect of preparation because many
                             patients have anxiety and fear about cardiac catheterization.
                            Review the purpose of the procedure, inform the patient about the length of the procedure, state who will be present, and describe the
                             appearance of the catheterization laboratory. Tell the patient about the sensations he or she may experience during the procedure, such
                             as palpitations (as the catheter is passed up to the left ventricle), a feeling of heat or a hot flash (as the medium is injected into either side
                             of the heart), and a desire to cough (as the medium is injected into the right side of the heart). Written, electronic, or illustrated materials
                             or DVDs may be used to assist in understanding.
                 The risks of cardiac catheterization are usually explained by the cardiologist. The risks vary with the procedures to be performed and the patient's
                 physical status (Table 35-5). Several complications may follow coronary arteriography, such as:
                    • Myocardial infarction (MI)
                    • Stroke
                    • Arterial bleeding
                    • Thromboembolism
                    • Lethal dysrhythmias
                    • Arterial dissection
                    • Emergent coronary artery bypass surgery
                    • Death

            TABLE 35-5 Complications of Cardiac Catheterization
      RIGHT-SIDED HEART CATHETERIZATION                                                               o    Arterial bleeding or thromboembolism
            o    Thrombophlebitis                                                                      o    Dysrhythmias
            o    Pulmonary embolism                                                               RIGHT-SIDED OR LEFT-SIDED HEART CATHETERIZATION*
            o    Vagal response                                                                        o    Cardiac tamponade
      LEFT-SIDED HEART CATHETERIZATION AND CORONARY                                                   o    Hypovolemia
       ARTERIOGRAPHY                                                                                   o    Pulmonary edema
            o    Myocardial infarction                                                                 o    Hematoma or blood loss at insertion site
            o    Stroke                                                                                o    Reaction to contrast medium

                           The cardiologist or radiologist obtains a written informed consent from the patient or responsible party before the procedure.
                           The patient is admitted to the hospital on the day of the catheterization procedure. He or she may be admitted earlier if there is renal
                            dysfunction. Fluids and acetylcysteine (Mucomyst) may be given 12 to 24 hours before the procedure for renal protection. Contrast-
                            induced renal dysfunction can result from vasoconstriction and the direct toxic effect of the contrast agent on the renal tubules. Hydration
                            and the administration of acetylcysteine pre- and post-study help eliminate or minimize contrast-induced renal toxicity.

                                                                                      2
                         Standard preoperative tests are performed, which usually include a chest x-ray, complete blood count, coagulation studies, and 12-lead
                          ECG. The patient receives nothing by mouth after midnight or has only a liquid breakfast if the catheterization is to take place in the
                          afternoon. The catheterization site is shaved and antiseptically prepared according to agency policy.
                         Before the procedure, take the patient's vital signs, auscultate the heart and the lungs, and assess the peripheral pulses. Question him or
                          her about any history of allergy to iodine-based contrast agents. Be sure that the signed informed consent is completed. An
                          antihistamine or steroid may be given to a patient with a positive history or to prevent a reaction. A mild sedative is usually administered
                          before the procedure. If the patient normally takes a digitalis preparation or diuretic, it is usually withheld before the catheterization.
                          Analysis of electrolytes, blood urea nitrogen (BUN), creatinine, coagulation profile, and CBC is essential before and after the procedure,
                          and abnormalities are discussed with the physician.


          o    Procedure
                        The patient is taken to the cardiac catheterization laboratory (sometimes referred to as the “cath lab”), placed in the supine position on
                         the x-ray table, and securely strapped to the table. Inform him or her that this precaution is necessary because the table turns like a cradle
                         during the procedure. The physician injects a local anesthetic at the insertion site. During the procedure, the patient is instructed to
                         report any chest pain, pressure, or other symptoms to the staff.
                        The right side of the heart is catheterized first and may be the only side examined. The cardiologist inserts a catheter through the
                         femoral vein to the inferior vena cava or through the basilic vein to the superior vena cava; advanced through the right atrium, through
                         the right ventricle, and, at times, into the pulmonary artery (Fig. 35-8).
                                     Intracardiac pressures (right atrial, right ventricular, pulmonary artery, and pulmonary artery wedge pressures) and blood
                                      samples are obtained. A contrast medium is usually injected to detect any cardiac shunts or regurgitation from the pulmonic or
                                      tricuspid valves.
                        In a left-sided heart catheterization, the cardiologist advances the catheter against the blood flow from the femoral or brachial artery up
                         the aorta, across the aortic valve, and into the left ventricle. Alternatively, he or she may pass the catheter from the right side of the
                         heart through the atrial septum, using a special needle to puncture the septum. Intracardiac pressures and blood samples are obtained.
                         The pressures of the left atrium, left ventricle, and aorta, as well as mitral and aortic valve status, are evaluated. The cardiologist injects
                         contrast dye into the ventricle; cineangiograms (rapidly changing films) evaluate left ventricular motion. Calculations are made regarding
                         end-systolic volume, end-diastolic volume, stroke volume, and ejection fraction.
          o    Follow-up care
                        Pt is typically restricted to bed rest & insertion site is kept straight
                        Soft knee brace can be applied to prevent bending of the affected extremity.
                        **Some cardiologist allow the HOB to be elevated up to 30 degrees during the period of bedrest, whereas others prefer that the pt remain
                         supine. Current practice is for pts to remain in bed for 4-6 hours unless a vascular closure device is used (VCD). (Various VCDs are used to
                         eliminate the need for manual compression or sandbags after the catheterization. Examples include arteriotomy sutures and collagen
                         plugs to seal the insertion site)
                        Monitor VSs q 15 min for 1 hr, then q 30 min for 2 hrs or until VSs stable, then q4 hrs or according to hospital policy
                        Assess insertion site for bloody drainage, or hematoma formation (a swelling comprising a mass of extravasated blood [usually clotted]
                         confined to an organ, tissue, or space caused by a break in a blood vessel)
                        Assess peripheral pulses in the affected extremity, skin temperature, and color w/ q VS check
                        Observe for complications of cardiac catheterization (See Table 35-5). **Report any reports of pain and discomfort at the insertion site,
                         chest pain, nausea or feelings of light-headedness.
                        Because contrast medium acts as an osmotic diuretic, monitor urine output and ensure that the pt receives sufficient oral and IV fluids for
                         adequate excretion of the medium.
                        **If the pt experiences symptoms of cardiac ischemia such as chest pain, dysrhythmias, bleeding, hematoma formation, or a dramatic
                         change in peripheral pulses in the affected extremity, contact the Rapid Response Team or physician immediately to provide prompt
                         intervention! Neurologic changes, such as visual disturbances, slurred speech, swallowing difficulties, and extremity weakness, should also
                         be reported immediately.
                        Review home instructions. Remind pt to:
                                     Limit activity for several days, including avoiding lifting and exercise.
                                     Leave the dressing in place for at least the first day at home.
                                     Observe the insertion site over the next few weeks for increased swelling, redness, warmth, and pain. Bruising or a small
                                      hematoma is expected.

STRESS TEST (pt prep & procedure protocol, pp 725)

          o    General Information: Stress Test (exercise electrocardiography) assesses the CV response to an increased workload; helps determine the functional
               capacity of the heart and screens for asymptomatic CAD. Dysrhythmias that develop during the exercise may be identified, & the effectiveness of the
               antidysrhythmic drugs can be evaluated.
          o    Pt Prep
                         Pt must be adequately informed about the purpose of the test, the procedure, and the risks involved because of risks associated.
                         Written consent must be obtained. Anxiety and fear are common before stress testing. Therefore assure the pt that the procedure is
                          performed in a controlled environment in which prompt nursing and medical attention is available.
                         The pt is instructed to get plenty of rest the night before the procedure.
                         Pt may have a light meal 2 hours before the test but should avoid smoking or drinking alcohol or caffeine-containing beverages on the
                          day of the test.
                         The cardiologist decides whether the pt should stop taking any cardiac medications. Usually, cardiovascular drugs such as beta blockers or
                          CCBs are w/held on the day of the test to allow the heart rate to incrs during the stress portion of the test.
                         Pts are advised to wear comfortable, loose clothing and rubber-soled, supportive shoes.
                         Instruct them to tell the physician if symptoms such as chest pain, dizziness, SOB, and an irregular heartbeat are experienced during the
                          test.
                                                                                  3
                         Before the stress test, a resting 12-lead ECG, CV hx, and physical examination are performed to check for any ECG abnormalities or
                          medical factors that might interfere with the test.
                         Check to see that all emergency supplies such as cardiac drugs, a defibrillator, and other necessary resuscitation equipment are available
                          in the room in which stress test is performed. It is important to be proficient in the use of resuscitation equipment when assisting the
                          physician b/c chest pain, dysrhythmias, and other ECG changes may occur.
          o     Procedure Protocol
                         Electrodes are placed on pt’s chest and are attached to a multilead monitoring system.
                         Note baseline BP, HR, and RR.
                         Two major modes of exercise are available: pedaling a bicycle ergometer and walking on a treadmill.
                         During the test, the BP and ECG are closely monitored as the resistance to cycling or the speed and incline the treadmill are increased. The
                          pt exercises until one of these findings occurs:
                                    A predetermined HR is reached and maintained
                                    S/Ss such as chest pain, fatigue, extreme dyspnea, vertifo, hypoTN, and ventricular dysrhythmias appear.
                                    Significant ST segment depression or T wave inversion occurs.
                                    The 20-minute protocol is completed.


