Cardiovascular Disorders

 Cardiac Ausculatory Landmarks

 APTM - Aortic, pulmonic, tricuspid, mitral

 Heart Sounds

 S1-lub sound, high pitched, apex, beginning systoles, closing of mitral and
tricuspid valve

 S2- dub, 2nd intercostal space, end of systole, closing of pulmonic and aortic
valves, normal sound

 S3- ventricular gallop, low pitched, apex, early diastole, early and rapid filling of
ventricles, common in children, sometimes in older (50) adult and last trimester
of pregnancy

 S4-ventricular gallop, low pitched sound, apex, late in diastole before S1, atrium
is filling against increased resistance of ventricle, as in CAD, CHF, may be normal
in athletes and children

 Pulses

 0,1,2,3,4

 Unequal pulses are significant findings

 MAP = [(2 x diastolic)+systolic] / 3

Must be at least 60 mm Hg to maintain adequate blood flow through coronary arteries and
perfuse major organs (brain)

 Best indicator of fluid balance is weight - 2.2 lb = 1 kg = 1 L of fluid

Sinus bradycardia (SB) has the same conduction pathway as sinus rhythm, but the sinoatrial node fires at
a rate of <60/min.

Symptomatic if heart rate <60/min, & dizziness, syncope, chest pain, and hypotension.

The client with symptomatic SB is first treated with atropine. If atropine is ineffective, transcutaneous
pacing or an infusion of dopamine or epinephrine is considered.

A permanent pacemaker may be needed. If SB is the result of a medication (eg, beta blocker, digoxin), the
drug may need to be held, discontinued, or given in a reduced dosage.

The client has sinus bradycardia, which can be caused by:

•Drugs (eg, beta blockers, calcium channel blockers, digoxin). Consider withholding beta blockers if
systolic blood pressure <100 mm Hg or heart rate <60 and notify the provider.

•Vagal stimulation (eg, carotid sinus massage, Valsalva maneuver)

•Diseases (eg, hypothyroidism, myocardial infarction, increased intracranial pressure)

Sinus tachycardia involves a heart rate of 101-200/min but also has a normal P wave preceding each QRS,
with a normal shape and duration. The PR interval is normal (0.10-0.20 second) and the QRS is <0.12
second.

Tachycardia is a normal compensatory mechanism to increase the cardiac output associated with
hypotension.
Atrial fibrillation is characterized by disorganized electrical activity in the atria due to multiple ectopic foci.
It leads to loss of effective atrial contraction and places the client at risk for embolic stroke as a result of
the thrombi formed in the atria. During atrial fibrillation, the atrial rate may be increased to 350-600/min.
The ventricular response can vary. The higher the ventricular rate, the more likely the client will have
symptoms of decreased cardiac output (ie, hypotension). Clients with atrial fibrillation are usually
prescribed an anticoagulant, such as rivaroxaban (Xarelto), due to increased risk for blood clots that can
lead to stroke.

The treatment goals are to reduce the ventricular rate to <100/min and prevent stroke. Ventricular rate
control is the priority. Medications used for rate control include calcium channel blockers (ie, diltiazem),
beta blockers (ie, metoprolol), and digoxin.

Electrical cardioversion is a treatment modality considered for AF that has been unresponsive to drug
therapy. If a client is in AF for more than 48 hours, anticoagulation therapy is needed for 3-4 weeks before
cardioversion. Anticoagulation therapy is necessary as cardioversion may dislodge an atrial thrombus,
putting the client at risk for a stroke or other sequelae of thromboembolism.

The client with first-degree atrioventricular block may have a normal heart rate, but the atrioventricular
conduction time is prolonged. In 1st-degree AV block, every impulse is conducted to the ventricles, but
the time of AV conduction is prolonged. This is evidenced by a prolonged PR interval of >0.20 second.

First-degree atrioventricular (AV) block can be associated with beta-adrenergic blocker drugs, such as
atenolol (Tenormin), as they delay conduction at the AV node. This is reflected as prolonged PR interval
on ECG. Only second- or third-degree heart block should be the priority.
Second-degree atrioventricular block, type 2 has more P waves than QRS complexes. The PR interval is
constant on conducted beats; it reflects an intermittent block of atrial impulses.

Mobitz II (type II second-degree atrioventricular block) is usually not associated with electrolyte
disturbances but is more often associated with conduction system disease or drug toxicity (eg, beta
blockers, calcium channel blockers).

Complete heart block, or 3rd-degree atrioventicular (AV) block, is a form of AV dissociation in which no
impulses from the atria are conducted to the ventricles. The atria are stimulated and contract
independently of the ventricles. The ventricular rhythm is an escape rhythm.

Complete heart block has more P waves than QRS complexes, and PR intervals are variable. There is no
communication between the atria and ventricles; each is firing independently of the other.

Ventricular bigeminy is a rhythm in which every other heartbeat is a premature ventricular contraction
(PVC). Unlike the QRS complexes in this client's ECG, PVCs are not associated with P waves, and the QRS
complexes are wide and distorted.
A Premature atrial contraction (PAC) is a contraction starting from an ectopic focus in the atrium (other
than the sinus node) and coming sooner than the next sinus beat. The P wave has a different shape
than the P wave that originated in the sinus node.