ECHOCARDIOGRAPHY (the purpose)

          o     Noninvasive, risk-free test, easily performed at bedside or on an ambulatory care basis.
          o     It uses ultrasound waves to assess cardiac structure and mobility, particularly of the valves. It helps to assess and diagnose cardiomyopathy,
                valvular disorders, pericardial effusion, L ventricular function, ventricular aneurysms, and cardiac tumors.
                           Cardiomyopathy = any disease that affects the heart muscle
                           Pericardial effusion = fluid in the pericardial cavity, btwn visceral and the parietal pericardium.
                           Ventricular aneurysms = abnormal dilatation of a blood vessel, usually an artery of the ventricles.
          o     The transducer transmits high-freque ncy sound waves and receives them as they are reflected fr different structures. These echoes are usually
                videotaped simultaneously with the echocardiogram and can be recorded on graph paper for a permanent record. Routine measurements, that
                require several images, include chamber size, ejection fraction, and flow gradient across the valves.


MEDICATIONS (nursing considerations when administering lipid lowering drugs, particularly statin)

          o     Nursing Considerations (lipid-lowering agents, statins)
                          TABLE 38-2 Commonly Used Drugs for Atherosclerosis (pp 796)
                         HMG-CoA reductase inhibitors (statins):
                                o      Lovastatin (Mevacor)
                                o      Atorvastatin (Lipitor)
                                o      Simvastatin (Zocor)
                                o      Fluvastatin (Lescol)
                                o      Rosuvastatin (Crestor)
                                o      Pravastatin (Pravachol)
                         Fibric acids:
                                o      Gemfibrozil (Lopid)
                                o      Fenofibrate (Tricor)
                                o      Advicor (combination of niacin [fibric acid] and lovastatin)
                                o      Zetia
                                o      Lovaza
                         Because most of these drugs can produce major S/Es, they are generally given only when nonpharmacologic management has been
                          unsuccessful.
                         Statins: is a class of drugs known as HMG-CoA reductase inhibitors (aka antihyperlipoproteinemics)  reduces total cholesterol for an
                          extended period
                         Statins reduce cholesterol synthesis in the liver and incrs clearance of LDL-C from the blood. **Therefore they are contraindicated in pts
                          with active liver disease or during pregnancy b/c they can cause muscle myopathies and marked decrs in liver function. Statins drugs are
                          d/c’d if the pt has muscle cramping (may indicate rhabdomyolisis, incrs myglobin) or elevated liver enzyme levels (fat comes from liver &
                          incrs consumption).
                         Alternatives in place of statins or in combo with statin-type drugs:
                                      Ezetimibe (Zetia) – lipid lowering agent used in place/combo with statin
                                      Vytorin = ezetimibe + simvastatin – reduces absorption of cholesterol AND decrs the amount of cholesterol synthesis in the
                                       liver
                                      Advicor = niacin + lovastatin – niacin is a B vit that causes flushing
                                      Pravigard = aspirin + pravastatin
                                      Caduet = amlodipine (norvasc) + atorvastatin – decrs BP WHILE decrs triglycerides (TGs), incrs HDL, and lowering LDL
                         Interventions: assess liver function  n/v early sign d/t inflammation of liver; ask about muscle aching; obtain LFTs


VASCULAR DISORDER

    1. PHYSICAL ASSESSMENT FINDINGS
          o    PAD (PEIRPHERAL ARTERIAL DISEASE)
                                                                                 4
                       Chart 38-2 KEY FEATURES Chronic Peripheral Arterial Disease
   STAGE I: ASYMPTOMATIC                                                                          o    Pain is described as numbness, burning, toothache-type
        o       No claudication is present.                                                             pain.
        o       Bruit or aneurysm may be present.                                                 o     Pain usually occurs in the distal portion of the extremity
        o       Pedal pulses are decreased or absent.                                                   (toes, arch, forefoot, or heel), rarely in the calf or the ankle.
   STAGE II: CLAUDICATION                                                                        o     Pain is relieved by placing the extremity in a dependent
        o       Muscle pain, cramping, or burning occurs with exercise and                              position.
                is relieved with rest.                                                       STAGE IV: NECROSIS/GANGRENE
        o       Symptoms are reproducible with exercise.                                          o     Ulcers and blackened tissue occur on the toes, the forefoot,
   STAGE III: REST PAIN                                                                                and the heel.
        o       Pain while resting commonly awakens the patient at night.                         o     Distinctive gangrenous odor is present.

                        General Information: peripheral vascular disease (PVD) includes disorders that change the natural flow of blood through the arteries and
                         veins of the peripheral circulation. PVD implies arterial disease (PAD = peripheral arterial disease) rather than venous involvement. PAD is
                         a result of systemic atherosclerosis. It’s a chronic condtn in which partial or total arterial occlusion (blockage) deprives the lower
                         extremities of oxygen and nutrients leads to blockage of arteries in lower legs and feet  (see below)
                        Intermittent Claudication – “to limp”; usually pt can walk only a certain distance before cramping, burning muscle discomfort or pain
                         forces them to stop. The pain stops after rest. When pts resume walking, they can walk the same distance before the pain returns  pain
                         is considered producible. As the disease progresses, they can walk only shorter and shorter distances before pain recurs  pain may
                         occur even while at rest
                        Rest Pain – begin while the disease is still in the stage of intermittent claudication; is a numbness or burning sensation, often described as
                         feeling like a toothache that is severe enough to wake pts at night. Usually located in the toes, the foot arches, the forefeet, the heels, &
                         rarely, in the calves or ankles. Pts can sometimes get pain relief by keeping the limb in a dependent position (below the heart). Those w/
                         rest pain often have advanced disease that may result in limb loss.
                        Inflow Disease – pts with this disease have discomfort in the lower back, buttocks, or thighs.
                                     Mild inflow disease – have discomfort after walking about two blocks; not severe but causes them to stop walking; relieved w/
                                      rest.
                                     Moderate inflow – pain in these areas after walking about one or two blocks; discomfort described as being more like pain, but
                                      eases w/ rest most of the time.
                                     Severe inflow – pain after walking less than one block; usually have rest pain.
                        Outflow Disease – described as burning or cramping in the calves, ankles, feet, & toes. Instep or foot discomfort indicates an obstruction
                         below the popliteal artery.
                                     Mild outflow – discomfort after walking about 5 blocks.
                                     Moderage outflow – pain after walking about 2 blocks; intermittent rest pain may be present.
                                     Severe outflow – cannot walk more than ½ block and usually experience rest pain; may hang their feet off the bed at night for
                                      comfort and report more frequent rest pain than those with inflow disease.
                        Observe for loss of hair on the lower calf, ankle, and toenail. W/ severe arterial disease  extremity is cold and gray-blue (cyanotic) or
                         darkened. Pallor may occur when the extremities is elevated.
                        Dependent rubor (redness) may occur when the extremity is lowered
                        Muscle atrophy can accompany prolonged chronic arterial disease.
                        CHART 38-3:
                                     Hx: pt reports claudication after walking about 1-2 blocks, rest pain usually present, pain at ulcer site, 2-3 risk factors present
                                     Ulcer location and appearance: end of toes, btwn the toes, deep, ulcer bed pale w/ even edges, little granulation tissue
                                     Other assessment findings: cool or cold foot, decreased/absent pulses, atrophy of skin, hair loss, pallor w/ elevation,
                                      dependent rubor, possible gangrene, when acute neurologic deficits noted
                                     Tx: tx underlying cause (surgical, revascularization), prevent trauma and infection, pt education stressing foot care

BUERGER’S DISEASE

                        General Information: (aka thromboangiitis obliterans) is an uncommon occlusive disease limited to the medium and small arteries and
                         veins. The distal upper and lower limbs are the most frequently affected. Typically identified in young adult men who smoke. Larger arties
                         such as the femoral and brachial become involved in the late stages of the disease. The veins are less commonly involved.
                        Disease often extends into the tissues around the vessels  fibrosis and scarring that bind the artery, vein, and nerve firmly together.
                        Cessation of cigarette usually arrests the disease process. Continued smoking causes occlusion in the more proximal vessels.
                        Physical Assessment Findings:
                                   First clinical manifestation  claudication (muscle pain caused by inadequate blood supply) of the arch of the foot.
                                   Intermittent claudication may occur in the lower extremities.
                                   Pain – may be ischemic, occurring in the digits while the pt is at rest. Often there is aching pain that is more severe at night.
                                   Intermittent shocklike pain – can be the result of ischemic neuropathy
                                   Increased sensitivity to cold & report coldness and numbness
                                   Pulses often diminished in distal extremities and they are cool and red/cyanotic in the dependent position.
                                   Diagnosis (physical findings) – peripheral ischemia; ulceration and gangrene may be present in the digits; ulcerations usually
                                    sharply demarcated; gangrenous lesion can be small or can affect the entire digit
                                   Arteriograms – useful in delineating the degree of the disease in the artiers; reveals multiple segmental occlusions in the
                                    smaller arteries of the forearm, hand, leg, and foot.

CHRONIC VENOUS INSUFFICIENCY (pp 821)



                                                                                 5
                        General Information: vein function requires properly functioning veins- patent (open) with competent valves, requires assistance of the
                         surrounding muscle beds to help pump blood toward the heart. If 1/+ veins are not operating properly, they become distended and
                         clinical manifestations occurs. 3 distinct problems that alter blood flow of veins:
                                    1. Thrombus formation – can lead to PE. Venous thromboembolism (VTE) is the current term that includes DVT and PE.
                                    2. Defective valves – lead to venous insufficiency and varicose veins; not life-threatening but problematic
                                    3. Skeletal muscle lacks contractility
                        Venous insufficiency – occurs as a result of prolonged venous HTN that  stretches the veins and damages the valves  valvular damage
                          backup of blood and further venous HTN  edema. Because pt cannot eliminate waste products  they build up within tissues 
                         stasis (stoppage) results in venous ulcers, swelling and cellulitis (spreading, bacterial infection of skin and sub-q tissues, usually lower
                         legs).
                        Venous HTN – can occur in people who stand or sit in one position for a long periods (teachers, office personnel)
                        Obesity – can also cause chronically distended veins  damaged valves.
                        Thrombus formation – can contribute to valve destruction
                        Pts who have had Thrombophlebitis  Chronic Venous Insufficiency  In severe cases, venous ulcers develop.
                        Assessment:
                                    Venous Leg Ulcers – major cause of death, pain, and health care costs
                                    Venous insufficiency may result in  edema in both legs; stasis dermatitis/reddish-brown discoloration along the ankles,
                                     extending up the calf.
                                    Stasis Ulcers – result from edema or from minor injury to the limb; typically occur over the malleolus, medially (inner ankle);
                                     has irregular borders; are chronic and difficult to heal
                                    CHART 38-3:
                                           o     Hx: chronic nonhealing ulcer, no claudication or rest pain, moderate ulcer discomfort, pts report of ankle or leg
                                                 swelling
                                           o     Ulcer location and appearance: ankle area, brown pigmentation, ulcer bed pink, usually superficial w/ uneven
                                                 edges, granulation tissue present
                                           o     Other assessment findings: ankle discoloration and edema, full veins when leg slightly dependent, no neurologic
                                                 deficit, pulses present, may have scarring from previous ulcers
                                           o     Tx: Long-term wound care (unna boot, damp-to-dry dressings), elevate extremity, pt education, prevent infection

MEDICATIONS (know all you need to know about Coumadin and Heparin)

         o    Teach pts recovering from DVT to stop or avoid smoking and to avoid the use of oral contraceptives to decrs the risk of recurrence. Alternative forms
              of birth control may be used
         o    Most pts are discharged on a regimen of warfarin (Coumadin) or LMWH. Instruct pts and families to avoid potentially traumatic situations such as
              participation in contact sports
         o    Provide written and oral information about signs and symptoms of bleeding (see CHART 38-6 below!!). Reinforce the need to report any of these
              manifestations to the HCP immediately!
         o    Warfarin –
                         anticoagulant effect of warfarin may be reversed by omitting one or two doses of the drug or by administration of vit K. **In case of
                          injury, teach pts to apply pressure to bleeding wounds and to seek medical assistance immediately. Encourage them to carry an
                          identification card or wear a medical alert bracelet that states they are taking warfarin or any other anticoagulant.
                         Instruct pts to tell their dentist and other HCPs that they are taking warfarin before receiving treatment or prescriptions. PT are affected
                          by many prescription and OTC drugs such as NSAIDs.
                         Action s of warfarin is also affected by high-fat and vit K-rich foods, such as cabbage, cauliflower, broccoli, asparagus, turnips, spinach,
                          kale, fish and liver. Therefore instruct pts to eat a well-balanced diet w/ moderate amounts of vit K and to avoid taking additional drugs
                          w/o consulting a HCP (CHART 38-7)
                                                          Chart 38-7 PATIENT AND FAMILY EDUCATION GUIDE
                                                       Food and Drugs That Interfere with Warfarin (Coumadin)
                    Eat small amounts of foods rich in vitamin K each day,                                          •       Acetaminophen
                    including any of these:                                                                         •       Vitamin E
                        •        Broccoli                                                                           •       Histamine blockers
                        •        Cauliflower                                                                        •       Cholesterol-reducing drugs
                        •        Spinach                                                                            •       Antibiotics
                        •        Kale                                                                               •       Birth control pills
                        •        Green leafy vegetables                                                             •       Antidepressants
                        •        Brussels sprouts                                                                   •       Thyroid drugs
                        •        Cabbage                                                                            •       Antifungal infections
                        •        Liver                                                                              •       Other anticoagulants
                    If possible, avoid:                                                                             •       Corticosteroids
                        •        Allopurinol                                                                        •       Herbs, such as St. John's wort, garlic,
                        •        NSAIDs                                                                             ginseng, Ginkgo biloba

                      Teach pts also to prevent dehydration – avoid alcohol and sitting for prolonged periods
                      Arrange for follow-up laboratory appts to have blood drawn at frequent intervals – usually q wk until pt’s values are stabilized.
                      Pts discharged w/ warfarin need access to a pharmacy to renew Rxs and obtain a medical alert bracelet; also, they need access to a
                       laboratory for frequent monitoring of PT and INRs unless they are self-monitoring.
         o    LMWH – teach injection to pt, caregiver, family member or friends
         o    COUMADIN
                      If pt is receiving continuous UFH, warfarin may be added 5 days later.


                                                                                6
                        Warfarin works in the liver to inhibit synthesis of vit K-dependent clotting factors and takes 3-4 days before it can exert therapeutic
                         anticoagulation. The heparin continues to provide therapeutic coagulation until this effect is achieved  then IV heparin is d/c’d.
                        Therapeutic levels – monitored by measuring PT & INR (PTs are often inconsistent and misleading, that’s why INR was developed). INR
                         should be between 1.5-2.0 to prevent future DVT and to minimize risk of stroke or hemorrhage. For pts with additional CV problems, INR
                         may be higher
                        Start at low dose – 5 mg, and gradually titrated up according to the INR. Pts usually receive this drug for 3-6 months or longer after
                         episode of DVT if not precipitating factors were discovered, w/ recurrence, or if there is continuing risk factors.
                        Nursing assessments – bleeding; Ensure that vit K, the antidote for warfarin, is available in case of excessive bleeding (see CHART 38-6).
                         **However, anticoagulation is not possible for 3 weeks after vitamin K administration (SO, YOU BETTER BE DAMN SURE THAT THE PT IS
                         BLEEDING BEFORE GIVING VIT K OTHERWISE CLOTS WILL FORM AND CAN CAUSE DVT)

                                                      Chart 38-6 BEST PRACTICE FOR PATIENT SAFETY & QUALITY CARE
                                                                 The Patient Receiving Anticoagulant Therapy
   Carefully check the dosage of anticoagulant to be administered, even if the pharmacy prepared the drug.
   Monitor the patient for signs and symptoms of bleeding, including hematuria, frank or occult blood in the stool, ecchymosis, petechiae, altered mental status
    (indicating possible cranial bleeding), or pain (especially abdominal pain, which could indicate abdominal bleeding).
   Monitor vital signs frequently for decreased blood pressure and increased pulse (indicating possible internal bleeding).
   Have antidotes available as needed (e.g., protamine sulfate for heparin; vitamin K for warfarin [Coumadin, Warfilone]).
   Monitor activated partial thromboplastin time (aPTT) for patients receiving unfractionated heparin. Monitor prothrombin time (PT) or International Normalized
    Ratio (INR) for patients receiving warfarin or low–molecular weight heparin (LMWH).
   Apply prolonged pressure over venipuncture sites and injection sites.
   When administering subcutaneous heparin, apply pressure over the site and do not massage.
   Teach the patient going home while taking an anticoagulant to:
          o     Use only an electric razor
          o     Take precautions to avoid injury; for example, do not use tools such as hammers or saws, where accidents commonly occur
          o     Report signs and symptoms of bleeding, such as blood in the urine or stool, nosebleeds, ecchymosis, or altered mental status
          o     Take the prescribed dosage of drug at the precise time that it was prescribed to be given
          o     Not stop taking the drug abruptly; the physician usually tapers the anticoagulant gradually