A premature ventricular contraction (PVC) is a contraction originating from an ectopic foci in the ventricle.
It appears early in the rhythm and has a wide and distorted shape as compared to the underlying rhythm.
A consecutive run of ≥3 PVCs is considered VT.

•An atrial paced rhythm would have a pacer spike before the P wave only. The P wave may appear
normal or abnormal; the QRS complex will appear normal.

•A ventricular paced rhythm would only have a pacer spike prior to a wide QRS complex. Impulses are
generated in only one ventricle (typically the right ventricle).

•An atrioventricular pacemaker (also known as a sequential or dual chamber pacemaker) paces the right
atrium and right ventricle in sequence. The ECG will have 2 pacer spikes, one before the P wave and one
before the QRS complex. The P wave following the atrial pacer spike may be normal or abnormal
appearing. The QRS complex following the ventricular pacer spike is typically wide and distorted. An
atrioventricular pacemaker can improve synchrony between the atria and ventricles. It may be
implanted in the client with bradycardia, heart block, or cardiomyopathy.

•Biventricular pacemakers (also known as sequential biventricular pacemakers) generate impulses in

both ventricles. Two ventricular pacing spikes may be seen on the ECG, and one spike may appear after
the beginning of the QRS complex.

To check for mechanical capture, the nurse should palpate the client's pulse rate and compare it with
the electrical rate displayed on the cardiac monitor.

Failure to sense appears on an ECG as asynchronous pacer spikes in inappropriate or random locations
(eg, pacer spike on the T wave). It should not be confused with failure to capture, in which pacer spikes
are located appropriately but there is no electrical response elicited from the heart (eg, no QRS complex
after a pacer spike).
Failure to capture occurs when the pacemaker sends an impulse to the ventricle, but the myocardium
does not depolarize (pacer spike with no QRS complex; no palpable pulse beat); this is usually associated
with pacer lead (wire) displacement or battery failure. The malfunction can result in bradycardia (pulse
<60/min) or asystole and decreased cardiac output; the nurse should perform an assessment and notify
the health care provider

Paroxysmal supraventricular tachycardia (PSVT). In PSVT, the heart rate can be 150-220/min. With
prolonged episodes, the client may experience evidence of reduced cardiac output such as hypotension,
palpitations, dyspnea, and angina.

Treatment includes vagal maneuvers such as Valsalva, coughing, and carotid massage.

Adenosine is the drug of choice for PSVT treatment. Due to its very short half-life, adenosine is
administered rapidly via IVP over 1-2 seconds and followed by a 20-mL saline bolus. An increased dose
may be given twice if previous administration is ineffective. The client's ECG should be monitored
continuously. A brief period of asystole is due to adenosine slowing impulse conduction through the
atrioventricular node. The client should be monitored for flushing, dizziness, chest pain, or palpitations
during and after administration.
Beta blockers, calcium channel blockers, and amiodarone can also be considered as alternatives. If vagal
maneuvers and drug therapy are unsuccessful, synchronized cardioversion may be used.

The synchronizer switch must be turned on when cardioversion is planned. The synchronize circuit in
the defibrillator is programmed to deliver a shock on the R wave of the QRS complex on the
electrocardiogram (ECG). This allows the unit to sense this client's rhythm and time the shock to avoid
having it occur during the T wave. A shock delivered during the T wave could cause this client to go into
a more lethal rhythm (eg, ventricular tachycardia, ventricular fibrillation). If this client becomes
pulseless, the synchronize function should be turned off and the nurse should proceed with
defibrillation.

Synchronized cardioversion is indicated for ventricular tachycardia with a pulse, supraventricular

tachycardia, and atrial fibrillation with a rapid ventricular response.
Ventricular tachycardia (VT) is a potentially life-threatening dysrhythmia characterized by a ventricular
rate of 100-250/min. The rhythm is often regular, but it can be irregular. QRS complexes are wider than
0.12 seconds and the P wave is usually buried in the QRS complex, making a PR interval unmeasurable.
Pulseless VT is treated with cardiopulmonary resuscitation (CPR) and defibrillation.

Clients in ventricular tachycardia (VT) can be pulseless or have a pulse. Treatment is based on this
important initial assessment. VT with a pulse should be further assessed for clinical stability or
instability. Signs of instability include hypotension, altered mental status, signs of shock, chest pain, and
acute heart failure.

The unstable client in VT with a pulse is treated with synchronized cardioversion. The stable client in VT
with a pulse is treated with antiarrhythmic medications (eg, amiodarone, procainamide, sotalol).

Ventricular Fibrillation

VF is a lethal dysrhythmia characterized by varying shapes and amplitude on the electrocardiogram.

Mechanically, the ventricle is just "quivering" with no effective contraction or cardiac output. VF results
in a pulseless, unresponsive, apneic state. Without rapid treatment, the client will not recover.
Interventions consist of immediate activation of the emergency response system, followed by initiation
of CPR and advanced cardiac life support with defibrillation, and drug treatment with epinephrine and
then amiodarone.