         o    HEPARIN
                     Ufractionated Heparin Therapy (UFH, Hepalean) (pp 818)
                               acts w/ antithrombin III to produce selective inhibition of clotting factors IIa (thrombin) and Xa. At higher doses, it inhibits
                                practically all clotting factors  the ultimate result is inhibition of fibrin formation.
                               The physican prescribes UFH to prevent the formation of other clots, which often develop in the presence of an existing clot,
                                and to prevent enlargement of the existing clot. Over long period, the existing clot is slowly absorbed by the body.
                               Before administration, obtain a baseline of: PT, aPTTm INR, CBC w/ platelet count, urinalysis, stool for occult blood, and
                                creatinine level. **Notify physician if the platelet count is below 120,000/mm3.
                               Initially, IV bolus is prescribed – 80-100 units/kg of body weight or 5000 units followed by continuous infusion.
                               Therapeutic aPTT – 18-20 units/kg/hr or at least 30,000 units over 24 hours. aPTT is measured at elast daily
                               Therapeutic levels of aPTTs are usually 1.5-2 times the normal control levels. **Notify physician if the value is > 70 seconds, or
                                follow hospital protocol for reporting critical laboratory values. Assess pts for signs and symptoms of bleeding, which include
                                hematuria (blood in urine), frank or occult blood in the stool, ecchymosis (brusing), petechiae (small, purplish, hemorrhagic
                                spots on skin in pts w/ platelet deficiencies), an altered level of consciousness or pain.
                               UFH can also decrs platelet count – severe reductions, although rare, result from the development of antiplatelet bodies
                                within 6-14 days after beginning tx. Platelets aggregate into “white clots” that can cause thrombosis, usually in the form of an
                                acute arterial occlusion. The HCP d/cs heparin administration if severe heparin-induced thrombocytopenia (HIT) (platelet
                                count<150,000), or “white clot syndrome” occurs. LMWH is used more commonly d/t complications of UFH
                               Bivalirudin (Angiomax and lepirudin (Refludan) – highly selective direct thrombin inhibitors used as alternatives to heparin for
                                pts who have had HIT; these drugs incrs risk for bleeding; warfarin can also be a substitute
                               Ensure protamine sulfate, the antidote for heparin, is available if needed for excessive bleeding.
                     LMWH (Low-Molecular Weight Heparin)
                               Enoxaparin (Lovenox), dalteparin (Fragmin) and ardeparin (Normiflo) – prevent DVTs.
                               LMWHs bind less to plasma proteins, blood cells, and vessel walls  longer half-life and more predictable response.
                               These drugs inhibit thrombin formation b/c of reduced factor IIa activity and enhanced inhibition of factor Xa and thrombin
                               Candidates – pts must have stable DVT or PE, low risk for bleeding, adequate renal function, and normal VSs; must be willing to
                                learn self-injection, or have a fam, friend or home care nurse administer the sub-q injs
                               When switching from UFH to LMWH, UFH is discontinued at least 30 minutes before the first LMWH injection. The usual dose
                                of enoxaparin is 1mg/kg of body weight, not to exceed 90 mg, and is repeated q12h. it pt’s creatinine level is > 2 mg/dL
                                (indicating renal insufficiency), the HCP lowers the dose
                               Monitor INR daily. Assess all stools for occult blood. aPTTs are not checked on an ongoing basis b/c the doses of LMWH are not
                                adjusted

NURSING INTERVENTIONS

         o    Peripheral Arterial Disease (positioning, promoting vasodilation, pp 807)
                        Positioning
                                    Some pts have swelling in their extremities. **Because swelling prevents arterial flow, feet should be elevated(???). Teach
                                     them to avoid raising their legs above the heart level b/c extreme elevation slows arterial blood flow to the feet.


                                                                                7
                                   In severe cases, pts w/ PAD and swelling may sleep with the affected leg hanging from the bed or sit upright in a chair for
                                    comfort. **Instruct all pts with the disease to avoid crossing their legs and avoid wearing restrictive clothing (e.g., garters to
                                    hold up nylon stockings, particularly among older women), which interfere with blood flow. Teach them the importance of
                                    inspecting their feet daily for color or other changes.
                       Promoting Vasodilation
                                   Achieved by providing warmth to the affected extremity and preventing long periods of exposure to cold.
                                   Maintain warm environment at home – wear socks or insulated shoes at all times
                                   **Caution pt to never apply direct heat to the limb such as with the use of heating pads or extremely hot water. Sensitivity is
                                    decreased in the affected limb. Burns may result.
                                   Prevent exposure of affected limb to the cold  cold temps cause vasoconstriction  decrs arterial blood flow. Also, drink
                                    adequate fluids to prevent increased blood viscosity (thins it out!!!)
                                   Emotional stress, caffeine, and nicotine  vasoconstriction. **Emphasize that complete abstinence from smoking or chewing
                                    tobacco is the most effective method of preventing vasoconstriction. Vasoconstrictive effects of each cigarette may last up to 1
                                    hr after cigarette smoked.
         o   Buerger’s Disease
                       Pt Instruction to prevent progression of disease
                                   To prevent progression, complete abstinence from tobacco in all forms is essential
                                   Avoid extreme cold or prolonged exposure to cold to prevent vascoconstriction
                                   Instruct pt about drugs that may be used for vasodilation (nifedipine [Procardia])
                                   Tx for Buerger’s disease is similar to that for PAD (see “promoting vasoidlation” and “positioning” above)

NUTRITION

         o   Foods low in cholesterol (<200 mg/day)
                      (pp 805) Omega-3 fatty acids from fish and plant sources  effective in reducing lipid levels, stabilizing atherosclerotic plaques, and
                       reducing sudden death from an MI
                                  Eat fish 3xs/day or daily fish oil (1 gm) nutritional supplement
                                  Plant sources of omega-3 – flaxseed, flaxseed oil, walnuts, canola oil
                      Canola (rapseed oil – rich in monosaturated fat
                      Safflower and sunflower oil – rich in polyunsaturated oils
                      Increase fiber – 24-35 g/daily
                      (Below, is from Grodner, pp 452)
                      Dairy products – ½% milk, 1% milk, buttermilk, yogurt, cottage cheese, fat-free and low-fat cheese
                      Eggs – 2 egg yolks per week, egg whites or egg substitute
                      Meat, poultry, fish - < 5 ounces/day, lean cuts loin, leg, round, extralean hamburger; cold cuts made w/ lean meat or soy protein; skinless
                       poultry; fish
                      Fats & oil – unsaturated oils; soft or liquid margarines and vegetable oil spreads; salad dressings, seeds, & nuts
                      TLC diet options – soluble-fiber food sources = barley, oats, psyllium, apples, bananas, berries, citrus fruits, nectarines, peaches, pears,
                       plums, prunes, broccoli, brussels sprouts, carrots, dry beans, soy products (tofu, miso)
                      Fruits, vegetables, legumes, whole grains, fish, skinless chicken, turkey, tofu
         o   Foods high in cholesterol (pp795)
                      Cholesterol is found only in animal sources such as meat and eggs and are also high in saturated fats
                      High in saturated fat – palm or coconut oil
                      (Below, is from Grodner, pp 452)
                      Breads & cereal – many baked products, including doughnuts, biscuits, butter rolls, muffins, croissants, sweet rolls, Danish, cakes, pies,
                       coffee cakes, cookies; many grain-based snacks, including chips, cheese puffs, snack mix, regular crackers, buttered popcorn
                      Vegetables – fried or prepared w/ butter, cheese, or cream sauce
                      Fruits – fruits fried or served w/ butter or cream
                      Dairy products – whole milk, 2% milk, whole-milk yogurt, ice cream!! NO!!, cream, cheese
                      Eggs – egg yolk, whole eggs
                      Meat, poultry & fish – higher fat meat cuts = ribs, t-bone steak, regular hamburger, bacon, sausage; cold cuts = salami, bologna, hot dogs;
                       organ meats = liver, brains, sweetbreads; pultry / skin; fried meat; fried poultry; fried fish
                      Fats & oils – butter, shortening, stick margarine, chocolate!! NO!!, coconut


HTN – HYPERTENSION

CLASSIFICATION (JNC) AND RECOMMENDATION (PP 796)
                                                               TABLE 38-3 Blood Pressure Classification




                                                                                8
          o    RECOMMENDATIONS
                        These patients need lifestyle changes to prevent CV complications (Tables 38-4).
                                                      TABLE 38-4 Meeting Healthy People 2010 Objectives
               o   BLOOD PRESSURE
                   Objective 12.11: Increase the proportionof adults with high blood pressure who are taking action to help control their blood pressure.
               o   Teach adults with high blood pressure the importance of controlling sodium intake, including reading food labels for sodium content and
                   avoiding high-sodium foods, such as bacon, ham, and processed snacks.
               o   Refer overweight adults to a support group or weight- reduction program.
               o   Teach about the importance of exercise and increased physical activity to reduce blood pressure.
               o   For the adult who smokes, teach about the relationship between cardiovascular disease and smoking. Refer the person to a smoking cessation
                   program.
               o   Participate in community or health care agency health fairs to screen for hypertension and provide community education.
               o   Teach all adults to have their blood pressure taken at least once every 2 years. For those with hypertension, monitor blood pressure as
                   recommended by the health care provider.