Ventricular fibrillation is characterized on the electrocardiogram by irregular waveforms of varying

shapes and amplitude. It represents the firing of multiple ectopic foci in the ventricle. The client in
ventricular fibrillation will not have a pulse, and defibrillation is essential in addition to CPR under the
ACLS guidelines.

Hypomagnesemia (normal: 1.5-2.5 mEq/L [0.75-1.25 mmol/L]) causes a prolonged QT interval that
increases the client's susceptibility to ventricular tachycardia. Torsades de pointes is a type of
polymorphic ventricular tachycardia coupled with a prolonged QT interval; it is a lethal cardiac
arrhythmia that leads to decreased cardiac output and can develop quickly into ventricular fibrillation.
The American Heart Association recommends treatment with IV magnesium sulfate.
Torsades de Points

Asystole

Asystole represents the total absence of ventricular electrical activity in the heart. No ventricular
contraction occurs. The client is pulseless, apneic, and unresponsive. Asystole is usually a result of
advanced cardiac disease, end-stage heart failure, or a severe electrical conduction system disturbance.

Treatment consists of cardiopulmonary resuscitation (CPR) and initiation of advanced cardiac life
support measures, including administration of epinephrine and/or vasopressin, placement of an
advanced airway, and treatment of any reversible causes.

Coronary Artery Disease

 Narrowing or obstruction of one or more coronary arteries results from atherosclerosis, an

accumulation of lipid-containing plaque in the arteries.
  Symptoms occur when the coronary artery is occluded to point that blood supply to the muscle
becomes inadequate, causing ischemia.

 Coronary artery disease (CAD) results in hypertension, angina, dysrhythmias, myocardial

infarction, heart failure, and death.

 The goal of treatment (which includes a low-fat diet, regular exercise, and medications such as
cholesterol-decreasing drugs) is to slow the atherosclerotic progression.

 Findings may be normal during asymptomatic periods, but the affected client experiences chest
pain, dyspnea, syncope, and excessive fatigue.

 A variety of studies are used to diagnose CAD.

Medications

 Nitrates are used to dilate the coronary arteries.

 Calcium channel blockers are prescribed to dilate the coronary arteries and reduce vasospasm.

 Cholesterol-decreasing medications slow the development of atherosclerotic plaques.

 Beta-blockers are prescribed to reduce blood pressure in hypertensive clients.

Angina

 Angina is chest pain resulting from myocardial ischemia caused by inadequate myocardial
blood and oxygen supply.

 Causes include obstruction of coronary blood flow resulting from atherosclerosis, coronary
artery spasm, and conditions increasing myocardial oxygen consumption.

 Angina occurs in a variety of patterns; pain relief may or may not be achieved by the use of
nitroglycerin.

 The goal of treatment is to provide relief of acute attacks, correct imbalances of myocardial
oxygen supply and demand, and prevent progression of the disease and further attacks to
reduce the risk of myocardial infarction.

Patterns of Angina

Stable: Also called exertional angina

 Occurs during activities that involve exertion or emotional stress; relieved by rest or
nitroglycerin

 Usually has a stable pattern of onset, duration, severity, and relieving factors

Unstable: Also called preinfarction angina

 Occurs with an unpredictable degree of exertion or emotion and increases in occurrence,

duration, and severity over time

 May not be relieved by nitroglycerin

Variant: Also called Prinzmetal or vasospastic angina

 Results from coronary artery spasm

  May occur when the client is at rest

 May be associated with ST-segment elevation on electrocardiography

 May be relieved by nitroglycerin

 Assessment findings include:

 Pain

 Dyspnea

 Pallor

 Sweating

 Palpitations and tachycardia

 Dizziness and faintness

 Hypertension

 Digestive disturbances

Both laboratory and imaging studies are used to diagnose the cause of angina:

 Electrocardiographic (ECG) findings are normal during rest, with ST-segment depression, T-wave
inversion, or both during an episode of pain.

 Chest pain or changes in the ECG or vital signs during stress testing may indicate ischemia.

 Cardiac enzymes are normal.

 Cardiac catheterization provides a definitive diagnosis by eliciting information about the patency
of the coronary arteries.

Immediate Management

 Assess the client’s pain and institute pain-relief measures.

 Administer nitroglycerin as prescribed to dilate the coronary arteries, reduce oxygen

requirements of the myocardium, and relieve chest pain.

 Administer oxygen at 3 L/min by way of nasal cannula.

 Restrict the client to bed rest in the semi-Fowler position.

 Monitor the client’s vital signs.

 Obtain a 12-lead ECG.

 Institute continuous cardiac monitoring.

 Initiate an intravenous (IV) line.

 Obtain blood for a troponin determination and other laboratory tests.

 Stay with the client.

After an Acute Episode

  Help the client identify angina-precipitating events and situations.

 Instruct the client to stop activity and rest if chest pain occurs and to take nitroglycerin as
prescribed.

 Instruct the client to seek medical attention if the pain persists after treatment.

Surgical Procedures

 Procedures are the same as those performed in CAD.

Medications

 Medications are similar to those used to treat CAD.

 Antiplatelet therapy may be prescribed to inhibit platelet aggregation and reduce the risk of
acute myocardial infarction.

Myocardial Infarction

 Myocardial infarction (MI) occurs when myocardial tissue is abruptly and severely deprived of
oxygen.

 Ischemia may lead to necrosis of myocardial tissue in several locations, resulting in a variety of
complications, if blood flow is not restored.

Risk factors for MI are numerous:

 Atherosclerosis and coronary artery disease (includes hereditary factor)

 Increased cholesterol levels

 Smoking

 Hypertension

 Obesity

 Physical inactivity

 Impaired glucose tolerance

 Stress

Assessment findings include:

 Pain

 Nausea and vomiting

 Diaphoresis

 Dyspnea

 Dysrhythmias

 Fear and anxiety

 Pallor, cyanosis, and coolness of extremities

 Both laboratory and monitoring studies are used to diagnose MI.

Nursing Considerations
During an Acute Episode

 The same interventions used to treat angina are instituted.

 Administer morphine sulfate as a priority to manage pain.

 Administer antidysrhythmics and other medications as prescribed.

 Thrombolytic therapy may be prescribed within 6 hours of a coronary event; monitor the client
for bleeding.

 Monitor the client for cardiac dysrhythmias; tachycardia and premature ventricular
contractions often occur in the hours after MI.

 Monitor the client’€™s intake and output.

 Assess the respiratory rate and breath sounds for signs of heart failure, as indicated by the
presence of crackles, wheezing, or dependent edema.

Monitor the BP closely after administering medications; if it is less than 100 mm Hg systolic or 25 mm Hg
lower than the previous reading, lower the head of the bed and notify the physician.

Interventions after an Acute Episode

 Restrict the client to bed rest; allow the client to stand to void or use a bedside commode, if the
physician permits this.

 The client should progress to dangling the legs over the side of the bed or going from the bed to
chair for 30 minutes three times a day, then to walking in the client's room and to the bathroom,
followed by ambulation in a hallway.

 Monitor the client for complications.

 Encourage the client to verbalize feelings regarding the MI.

Testing
  Exercise stress testing and echocardiography are used to assess electrocardiographic changes
and ischemia, to evaluate the need for medical therapy, or to identify clients who may require
invasive therapy.

 A thallium scan is prescribed to assess the client for ischemia or necrotic muscle tissue.

 Multigated cardiac blood pool imaging scans are used to evaluate left ventricular function.

 Cardiac catheterization is prescribed to determine the extent and location of obstructions of the
coronary arteries.

Heart Failure

 Heart failure is the inability of the heart, in the setting of impaired pumping capability, to
maintain adequate circulation to meet the metabolic needs of the body.

 Cardiac output is diminished, and the peripheral tissue is not adequately perfused.

 Congestion of the lung and periphery may occur, and this may in turn develop into acute
pulmonary edema.

 Acute heart failure occurs suddenly.

 Chronic heart failure develops over time, but a client with chronic heart failure may experience
an acute episode.

 Assessment findings vary, depending on whether heart failure is left- or right-sided heart failure
and whether heart failure has progressed to acute pulmonary edema.

Acute Pulmonary Edema

 Place the client in a high Fowler position, with the legs dependent, to reduce pulmonary
congestion and relieve edema.

 Administer oxygen to improve gas exchange and pulmonary function.

 Perform suctioning as needed to maintain a patent airway.

 Prepare to administer diuretics and other medications as prescribed.

 Insert a Foley catheter and monitor the urine output.

 Administer morphine sulfate to relieve anxiety and promote vasodilation, then monitor the client
for respiratory depression and hypotension.
  Assess the client’s level of consciousness.

 Prepare for intubation and ventilatory support if required; monitor lung sounds for congestion
and diminution.

 Assess the client for edema in dependent areas and in sacral, lumbar, and posterior thigh area in
the client restricted to bed rest.

 Monitor the client’s weight to help determine the response to treatment.

 Monitor the potassium level, which may decrease as a result of diuretic therapy, closely.

Interventions After an Acute Episode

 Instruct the client in the prescribed medication regimen, which may include digoxin (Lanoxin), a
diuretic, and vasodilators.

 Instruct the client to avoid large amounts of caffeine, found in coffee, tea, cocoa, chocolate, and
some carbonated beverages.

 Educate the client about a prescribed low-sodium, low-fat, low-cholesterol diet.

 Provide the client with list of potassium-rich foods; diuretics (except for potassium-sparing
diuretics) will cause hypokalemia.

 Educate the client regarding fluid restriction, if prescribed, advising the client to spread fluids out
during the day and to suck on hard candy to relieve thirst.

 Instruct the client to alternate periods of activity and rest.

 Advise the client to avoid isometric activities, which increase pressure in the heart.

 Instruct the client to check his or her weight daily.

 Instruct the client to report signs of fluid retention (e.g., edema, weight gain).

Pericarditis

 Pericarditis is acute or chronic inflammation of the pericardium.

 Assessment findings include:

 Precordial pain in the anterior chest that radiates to the left side of the neck, the left
shoulder, or the back, aggravated by breathing (particularly inspiration), coughing, and
swallowing

 Worsening of pain when the client is supine; may be relieved when the client leans
forward

 Pericardial friction rub (scratchy, high-pitched sound) heard on auscultation, produced by

rubbing of inflamed pericardial layers

 Fever and chills

 Increased white blood cell (WBC) count

 Electrocardiographic changes

Nursing Considerations
  Position the client in a side-lying position or high Fowler position or upright and leaning forward.