MEDICATION (MOA, common S/Es, & nursing considerations/instructions [particularly diuretics])

          o    Thiazide-type diuretics
                         3 basic types, MOA:
                                     1. Thiazide (low-ceiling) – hydrochlorothiazide (HydroDIURIL, Urozide) prevent sodium and water reabsorption in the distal
                                      tubules while promoting potassium excretion
                                            o     Caution is indicated in using thiazide diuretics in hypertensive pts with gout or with hx of significant hyponatremia,
                                                  because these problems can worsen.
                                     2. Loop (high-ceiling) diuretics – furosemide (Lasix, Furoside) depress sodium reabsorption in the ascending loop of Henle and
                                      promote sodium and potassium excretion
                                     3. Potassium-sparing diuretics – spironolactone (Aldactone, Novospiroton) act on distal tubule to inhibit reabsorption of
                                      sodium ions in exchange for potassium, thereby retaining potassium
                         Diuretics are drug of choice for pts who have asthma, chronic airway limitation, chronic renal disease, and select cases of heart failure.
                         S/Es:
                                     Decreased libido (desire for sex)
                                     **The most frequent side effect associated with diuretics is hypokalemia. Monitor the serum K level and assess for irregular
                                      pulse and muscle weakness, which may indicate hypokalemia.
                                     Hyperkalemia if pt is taking potassium supplements
                                     Electrolyte disturbances characterized by weakness and an irregular pulse may indicate hypokalemia.
                         Nursing Considerations/Instructions:
                                     Teach men that they may experience decreased libido and decreased sexual performance
                                     **Teach the pts taking K-depleting diuretics to eat foods high in potassium, such as bananas and orange juice.
                                     Assess for hypokalemia and hyperkalemia for pts taking potassium-sparing diuretics. Hyperkalemia can occur also if they are
                                      taking angiotensin-converting enzyme (ACE) inhibitors and/or ARBs.
                                     Drug regimen is enhanced because the drug can usually be prescribed on a once-a-day or, at most, twice-a-day schedule.
                                     Monitor I&O and K levels
          o    Calcium Channel Blockers
                         Verapamil hydrochloride (Calan) and amlodipine (Norvasc) lower BP by interfering with the transmembrane flux of calcium ions 
                          results in vasodilation  decreases BP
                         Nursing Considerations: monitor BP & HR
          o    ACE inhibitors
                         MOA: block the action of angiotensin-converting enzyme as it attempts to convert angiotensin I to angiotensin II  vessels constrict less
                         Captopril (Capoten) and enalapril (Vasotec)
                         Nursing Considerations/Instructions: **Instruct the pt receiving an ACE inhibitor for the first time to get out of bed slowly to avoid the
                          severe hypotensive effect that can occur w/ initial use. Orthostatic hypotension may occur with subsequent doses, but is less severe. If
                          dizziness continues of there is significant decrs in the systolic BP (more than a change of 20 mm/Hg), notify the health care provider or
                          teach pts to notify their provider. The older pt is at greatest risk for postural hypotension b/c of the CV changes associated w/ aging. If a
                          cough develops, the drug is discontinued. Monitor BP & HR, report edema and cough  noncompliance  warn, do not stop taking drug
                           could lead to hypertensive crisis
          o    Angiotensin II Receptor Blockers (ARBs)
                         MOA: selectiviely block the biding of angiotensin II to its receptor in vascular and adrenal tissue but not inhibiting ACE
                         Candesartan (Atacand) & lorsartan (Cozaar)
                         They are excellent options for pts who report nagging cough associated w/ ACE inhibitors and for those with hyperkalemia (side effects of
                          ACE inhibitors) these drugs do not require initial adjustment of the dose for older adults for any pt w/ renal impairment.
                         S/Es: report angioedema ( edematour areas of skin, mucous membranes, or internal organs; frequently associated w/ hives; can cause
                          resp distress when present in the mouth, pharynx or larynx); Cozaar  hyperkalemia
                         Nursing Considerations: Like the ACEs, the ARBs are not as effective in African Americans unless these drugs are taken w/ diuretics or
                          another category such as beta blocker or CCB
          o    Aldosterone Receptor Antagonists
                         MOA: block the hypertensive effect of the mineralocorticoid hormone ALDOSTERONE. Aldosterone increases sodium reabsorption by the
                          kidney and is a significant contributor to HTN, cardiac and vascular remodeling, & HF
                         Eplerenone (Inspra)
                                                                                  9
                                     MOA: lowers Bp by blocking aldosterone binding at the mineralocorticoid receptor sites in the kidney, heart, blood vessels, and
                                      brain
                                     Recommended daily dosage is 50 mg daily, can be increased to 100 mg daily
                                     S/Es: dose-related adverse effects of hypertriglyceridemia, hyponatremia, and hyperkalemia.
                                     Nursing Considerations/Instructions:
                                            o     **Using ACE inhibitors or ARBs at the same time  incrs risk of hyperkalemia. Monitor K levels initially q 2 wks for
                                                  the first few months, then monthly after that
                                            o     When taking eplerenone (Inspra), itraconazole (Sporanox) and ketoconazole (Nizarol) should not be taken  drug
                                                  interactions are common
                         Nursing Considerations/Instructions:
                                     **Teach pts that grapefruit juice and the popular herb St. John’s wort can also incrs the chance of adverse effects.
                                     Remind pts (like for all hypertensives) not to get up quickly, drive, or climb stairs until they are familiar w/ the effects of the
                                      drug.
          o    Beta-adrenergic blockers
                         Are cardioselective or non-cardioselective.
                         MOA: cardioselective beta blockers lower BP by blocking beta receptors in the heart and peripheral vessels  reducing cardiac rate and
                          output  decrs HR and myocardial contractility
                         S/Es: fatigue, weakness, depression, and sexual dysfunction (although it depends on the “selective” blocking effects of the drug
                         Nursing Considerations/instructions:
                                     Non-cardioselective beta blockers are usually not prescribed for pts w/ respiratory disorders b/c they prevent normal dilation
                                      of the bronchi  can cause pulmonary vasoconstriction and respiratory compromise
                                     Pts w/ diabetes who take beta blockers may not have the usual manifestations of hypoglycemia b/c the sympathetic NS is
                                      blocked. The body’s responses to hypoglycemia such as gluconeogenesis may also be inhibited by certain beta blockers.
                                     **Beta blockers are the drug of choice for hypertensive pts w/ ischemic heart disease (IHD) b/c the heart is the most common
                                      target end-organ damage with HTN. If this drug is not tolerated, a long-acting CCB can be used
                                     In pts with unstable angina or MI, beta blockers or CCBs should be used initially in combo w/ ACE inhibitors or ARBs, w/
                                      addition of other drugs if needed to control BP
                                     Best practice for controlling HTN in post-MI pts includes combo therapy of beta blockers, ACE inhibitors or ARBs (not as
                                      common), and aldosterone antagonists plus intense management of lipids and the use of aspirin.
                                     Low-dose aspirin should be considered only once the BP is controlled b/c of the increased risk for hemorrhagic stroke in pts
                                      /w uncontrolled HTN
          o    Renin Inhibitors
                         Effective for mild-moderate HTN
                         Aliskiren (Tekturna) – can be used alone or w/ a thiazide diuretic
                         Renin – produced in the kidneys that causes vasoconstriction, incrs peripheral resistance, and incrs CO  incrs BP
                         MOA: renin inhibitors prevent renin from producing this action
                         S/Es: minimal, not common, although respiratory distress may occur
          o    Central Alpha Agonists
                         MOA: act on CNS, preventing reuptake of norepinephrine  lower peripheral vascular resistance and BP
                         Clonidine (Catapres) – given as a transdermal patch, providing control of BP for as long as 7 days
                         S/Es: sedation, postural hypotension, impotence
                         Nursing Consideration: this group of drugs is not indicated for first-line management of HTN
          o    Alpha-adrenergic Antagonists
                         Prazosin (minipress), doxazosin (Cardura), terazosin (Hytrin)
                         MOA: dilate the arterioles and veins  lowers BP quickly, but their use is limited b/c of frequent and bothersome S/Es.
                         Nursing Considerations: Cardura and Hytrin may be prescribed when pts have benign prostatic hypertrophy (enlargement) (BPH) b/c of
                          the dilating effects of the vessels  decrs hypertrophy and improving BF

NUTRITION (those that are needed, those that should be avoided)

          o    Needed
                        Limit dietary fat intake to < 30% of total daily calories.
                        Drink adequate fluids to prevent dehydration
          o    Avoided
                        Sodium restriction
          o    (SEE NUTRITION UNDER VASCULAR DISRODERS ABOVE!!!)

NURSING PROCESS: RISK FOR INEFFECTIVE THERAPEUTIC REGIMENT MANAGEMENT (outcome indication, pp 802)

          o    Outcome Indication:
                       Expected outcomes: the pt with HTN is expected to take personal actions to promote wellness, recovery and rehabilitation based on
                        professional advice. Indicators include that the pt will consistently:
                                  Discuss prescribed tx regiment with HCP
                                  Perform tx regimen as prescribed
                                  Monitor tx and drug responses
                                  Keep appts w/ HCP
                       **Patients who do not adhere to antihypertensive tx are at great risk for target organ damage and hypertensive crisis (malignanet HTN)
                        (CHART 38-1)


                                                                                  10
                                                 Chart 38-1 BEST PRACTICE FOR PATIENT SAFETY & QUALITY CARE
                                                       Emergency Care of Patients with Hypertensive Crisis
   ASSESS
         o   Severe headache
         o   Extremely high blood pressure
         o   Dizziness
         o   Blurred vision
         o   Disorientation
   INTERVENE
         o   Place patient in a semi-Fowler's position.
         o   Administer oxygen.
         o   Administer IV nitroprusside (Nitropress), nicardipine (Cardene IV), or other infusion drug as prescribed (for nitroprusside, cover infusion bag to
             prevent drug breakdown by light).
         o   Monitor blood pressure every 5 to 15 minutes until the diastolic pressure is below 90 and not less than 75; then monitor blood pressure every 30
             minutes.
         o   Observe for neurologic or cardiovascular complications, such as seizures; numbness, weakness, or tingling of extremities; dysrhythmias; or chest
             pain.