 Administer analgesics, nonsteroidal antiinflammatory drugs, or corticosteroids for pain as

prescribed.

 Auscultate for pericardial friction rub.

 Obtain blood for cultures and administer antibiotics for bacterial infection as prescribed.

 Assist with pericardiocentesis (withdrawal of pericardial fluid from the pericardial space).

 Monitor the client for signs of cardiac tamponade, including pulsus paradoxus, jugular vein
distention with clear lung sounds, muffled heart sounds, narrowed pulse pressure, tachycardia,
and decreased cardiac output; notify the physician if signs of cardiac tamponade occur.

Pericardiocentesis

Myocarditis

 Acute or chronic inflammation of the myocardium is caused by pericarditis, systemic infection,

or an allergic response.

Assessment findings include:

 Fever

 Pericardial friction rub

 Gallop rhythm

 Murmur that sounds like fluid passing an obstruction

 Chest pain

Nursing Considerations

 Help the client into a position of comfort (e.g., sitting up and leaning forward).
  Administer analgesics, salicylates, and nonsteroidal antiinflammatory drugs as prescribed to
reduce fever and pain.

 Assess the client for pericardial friction rub, gallop rhythm, and murmur.

 Obtain blood for cultures and administer antibiotics for bacterial infection as prescribed.

 Monitor the client for complications (e.g., thrombus, heart failure, cardiomyopathy).

Endocarditis

Description

 Endocarditis, inflammation of the inner lining of the heart and valves, occurs primarily in IV drug
abusers, individuals who have undergone valve replacement, and subjects with mitral valve
prolapse or other structural defects.

 Portals of entry for infectioius organisms include the oral cavity (especially if the client has
undergone a dental procedure in preceding 3 to 6 months), skin, infections, and invasive
procedures or surgery.

Assessment findings include:

 Fever

 Anorexia and weight loss

 Fatigue

 Cardiac murmur

 Heart failure

 Embolic complications caused by from vegetative fragments traveling through the

circulation

 Petechiae

 Splinter hemorrhages in the nail beds

 Osler nodes (tender reddish lesions) on the pads of the fingers, hands, and toes

 Janeway lesions (nontender hemorrhagic lesions) on the fingers, toes, nose, and earlobes

 Splenomegaly

 Clubbing of fingers

Nursing Considerations

 Monitor the client’s cardiovascular status and watch for signs of heart failure.

 Monitor the client for splenic emboli, evidenced by sudden abdominal pain radiating to the left
shoulder and rebound abdominal tenderness on palpation.

 Monitor the client for renal emboli, evidenced by flank pain radiating to the groin, hematuria, and
pyuria.
  Monitor the client for confusion, aphasia, and dysphagia, which may indicate a central nervous
system embolus.

 Monitor the client for signs of pulmonary emboli (i.e., pleuritic chest pain, dyspnea, and cough).

 Assess the skin, mucous membranes, and conjunctiva for petechiae.

 Assess the nail beds for splinter hemorrhages.

 Look for Osler nodes and Janeway lesions.

 Assess the fingers for clubbing.

 Obtain blood for cultures and administer antibiotics as prescribed.

Cardiac Tamponade

 Pericardial effusion occurs when the space between the parietal and visceral layers of the
pericardium fills with fluid.

 The condition places the client at risk for cardiac tamponade, an accumulation of fluid in the
pericardial cavity, which restricts ventricular filling, causing cardiac output to drop.

 Acute cardiac tamponade can occur when a small volume (20 to 50 mL) of fluid accumulates
rapidly in the pericardium.

Assessment findings include:

 Pulsus paradoxus

 Increased central venous pressure

 Jugular venous distention with clear lungs

 Distant, muffled heart sounds

 Decreased cardiac output

Nursing Considerations

 The client requires hemodynamic monitoring in a critical care unit.

 Administer IV fluids to manage diminished cardiac output.

 Prepare the client for chest x-ray or echocardiography.

 Prepare the client for pericardiocentesis.

 Be alert for recurrence of tamponade after pericardiocentesis.

 If the client experiences recurrent tamponade or recurrent effusions or develops adhesions as a

result of chronic pericarditis, a portion (pericardial window) or all of the pericardium
(pericardiectomy) may be removed to permit adequate ventricular filling and contraction.

Valvular Heart Disease

 The heart valves cannot fully open (as a result of stenosis) or close (because of insufficiency or
regurgitation), preventing efficient blood flow through the heart.

 Manifestations are similar for the various types.

  In mitral stenosis, the valve tissue thickens and narrows, causing narrowing of the valve opening.

 In mitral insufficiency/regurgitation, the valve is incompetent, preventing complete closure.

 In mitral valve prolapse, the valve leaflets protrude into the left atrium during systole.

 In aortic stenosis, the tissue of the aortic valve thickens, causing narrowing of the valve opening.

 In aortic insufficiency/regurgitation, the valve is incompetent, preventing complete closure.

Nursing Considerations: Repair and Valve-Replacement Procedures

Balloon Valvuloplasty

 A balloon catheter is passed from the femoral vein through the atrial septum to the mitral valve
or through the femoral artery to the aortic valve, then inflated to enlarge the orifice.

Mitral Annuloplasty

 The malfunctioning valve annulus is tightened and sutured to eliminate or markedly reduce
regurgitation.

Commissurotomy/Valvotomy

 During this procedure, accomplished with cardiopulmonary bypass during open-heart surgery,
the valve is visualized, thrombi removed from the atria, fused leaflets incised, and calcium
debrided from the leaflets to widen the orifice.

Mechanical Prosthetic Valves

 Thromboembolism is a problem after valve replacement, and lifetime anticoagulant therapy is

required.

Bioprosthetic Valves

 Biological grafts are xenografts (valves from other species) or homografts (from human cadavers).

 With little risk of clot formation, long-term anticoagulation is not indicated.

Nursing Considerations: Client Instructions After Valve Replacement

 Tell the client that fatigue is common and that adequate rest is important.

 Stress the need for anticoagulant therapy if a mechanical prosthetic valve has been inserted.

 Explain the hazards of anticoagulant therapy and tell the client to notify the physician if bleeding
or excessive bruising occurs.

 Stress the importance of good oral hygiene to reduce the risk of infective endocarditis.

 Instruct the client to monitor the incision and report drainage or redness.

 Dental procedures should be avoided for 6 months.

 Heavy lifting (more than 10 lb) is to be avoided.

 If a prosthetic valve has been inserted, a soft clicking sound may be heard on auscultation.

 Stress the importance of prophylactic antibiotics before invasive procedures and the
importance of informing all healthcare professionals of the history of valvular disease.
Cardiomyopathy

Cardiomyopathy is a subacute or chronic disorder of heart muscle.

 Treatment is palliative and supportive, not curative.

 Lifespan is shortened.

Assessment findings are similar for all types:

 Fatigue and weakness

 Heart failure

 Dysrhythmia or heart block

 Dyspnea

 Angina

 Cardiomegaly

 Syncope

 Palpitations

 Gallop

 Emboli

Nursing Considerations: Help the client deal with the numerous lifestyle changes that will be required
and issues related to a shortened lifespan.

Venous Disorders / NCLEX Tips

 The client with a venous disorder is usually advised to wear antiembolism stockings during the
day and evening; these should be put on after the client awakens, before he or she gets out of
bed.

 The client should avoid prolonged sitting or standing, constrictive clothing, and crossing the legs
when seated.

 The client should elevate the legs for 10 to 20 minutes every few hours each day; the legs should
be elevated above the level of the heart when the client is in bed.

 Avoid using the knee gatch or placing a pillow under the knees.

 Avoid massaging the extremity.

 If the client is on bed rest, encourage a change of position every 2 hours.

 Teach the client to use intermittent sequential pneumatic compression system (to reduce
venous stasis and aid venous return of the blood to the heart), if prescribed; usually the client is
advised to apply the compression system twice daily for 1 hour, morning and evening.

 Inspect the legs for edema and measure and record the circumference of each thigh and calf.

 Plan a progressive walking program.

  When performing wound care or dressing changes, keep tape off the skin by applying tape to the
dressing material.

 Instruct the client to cease or avoid smoking.

 Stress the importance of follow-up physician visits and laboratory studies.

Venous Thrombosis

 Development of a clot in a vein results in inflammation and thickening of the vein wall and can
also lead to embolization.

There are several types of venous thrombosis:

 Phlebothrombus is a thrombus without inflammation.

 Phlebitis is vein inflammation associated with invasive procedures and equipment such
as intravenous (IV) lines.

 Thrombophlebitis is inflammation associated with a thrombus.

 Deep-vein thrombophlebitis, which occurs in the deeper veins, is more serious than a
superficial thrombophlebitis because of the risk for pulmonary embolism.

Risks Factors for Thrombosis

 Venous stasis

 Hypercoagulability disorders

 Injury to the venous wall sustained during an IV injection

 Surgery, particularly hip or abdominal surgery

 Pregnancy

 Ulcerative colitis

 Use of oral contraceptives

 Certain malignancies

 Fractures and other injuries to the pelvis or lower extremities

Phlebitis

Assessment findings include:

 A red, warm area spreading up the affected extremity

 Pain and soreness

 Swelling

Nursing Considerations

 Administer warm, moist soaks as prescribed to dilate the vein and promote circulation.

 Monitor the client for signs of complications (e.g., tissue necrosis, infection, pulmonary embolus).
Venous Insufficiency

 Results from prolonged venous hypertension, which stretches the veins and damages the valves

 Resultant edema and venous stasis cause venous-stasis ulcers, swelling, and cellulitis

 Treatment focuses on decreasing edema, promoting venous return from affected extremity, and
healing existing ulcers

Assessment

 Stasis dermatitis, or brown discoloration along the ankles and extending up to the calf

 Edema

Nursing Considerations
Unna Boot

 Dressing constructed of gauze moistened with zinc oxide; will be changed weekly (usually by the
health care provider).

 Wound is cleansed with normal saline solution before application of Unna boot; providone-iodine
(Betadine) and hydrogen peroxide are not used because they destroy granulation tissue.

 The Unna boot, which is covered with an elastic wrap that hardens, promotes venous return and
prevents stasis.