         o     Interventions:
                         Pharmacologic tx to control HTN is taken for the rest of the pt’s lives/ frequently, however, some stop taking their drugs b/c they have no
                          symptoms and have troublesome S/Es.
                         Collaborate w/ the pharmacists to discuss goals of therapy w/ the pt (hospital setting), including potential S/Es, to help identify potential
                          problems. Assist pt in tailoring the therapeutic regiment to pt’s lifestyle and daily schedule.
                         Pts in hypertensive crisis are admitted to critical care units, where they receive IV antihypertensive therapy such as nitroprusside
                          (Nipride), nicardipine (Cardene IV), fenoldopam (Corlopam), or labetalol (Normodyne). These drugs act quickly as vasodilators  decrs
                          BP
                         Reviewing instructions and sending home written instructions appear to have the most impact on improving short-term adherence but
                          less impact on long-term therapy.
                         Pt should obtain ambulatory BP monitoring (ABPM) device for use at home so that pressure can be checked.
                         If wt reduction is desired, suggest having a scale in the home for wt monitoring. For those who do not want to self-monitor, are not able
                          to self-monitor or have “white-coat” syndrome when they get to their HCP (causing elevated BP), continuous ABPM may be used


CORONARY ARTERY DISEASE

PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY (PTCA)

         o     General Information: PTCA, most commonly done before stent placement, is an invasive but nonsurgical technique. It’s performed to reduce the
               frequency and severity of discomfort for pts w/ angina and to bridge pts to coronary bypass graft (CABG). Because of the artery’s normal elasticity
               and “memory” to retain its original shape, the artery often re-occludes if a stent is not used as part of the procedure.
         o     Before procedure, pt receives an initial dose of clopidogrel (Plavix), and antiplatelet drug. Physician performs the angioplasty under fluoroscopic
               guidance in the cardiac cath lab. The balloon-tipped catheter is introduced through a guidewire to the coronary artery occlusion; physician activates
               a compressor that inflates the balloon to force the plaque against the vessel wall, thus dilating the wall, and reduces or eliminates the occluding clot.
               Balloon inflation may be repeated until angiography indicates a decrs in the stenosis (narrowing) to < 50% of the vessel’s diameter.
         o     Post Procedure Monitoring & Appropriate Action:
                          After the procedure, IV Heparin is administered in a continuous infusion to prevent thrombus formation.
                          IV intracoronary nitroglycerin or diltiazem (Cardizem) is given to prevent coronary spasm.
                          **After the procedure, monitor for problems including acute closure of vessel (causes chest pain), bleeding from the insertion site, and
                           reaction to the contrast medium used in angiography. Also monitor for hypotension, hypokalemia, and dysrhythmias. Report any of
                           these findings to the physician immediately!!!!
                          HCP usually prescribes a long-term nitrate and dual antiplatelet therapy w/ aspirin and clopidogrel (Plavix) for pts after PTCA.
                          Beta blocker + an ACE inhibitor/ARB are added for pts who have had primary angioplasty after an MI
                          Some may experience hypokalemia after the procedure and require careful monitoring and potassium supplements.
                                      Hypokalemia: pulse is usually thread and weak; palpation is difficult and the pulse is easily blocked with light pressure; pulse
                                       rate can range from very slow to very rapid, and an irregular heartbeat (dysrhythmia) may be present; measure BP w/ pt in
                                       lying, sitting, and standing positions b/c orthostatic/postural hypotension occurs.
                          Provide careful explanations of drug therapy and any recommended lifestyle changes.
                          Nursing interventions for NITRATES:
                          1. Nitroprusside sodium (Nipride, Nitropress) –
                                      monitor BP q 2-5 min when initiating therapy; if BP drops excessively, elevate the legs, decrs the dose, and incrs fluids per unit
                                       policy  this agent is potent, rapidly reversible vasodilator acting on both peripheral venous and arterial musculature. BP may
                                       dorp in 2 min.
                                      protect from light  this agent is light sensitive
                                      maintain dose at less than 3 mcg/kg/min if possible  doses higher than 3 mcg/kg/min are assoc w/ thiocyanate or cyanide
                                       toxicity
                                      if pts requiring doses higher than 3 mcg/kg/min for longer than 24-36 hr, monitor for metabolic acidosis, confusion of
                                       hyperreflexia. Examine blood thiocyanate level  these are indications for the toxic effects cyanide.

                                                                                  11
                         2. Nitroglycerin –
                                    Intermittent administration of IV nitroglycerin should be considered  tolerance may develop rapidly to nitroglycerin
                                     administered continuous IV
                                    Monitor for h/a  h/a is a frequent s/e of initial nitroglycerin therapy
                         3. Milrinone (Primacor) –
                                    Assess BP and pulse q 5 min. if BP drops 30 mm Hg, stop infusion and call HCP  HYPOTENSION is common adverse effect
                                    Monitor I&O and weight  the drug causes dieresis
                         4. Fenoldopam (Corlopam) –
                                    Same as milrinone

CORONARY ARTERY BYPASS GRAT (CABG)

         o     General Information: Most common type of cardiac surgery and most common procedure for older adults. The occluded arteries are bypassed w/ the
               pt’s own venous or arterial blood vessels or synthetic grafts. The internal mammary artery (IMA) is the current graft of choice b/c it has a 90%
               patency rate at 12 years after the procedure. Indicated when pts do not respond to medical management of CAD or when disease progression is
               evident.
         o     Post-surgery Health Teaching (activity and exercise, pp 871)
                         Collaborate w/ the PT to establish an activity and exercise schedule as part of rehabilitation, depending on cardiac procedure that was
                          performed.
                         First Week = Instruct pt to remain near home after discharge and continue a walking program. Pts may engage in light housework or any
                          activity done while sitting and that does not precipitate angina.
                         Second Week = encouraged to incrs social activities and possibly return to work part-time
                         Third Week = may begin to lift heavy objects as heavy as 15 lbs (2 gallons of milk) but should avoid lifting or pulling heavier objcts for the
                          first 6-8 weeks.
                         Chart 40-10: suggested instructions for activity level

                                                          Chart 40-10 PATIENT AND FAMILY EDUCATION GUIDE
                                                          Activity for the Patient with Coronary Artery Disease
   Begin by walking the same distance at home as in the hospital (usually 400 feet) three times each day.
   Carry nitroglycerin with you.
   Check your pulse before, during, and after the exercise.
   Stop the activity for a pulse increase of more than 20 beats/min, shortness of breath, angina, or dizziness.
   Exercise outdoors when the weather is good.
   Gradually increase the walking until the distance is ¼ mile twice daily (usually the end of the second week).
   After an exercise tolerance test and with your physician's approval, walk at least three times each week, increasing the distance by ¼ mile every other week,
    until the total distance is 2 miles.
   Avoid straining (lifting, pushups, pull-ups, and straining at bowel movements).

                         After exercise test: formal exercise program should include 5-7 minute warm-up and cool-down periods, as well as 30 minutes of aerobic
                          exercise. Pt should engage in aerobic exercise a minimum of 3 (preferably 5) times/wk.
                         Complementary alternative therapy:
                          o     Progressive muscle relaxation, guided imagery, music therapy, pet therapy, and therapeutic touch may decrs anxiety, reduce
                                depression, and icnrs compliance w/ activity and exercise regiments after heart surgery
                         Sexual activity:
                          o     Inform pt his/her partner that engaging in their usual sexual activity is unlikely to damage the heart. Pts can resume intercourse on
                                the advice of the HCP, usually after an exercise tolerance assessment. In general, those how can walk one block or climb two flights
                                of stairs w/o symptoms can usually safely resume sexual activity. Suggest initially these pts have intercourse after a period of rest (in
                                the morning when they are well rested or wait 1½ hours after exercise or a heavy meal)

NRSG DX: INEFFECTIVE COPING (pp 860)

         o     Expected outcomes: The pt w/ CAD is expected to take personal actions to manage stressors r/t CAD. Indicators include that the pt will consistently:
                         Identify effective coping patterns
                         Verbalize sense of control
                         Report a decrs in stress
                         Verbalize acceptance of the situation
                         Seek information concerning illness and tx
                         Modify lifestyle as needed
                         Adapt to life changes
         o     Interventions:
                         Assess level of anxiety while allowing expressions of any apprehension, and attempt to define its origin. Simple, repeated explanations of
                          therapies, expectations, & surroundings, as well as pt progress, may help relieve anxiety
                         Identify coping mechanisms
                                     Most common are denial, anger, and depression.
                                     1. Denial allows pt to decrs threat and use proble-focused coping mechanisms. The pt may avoid discussing what has happened
                                      and yet comply with tx regimen. This type of denial decrs anxiety and should not be discouraged. **However, denial that
                                      results in a pt who refuses to follow tx regimens can be harmful (d/t extreme anxiety/fear; threats only worsen the behavior)
                                       remain calm, and avoid confronting the pt. Clearly indicate when a behavior is not acceptable and is potentially harmful as
                                      a result of noncompliance.

                                                                                 12
                                      2. Anger may represent an attempt to regain control of life. Encourage pt to verbalize the source of frustration and provide
                                       opportunities for decision making and control. Collaborate with spiritual chaplain in the hospital to help tp cope w/ the
                                       situation.
                                      3. Depression may be a response to grief and loss of function. Listen as the pt verbalizes feelings of loss, being careful not to
                                       offer false or general reassurances. Acknowledge depression, but encourage pt to perform ADLs and other activities w/in
                                       restrictions.(CHART 40-5)

     CHART 40-5 INTERVENTION ACTIVITES Coping Enhancement: Assisting a patient to adapt to perceived stressors, changes, or threats that interfere with meeting
     life demands and roles.
    Appraise the patient's understanding of the disease process.
    Use a calm, reassuring approach.
    Provide an atmosphere of acceptance.
    Assist the patient in developing an objective appraisal of the event.
    Help patient to identify the information he or she is most interested in obtaining.
    Provide factual information concerning diagnosis, treatment, and prognosis.
    Foster constructive outlets for anger and hostility.
    Explore with the patient previous methods of dealing with life problems.
    Support the use of appropriate defense mechanisms.