 Monitor client for signs of arterial occlusion caused by a too-tight Unna boot.

 Note: other occlusive dressings or a hydrocolloid dressing may be prescribed to cover the ulcer.

 Medications

 Topical agents may be prescribed to debride the ulcer, eliminate necrotic tissue, and promote
healing.

 When applying topical agents, apply an oil-based agent (e.g., petroleum jelly [Vaseline]) on
surrounding skin; because debriding agents can injure healthy tissue.

 Antibiotics may be prescribed if infection or cellulitis develops.

Ulcer formation: edges are uneven, ulcer bed is pink, and granulation is present
Deep Vein Thrombosis

Assessment findings include:

 Calf or groin tenderness or pain, with or without swelling

 Warm skin, tender to touch

Nursing Considerations

 Provide bed rest.

 Administer intermittent or continuous warm, moist compresses.

 Monitor the client for shortness of breath and chest pain, which may indicate pulmonary
embolism.

 Administer thrombolytic therapy or anticoagulant therapy as prescribed. (Heparin prevents

enlargement of existing clot and prevents formation of new clots.)

 Teach the client about the hazards of anticoagulation therapy and how to recognize signs and
symptoms of bleeding.

Varicose Veins

 Distended, protruding veins that appear darkened and tortuous

 Vein walls weaken and dilate, and valves become incompetent

Assessment

 Pain in the legs, with a dull aching after standing

 Feeling of fullness in legs

 Ankle edema

Interventions

 Assist with the Trendelenburg test: Place the client in a supine position with the legs elevated.
When the client sits up, if varicosities are present, veins fill from the proximal end; veins normally
fill from the distal end.

 Prepare the client for sclerotherapy, laser therapy, or vein stripping

Arterial Disorders / NCLEX Tips

 Teach the client to walk to the point of claudication, stop and rest, then walk a little farther.

 Instruct the client to elevate the feet while at rest but to refrain from elevating them above the
level of the heart, because extreme elevation slows arterial blood flow to the feet. (In severe
peripheral arterial disease, a client with edema may sleep with the affected limb hanging from
the bed or sit upright in a chair for comfort.)

 The client should avoid crossing the legs, avoid exposing the extremities to cold (which causes
vasoconstriction), and wear socks or insulated shoes for warmth at all times.

 Warn the client never to apply heat directly to the limb (e.g., heating pad or hot water), because
the decreased sensitivity in the limb make it easier to sustain a burn.
  The client should inspect the skin of the extremities daily and report signs of skin breakdown.

 Advise the client to avoid the use of tobacco and caffeine because of their vasoconstrictive
effects.

Peripheral Arterial Disease

In this chronic disorder, also known as PAD, partial or total arterial occlusion deprives the legs of oxygen
and nutrients.

Assessment findings include:

 Intermittent claudication

 Pain at rest that awakens the client at night and is relieved when the extremity is placed
in a dependent position

 Cold, gray blue skin on the legs

 Elevational pallor and dependent rubor in the legs

 Diminished peripheral pulses (or an absence of pulses)

 Arterial ulcer formation, characterized by the client as painful

 Blood pressure measurements at the thigh, calf, and ankle lower than the brachial
pressure

Nursing Considerations

 Assess the client’s pain.

 Monitor the extremities for color, motion and sensation, and peripheral pulses.

 Monitor the blood pressure.

 Assess the client for signs of ulcer formation or gangrene.

 Help develop individualized exercise program, which is initiated gradually and slowly increased.

 Educate the client in the use of any hemorrheologic and antiplatelet medications that are
prescribed.

 Prepare the client for procedures that may be performed to improve arterial blood flow:
percutaneous transluminal angioplasty (during which an intravascular stent may be inserted),
laser-assisted angioplasty, atherectomy, or bypass surgery.

Raynaud Disease

 Vasospasm of the arterioles and arteries of the arms and legs causes constriction of the
cutaneous vessels.

 Attacks, which are intermittent, occur with stress or exposure to cold and mainly affect the
fingers, toes, ears, and cheeks.

Assessment reveals:

 Blanching of the extremity, followed by cyanosis, during vasoconstriction

  Reddening of the tissue when vasospasm is relieved

 Numbness, tingling, and swelling in the affected body part

 Coldness of the affected body part on palpation

Nursing Considerations

 Monitor the client’€™s pulses.

 Administer vasodilators as prescribed.

 Help the client identify and avoid precipitating factors (e.g., cold and stress).

 Instruct the client to cease or avoid smoking.

 Instruct the client to wear warm clothing, socks, and gloves in cold weather.

 Advise the client to avoid activities that could result in injuries to the fingers and hands.

Buerger Disease (Thromboangiitis Obliterans)

This occlusive disease affects the median and small arteries and veins, most commonly in the distal arms
and legs.

Assessment findings include:

 Intermittent claudication

 Ischemic pain in the digits while the client is at rest and aching pain that is more severe
at night

 Sensation of cool, numbness, or tingling

 Diminished pulses in the distal extremities

 Coolness and redness of dependent extremities

 Development of ulcerations in the extremities

Nursing Considerations

 Interventions are similar to those implemented for Raynaud disease.