HEART FAILURE

          o     Heart failure = aka pump failure, is a general term for the inability of the heart to work effectively as a pump.

PHYSICAL SSESSMENT/CLINICAL MANIFESTATIONS

          o     Left-sided HF:
          o     A. Assessment
                          CO is diminished  impaired tissue perfusion (b/c on left side, blood goes out from ventricles to aorta  which goes out into systemic
                           circulation), anaerobic metabolism and unusual fatigue
                          Assess activity intolerance by asking whether the pt can perform normal ADLs or climb flights of stairs w/o fatigue or dyspnea.
                          Many pts with HF experience weakness or fatigue w/ activity or have a feeling of heaviness in their arms and legs.
                          Ask about their ability to perform simultaneous arm and leg work (walking while carrying a bag of groceries). Such activity may place an
                           unacceptable demand on the failing heart.
                          Ask pt to identify his/her most strenuous activity in the past week. Many ppl unconsciously limit their activities in response to fatigue or
                           dyspnea and may not realize how limited they have become.
                          Impaired perfusion to myocardium w/ L ventricular failure (esp w/ cardiac hypertrophy)  chest pain, palpitations, skipped beats, fast
                           heartbeat
                          Diminished L-ventricular blood ejection  hydrostatic pressure incrs in the pulmonary venous sytem  fluid-filled alveoli and pulmonary
                           congestion
                          Cough – often an early manifestation of HF. Pt describes cough as irritating, nocturnal, and usually nonproductive. **As HF becomes very
                           severe, he/she may begin expectorating frothy, pink-tinged sputum – a sign of life-threatening pulmonary edema.
                          Rising pulmonary venous pressure and pulmonary congestion  dyspnea. Carefully question about the presence of dyspnea and when
                           and how it developed. The pt may refer to dyspnea as “trouble catching my breath,” “breathlessness,” or “difficulty in breathing”
                                      Exertional dyspnea – aka dyspnea upon exertion/on exertion (DUE, DOE); as it develops the pt often stops previously tolerated
                                       levels of activity b/c of SOB
                                      Orthopnea – dyspnea at rest in the recumbent (lying flat) position. Ask how many pillows are used to sleep whether the pt
                                       sleeps in an upright position in bed, recliner, or other type of chair.
                                      Paroxysmal nocturnal dyspnea (PND) – sudden awakening w/ a feeling of breathlessness 2-5 hours after falling asleep. Sittin
                                       gupright, dangling the feet, or walking usually relieves this condition
          o     B. Physical Assessment/Clinical Manifestations (pp768)
                          Impaired tissue perfusion, pulmonary congestion, & edema dominate L-sided HF (CHART 37-1)
                                                                        Chart 37-1 KEY FEATURES
                                                                         Left-Sided Heart Failure

DECREASED CARDIAC OUTPUT                                                                 •Weak peripheral pulses
  •Fatigue                                                                               •Cool extremities
  •Weakness                                                                            PULMONARY CONGESTION
  •Oliguria (scant urine) during the day (nocturia at night)                             •Hacking cough, worse at night
  •Angina (b/c of decreased CO to coronary arteries that supplies the                    •Dyspnea/breathlessness
  muscles)                                                                               •Crackles or wheezes in lungs
  •Confusion, restlessness (b/c of brain hypoxia)                                        •Frothy, pink-tinged sputum
  •Dizziness (b/c of brain hpoxia)                                                       •Tachypnea
  •Tachycardia, palpitations                                                             •S3/S4 summation gallop
  •Pallor
                           Renal failure and death can occur.
                           A proportional pulse pressure < 25% indicates severely compromised CO



                                                                                   13
                          Take apical pulse for a full minute (note any irregularities in heart rhythm). An irregular heart rhythm resulting from premature atrial
                           contractions (PACs), premature ventricular contractions (PVCs), or a-fib (AF) is common in HF  this sudden development of irregular
                           rhythm may further compromise CO
                          Monitor RR, rhythm and character, as well as O2 saturation. The RR typically exceeds 20 breaths/min.
                          Assess orientation to person, place and time b/c in daily conversation many people are skillful at covering up memory losses. Older adults
                           are frequently disoriented or confused when the heart fails b/c of brain hypoxia (decrsd O2)
                          Increased heart size  displacement of the apical impulse to the left.
                                      S3 gallop (early diastolic filling sound) – an incrs in L-ventricular pressure on auscultation.
                                      S4 – sign of decrs ventricular compliance, but not HF.
                          Crackles & wheezes of lungs
                                      Late inspriatory crackles and fine profuse crackles that themselves from breath to breath and do not diminish w/ coughing 
                                       HF
                                      Crackles are produced by intra-alvolar flui and are often noted first in the dependent areas of the lungs. **They usually develop
                                       in the bases and spread upward as condition worsens. Identify precise location of crackles
                                      Wheezes  narrowing of bronchial lumen caused by engorged pulmonary vessels
           o    Right-sided HF
           o    A. Assessment
                          Systemic congestion occur as the R ventricle fails, fluid is retained, and pressure builds in the venous system
                          Edema develops in the lower legs and ascends to the thighs and abdominal wall.
                          Pts may notice that their shoes fit more tightly, or their shoes or socks may leave indentations on their swollen feet.
                          They may have removed their rings b/c of swelling in fingers and hands.
                          Ask about wt gain. An adult may retain 4-7 liters of fluid (10-15 lb [4.5 to 6.8 kg]) before pitting edema occurs
                          GI reports of N/V may be a direct consequence of liver engorgement resulting from fluid retention. In advanced HF, ascites and an
                           increased abdominal girth may develop from the pronounced liver congestion.
                          Fluid retention  diuresis at rest (fluid in the peripheral tissue is mobilized and excreted & the pt describes frequent awakening at night
                           to urinate)
                          Question about salt and types of food consumed. Ask about daily fluid intake. Pts w/ HF may experience increased thirst and drink
                           excessive fluid (4000 – 5000 mL) b/c of sodium retention.

           o B. Physical Assessment/Clinical Manifestations (pp 769)
                                                                     Chart 37-2 KEY FEATURES
                                                                     Right-Sided Heart Failure
         o   SYSTEMIC CONGESTION
         o   Jugular (neck vein) distention
         o   Enlarged liver and spleen
         o   Anorexia and nausea
         o   Dependent edema (legs and sacrum)
         o   Distended abdomen
         o   Swollen hands and fingers
         o   Polyuria at night
         o   Weight gain
         o   Increased blood pressure (from excess volume) or decreased blood pressure (from failure)
                        R-ventricular HF is associated w/ increased systemic venous pressures and congestion.
                        Assess the neck veins for distension and measure abdominal girth
                        Hepatomegaly , hepatojugular reflex, and ascites may also be assessed
                        Assess for dependent edema. In ambulatory pts, edema is in the ankles and legs. When restricted to bedrest, the sacrum is dependent
                         and edema accumulates there. **Edema is an extremely unreliable sign of HF, and therefore accurate daily weights are needed to
                         document fluid retention. Weight is the most reliable indicator of fluid gain or loss.
                  
     APPROPRIATE NURS INTERVENTIONS FOR NURSING DX: IMPAIRED GAS EXCHANGE AND POTENTIAL PULMONARY EDEMA
         o   Nursing Interventions for Impaired Gas Exchange
                        Care is to promote an optimal spontaneous breathing pattern that increases oxygenation and maintains a normal CO2 level in blood.
                        Ventilation assistance – monitor pt’s resp rate, rhythm, and quality q 1-4 hrs. auscultate breath sounds q 4-8 hrs (O2 content of the blood
                         is often decreased in pts who have pulmonary congestion). **Provide the necessary amount of supplemental oxygen w/in a range
                         prescribed by the HCP to maintain O2 sat at 90% or >

                                                                 Chart 37-3 INTERVENTION ACTIVITIES
                                                                     The Patient with Heart Failure
Ventilation Assistance: Promotion of an optimal spontaneous breathing                    Hemodynamic Regulation: Optimization of heart rate, preload, afterload,
pattern that maximizes oxygen and carbon dioxide exchange in the lungs.                  and contractility.
  •Monitor respiratory and oxygenation status.                                              •Monitor and document heart rate, rhythm, and pulses.
  •Initiate and maintain supplemental oxygen, as prescribed.                                •Monitor peripheral pulses, capillary refill, and temperature and color of
  •Position to alleviate dyspnea.                                                           extremities.
  •Auscultate breath sounds, noting areas of decreased or absent                            •Monitor pulmonary capillary/pulmonary artery wedge pressure and
  ventilation and presence of adventitious sounds.                                          central venous/right atrial pressure, if appropriate.
  •Position to minimize respiratory efforts (e.g., elevate the head of the                  •Administer vasodilator and/or vasoconstrictor medication, as
  bed, and provide overbed table for patient to lean on).                                   appropriate.
  •Monitor the effects of position change on oxygenation: ABG, SaO2, SVO2,                  •Administer positive inotropic/contractility medications.
  end-tidal CO2, Qsp/QT, A-aDO2 levels.                                                     •Maintain fluid balance by administering IV fluids or diuretics, as
                                                                                            appropriate.

                                                                                  14
  •Monitor intake/output, urine output, and patient weight, as appropriate.                      •Arrange physical activities to reduce competition for oxygen supply to
  •Monitor electrolyte levels.                                                                   vital body functions (e.g., avoid activity immediately after meals).
  •Auscultate heart sounds.                                                                      •Encourage physical activity (e.g., ambulation or performance of activities
Energy Management: Regulation of energy use to treat or prevent fatigue                          of daily living, consistent with patient's energy resources).
and optimize function.                                                                           •Monitor patient's oxygen response (e.g., pulse rate, cardiac rhythm, and
  •Monitor cardiorespiratory response to activity (e.g., tachycardia, other                      respiratory rate) to self-care or nursing activities.
  dysrhythmias, dyspnea, diaphoresis, pallor, hemodynamic pressures, and                         •Teach patient and significant other techniques of self-care that will
  respiratory rate).                                                                             minimize oxygen consumption (e.g., self-monitoring and pacing
  •Determine patient's physical limitations.                                                     techniques for performance of activities of daily living).
  •Encourage alternate rest and activity periods.
                          **If pt has dyspnea, place pt in a high Fowler’s position w/ pillows under eaech arm to maximize chest expansion and improve
                           oxygenation. Repositioning and performing coughing and deep-breathing exercises q2hrs help improve oxygenation and prevent
                           atelectasis.
           o    Nursing Interventions for Potential Pulmonary Edema
                          Monitor for manifestations of acute pulmonary edema, a life-threatning event that can result from severe HF (w/ fluid overload), acute
                           MI, mitral valve disease, and possibly dysrhythmias.
                          In pulmonary edema, the L ventricle fails to eject sufficient blood and pressure incrs in the lungs b/c of the accumulated blood. The incrsd
                           pressure causes fluid to lake across the pulmonary capillaries and into the lung airways and tissues.
                          **Assess for early manifestations, such as crackles in the lung bases, dyspnea at rest, disorientation, and confusion, esp in older pts.
                           Documentation of the precise location of the crackles is essential b/c the level of fluid ascends as the pulmonary edema worsens
                          Pt w/ acute pulmonary edema is also extremely anxious, tachycardic, and struggling for air. As it worsens, pt may have moist cough
                           productive of frothy, blood-tinged sputum & skin may be cold, clammy, or cyanotic (CHART 37-4)
                                                                           Chart 37-4 KEY FEATURES
                                                                               Pulmonary Edema
    Crackles                                                                                      Cough with frothy, pink-tinged sputum
    Dyspnea at rest                                                                               Premature ventricular contractions and other dysrhythmias
    Disorientation or acute confusion (especially in older adults as early                        Anxiety
     symptom)                                                                                      Restlessness
    Tachycardia                                                                                   Lethargy
    Hypertension or hypotension
    Reduced urinary output
                          Indications of congestion (CHART 37-5, pp 776): presence of cough or dyspnea, weight gain, jugular venous distention and peripheral
                           edema.
                          Pt diagnosed with PE is admitted to the acute care hospital, often in a critical care unit. Reassure the pt that his or her distress will decrs
                           w/ proper management.
                          **If the pt is not hypertensive, place pt in a sitting (high Fowler’s) position w/ legs down to decrease venous return to the heart. The
                           priority nursing action is to administer high-flow oxygen therapy at 5-6 L/min by facemask or at 10-15 L/min by non-rebreather mask with
                           reservoir. Apply a pulse oximeter and cardiac monitor to keep the pt’s oxygen sat above 90%.**
                          If supplemental O2 does not resolve the pt’s resp distress, collaborate w/ the RT, if available, for more aggressive therapy such as
                           continuous positive airway pressure (CPAP) ventilation. Intubation and mechanical ventilation are used if needed
                          If pt’s systolic BP is above 100, give sublingual nitroglycerin (NTG) to decrs afterload and preload q 5 minutes for 3 doses while
                           establishing IV access for additional drug therapy.
                          Lasix is given IV over 1-2 mins, usually at a starting dose of 40 mg, w/ another 40 mg repeated if needed in 30 mins. Each increment of 40
                           mg of lasix should be administered over 1-2 mins to avoid ototoxicity.
                          Bumex (loop diuretic) may be administered 1-2 mg IVP or as a continuous infusion to provide consistent fluid removal over 24 hours.
                          Monitor VS frequently, q 30-60 mins
                          If pt’s BP is adequate, IV morphine sulfate may be prescribed 1-2 mg at a time, to reduce venous return (preload), decrs anxiety, and
                           reduce the work of breathing.
                          Monitor RR and BP closely (esp BP) while these drugs are given
                          Nursing interventions from ATI “Adult Medical-Surgical Nursing” (pp 356)
                                  o     Maintain a patent airway. Suction as needed.
                                  o     Position client in high-Fowler’s position w/ feet and legs dependent or sitting on the side of the bed to decrs preload.
                                  o     Administer oxygen using a high-flow rebreather mask. BiPAP or intubation/ventilation may become necessary. Be prepared to
                                        intervene quickly.
                                  o     Restrict fluid intake (slow or d/c infusing IV fluids).
                                  o     Administer medications as prescribed.
                                                    Rapid-acting diuretics, such as furosemide (Lasix) and bumetanide, to promote fluid excretion
                                                    Morphine to decrs sympathetic NS response and anxiety and to promote mild vasodilation
                                                    Vasodilators (nitroglycerin, sodium nitroprusside) to decrs preload and afterload
                                                    Inotropic agents, such as digoxin (Lanoxin) and dobutamine, to improve cardiac output
                                                    Antihypertensives, such as ACE inhibitors and beta blockers
                                  o     Monitor hourly urine output. Report intake > output and/or hourly urine output < 30 mL/hr.
                                  o     Monitor lab values, such as serial ABGs and serum K+ (hypokalemia risk w/ rapid-acting diuretics).
                                  o     Provide emotional support for the client and family.
                                  o     Client education (include family members if this is a long-term problem)
                                                    Instruct the client on effective breathing techniques.
                                                    Instruct the client on medications
                                                                 Stress importance of continuing to take meds even if the client is feeling better.
                                                                 Teach common S/Es and reasons to contact the primary care provider.
                                                    Instruct client on a low-sodium diet and fluid restriction.

                                                                                    15
                                                  The client should measure weight daily at the same time. Notify the primary provider of a gain of more than 2 lb
                                                   in 1 day or 5 lb in 1 week.


MEDICATIONS (know all you need to know about digoxin and diuretics)

          o     Digoxin
                            Teach the caregiver and pt how to count a pulse rate, esp if pt is on digoxin or beta blockers. CHART 37-6 lists instructions for the pt taking
                             either of these drugs at home.
                                                         Chart 37-6 PATIENT AND FAMILY EDUCATION GUIDE
                                                                    Beta Blocker/Digoxin Therapy
    Establish same time of day to take this medication everyday.
    Continue taking this medication unless your health care provider tells you to stop.
    Do not take digoxin at the same time as antacids or cathartics (laxatives).
    Take your pulse rate before taking each dose of digoxin. Notify your health care provider of a change in pulse rate (60 to 100 beats/min is normal) or rhythm, as
     well as increasing fatigue, muscle weakness, confusion, or loss of appetite (signs of digoxin toxicity).
    If you forget to take a dose, it may be delayed a few hours. However, if you do not remember it until the next day, you should take only your usual daily dose.
    Report for scheduled laboratory tests (e.g., potassium and digoxin levels).
    If potassium supplements are prescribed, continue the dose until told to stop by your health care provider.

          o     Diuretics
                         Advise pt taking diuretics to take them in the morning to avoid waking during the night for voiding.
                         Emphasizes importance of weighing each morning
                         Emphasize the relationship btwn weight gain, fluid retention, and HF. Daily weights indicate whether the pt is losing or retaining fluid.

HEALTH TEACHING (Table 37-4, p 777 & indication of worsening/recurrent HF)



                                                 TABLE 37-4 Heart Failure Self-Management Health Teaching (MAWDS)
    Medications:
           o   Take medications as prescribed, and do not run out.
           o   Know the purpose and side effects of each drug.
           o   Avoid NSAIDs.
    Activity:
           o   Stay as active as possible, but don't overdo it.
           o   Know your limits.
           o   Be able to carry on a conversation while exercising.
    Weight:
           o   Weigh each day at the same time on the same scale to monitor for fluid retention.
    Diet:
           o   Limit daily sodium intake to 2 to 3 grams as prescribed.
           o   Limit daily fluid intake to 2 liters.
    Symptoms:
           o   Note any new or worsening symptoms, and notify the health care provider immediately.

          o     Indication of worsening or recurrent HF
                          Instruct the caregiver and pt to immediately report the HCp the occurrence of any of these symptoms:
                                      Rapid weight gain (3 lb in a week or 1-2 lb overnight)
                                      Decrs in exercise tolerance lasting 2-3 days
                                      Cold symptoms (cough) lasting more than 3-5 days
                                      Excessive awakening at night to urinate
                                      Development of dyspnea or angina at rest or worsening angina
                                      Increased swelling in the feet, ankles, or hands




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