Aortic Aneurysm

Nursing Considerations

 The goal of treatment is to limit progression of the disease and prevent rupture by modifying
risk factors, controlling blood pressure to prevent strain on the aneurysm, and recognizing
symptoms early.

 Obtain information regarding back or abdominal pain.

 Check the client’€™s peripheral circulation.

 Teach the client how to monitor the blood pressure and advise the client of the importance of
regular physician visits to assess the size of the aneurysm.
  Administer antihypertensives as prescribed to maintain the blood pressure within normal limits
and to prevent strain on the aneurysm.

 Notify the physician immediately if signs of rupture are noted: chest or severe back or
abdominal pain, shortness of breath, difficulty swallowing, hoarseness, soreness over the
umbilicus, sudden development of discoloration in the extremities, or changes in the blood
pressure.

Arterial Procedures

Abdominal Aneurysm Resection

In this surgical resection or excision of the aneurysm, the excised section is replaced with a graft sewn
end to end.

Nursing Considerations

 Monitor the peripheral pulses distal to the graft site.

 Watch for signs of graft occlusion (e.g., changes in pulses, cool-to-cold extremities distal to the
graft, white or blue extremities or flanks, severe pain, abdominal distention, decreased urine
output).

 Limit elevation of the head of the bed to 45 degrees to prevent flexion of the graft.

Thoracic Aneurysm Repair

 A thoracotomy or median sternotomy approach is used to enter the thoracic cavity.

 The aneurysm is exposed and excised, and a graft or prosthesis is sewn onto the aorta.

 Cardiopulmonary bypass may be necessary.

Nursing Considerations

 Monitor chest tubes for increased chest drainage, which may indicate bleeding or separation at
the graft site.

 Assess sensation and motion in all extremities and notify the physician of deficits, which may be
a result of diminished blood supply during surgery.

Embolectomy

 An embolus is removed from an artery with the use of a catheter.

Nursing Considerations

 Conduct a baseline vascular assessment

 Administer anticoagulants and thrombolytics

 Place a bed cradle on the bed and avoid bumping or jarring the bed

 Maintain the extremity in slightly dependent position

Postoperative Interventions

 Monitor the peripheral circulation and sensory and motor function in the affected extremity.

 Watch for signs and symptoms of new thrombi or emboli.

  Monitor the client for complications of artery reperfusion (e.g., spasms, swelling of skeletal
muscles).

 Bed rest in a semi-Fowler position may be prescribed initially.

 Place a bed cradle on the client’€™s bed.

 Administer anticoagulants as prescribed.

 Instruct the client to avoid sitting for prolonged periods or crossing the legs when sitting, to
elevate the legs when sitting, and to wear antiembolism stockings.

Vena Cava Filter Placement and Ligation of the Inferior Vena Cava

 An intracaval filter (umbrella) is inserted, partially occluding the inferior vena cava and trapping
emboli to prevent pulmonary emboli.

Nursing Considerations

 If the client has been taking an anticoagulant, consult with the physician regarding its
discontinuation before the procedure to prevent hemorrhage.

 Postoperative interventions are similar to those implemented after embolectomy.

Hypertension

 Increased blood pressure is a major risk factor for coronary, cerebral, renal, and peripheral
vascular disease.

 The cause of primary or essential hypertension is unknown, but risk factors are similar to those
for CAD.

 Secondary hypertension occurs as a result of other disorders.

 Although the affected individual may be asymptomatic, assessment findings often include:

 Headache

 Visual disturbances

 Dizziness

 Chest pain

 Tinnitus

 Flushed face

 Epistaxis

Interventions

 The goals of treatment include reduction of the blood pressure and prevention or lessening of
organ damage; treatment of secondary hypertension depends on the cause.

 Nonpharmacological approaches (e.g., lifestyle changes) may be initially prescribed, but, if the
blood pressure cannot be reduced after a reasonable period (i.e., 1 to 3 months), the client may
require pharmacological treatment.
 Describe the disease process to the client, explaining that symptoms usually do not develop
until organs have sustained damage.

 Weight reduction is encouraged as necessary, and the non-overweight client is instructed to

maintain an ideal weight.

 Educate the client on dietary restrictions (i.e., sodium, fat, calories, cholesterol) and discuss how
to shop for and prepare low-sodium meals, explaining that fresh foods are best and stressing
the need to avoid canned foods, which are generally high in sodium.

 Help the client plan a regular exercise program, avoiding heavy lifting and isometric exercises.

 Urge the client to stop smoking.

 Help the client identify ways to reduce stress, such as incorporating relaxation techniques into
the daily living, and teach the client these techniques.

 Medications will be prescribed on basis of the individual’s needs; review medications that the
client is already taking with the physician with the goal of eliminating unnecessary medications
that may be contributing to the client’s hypertension.

 Stress the importance of complying with the treatment regimen, and evaluate the client’s
compliance, especially with medication therapy.

 Teach the client how to monitor the blood pressure and maintain a diary of blood pressure
readings.

 Ensure that the client understands that the medication regimen will likely be a lifelong
commitment and stress the need for follow-up treatment.

 Tell the client to contact the physician if uncomfortable side effects occur but stress the
importance of not discontinuing prescribed medications.